Good Samaritan Society - Waconia And Westview Acre

plan of care.

record review and interview, the facility failed to conduct the initial and quarterly care conferences

Data Set (MDS) dated [DATE], indicated R60 was admitted on [DATE], cognitively intact, and had the following diagnoses: peripheral vascular disease (poor circulation in the limbs), benign prostatic hypertrophy (enlarged prostrate), renal insufficiency, hyperlipidemia (elevated level of fat in the blood stream), and depression.R60's medical record lacked evidence a care conference was offered or conducted since admission.On 3/25/26 at 8:03 a.m., the administrator confirmed the facility had no record of any care conferences being conducted for R60.On 3/26/26 at 9:55 a.m., the social work designee (SW)-A and the director of nursing (DON) stated care conferences were organized by the social worker in cooperation with the MDS coordinator and should have been conducted within 3 days of admission, quarterly, with a significant change, or at family request. SW-A and the DON confirmed R60 had not had any care conferences and stated they were missed during a staff change over. SW-A stated the importance of conducting care conferences were to ensure the residents received what they needed and their family members/representatives provided input into their care.

The DON stated they expected the initial care conference to have been conducted within 3 days of admission and then quarterly, with a significant change or at family request.

The DON stated the importance of completing care conferences was to have clear communication and collaboration with the families.The facility Comprehensive Care plan and Care Conferences Policy last reviewed 12/29/25, indicated the facility will establish a baseline care plan and provide the resident and/or representative with a written summary of the care plan, and document the meeting occurred with the resident and representative and any significant discussion that occurred.

245234 03/26/2026

Good Samaritan Society - Waconia and Westview Acre 333 Fifth Street West Waconia, MN 55387

nursing home.

record review and interviews, the facility failed to provide quarterly statements to 1 of 1 resident

[DATE], indicated R36 admitted [DATE], cognitively intact, and had the following diagnoses: heart failure, hypertension (high blood pressure), renal insufficiency, diabetes, and schizophrenia.On 3/23/26 at 1:20 p.m., R36 stated the facility was responsible for management of their money, but they had no idea what was going on with the account and the facility received their statements.On 3/26/26 at 12:12 p.m., the business office manager (BOM) stated they received monthly statements at R36's request and then met with the resident to explain and provide the documents to them.

Additionally, the BOM confirmed they had no documentation to confirm conversations or explanations occurred.R36's medical record lacked evidence of agreement or statements were provided or explained to R36.On 3/26/26 at 12:50 p.m., administrator stated they expected personal fund account summaries were provided per regulations. It was important to provide documents to residents and document all conversations regarding accounts.

Residents needed to be informed of account balances and facility needed documentation to refer back to.The facility Resident Trust Account Policy last revised 5/23/24, indicated as fiduciary of resident funds the location must hold, safeguard, manage, and account for the funds as well as ensure they are handled in accordance with state and federal regulation.

245234 03/26/2026

Good Samaritan Society - Waconia and Westview Acre 333 Fifth Street West Waconia, MN 55387

During interview on 3/26/26, at 10:56 a.m.

Social worker (SW)- A stated R82 was educated regarding the risks and benefits of discharge AMA versus discharge to AL or home with services. SW-A stated R82 was adamant was going to discharge to home.

When interviewed on 3/26/26, at 11:09 a.m. director of nursing (DON) stated they attempted to convince R82 to remain in facility to allow them to contact the provider regarding desire to discharge to home.

DON stated facility goal when a resident expressed they intended to discharge even if AMA was to contact the provider to attempt to facilitate a safe discharge for the resident rather than they discharge AMA with no assistance to obtain services or orders for medications. DON reviewed R82's EMR, DON noted facility was made aware on 1/26/26, R82 intended to discharge, however DON was unable to locate documentation provider had been informed, no attempt had been made to facilitate a safe planned discharge for R82.

Facility Discharge and Transfer Rehab/Skilled, Therapy and Rehab policy dated 1/15/26, indicated discharge home facility would obtain an order from the physician for discharge to home with medications, arrange community resources and referrals, and coordinate a discharge plan with interdisciplinary team and resident. In addition, the policy indicated discharge AMA facility was to inform the physician of the situation.

245234 03/26/2026

Good Samaritan Society - Waconia and Westview Acre 333 Fifth Street West Waconia, MN 55387

During interview on 3/25/26, at 3:04 p.m.

Director of nursing (DON) reviewed R82's EMR, indicated was unable to locate a discharge summary for R82. DON was unsure why there was discharge summary.

Facility Discharge and Transfer – Rehab/Skilled, Therapy and Rehab policy dated 1/15/26, indicated when a resident discharge from the facility a discharge summary would be completed.

245234 03/26/2026

Good Samaritan Society - Waconia and Westview Acre 333 Fifth Street West Waconia, MN 55387

Review of R10's electronic medical record (EMR) indicated R10 was admitted to the facility on [DATE].

Further review of R10's EMR revealed a baseline care plan had not been initiated or completed within 48 hours of admission.

The ADL baseline care plan was first documented on 2/17/26, greater than 48 hours after admission.

R11R11's quarterly MDS dated [DATE] identified R11 had intact cognition and required assistance with ADLs. R11's diagnoses included neurocognitive disorder with Lewy bodies (a progressive brain disorder causing changes in thinking, movement, and behavior), non-Alzheimer's dementia (decline in memory and thinking not caused by Alzheimer's disease), and depression (persistent sadness or loss of interest).

The MDS indicated R11 received antipsychotic medication.

Review of R11's EMR indicated R11 was admitted to the facility on [DATE].

Further review of R11's EMR revealed a baseline care plan had not been initiated or completed within 48 hours of admission.

The ADL baseline care plan was first documented on 12/1/25, greater than 48 hours after admission.

During interview on 3/25/26 at 3:25 p.m., registered nurse case manager (RN)-B indicated baseline care plans included areas such as transfer status, high-risk ( black box) medication warnings, medications, fall risk, behaviors, pain, risk for pressure ulcers, psychotropic medication use, and presence of a feeding tube.

RN-B stated baseline care plans should be completed within 24-48 hours of admission. RN-B confirmed R11's ADL interventions were not initiated until 12/1/25.

During interview on 3/25/26 at 4:07 p.m., the Director of Nursing (DON) indicated care plans were expected to be initiated upon admission, with assessments set up to automatically populate the care plan.

The DON stated the RN manager or herself would follow up or complete the care plan, with an expectation for completion within 48 hours so staff were aware of how to provide care.

The DON further stated, at a minimum, fall and ADL interventions should be in place within that timeframe.

The DON confirmed R11's ADL interventions were initiated on 12/1/25, which was beyond the required 48-hour timeframe.

During interview on 3/26/26 at 11:31 a.m., the DON provided consistent information regarding care plan initiation and expectations for completion within 48 hours of admission, including implementation of fall and ADL interventions.

The DON confirmed R10's ADL interventions were initiated on 2/17/26, which was beyond the required 48-hour timeframe.

The facility Care Plan policy was requested but was not received

245234 03/26/2026

Good Samaritan Society - Waconia and Westview Acre 333 Fifth Street West Waconia, MN 55387

During interview on 3/25/26

included in the care plan. A facility care plan policy was requested but was not received.

245234 03/26/2026

Good Samaritan Society - Waconia and Westview Acre 333 Fifth Street West Waconia, MN 55387

Review of R25's comprehensive care plan, with a print date of 3/26/26, indicated R25 required assistance of one staff with a front wheeled walker for mobility.

During the following observations, no use of a front wheeled walker was observed:3/24/26 at 3:26 p.m., R25 was observed sitting outside the elevator in his wheelchair and was self-propelling via wheelchair to and from various locations within the facility.3/24/26 at 6:48 p.m., R25 was observed self-propelling via wheelchair to and from various locations on the second-floor unit.3/25/26 at 8:33 a.m., R25 was observed self-propelling via wheelchair to and from various locations on the second-floor unit.3/25/26 at 3:13 p.m., R25 was observed sitting outside the elevator in his wheelchair and was self-propelling via wheelchair to and from various locations within the facility.

Further review of R25's electronic medical record (EMR) lacked evidence the care plan had been revised to reflect R25's current use of a wheelchair for mobility assistance.

During interview on 3/25/26 at 3:40 p.m., registered nurse care manager (RN)-B stated the wheelchair use had not been reflected in R25's care plan and should have been revised.

During interview on 3/26/26 at 10:46 a.m., the director of nursing (DON) confirmed wheelchair use for R25's mobility had not been revised in the care plan and should have been, to ensure the care plan was clearly identified for staff to provide safe care. A facility care plan policy was requested but was not received.

245234 03/26/2026

Good Samaritan Society - Waconia and Westview Acre 333 Fifth Street West Waconia, MN 55387

During follow-up observations on 3/24/26, at 12:37 p.m., 3/24/26, at 3:48 p.m., 3/24/26, at 6:55 p.m., 3/25/26, at 8:29 a.m., 3/25/26, at 4:15 p.m. and 3/26/26, at 7:16 a.m. R15 continued to have long gray hair on chin, above upper lip and below lower lip, about an inch in length.

During interview on 3/26/26, at 10:18 a.m. family member (FM)-A stated they had asked the facility to shave R15, FM-A further stated R15 would be very bothered if she knew she had long hairs on her face. FM-A stated I don't know why they don't remove the hairs for her, I would think they could easily do that for her, she has a electric razor in her drawer.

When interviewed on 3/26/26, at 10:32 a.m. nursing assistant (NA)-A stated R15 did not refuse cares, if a resident was unable to request to be shaved the resident should then be shaved when they start to look scruffy.

When interviewed on 3/26/26, at 10:36 a.m. trained medication aide (TMA)-A stated R15 was cooperative with cares, TMA-A stated she had noticed R15 had long hair on her chin but had not shaved her this morning. TMA-A observed R15 with surveyor and stated R15 did look like she should have been shaved before now for R15's dignity When interviewed on 3/26/26, at 11:09 a.m. director of nursing (DON) stated the expectation was both men and women should be shaved when there was hair/whiskers that had grown for their comfort and dignity.

Facility Activities of Daily Living - R/S, LTC policy dated 12/10/26, indicated ADLs are those necessary tasks conducted in the normal course of a resident's daily life that included general personal, daily hygiene/grooming: care of hair, hands, face, shaving, applying makeup, skin, nail and oral care.

245234 03/26/2026

Good Samaritan Society - Waconia and Westview Acre 333 Fifth Street West Waconia, MN 55387

Review of R25's physician orders, dated 3/4/26, indicated an order for staff to apply compression (TEDS) stockings in the morning and remove them in the evening for edema management.

Review of the Treatment Administration Record (TAR) from 3/1/26 through 3/26/26 indicated staff documented the application and removal of compression stockings as completed, as ordered.

During observation and interview on 3/23/26 at 3:07 p.m., R25 was observed seated in his wheelchair without compression stockings in place.

Observation of R25's lower extremities revealed he was wearing regular socks that were causing indentations around his lower extremities. R25 stated staff had not consistently assisted with applying the compression stockings, and he had been wearing regular socks for the past several weeks.

During observation on 3/24/26 at 12:59 p.m., R25 was observed seated in his wheelchair in the dining room without compression stockings in place.

Observation of his lower extremities revealed he was wearing regular socks that were causing indentations.

During observation on 3/25/26 at 8:33 a.m., R25 was observed seated in his wheelchair in the living room area without compression stockings in place.

Observation of his lower extremities revealed he was wearing regular socks that were causing indentations.

During interview on 3/25/26 at 3:18 p.m., Nursing Assistant (NA)-C stated she was not aware R25 had compression stockings that he should have been wearing during the day.

During interview on 3/25/26 at 3:19 p.m., Registered Nurse (RN)-A stated R25 had an order for compression stockings to be applied in the morning and removed at bedtime. RN-A stated R25 did not refuse compression stockings. RN-A confirmed R25 did not have compression stockings on at that time and was wearing regular socks. RN-A confirmed the TAR indicated the compression stockings were applied and removed as ordered and acknowledged the documentation was not accurate when the stockings were not in place.

During interview on 3/25/26 at 3:40 p.m., the Registered Nurse Care Manager (RN)-B stated she had not been aware of R25's edema. RN-B reviewed R25's electronic medical record (EMR) and stated R25 had non-pitting edema in the right and left lower extremities and should have been wearing compression stockings. RN-B indicated she would have expected R25 to wear them, as there was an order in place, and stated they were important to help manage his edema. RN-B confirmed staff had been documenting on the TAR that the compression stockings were applied and removed as ordered.

During interview on 3/26/26 at 10:46 a.m., the Director of Nursing (DON) stated compression stockings should have had an order to be applied in the morning and removed at night and that this intervention should have been care planned.

The DON stated staff were expected to assist R25 with application and removal.

The DON further indicated compression stockings were important to help manage edema, promote circulation, and reduce the risk of blood clots.

The DON also stated staff were expected not to document care that was not completed, as doing so would be false documentation. A facility policy regarding compression stocking application, documentation, and care planning was requested but was not received.

245234 03/26/2026

Good Samaritan Society - Waconia and Westview Acre 333 Fifth Street West Waconia, MN 55387

Review of R15's EMR wound documentation identified:On 12/3/25, left heel stag 3 measured 1.5cmx0.4cmx0.2cm with100% slough, right heel stage 3 measured 1.3cmx1.1cmx0.2cm with 90%granulation and 10% slough.On 12/12/25, left heel stage 3, measured 0.9cmx0.4cmx0.2cm with 100% slough. right heel stage 3 measured 1.4cmx0.9cmx0.2cm with 90% granulation and 10% slough.The next documented measurements were completed 47 days later on 1/28/26, right heel stage 3 measured 0.5cmx0.3cmx0.2cm with 100% granulation, left heel stage 3 measured 0.2cmx0.2cmx0.2cm with 100% granulation.On 2/4/26, left heel stage 3 was documented as 0cmx0cmx0cm with100% epithelial. right heel stage 3 measured 0.8cmx0.5cmx0.1cm with 100% epithial wound bed.On 2/12/26, right heel 1cm x 1cm x 0cm scabbed. left heel scabbed 1.5cm x 1.5cm x 0cm.On 2/18/26, right heel 0.1cm x 0.2cm x 0.1cm 100% granulation. left heel 0.9cm x 0.4cm x 0cm 100% slough.The next documented measurements were completed 15 days later on 3/5/26, left heel stage 3 pressure ulcer scab covered measured as 0cmx0cmx0cm.

Right heel stage 3 pressure ulcer 1cmx0.5cmx0cm scab covered.On 3/12/26, left heel stage 3 pressure ulcer measured 0.5cmx0.3cmx0.1cm, right heel stage 3 pressure ulcer measured 1cmx0.5cmx0.1cm.On 3/19/26, left heel stage 3 measured 0.5cmx0.3cmx0.1cm, right heel stage 3 measured 1cmx0.5cmx0.1cm.

When interviewed on 3/26/26, at 11:09 a.m. director of nursing (DON) stated the expectation was all wounds would be measured and documented on weekly. DON stated she expected the nurses/nurse managers to take ownership with their wounds. DON reviewed R15's EMR, stated unable pull data that is not in the chart.

Facility Pressure Ulcer/Wound Care Resource Packet-Rehab/Skilled policy stated 12/8/25, indicated wound RN assessment is required at least every seven days and as needed when skin integrity is impaired or open area is present.

245234 03/26/2026

Good Samaritan Society - Waconia and Westview Acre 333 Fifth Street West Waconia, MN 55387

Review of R88's electronic medical record (EMR) indicated R88 received routine dialysis treatments at an external dialysis center on a scheduled basis (Mondays, Wednesdays, and Fridays).

Review of facility documentation, including dialysis communication forms and transfer records from 3/18/26 to 3/25/26, revealed the facility failed to send required clinical information with R88 to the dialysis center.

Missing or incomplete information included, but was not limited to, vital signs, current medication list, recent changes in condition, weights, and/or physician orders.

During interview on 3/24/26 at 12:13 p.m., R88 stated she went to an offsite dialysis center and reported the facility did not send any paperwork or communication form with her to her dialysis appointments.

During interview on 3/25/26 at 3:55 p.m., the Director of Nursing (DON) confirmed the expectation that communication forms should accompany the resident to each dialysis appointment to ensure continuity of care.

The DON acknowledged the facility did not consistently ensure this information was provided. A call to the Fresenius Dialysis Center was placed on 3/27/26 at 8:04 a.m.; a message was left, and no return call was received.

The facility was requested to provide a policy regarding communication with outside providers, including dialysis centers; however, the facility did not provide the requested policy.

245234 03/26/2026

Good Samaritan Society - Waconia and Westview Acre 333 Fifth Street West Waconia, MN 55387

Review of R10's electronic medical record (EMR) lacked evidence a trauma assessment was completed upon admission to identify past trauma, triggers, or individualized care needs related to trauma history.

Review of R10's comprehensive care plan, print date 3/26/26, did not include trauma-informed interventions, approaches to minimize triggers, or strategies to promote emotional safety.

During interview on 3/26/26 at 9:55 a.m., the Director of Nursing (DON) and Social Services Designee (SSD) confirmed R10 had a known history of PTSD; however, no trauma assessment had been completed at the time of admission.

The DON and SSD further confirmed trauma-informed interventions had not been developed or implemented for R10.

The facility's Trauma-Informed Care policy, dated 12/31/25, indicated the facility would provide trauma-informed care and avoid re-traumatizing residents.

The policy further indicated staff would ensure residents who experienced trauma received culturally competent, trauma-informed care in accordance with professional standards of practice, accounting for residents' experiences and preferences to eliminate or mitigate triggers that could cause re-traumatization.

The policy indicated a trauma assessment was required within five days of admission for all new residents and as needed.

The trauma assessment was to be completed by Social Services while interviewing the resident and/or representative.

During the interview, staff were to focus on understanding the resident's experience (what happened to the resident) rather than attempting to correct behaviors.

The policy further indicated staff were to document how trauma was currently affecting the resident.

245234 03/26/2026

Good Samaritan Society - Waconia and Westview Acre 333 Fifth Street West Waconia, MN 55387

Review of the consultant pharmacist's monthly medication regimen review (MMR), dated 12/18/25, identified a recommendation for completion of an AIMS assessment to monitor for potential side effects related to antipsychotic medication use.

Subsequent MMRs, dated 1/14/26, 2/13/26, and 3/6/26, reiterated the same recommendation.

Review of R11's electronic medical record (EMR) revealed no evidence that an AIMS assessment had been completed following the pharmacist's recommendation.

Further review showed the recommendation remained unaddressed as of 3/20/26.

During an interview on 3/20/26 at 10:15 a.m., the director of nursing (DON) confirmed the consultant pharmacist (CP) recommended completion of an AIMS assessment and acknowledged the facility had not completed the assessment or followed up on the recommendation in a timely manner.

During an interview on 3/25/26 at 1:45 p.m., DON stated when MMRs were received, she divided the recommendations between two registered nurse case managers and forwarded provider-related recommendations to the providers.

During an interview on 3/25/26 at 3:25 p.m., registered nurse case manager (RN-B) stated the DON printed the pharmacist recommendations and distributed them to the nurse managers, where they were placed in a drawer for follow-up. RN-B stated the nurse manager was responsible for completing the AIMS assessment and that recommendations should be followed up as soon as possible, including consideration of gradual dose reduction (GDR) and monitoring for adverse medication reactions. RN-B confirmed the AIMS assessment had not been completed.

During an interview on 3/25/26 at 4:07 p.m., the DON stated MMR recommendations were expected to be completed prior to the next consultant pharmacist visit.

The DON stated the recommendation had been assigned to the RN case manager; however, for unknown reasons, it was not completed.

The DON further stated the recommendation was important as it related to monitoring the resident's medication and potential adverse effects.

During an interview on 3/26/26 at 2:18 p.m., the Consultant Pharmacist (CP) stated the expectation was for facilities to respond to recommendations within the first month and no later than 60 days.

The CP stated there had been no response to the recommendation in December, January, or February and reported the lack of follow-up may have been related to turnover in the DON position, resulting in the recommendation not being addressed.

Review of the facility policy titled Medication: Drug Regimen Review, dated 12/1/25, indicated drug regimen review included identifying and preventing clinically significant medication issues.

The policy further indicated the consultant pharmacist would complete a written report noting any irregularities, which would be provided to the DON, and the facility must ensure recommendations were acted upon and documented within 30 calendar days.

245234 03/26/2026

Good Samaritan Society - Waconia and Westview Acre 333 Fifth Street West Waconia, MN 55387

During interview on

anticipated coming into contact with the resident.

During interview on 3/25/26 at 3:55 p.m., the DON confirmed staff were expected to follow EBP precautions, including use of gown and gloves for high-contact care, and acknowledged the observed care was not provided in accordance with facility policy. R88R88's admission MDS, dated [DATE], identified R88 had intact cognition and required assistance with ADLs. R88's diagnoses included dependence on renal dialysis (requires routine dialysis treatment to perform kidney function), chronic kidney disease stage 5 (severe kidney failure where the kidneys no longer function adequately), and presence of other vascular implants and grafts (surgically placed devices or vessels used to support blood flow, often for dialysis access).

Review of R88's EMR identified the presence of a dialysis shunt.

Further review of the comprehensive care plan, with a print date of 3/26/26, and physician orders, dated 3/18/26, failed to include initiation of EBP precautions related to the presence of the dialysis shunt.

There was no documentation indicating assessment for EBP implementation, use of gown and gloves for high-contact care, or placement of appropriate signage and PPE outside of R88's room.

During observations on 3/23/26 at 11:12 a.m., 3/24/26 at 4:59 p.m., and 3/25/26 at 2:53 p.m., there was no appropriate signage or PPE placed outside R88's room to indicate the resident was on precautions.

During interview on 3/25/26 at 3:55 p.m., the director of nursing (DON) stated R88 should have been on EBP precautions due to the presence of a tunneled catheter.

She indicated there should have been signage outside the door and EBP supplies available in a cupboard outside the room.

The DON stated it was important to prevent infection transmission to the resident and to staff and confirmed gloves and a gown should be worn during care.

The facility Standard, Enhanced Barrier, and Transmission-Based Precautions policy, dated 7/7/25, indicated Enhanced Barrier Precautions (EBP) were implemented to reduce the transmission of multidrug-resistant organisms (MDROs) for residents who were infected or colonized with a CDC-targeted or epidemiologically significant MDRO, or when additional precautions were warranted.

The policy indicated EBP were used for residents with chronic wounds (e.g., pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomies), regardless of known MDRO status.

The policy indicated staff were to wear a gown and gloves during high-contact resident care activities, including transfers, dressing, bathing, hygiene care, toileting, linen changes, wound care, and care or use of indwelling medical devices.

The policy indicated EBP were intended to remain in place for the duration of the resident's stay; however, for residents with a wound or indwelling medical device only, precautions could be discontinued if the wound resolved or the device was removed