Good Samaritan Society - Maplewood

F-F686 Based on interview and document review, the facility failed to ensure weekly skin assessments were completed for 2 of 3 (Resident R3, Resident R12) residents reviewed for pressure ulcer risk.

Monthly QAPI meeting minutes dated 5/26/23, indicated performance improvment plan (PIP) for high risk pressure ulcers-current percentage for the month of April 2023 was 9.1%. State was 7.3% and national norm is 9.0%. Continue to see some long term care residents with chronic reoccurring areas that are non-compliant with repositioning/off loading to reduce pressure ulcer risk. Risks and benefits are explained to

the residents and documented in point click care (computer program). Although the QAPI minutes provided documentation the facility was working on addressing high risk pressure ulcers, it lacked indication it was addressing missing weekly skin assessments.

During interview on 8/22/24 at 3:00 p.m., the director of nursing (DON), stated the facility was working on addressing high risk pressure ulcers by looking at the clinically complex nature of people who were already admitting with pressure ulcers, some of which had wound vacs and trying to promote healing. They also really wanted involvement with a medical doctor, so the facility decided to get Vohera (name of a wound care company) to come in once a week. The DON also stated they address pressure ulcers in their weekly interdisciplinary team (IDT) meetings and how important documentation was. The main issue was getting the nurse to complete the documentation and not put it to the wayside. It is so important to do a skin assessment. We have provided education and the nurse manager RN-A has recently made time in the nurses schedule that is dedicated to completing skin assessments.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 37 245221 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245221 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - Maplewood 550 Roselawn Avenue East Saint Paul, MN 55117

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46885 potential for actual harm Based on observation, interview, and document review, the facility failed to ensure appropriate personal Residents Affected - Many protective equipment (PPE) was donned (applied) for 2 of 2 residents (Resident R42, Resident R18) who were on enhanced barrier precautions (EBP), and 2 of 2 residents (Resident R55, Resident R111) on transmission based precautions, and failed to ensure appropriate hand hygiene and glove use for 3 of 3 residents (Resident R42, Resident R7, Resident R18). Additionally, the facility failed to take appropriate steps to diagnose and manage a COVID-19 outbreak in accordance with Centers for Disease Control (CDC) guidance.

Findings include:

According to the Centers for Disease Control (CDC) Infection Control Guidance: SARS-CoV-2 updated [DATE REDACTED], Infection Control Guidance: SARS-CoV-2 COVID-19 | CDC under the heading, Nursing Homes, indicated the approach to an outbreak investigation could involve either contact tracing (an attempt to find all contacts of a confirmed case in order to test or monitor for infection) or a broad-based approach; however, a broad-based such as unit, floor, or other specific areas of the facility approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test.

This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected units or facility-wide every 3 to 7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days), should be considered.

Resident R55:

Resident R55's admission Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R55 had intact cognition.

Resident R55's Admission Record form dated [DATE REDACTED], indicated Resident R55 had COVID-19 on [DATE REDACTED].

Resident R55's care plan dated [DATE REDACTED], indicated Resident R55 tested positive for COVID-19 on [DATE REDACTED]. Interventions included observing for symptoms, monitoring breath sounds, rate rhythm, and use of any accessory muscles, when possible all services brought to resident in room such as rehabilitation, activities, and dining, droplet and contact precautions wear gowns, gloves, N95 masks (if available), and eye protection when changing contaminated linens.

Resident R55's care plan dated [DATE REDACTED], indicated Resident R55 had COVID-19 on [DATE REDACTED], and interventions included encouraging Resident R55 to wear a mask while staff in the room and when going outside of the room, encourage social distancing as appropriate per MDH (Minnesota Department of Health) and CDC (Centers for Disease Control) recommendations, provide a private room and use airborne/contact precautions, all cares provided

in the private room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 37 245221 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245221 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - Maplewood 550 Roselawn Avenue East Saint Paul, MN 55117

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Resident R55's Order Summary Report dated [DATE REDACTED], indicated Resident R55 had an order dated [DATE REDACTED], for airborne and contact precautions for 10 days and all cares and therapies were completed in room. Level of Harm - Minimal harm or potential for actual harm Resident R55's nursing progress notes dated [DATE REDACTED], indicated Resident R55 was on isolation droplet precautions and all services were being rendered in Resident R55's room. Residents Affected - Many Resident R5:

Resident R5's admission MDS dated [DATE REDACTED], indicated intact cognition.

Resident R5's Admission Record form dated [DATE REDACTED], indicated Resident R5 had COVID-19 on [DATE REDACTED].

Resident R5's care plan dated [DATE REDACTED], indicated Resident R5 had COVID-19 on [DATE REDACTED]. Interventions included to encourage Resident R5 to wear a mask while staff in the room and when going outside of the room. Encourage social distancing as appropriate per MDH/CDC recommendations, provide private room and use contact/airborne precautions. All cares provided in a private room.

Resident R5's Order Summary report dated [DATE REDACTED], indicated Resident R5 had an order dated [DATE REDACTED], ok for airborne and contact precautions. Patient can be placed in a single room and all meals, care, and therapy provided in the room for 10 days every shift for COVID-19 for 10 days.

Resident R5's progress notes dated [DATE REDACTED], indicated Resident R5 's respiratory infection was potentially a result of COVID-19 and Resident R5 was on isolation droplet precautions and all services rendered in Resident R5's room.

Resident R111:

Resident R111's admission MDS dated [DATE REDACTED], indicated intact cognition.

Resident R111's Admission Record form dated [DATE REDACTED], indicated Resident R111 had COVID-19 on [DATE REDACTED].

Resident R111's care plan dated [DATE REDACTED], indicated Resident R111 tested positive for COVID-19 on [DATE REDACTED]. Interventions included to encourage Resident R111 to wear a mask while staff were in the room and when going outside of the room, provide a private room and use airborne/contact precautions, all cares provided in a private room.

Resident R111's Order Summary report dated [DATE REDACTED], indicated Resident R111 had an order dated [DATE REDACTED], ok for airborne and contact precautions. Patient can be placed in a single room and all cares, meals, and therapy provided in room for 10 days every shift for COVID-19 for 10 days.

Resident R111's progress notes dated [DATE REDACTED] at 7:26 p.m., indicated Resident R111's respiratory infection was potentially a result of COVID-19, was on droplet precautions, and all services rendered were completed in Resident R111's room.

Resident R215:

Resident R215's admission MDS dated [DATE REDACTED], indicated intact cognition.

Resident R215's Admission Record form dated [DATE REDACTED], indicated Resident R215 had COVID-19 on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 37 245221 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245221 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - Maplewood 550 Roselawn Avenue East Saint Paul, MN 55117

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Resident R215's care plan dated [DATE REDACTED], indicated Resident R215 tested positive for COVID-19 on [DATE REDACTED]. Interventions included, encourage Resident R215 to wear a mask while staff were in the room and when going outside of the room, Level of Harm - Minimal harm or provide a private room and use airborne/contact precautions, all cares provided in a private room. potential for actual harm Resident R215's Order Summary Report dated [DATE REDACTED], indicated the following orders: Residents Affected - Many [DATE REDACTED], complete SARS-COV-2 testing on all residents ongoing per CDC.

[DATE REDACTED], notify the provider about any symptoms of hypoxia every shift for COVID.

[DATE REDACTED], ok for airborne and contact precautions, single room isolation for all cares for 10 days every shift for COVID.

Resident R215's progress notes dated [DATE REDACTED] at 2:23 p.m., indicated Resident R215's family member was updated on the recent COVID positive result.

Resident R215's progress notes dated [DATE REDACTED] at 7:46 p.m., indicated Resident R215's respiratory infection is potentially a result of COVID-19 and was on isolation airborne precautions and contact isolation precautions.

Resident R4:

Resident R4's admission MDS dated [DATE REDACTED], indicated intact cognition.

Resident R4's Admission Record form dated [DATE REDACTED], lacked information Resident R4 had COVID-19.

Resident R4's care plan dated [DATE REDACTED], indicated Resident R4 tested positive for COVID-19 on [DATE REDACTED] and was on strict isolation in a private room with airborne and contact precautions. Interventions indicated contact precautions: wear gowns and masks when changing contaminated linens, provide a private room and use contact precautions. The care plan lacked interventions for using an N95 mask.

Resident R4's Order summary Report form dated [DATE REDACTED], indicated the following order:

[DATE REDACTED], complete SARS CoV 2 testing on all residents ongoing per CDC.

[DATE REDACTED], airborne and contact precautions patient can be placed in a single room and all cares, meals and therapy is provided in room every shift for COVID-19 for 10 days.

Resident R4's progress notes dated [DATE REDACTED] at 10:59 p.m., indicated Resident R4's infection was potentially a result of COVID-19 and was on airborne and contact isolation precautions.

Facility team sheets dated [DATE REDACTED], were divided into 4 teams: team 1, team 2, team 3 and team 4. Team 3 included the following residents: Resident R55, Resident R5, Resident R111, Resident R215, and Resident R4 who all tested positive for COVID-19. Additionally, Resident R110, Resident R43, Resident R12 , and Resident R214, were on Team 3.

Facility POC COVID-19 Test forms were reviewed and identified the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 37 245221 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245221 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - Maplewood 550 Roselawn Avenue East Saint Paul, MN 55117

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Resident R55 tested positive for COVID-19 on [DATE REDACTED].

Level of Harm - Minimal harm or Resident R5 tested negative for COVID-19 on [DATE REDACTED], and [DATE REDACTED]. Additionally, another test dated [DATE REDACTED], indicated potential for actual harm Resident R5 tested positive for COVID-19.

Residents Affected - Many Resident R111 tested positive for COVID-19 on [DATE REDACTED], no previous tests were located.

Resident R215 tested negative for COVID-19 on [DATE REDACTED], and [DATE REDACTED].

Resident R4 tested negative for COVID-19 on [DATE REDACTED], and tested positive for COVID-19 on [DATE REDACTED].

Resident R110 tested negative for COVID-19 on [DATE REDACTED], and negative for COVID-19 on [DATE REDACTED].

Resident R43 tested negative for COVID-19 on [DATE REDACTED], no previous tests were located.

Resident R12 tested negative for COVID-19 on [DATE REDACTED], and on [DATE REDACTED].

Resident R214 tested negative for COVID-19 on [DATE REDACTED].

Facility form, Monthly Report of Resident Infections in Location dated [DATE REDACTED], indicated the following:

Resident R55 had COVID-19 on [DATE REDACTED], and a productive cough with nasal drainage,, and congestion started on [DATE REDACTED].

Resident R5 had COVID-19 on [DATE REDACTED], and had symptoms of a productive cough, nasal drainage with congestion on [DATE REDACTED].

Resident R111 had COVID-19 on [DATE REDACTED] and symptoms of a non productive cough started on [DATE REDACTED].

Resident R215 had COVID-19 on [DATE REDACTED], and symptoms started on [DATE REDACTED].

Resident R4 had COVID-19 on [DATE REDACTED], and symptoms started on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 37 245221 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245221 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - Maplewood 550 Roselawn Avenue East Saint Paul, MN 55117

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During interview on [DATE REDACTED] at 7:53 a.m., the infection preventionist (IP) stated she worked as the IP every Wednesday, Thursday, and Friday. IP stated if an employee showed up to work with symptoms of a Level of Harm - Minimal harm or reportable communicable disease, they were tested with a rapid COVID-19 test and if they had signs or potential for actual harm symptoms, would be sent home. IP stated they had 5 residents who tested positive for COVID-19, and all were on team 3. IP further stated all staff should wear a surgical mask on the unit and a designated nurse Residents Affected - Many and nursing assistant (NA) would care for those residents with full PPE to include an N95 mask, gloves, gown, and a face shield. IP stated the N95 masks should fit securely to the face with no other mask located inside the N95 and regular glasses were not sufficient because they were not protective. IP further stated a couple staff were sick, one staff person had not worked at the facility and the other one was sent home as soon as they found out the staff person was COVID-19 positive. IP further stated they completed contact tracing and stated she was just finishing up on that on [DATE REDACTED]. IP stated with contact tracing, they look at someone in contact with a person at 6 feet or less for 15 minutes or more and test on day 1, then 48 hours later, and an additional 48 hours after that. IP stated COVID-19 first started when Resident R55's family member was positive for COVID-19, did not mask, and did not tell staff their positive status. IP further stated the 2nd person was Resident R5 on [DATE REDACTED], then Resident R111 on [DATE REDACTED], and then Resident R215 on [DATE REDACTED], and last, Resident R4 tested positive on [DATE REDACTED]. IP stated when not working, the director of nursing (DON) or nurse manager will test residents if they have signs and symptoms and will start transmission-based precautions and if a resident had symptoms and tested negative, they would require two negative tests 48 hours apart. IP stated they had four additional residents on team 3 and did not know whether they were tested and verified the residents were Resident R110, Resident R43, Resident R12, and Resident R214 and stated she planned to follow up on those residents [DATE REDACTED]. IP stated it was a situation where testing should be done on group three if staff were wearing PPE and a designated nurse and NA looked after the individuals. Further, IP stated hand hygiene occurred prior to entering a room and completing a task such as activities of daily living, take off the gloves, wash hands and donn new gloves. Not sanitizing hands can bring bacteria and spread infection if donning gloves without performing hygiene. IP stated residents on enhanced barrier precautions (EBP) had incisions, ulcers, catheters, and signage was placed outside the resident's door and a cart was placed in the hallway. If a resident had COVID-19, they were not on EBP, but were on airborne and droplet precautions. IP expected staff to donn a gown and gloves for EBP and the signage instructed staff what the high-risk areas were including dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care, central lines, urinary catheters, feeding tube, tracheostomy, wound care, and any skin opening requiring a dressing according to the CDC.

During interview on [DATE REDACTED] at 10:55 a.m., registered nurse (RN)-B stated she tested at home and did not have signs or symptoms of COVID-19 and if there was a COVID-19 outbreak, they tested on day 1, 3, and 5 and further stated with this outbreak, all staff would be tested but did not know whether residents would also be tested and stated if they have signs and symptoms, they were tested right away.

During interview on [DATE REDACTED] at 10:57 a.m., nursing assistant (NA)-B stated she tested for COVID-19 this morning and had been testing the last 3 days and was without signs or symptoms. NA-B stated she heard that morning the facility would be testing everyone on the unit and staff due to everyone walking through the floors.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 37 245221 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245221 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - Maplewood 550 Roselawn Avenue East Saint Paul, MN 55117

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During interview on [DATE REDACTED] at 11:02 a.m., RN-F walked down the hall with four tests for COVID AG cards and stated they were all negative tests for Resident R12, Resident R43, Resident R110, and Resident R214 and stated these residents were on Level of Harm - Minimal harm or team 3 in the middle of other residents who had COVID. RN-F further stated they test residents and staff, potential for actual harm and the test results were placed in a folder.

Residents Affected - Many During interview on [DATE REDACTED] at 2:19 p.m., the director of nursing (DON) stated COVID-19 testing was completed on residents who were symptomatic or had an exposure and they watched for signs and symptoms. DON further stated employees with close contact were also tested and stated the first case of COVID-19 was on [DATE REDACTED], then [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED]. DON further stated they tested the other four residents on team 3 who were negative but did not think they completed testing promptly enough.

The DON further stated she expected staff to wear an N95, gloves and a gown along with face shields and staff could not wear regular glasses as an eye protectant to prevent the spread of COVID-19. DON further stated the N95 had to be fitted to the face without a surgical mask underneath. Further, the DON stated she expected staff complete hand hygiene before and after glove use. The DON stated signs for EBP went up on admission and expected gloves and gowns to be worn for any close contact.

A COVID-19 Confirmed Case Checklist dated [DATE REDACTED], indicated when a case of COVID-19 has been suspected or confirmed in the location, the resident is confined to their room, airborne and contact transmission-based precautions are initiated, employees are assigned to care for the positive resident, source control is implemented on affected units, look back two days from start of symptoms or positive test, whichever was sooner, to identify all residents, staff and visitors as able who had close contact or higher risk exposure with this resident, initiate outbreak testing via contact tracing or broad-based testing. Test all employees and residents determined to be close contacts/higher risk exposures on day 1, 3, and 5 and contact trace any additional identified positives. If unable to conduct contact tracing, move to broad based testing of all employees and residents on a unit/hall or facility on day 1, day 3, and day 5. If the outbreak becomes uncontained, move to testing of all employees and residents every 3 to 7 days until no new cases of COVID-19 are identified for 14 days.

42586

Resident R55's admission Minimum Data Set (MDS) dated [DATE REDACTED], indicated intact cognition and a diagnoses of COVID-19.

Resident R55 required partial/moderate assistance with ADL's and mobility.

Resident R55's physician's order dated [DATE REDACTED], indicated droplet precautions x 10 days. All cares and therapies in room, every shift for 10 days.

Resident R55's care plan dated [DATE REDACTED], indicated Resident R55 has respiratory infection: tested Positive for COVID on [DATE REDACTED].

It further indicated the following interventions:

-observe for symptoms, e.g., cough, changes in functional ability or activity tolerance, O2 saturations, etc.

-monitor/document breath sounds, document rate, rhythm, and the use of any accessory muscles.

-when possible, all services brought to resident in room (e.g. rehabilitation, activities, dining, etc.).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 37 245221 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245221 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - Maplewood 550 Roselawn Avenue East Saint Paul, MN 55117

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 -DROPLET and CONTACT PRECAUTIONS: Wear gowns, gloves, N95 masks (if available), and eye protection when changing contaminated linens. Bag linens and close bag tightly before taking to laundry. Level of Harm - Minimal harm or potential for actual harm -encourage/assist resident to perform hand hygiene

Residents Affected - Many -monitor/document/report new or worsening signs/symptoms of COVID-19 fever of 100.0 or greater, chills, shortness of breath, difficulty breathing, new or change in cough, sore throat, new loss of taste or smell, new sputum production, congestion, runny nose (rhinorrhea), fatigue, muscle or body aches, headache, nausea or vomiting, or diarrhea.

-keep door closed for isolation

-provide private room if available.

Resident R111 (TA) admission Minimum Data Set (MDS) dated [DATE REDACTED], indicated intact cognition and diagnosis of COVID-19. Resident R111 required substantial assistance with mobility, lower extremity impairment on one side, used

a walker and a wheelchair, and had a catheter.

Resident R111's physician' orders dated [DATE REDACTED], indicated ok for droplet precautions. Patient can be placed in a single room and all cares, meals, and therapy provided in room for 10 days, every shift for COVID-19 for 10 days.

Resident R111's care plan dated [DATE REDACTED], indicated has infection testing positive for COVID on [DATE REDACTED] and is in strict isolation droplet and contact precautions. It further included the following interventions:

-monitor/document/report to health care provider s/s of delirium: Changes in behavior, altered mental status, wide variation in cognitive function throughout the day, communication decline, disorientation, periods of lethargy, restlessness and agitation, altered sleep cycle.

-when possible, all services brought to resident in room (e.g. rehabilitation, activities, dining, etc.).

-CONTACT PRECAUTIONS: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry.

-educate resident/family regarding preventive measures to contain the infection.

-provide private room and use contact precautions.

During observation on [DATE REDACTED] at 5:35 p.m., there was a sign on the outside of Resident R111's and Resident R55's door which indicated: Airborne Precautions everyone must: clean their hands, including before entering and when leaving the room. Put on an N95 or higher level respirator before room entry. Remove respirator after exiting

the room and closing the door. Door to room must remain closed. Nursing assistant (NA)-F entered Resident R111's room wearing 2 surgical masks, gown, and personal eye glasses. NA-F then exited the room (after having removed the gown) and donned another gown, and entered Resident R55's room, set her meal tray down, removed her gown, and exited the room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 37 245221 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245221 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - Maplewood 550 Roselawn Avenue East Saint Paul, MN 55117

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During interview on [DATE REDACTED] at 5:40 p.m. NA-F verified knowing the residents in rooms Resident R111 and Resident R55 were

on airborne precautions due to testing positive for COVID-19 and was supposed to be wearing an N95 but Level of Harm - Minimal harm or was unable too stating I can't breathe with an N95 mask on so I wear 2 surgical masks instead. Resident R55 was potential for actual harm also supposed to wear goggles/eye protection but was unable to find any stating sometimes we're short of that. Residents Affected - Many

During observation and interview on [DATE REDACTED] at 5:47 p.m., RN-G went into Resident R111's room wearing an N95 with

a surgical mask underneath it, a gown, and no eye protection. RN-G stated they weren't wearing eye protection because they were just giving the resident his pills, but should have been. Staff should wear eye protection every time they go into a residents room who are on airborne precautions. All staff have been fitted for an N95 and shouldn't be wearing a surgical mask underneath it.

During observation and interview on [DATE REDACTED] at 12:28 p.m., nursing assistant (NA)-G entered Resident R111's room wearing an N95 with a surgical mask underneath, a gown, and no eye protection. NA-G stated they had been fitted for N95's and didn't know if it was acceptable to wear a surgical mask underneath it. NA-G further stated he didn't wear eye protection because he wasn't performing cares and was only bringing the resident his meal tray.

During interview on [DATE REDACTED] at 12:35 p.m., registered nurse (RN)-E stated when entering a residents room who is on airborne precautions, staff are required to wear a gown, gloves, N95, and face shield. Anyone who enters the room for any reason needs to wear personal protective equipment (PPE) even if they are not performing cares. All staff have been fitted for an N95 and should not be wearing a surgical mask underneath it. RN-E also verified rooms [ROOM NUMBERS] were airborne precaution rooms due to residents testing positive for COVID-19.

During interview on [DATE REDACTED] at 9:15 a.m., nurse manager registered nurse (RN)-A stated any staff entering a resident's room who is on airborne precautions was required to wear an N95, face shield, gown, and gloves, even if they weren't performing cares. Staff must wear eye protection and not their own personal eye glasses and they must wear the N95 they have been fitted for. A surgical mask should not be worn underneath. If staff are not wearing the appropriate PPE they are putting themselves and other residents at risk of transmission and could expose them to getting COVID-19.

44647

Resident R18

Resident R18's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R18 had cognitive impairment and diagnoses of heart disease, Alzheimer's Disease, and anxiety disorder. Resident R18's MDS also indicated Resident R18 had pressure injury and was dependent on staff for mobility.

Resident R18's care plan revised [DATE REDACTED], indicated Resident R18 required EBP related to open wounds. Interventions including ensuring staff wore gown and glove when performing high contact care activities including transferring repositioning, and personal hygiene.

Resident R18's Kardex printed [DATE REDACTED], directed staff to don gown and gloves when performing high contact care activities such as dressing, providing hygiene, repositioning, changing linins and personal cares.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 37 245221 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245221 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - Maplewood 550 Roselawn Avenue East Saint Paul, MN 55117

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 An observation on [DATE REDACTED] at 1:13 p.m., Resident R18 was seated in a wheelchair in her room with lunch in front of her. Outside her door to the left was a EBP sign and directed staff to gown and glove when providing high Level of Harm - Minimal harm or contact care. potential for actual harm

An observation on [DATE REDACTED] at 2:03 p.m., nursing assistant- (A) and licensed practical nurse (LPN)-A entered Residents Affected - Many to assist Resident R18 back to bed. Outside of Resident R20's room to the left of the door was an EBP sign that directed staff to gown and glove when providing high contact care. Hand hygiene was performed upon entrance and gloves were donned however NA-A and LPN-A had not donned a gown. Resident R18 was lifted with the Hoyer lift and placed in bed. NA-A removed Resident R18's slippers. NA-A unfastened Resident R18's brief and tucked it down. NA-A provided cares from the front before LPN-A assisted to turn Resident R18 to the side. NA-A removed Resident R18's wet brief. Resident R18's bottom had blanchable redness and skin was intact. NA-A cleaned Resident R18 from the back side and removed gloves. Without performing hand hygiene, Resident R18 applied new gloves and applied barrier cream

before placing a clean brief and assisted Resident R18 to roll on their back. LPN-A pulled the brief through and secured. NA-A then removed gloves and without performing hand hygiene donned new gloves. NA-A adjusted Resident R18 to tilt to their right side and covered up. NA-A then removed gloves and tied garbage. Hand hygiene was performed, and NA-A and LPN-A exited the room.

An interview on [DATE REDACTED] at 2:17 p.m., NA-B verified the EBP sign to the side of Resident R18's door. Resident R18 stated they had not noticed the sign and should have worn a gown when providing cares to Resident R18. NA-B also verified they had not performed hand hygiene in-between glove exchanges and was supposed to.

When interviewed on [DATE REDACTED] at 7:536 a.m., the IP expected staff to perform hand hygiene upon when exchanging gloves during cares. This was important to minimize the risk spreading bacteria and risk of infection for the residents.

When interviewed on [DATE REDACTED] at 2:19 p.m., the Director of Nursing (DON) expected staff to perform hand hygiene before and after glove removal. EBP signs were place for residents with any open area, foley, feeding tube, and wounds. Staff were expected to follow EBP when providing close contact cares such as transferring and personal or hygiene cares.

48299

Resident R7

Resident R7's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R7 was cognitively intact and had diagnoses of heart failure (heart does not pump blood as well as it should), hypertension (high blood pressure), and chronic obstructive pulmonary disease (lung disease which blocks airflow and makes it difficult to breath). Resident R7 required supervision or touching assistance for toileting hygiene and transfers.

During observation on [DATE REDACTED] at 2:00 p.m., nursing assistant (NA)-C placed transfer belt around Resident R7, applied gloves, and assisted Resident R7 to stand from her wheelchair in the bathroom. Resident R7 sat on the toilet and was incontinent of bowel, and NA-C removed and threw away the incontinent product. NA-C unlocked Resident R7's wheelchair and backed out of bathroom, grabbed a clean incontinent product, returned to bathroom, and moved wheelchair closer to resident and locked wheelchair. Resident R7 stood up from the toilet, and NA-C wiped Resident R7's, applied clean incontinent product, pulled up Resident R7's underwear and pants and fixed Resident R7's shirt. NA-C assisted Resident R7 into wheelchair grabbing the transfer belt, removed the transfer belt, wiped the toilet seat, then removed gloves and washed hands.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 37 245221 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245221 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - Maplewood 550 Roselawn Avenue East Saint Paul, MN 55117

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During interview on [DATE REDACTED] at 2:12 p.m., NA-C stated Resident R7 required limited assistance for activities of daily living (ADLs). NA-C stated staff performed hand hygiene between assisting residents and between changes Level of Harm - Minimal harm or gloves. NA-C stated glove change and hand hygiene should be completed after dirty tasks and before clean potential for actual harm tasks, and verified they did not change gloves during toileting and incontinence cares. NA-C stated glove changes and hand hygiene were important to prevent infection. Residents Affected - Many

During interview on [DATE REDACTED] at 7:53 a.m., the infection preventionist (IP) expected staff to take gloves off and perform hand hygiene after assisting with ADLs, such as incontinence cares, and before touching clean items. This was important to minimize the risk of spreading bacteria and risk of infection for the residents.

During interview on [DATE REDACTED] at 2:19 p.m., the Director of Nursing (DON) expected staff to perform hand hygiene before and after glove removal.

49893

Resident R42

Resident R42's face sheet printed [DATE REDACTED], indicated diagnoses of pneumonia, heart failure, and diabetes

Resident R42's admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] indicated Resident R42 had moderate cognitive impairment, no upper or lower extremity impairment, uses a wheelchair, dependent on staff for toileting hygiene, bathing, lower body dressing, and substantial assist for personal hygiene and bed mobility. Resident R42 was frequently incontinent of urine and always incontinent of bowel. Resident R42 has moisture associated skin damage (MASD)

Resident R42's careplan indicated Resident R42 required enhanced barrier precautions related to open wounds. Interventions included wearing gown and gloves when performing high contact are activities including dressing, bathing, transferring, providing hygiene, changing linens, repositioning, and/or wound care.

Resident R42's Kardex printed [DATE REDACTED] directed staff to don gown and gloves when performing high contact care activities such as dressing, transferring, bathing, hygiene, changing linens, repositioning, and wound care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 37 245221 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245221 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - Maplewood 550 Roselawn Avenue East Saint Paul, MN 55117

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During observation on [DATE REDACTED] at 1:39 p.m., a sign on was noted on the wall outside Resident R42's door indicated EBP with instructions to don gown and gloves for high contact care. Nursing assistant (NA)-A entered Resident R42's Level of Harm - Minimal harm or room with shower chair and NA-C entered room with mechanical lift. Both NA-A and NA-C arrived wearing potential for actual harm gloves however did not don gowns. NA-D removed blankets and pillows from Resident R42's bed. NA-C removed Resident R42's pants. NA-C reached across Resident R42 and assisted with rolling him to his right side. NA-C's scrub top was Residents Affected - Many observed touching Resident R42's bed. NA-D removed Resident R42's incontinence product and placed mechanical lift sling under Resident R42. NA-C and NA-D then rolled Resident R42 to his left side exposing a bandage to Resident R42's buttocks. Center of bandage was noted to be saturated with drainage. NA-C disposed of incontinence product in a garbage bag. Without removing gloves or performing hand hygiene, NA-C and NA-D assisted with transferring Resident R42 from bed to the shower chair. Stool was noted on draw sheet on Resident R42's bed. NA-C and NA-D then removed gloves with NA-D washing hands in bathroom. NA-C left room. NA-D brought Resident R42 to the shower room. NA-D applied gloves however did not don gown. NA-D washed, rinsed, and towel dried Resident R42. With the same gloves, NA-D wrapped Resident R42 in sheet and blanket. NA-D then gathered shower linens placing them in bin. NA-D removed gloves and, without performing hand hygiene, took Resident R42 back to his room. NA-D donned gloves however no gown. NA-D removed soiled linens from Resident R42's bed and applied clean linens wearing the same gloves. NA-C entered room wearing gloves and no gown. NA-D removed gloves and donned new gloves without hand hygiene. Resident R42 was transferred from shower chair to bed. NA-D and NA-C assisted with applying incontinence product and dressing Resident R42. NA-C removed gloves and left the room. NA-D tidied room, removed gloves, opened window shades and put on new gloves. No hand hygiene was performed. NA-D then took bag of dirty linen and shower chair back to shower room.

During interview on [DATE REDACTED] at 2:52 p.m., NA-D confirmed signage outside Resident R42's room indicating EBP. NA-D stated gowns and gloves are to be worn for cares, transferring, dressing changes, and bathing. NA-D also stated hand hygiene should be performed before and after wearing gloves or when hands are dirty. NA-D confirmed they should have worn a gown when transferring and bathing Resident R42 and should have performed hand hygiene after removing gloves.

During interview on [DATE REDACTED] at 2:52 p.m., NA-C stated residents with wounds and catheters require EBP. Gown and gloves are required depending on level of contact, such as changing or helping residents getting dressed. NA-C stated they did not don a gown because they did not notice a sign outside Resident R42's door.

During interview on [DATE REDACTED] at 10:51 a.m., RN-A stated they would expect staff to don gloves and gown for direct care, clothing management, showering, and all other high contact cares for residents on EBP and confirmed staff should have worn gowns when assisting Resident R42. RN-A stated she would expect staff to sanitize hands before donning and after doffing gloves.

During interview on [DATE REDACTED] at 1:04 p.m., the director of nursing stated residents are evaluated for EBP on admission. All residents with incisions, wounds, and medical devices inserted in body are placed on EBP.

She would expect staff to wear gowns for close contact with residents and remove gowns before leaving the room. The director of nursing confirmed she would have expected NA-D and NA-C to wear gown and gloves when performing cares and bathing for Resident R42. The director of nursing further confirmed she would expect staff to perform hand hygiene between glove change.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 37 245221 Department of Health & Human Services Printed: 09/12/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245221 B. Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - Maplewood 550 Roselawn Avenue East Saint Paul, MN 55117

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 A policy tilted Multidrug-Resistant Organisms, MRSA VRE CRE and ESBL, All service Lines-Enterprise dated [DATE REDACTED] indicated All resident's with any of the following: wounds and/or indwelling medical devices (e. Level of Harm - Minimal harm or g., central line, urinary catheter, feeding tube, tracheostomy/ventilator: regardless of MDRO colonization potential for actual harm status are to be placed on EBP. Personal protective equipment (PPE) are used for high-contact resident care activitie [TRUNCATED] Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 37 245221