Good Samaritan Society - Westbrook

F-F881

Review of the September through December 2024 logs identified infection surveillance had not been tracked through to resolution, no tracking or trending had occurred, and December 2024 had not been performed.

Interview on 1/8/25, at 2:10 p.m. with the IP identified she tracked staff illness with an illness/absence report, which was completed when a staff member called in due to illness of themselves or a child. The process was for the charge nurse to complete the form and provide a copy to the IP, director of nursing (DON), and office manager who completed the schedule. The IP reported she collected the forms and completed a report at

the end of each month that was presented to the Quality Assurance (QA) committee. The IP reported she recalled Resident R23 also being tested for Norovirus, but she had not included her on the log, and no initial clinical monitoring documentation had been completed. She stated she did not have an explanation for why this did not occur, but it was not on her log. The IP reported she had not been including documentation on surveillance or resolution of infections and when a resident had been admitted with orders for a prophylactic antibiotic she had not investigated or questioned the order.

She identified completion of the IP training and provided a copy of her certificate, but stated she would like to receive additional education on how and what she needed to investigate and document, in addition to finding

a format that included the necessary information. The reporting of infections and/or antibiotic use was received electronically if staff completed the documentation correctly. She also stated she was told by staff, or a note was left for her, for antibiotic use which she recorded on her log form. She made no follow-up to identify antibiotic stewardship had occurred, including antibiotic timeouts. The IP was unaware of the need to report potential Norovirus outbreak and had not correlated GI illness or put measures in place to prevent potential spread and ensured staff remained off work until 72 hours after symptoms subsided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 245595 Department of Health & Human Services Printed: 09/11/2025 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 245595 B. Wing 01/09/2025

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

Good Samaritan Society - Westbrook 149 First Street, Box 218 Westbrook, MN 56183

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 0882 Interview on 1/9/25 at 9:43 a.m., with the DON reported her expectation for the IP to correlate potential outbreak concerns related to staff and resident illness and investigate root cause with potential intervention. Level of Harm - Minimal harm or The DON identified there was a checklist that was supposed to be completed and sent to the IP and DON potential for actual harm and she expected the IP to follow the facility policy and procedures about IC surveillance and documentation.

She confirmed antibiotics should not be started until a culture was received and 48 hours after an antibiotic Residents Affected - Some was started a time out was implemented with a form completed and sent to provider. She reported the physician was to review the appropriateness of the antibiotic and make the determination if it should continue or be changed. She confirmed Resident R7 had been admitted on a prophylactic antibiotic and there was no documentation to indicate there had been an attempt to investigate need for continued use, or an attempt to implement alternate treatments.

Interview on 1/9/25 at 9:50 a.m., with the administrator reported she was not aware of a possible correlation between the resident who was hospitalized with Norovirus and reported staff illness with the same symptoms. She reported she would expect staff or family illness to be investigated and staff is not allowed to return to work until the appropriate time follow resolution of symptoms. She stated she would expect documentation to be maintained to confirm this had taken place. She reported the IP had been on vacation and failed to identify anyone designated to cover infection control surveillance while the IP was on vacation.

Review of the December 2, 2024, Infection Prevention and Control Program Policy identified the program was to work to prevent, identify, investigate, and report in the attempt to control infections and communicable diseases for residents, staff, and visitors in a facility. The program was to follow the nationally accepted standards, and guidelines for infection control. The program was to include an acceptable system to monitor and document infection control and prevention. The program was to be reviewed annually by the IP or designee, to ensure compliance. The IP utilizes surveillance date to identify outcomes, trends and patterns with results communicated to the QAPI committee.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 245595