Good Samaritan Society - Windom

resident when they ended their Medicare Part A skilled services with days remaining.Findings include:

9/16/25.

There was a handwritten note dated 9/11/25 on the CMS-10123 form that the wife had been called and notified that the skilled services would end on 9/16/25. R13 was not provided with the CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) that identified the estimated cost of services if R13 would choose to continue with the skilled services on his own. R24's CMS-10123 Notice of Medicare Non-Coverage (NOMNC) form identified R24's services ended on 8/22/25.

There was a handwritten note dated 8/20/25 on the CMS-10123 form that the resident had been notified that the skilled services would end on 8/22/25. R24 was not provided with the CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) that identified the estimated cost of services if R24 would choose to continue with the skilled services on his own. R40's CMS-10123 Notice of Medicare Non-Coverage (NOMNC) form identified R40's services ended on 12/15/25.

There was a handwritten note dated 12/10/25 on the CMS-10123 form that the wife had been called and notified that the skilled services would end on 12/15/25. R40 was not provided with the CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) that identified the estimated cost of services if R40 would choose to continue with the skilled services on his own.

Interview on 2/12/26 at 1:00 p.m., with the director of nursing (DON) identified she was responsible for providing the beneficiary notices when a resident discharged from skilled services.

She was unaware that she needed to provide the CMS-10055 form.

She confirmed she had not provided the CMS-10055 form with the estimated cost to continue if the resident would choose to do so.

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Good Samaritan Society - Windom 705 Sixth Street Windom, MN 56101

be indicated on the resident's care plan or the administration record; however, she was not sure if

with the correct information, but they are working on it.

She would expect staff to add the target

245558 02/12/2026

Good Samaritan Society - Windom 705 Sixth Street Windom, MN 56101

Review of 4/7/25, Abuse and Neglect policy identified allegations of mistreatment, neglect, exploitation or abuse would be reported immediately to the administrator, but not later than two hours after the allegation was made. If administrator was unavailable staff were to report to the director of nursing or the supervisor of social services.

The designated individuals had the authority to intervene in any situation to protect residents, including removing any individuals from the location to protect residents. If there was an allegation of abuse from an employee to a resident, the employee would be removed from providing direct care to all residents.

Additionally, the employee will be placed on suspension pending the results of the internal investigation.

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Good Samaritan Society - Windom 705 Sixth Street Windom, MN 56101

Review of the facility investigation identified it was completed by the DON on 11/19/25, with interviews with R7, R10, R26, and R39, who reported to the DON they felt safe at the facility, felt safe with the people who cared for them, and denied that anyone ever verbally or physically abused them.

Also, on 11/19/25, the DON spoke to NA-C via phone and her notes identified she explained she had received some complaints from residents about door slamming, privacy concerns, and not listening to residents.

The DON investigative notes identified quotes from NA-C of [I] don't have any problems with the employees.only here on PRN basis.not working with them every day so [I] don't know them real well. NA-C expressed it was hard when there were only two staff on the floor.

The DON noted she explained to NA-C to be aware of these items, and she would be circling back with the residents in a couple of weeks to see if things were better.

The DON's investigation documentation failed to identify:The DON addressed the allegation of rough handling of residents during cares with NA-C.Additional staff were interviewed.Other residents were interviewed who were not identified in the complaint.Late reporting occurred from LPN-A to management after becoming aware on 11/16/25, related to allegations of potential abuse.

Interview on 2/12/26 at 11:00 a.m., with trained medication aide (TMA)-A identified if a resident made a complaint that someone was rough with them, she would report that right away to the case manager. If the case manager was not there, she would report that to the director of nursing.

Interview on 2/12/26 at 4:22 p.m., with the administrator identified that on 11/19/25, the director of nursing (DON) had received a report under her office door from licensed practical nurse (LPN)-A, regarding concern related to NA-C being rough while providing cares. By the time she had learned the details of the letter that morning on 11/19/25, the DON had reported she had addressed the issues and found it to be nothing.

Interview on 2/12/26 at 4:43 p.m., with medication aid (TMA)-B identified they had received reports from R26 that NA-C was rough when providing cares (unknown date). TMA-B reports staff left a note at the nurse's desk but had not recalled who was working at the time. TMA-B received training on abuse reporting and stated We are supposed to report to our direct supervisor unless the complaint involves the direct supervisor. In that case they would report to the administrator.

Review of the 4/7/25, Abuse and Neglect policy identified the facilities investigation may include interviewing employees, residents or other witnesses to the event.

The facility was to interview all involved (employees, residents and family) individually.

The investigation should be documented.

The facility will have evidence that all alleged or suspected violations were thoroughly investigated and would prevent further potential abuse while the investigation was in progress.

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Good Samaritan Society - Windom 705 Sixth Street Windom, MN 56101

Review of 1/15/26, Discharge and Transfer policy identified when a discharge or transfer occurred that information would be documented in the resident's medical record.

The Office of the State Long-Term Care Ombudsman must be notified of a transfer or discharge with the location of the discharge or transfer.

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Good Samaritan Society - Windom 705 Sixth Street Windom, MN 56101

Review of 10/27/25, MDS 3.0 (Minimum Data Set) RAI (Resident Assessment Instrument) policy identified that the facilities PCC system automatically calculated the MDS schedules.

Centers for Medicare & Medicaid Services (CMS) mandates MDS transmission no later than completion date plus 14 calendar days, the facility completes weekly transmission of MDS data.

The policy referred to the RAI manual for guidance not reflected in the policy.

There was no identification of time requirements for completing the various MDS assessments.

The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2025, identified quarterly MDS assessment would be conducted every 92 days and submitted within 14 days of completion.

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Good Samaritan Society - Windom 705 Sixth Street Windom, MN 56101

Review of the facility provided 12/29/25 Pre-admission Screening and Resident Review (PASARR) policy identified All prospective residents will be screened for possible serious mental disorders or intellectual disabilities and related conditions.

The initial pre-screening is referred to as PASARR Level I. A positive Level 1 screen necessitates an in-depth evaluation of the individual, known as PASARR Level II, conducted by the state-designated authority prior to admission.

245558 02/12/2026

Good Samaritan Society - Windom 705 Sixth Street Windom, MN 56101

Review of the 4/8/24, hospice agreement identified coordinated plan of care meant the plan of care for a resident would clearly delineate what services to be provided by hospice and the facility, based on assessments, and the residents current medical, physical, psychological, and social needs.

The facility will immediately notify hospice with a significant change in the residents' physical, mental, emotional, or social status. If clinical complications appear or a need to transfer the hospice resident from the facility for any condition, or the resident dies.

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Good Samaritan Society - Windom 705 Sixth Street Windom, MN 56101

Observation and interview on 2/9/26 at 2:59 p.m., R1 had a difficult time hearing and identified he had hearing aids, but they were in the office. He said if he wants them, he must ask staff for them.

Observation and interview on 2/11/26 at 9:45, am identified R1 did not have his hearing aids placed. R1 identified he was having difficulty hearing and stated his ears needed to be cleaned. R1 identified staff had not offered him his hearing aids.

Observation and interview on 2/12/26 at 8:59 a.m., identified R1 did not have his hearing aids and had already eaten breakfast. He identified when he has asked for his hearing aids or when he has complained that his ears need cleaning, staff say they will come back but they do not return with his hearing aids or come back to clean his ears.

Observation and interview on 2/12/26 at 9:04 a.m., with the medication aid (TMA)-A stated, he refuses his hearing aids everyday.

She identified that when R1 refuses she marks the treatment administration record (TAR) to note refusal and write a progress note. TMA-A retrieved the hearing aids from her cart and went into R1's room.

She asked R1 if he would like his hearing aids in. He responded yes and told the TMA his ears needed to be cleaned.

The TMA inserted the hearing aids and left the room.

Review of the facility provided 12/1/25, Hearing Services, Hearing Device Care policy identified if a resident is unable to handle his/her hearing aids, the staff needs to develop a plan for the insertion of the hearing aid in the morning and the removal in the evening for safe keeping.

Staff should check ear canals periodically for was buildup and document findings.

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Good Samaritan Society - Windom 705 Sixth Street Windom, MN 56101

Review of the 7/30/25, Oxygen Administration, Safety, Mask Types policy identified its purpose was to store O2 in a safe manner.

All appropriate signage was to be displayed according to federal, state, and local laws. O2 was noted to be dangerous.

Staff were to avoid use of flammable materials (oils, greases, alcohol-based products). O2 cannisters were to be stored on a clean, controlled area.

There was no mention of O2 signage placement outside of rooms that contained oxygen within the policy.

Review of the current, National Fire Prevention Association (NFPA) 99, published 2012, section 11.3.4.1, identified for storage of oxygen, a precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.

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Good Samaritan Society - Windom 705 Sixth Street Windom, MN 56101

services of a licensed pharmacist.

medication awaiting destruction were easily reconciled in 1 of 3 med rooms (South) to prevent

in the South medication room identified a locked cupboard that contained medication awaiting destruction. Of those medications, the following controlled/narcotic blister-pack medication had been discontinued, but were not noted on any list to verify the medications were tracked and secured from potential diversion:R26 had 4 tablets of tramadol (pain), each 50 milligram (mg) awaiting destruction.

R17 had 12 tablets of tramadol, each 50 mg dose awaiting destruction.R24 had 5 tablets of lorazepam (anti-anxiety), each 0.5 mg awaiting destruction.R7 had 1 tablet of preglabin (anti-convulsant) at 150 mg.R17 had 30 tablets of lorazepam, each 0.5 mg awaiting destruction.R2 had 9 tablets of Xanax (anti-anxiety), 0.5 mg each and another blister pack of Xanax 0.5 mg with 10 tablets remaining awaiting destruction.LPN-A noted she normally had not worked on the South wing, but stated the facility kept all controlled medication awaiting destruction in the locked cabinet.

Nursing staff had access to the key.

The facility practice was to store medications awaiting destruction in that locked cabinet within the locked medication room.

Staff would wait for the director of nursing (DON) to destroy medications.

Staff would not keep track of the medications once in the cabinet in order to be able to easily reconcile those medications to prevent potential diversion from being easily recognized.

Interview on 2/10/26 at 5:44 p.m., with the DON identified she was aware the narcotics were stored in the cabinet awaiting destruction and verified the medications were no longer tracked for easy reconciliation of potential diversion. A policy for medication storage was requested but not received prior to the end of the survey.

245558 02/12/2026

Good Samaritan Society - Windom 705 Sixth Street Windom, MN 56101

Review of the 10/9/25, Psychotropic Medication policy identified a registered nurse must complete an AIMS assessment for each resident prescribed an antipsychotic medication.

The AIMS assessment was to be completed every 6 months.

Any changes in the AIMS assessment, the facility would notify the family/representative and physician with the notification documented in the resident's medical record.

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Good Samaritan Society - Windom 705 Sixth Street Windom, MN 56101

rate.Findings include: Observation on 2/10/26 at 11:54 p.m., with licensed practical nurse (LPN)-B

tablet of spironolactone (diuretic) 25 mg, inside of a medication cup to R47 who was reported to be in her room. LPN-B knocked on R47's room door. R47 was not inside her room, so LPN-B left the medication cup containing the medications on R47's dresser drawer just inside her room and shut the door. LPN-B stated R47 was able to self-administer her medications, so she would leave them there for her to take them later. LPN-B then returned to the medication cart and finished the medication pass identifying and marked the medication had been administered in the electronic medical record (PCC).

Interview on 2/10/26 at 5:44 p.m. with the director of nursing identified staff were not to leave medications unattended inside of a resident room or mark the medications administered.

Review of the 4/8/25, Medication Administration Including Scheduling and Medication Aides policy identified medications were to be administered according to the Six Rights of medication administration [right patient, right medication, right dose, right route, right time, and right documentation]. In the section of self-administration, the policy noted staff were to be aware of medications kept in the room.

There was no mention staff should ensure security of those medications in the policy.

Review of the October 2025 through January 2026 Absence/[NAME] forms identified in:October 2025, 25 of 26 staff call-ins were due to staff or family illness with illnesses varying with gastrointestinal illnesses (stomach flu, nausea, vomiting, diarrhea) , respiratory illnesses, etc.November 2025, 6 of 23 staff call-ins were due to staff illnesses such as diarrhea, not feeling well, personal sick or sick, heading to the emergency room (ER)December 2025, 22 of 28 staff call-ins were reported for staff illnesses of stomach flu, sick, fevers, diarrhea, and nausea and/or vomiting.January 2026, of 23 of 28 staff call-ins were related to staff or family illness of flu, sore throats, body aches, stomach aches, nausea, diarrhea, vomiting, flu, and one with a child with Respiratory Syncytial Virus (RSV) (highly contagious respiratory disease) and one with Strep throat (bacterial infection of the throat easily spread).None of the forms identified what date an employee was allowed to RTW, if any trained nursing staff had made that determination, or what criteria was used to determine the appropriateness of RTW. or what staff had identified they were appropriate to return to work.

Review of the IC Safety Meeting minutes, presented to Quality Assurance Performance Improvement (QAPI) committee identified there was a section for Employee Health each month. In:November 2025's meeting, there were no recorded illnesses of staff reported.

The action plan noted they would review staff illnesses at the next meeting.Decembers 2025's meeting, there was no recorded illnesses of staff reported.

The action plan remained that the committee would review staff illnesses at the next meeting.

Interview on 2/12/26 at approximately 1:30 p.m., with RNC-A identified she agreed staff were not appropriately screened for their appropriateness to return to work and the forms lacked critical information on what criteria were to be used.

There was no other employee surveillance data they were aware of from the previous IP who was terminated on 2/9/26.

Review of the November 2025, and December 2025 QAPI meeting minutes identified there was no information on employee surveillance brought forth to QAPI from the Infection Control Committee Meetings.

Review of the 11/18/25, Infection Prevention and Control Program policy identified the facility was to have a system of surveillance for employees to report signs, symptoms and diagnosed illnesses that may present a risk to residents, employees, and other individuals.

Education to employees was to occur as appropriate.

Review of the 9/30/25, Surveillance policy identified appropriate surveillance of residents was identified, however, there was no mention on the inclusion of employee illnesses, the collection of that data, or how the facility was to ensure employees returned to work appropriately after an illness using professional standards to mitigate potential spread of infection by employees.

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Good Samaritan Society - Windom 705 Sixth Street Windom, MN 56101

Review of the undated, Bath Cleaning After Every Bath posted instructions identified staff were to:Close and lock the tub door.Rinse the tub using the sprayer.Put the drain in the tub.Press and hold the disinfectant button on the left side of the tub.Release the button when staff saw cleaning solution coming out of all jets and there was 1.5 to 2 gallons of disinfectant solution in the tub.Use the scrub brush to thoroughly scrub all interior surfaces of the tub with the solution.Remove the drain plug.Rinse the interior surfaces thoroughly.Press and hold the rinse button until clear water ran from the jets.Finish rinsing the tub interior.Start the air blower for all jets and allow to run for 30-45 seconds to push all the water out.Unlock the tub door and leave it slightly open.There were no posted instructions that included the [NAME] disinfectant criteria for appropriate disinfection using a 10-minute wet-contact time in any of the 3 whirlpool tub rooms.

Interview on 2/10/26 at 12:56 p.m., with the DON identified she would expect staff to follow the disinfectant instructions on allowing a 10-minute wet-contact time for appropriate disinfection to occur.

Review of the current, Cascade [NAME] Operation and Daily Maintenance Instructions, located at https://www.pennerbathing.com/wp-content/uploads/2020/12/Alcove-Tub-operation-manual-360750A.pdf, identified the tub instructions were the same as above, however, it was noted for staff to clean and disinfect the tub after every bath with [NAME] Cleaner/Disinfectant. [NAME] Cleaner/Disinfectant was a special non-abrasive cleaning and disinfecting solution and was the only cleaning solution designed and recommended for use with the Cascade Tub.

Review of the current, [NAME] Bathing Spas Disinfection Quick Guide, located at https://express.adobe.com/page/dGLlnlGnBbk3E/, Step 4, identified for staff to allow the disinfectant to remain in contact for 10 minutes.

All other instructions were the same and followed Cascade instructions. NEBULIZER ADMINISTRATION Observation on 2/10/26 at 4:50 p.m., of licensed practical nurse (LPN)-A identified she proceeded to administer a nebulizer treatment to R43. LPN-A went to the countertop in R43's room, and retrieved his nebulizer that was intact and assembled on the counter. LPN-A then opened the nebulizer medication cup (residue was noted to be inside the cup), poured in R43's medication, connected to the nebulizing machine and administered his medication. LPN-A stated staff were to disassemble the medication cup and mouthpiece after each medication administration, clean and rinse them out and leave on the counter to air-dry. LPN-A stated she should have either rinsed and cleaned his medication cup and mouthpiece or gathered new nebulizer supplies before she administered R43 his medication.

She agreed not cleaning and rinsing the mouthpiece and cup had the potential to cause a respiratory infection for residents when they were not cleaned and rinsed after each use.

Interview on 2/10/26 at approximately 5:00 p.m., with the DON identified she expected staff to clean and rinse nebulizers after each administration.

Review of the 12/10/25 Nebulizer policy identified following medication administration, staff were to disconnect the nebulizer parts (mask/mouthpiece and cup) and wash them in warm soapy water and rinse thoroughly, set on a paper towel, and let air-dry.

245558 02/12/2026

Good Samaritan Society - Windom 705 Sixth Street Windom, MN 56101