Good Shepherd Lutheran Home

F-F761: Based on observation and interview, the facility failed to maintain safe storage of medications when medication carts were left unlocked and unattended in 2 of 7 medication carts.

The facility's QAPI meeting minutes dated 3/13/25, lacked ongoing data related to the above repeat citation.

On 4/17/25 at 10:45 a.m., the quality assurance registered nurse (RN)-B acknowledged the importance of continued monitoring of prior Performance Improvement Projects (PIPS). RN-B stated formal auditing and then more periodic auditing, chart review, and observational audits, were completed to ensure improvements were sustained.

The facility's Quality Assurance and Performance Improvement Program policy, revised 4/15/24, indicated

the facility monitors the effectiveness of its performance improvement activities to ensure improvements are sustained.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 245269 Department of Health & Human Services Printed: 08/28/2025 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 245269 B. Wing 04/17/2025

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

Good Shepherd Lutheran Home 1115 4th Avenue North Sauk Rapids, MN 56379

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** 49035 potential for actual harm Based on observation, interview and document review, the facility failed to ensure proper personal protective Residents Affected - Few equipment (PPE) was used when providing cares for 1 of 1 residents (Resident R80) reviewed for enhanced barrier precautions (EBP).

Findings include:

Resident R80's admission Minimum Data Set, dated dated dated [DATE REDACTED], included Resident R80 had moderate cognitive impairment. Resident R80 had diagnosis of COVID-19, depression, and metabolic encephalopathy (a condition causing altered metal status).

Resident R80's undated care plan, included Resident R80 was on EBP due to a pressure ulcer on buttocks. Care plan included to wear a gown and gloves when providing high contact cares.

On 4/15/25 at 9:21 a.m., licensed practical nurse (LPN)-B was observed in Resident R80's room cutting her toenails. LPN-B was not wearing a gown and was leaning on foot of bed.

During interview on 4/15/25 at 9:25 a.m., LPN-B confirmed Resident R80 was on EBP for a pressure ulcer. LPN-B confirmed she had received education on EBP and should be wearing PPE whenever providing close contact cares. LPN-B confirmed she should have been wearing a gown.

On 4/15/25 at 9:48 a.m., physical therapy assistant (PTA)-F was observed assisting Resident R80 with walking in her room and transferring to her bed. PTA-F was observed assisting Resident R80 adjust the covers on her bed to cover Resident R80's lower body.

During interview on 4/15/25 at 9:51 a.m., PTA-F stated she had received training on EBP and Resident R80 was on EBP. PTA-F stated PPE should have been worn whenever assisting with personal cares, such as dressing or toileting.

During interview on 4/16/25 at 8:22 a.m., clinical manager (CM)-A confirmed Resident R80 was on EBP and staff should wear PPE whenever providing close contact cares, such as transferring, toileting and repositioning. CM-A confirmed staff should have been wearing a gown and gloves while clipping toenails, assisting with physical therapy, and adjusting covers on the bed.

During interview on 4/16/25 at 12:59 p.m., infection control prevention nurse (IP)-G stated all staff are trained

on EBP and the facility follows center for disease (CDC) guideline for precautions. IP-G confirmed gown and gloves should have been worn when clipping toenails and providing therapy assistance. IP-G confirmed all departments including therapy was trained on EBP.

During interview on 4/16/25 at 1:16 p.m., director of nursing (DON) stated PPE should be worn any time a staff person is completing hands on care for a resident on EBP. The DON stated this was important to protect all residents and staff.

Facility infection control and prevention manual dated October 2024, included EBP involved gown and glove use during high-contact resident care activities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 245269