Good Samaritan Society - Larimore

F-F809.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 23 355097 Department of Health & Human Services Printed: 09/08/2025 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 355097 B. Wing 02/13/2025

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

Good Samaritan Society - Larimore 501 E Front St Larimore, ND 58251

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 0732 Post nurse staffing information every day.

Level of Harm - Potential for 28398 minimal harm Based on observation, record review, and staff interview, the facility failed to ensure posting of accurate Residents Affected - Many staffing information on 4 of 4 days of survey (February 10-13, 2025). Failure to post accurate staffing data does not allow residents and visitors to be aware of the number of licensed and unlicensed staff on duty each shift.

Findings include:

Observation on all days of survey showed the Daily Staffing form posted in the hall by the residents' dining room. Review of the staffing forms showed the facility failed to post accurate information regarding the number of unlicensed staff working each shift from February 10-13, 2025.

During an interview on the morning of 02/13/25, an administrative nurse (#1) and staffing scheduler (#6) agreed the daily staffing forms were incorrect.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 23 355097 Department of Health & Human Services Printed: 09/08/2025 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 355097 B. Wing 02/13/2025

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

Good Samaritan Society - Larimore 501 E Front St Larimore, ND 58251

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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 45873 potential for actual harm Based on observation, record review, review of facility policy, review of professional reference, and staff Residents Affected - Few interview the facility failed to ensure a medication error rate of less than five percent for 3 of 5 residents (Resident #2, #4, and #5) observed during medication administration. Four medication errors occurred during staff administration of 26 medications, resulting in a fifteen percent error rate. Failure to properly prepare and administer medications may result in residents receiving an ineffective dose and experiencing adverse reactions.

Findings include:

Review of the facility policy titled Medication: Insulin Administration, Insulin Pens, Insulin Pumps occurred on 02/13/25. This policy, dated 09/05/24, stated, . Insulin Pen . Turn the dosage knob to '2' units to prime the pen. Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears.

Review of the facility policy titled Medications: Crushing occurred on 02/13/25. This policy, dated 01/31/24, stated, . Some medications, such as sustained release medications among others, are not to be crushed or chewed.

Skidmore-Roth's Mosby's 2023 Nursing Drug Reference, 36th Edition eText, 2023, Elsevier - Evolve, page 704, stated, . Isosorbide Mononitrate - Do not break, crush, or chew .

Information found at https://www.drugs.com/mtm/slow-mag.html, page 3, stated, How should I take Slow-Mag? . Swallow the tablet whole and do not crush, chew, or break it .

- Review of Resident #2's medical record occurred on all days of survey. Physician's orders identified Slow-Mag (a delayed release combination calcium/magnesium supplement) and Isosorbide Mononitrate ER (extended release) (medication used to control chest pain).

Observation on 02/12/25 at 8:28 a.m. showed a medication aide (MA) (#4) dispensed a Slow-Mag tablet and

an Isosorbide Mononitrate ER tablet from Resident #2's medication card, placed the tablets into a cup along with other scheduled medications, poured the medications from the cup into a plastic sleeve, and crushed

the medications. The MA then poured the crushed contents into pudding and administered the medications to Resident #2. The MA (#4) failed to follow manufacturer's instructions and crushed the Isosorbide Mononitrate ER and Slow-Mag.

- Observations on 02/12/25 showed the following:

* At 11:55 a.m., a nurse (#3) prepared a Humalog insulin pen for Resident #4. The nurse applied a needle, dialed the pen to two units, and with the needle pointed down, dispensed the insulin into a sink.

* At 12:17 p.m., a nurse (#3) prepared an Insulin Lispro pen for Resident #5. The nurse applied a needle, dialed the pen to two units, and with the needle pointed down, dispensed the insulin into a sink.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 23 355097 Department of Health & Human Services Printed: 09/08/2025 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 355097 B. Wing 02/13/2025

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

Good Samaritan Society - Larimore 501 E Front St Larimore, ND 58251

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 0759 The nurse (#3) failed to prime the insulin pens with the needle pointed up.

Level of Harm - Minimal harm or During an interview on 02/13/25 at 11:50 a.m., an administrative staff member (#1) stated she expected staff potential for actual harm to prime insulin pens vertically and not crush delayed or extended-release medications.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 23 355097 Department of Health & Human Services Printed: 09/08/2025 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 355097 B. Wing 02/13/2025

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

Good Samaritan Society - Larimore 501 E Front St Larimore, ND 58251

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 0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Level of Harm - Minimal harm or potential for actual harm 46477

Residents Affected - Many Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#9) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services has the potential to result in foodborne illness to residents, staff, and visitors.

Findings include:

During an interview on 02/10/25 at 1:52 p.m., the dietary manager (#9) stated he is currently enrolled in a certified dietary manager course but has not completed it.

The facility failed to ensure the dietary manager (#9) completed the required education for a certified dietary manager, certified food service manager, or a national certification for food service management and safety from a national certifying body.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 23 355097 Department of Health & Human Services Printed: 09/08/2025 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 355097 B. Wing 02/13/2025

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

Good Samaritan Society - Larimore 501 E Front St Larimore, ND 58251

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 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to Level of Harm - Minimal harm or eat at non-traditional times or outside of scheduled meal times. potential for actual harm 46477 Residents Affected - Some Based on observation, review of resident council minutes, and resident and staff interviews, the facility failed to provide snacks to residents within the facility. Failure to provide snacks may result in hunger, weight loss, and hypoglycemia (low blood sugar) for diabetic residents.

Findings include:

Upon request on the afternoon of 02/11/25, the facility failed to provide a policy on snacks.

Review of the resident council meeting minutes, dated November 2024-February 2025, identified the following resident concerns:

*11/27/24, Evening snack pass is happening more often but still not consistently.

*12/18/24, Evening snack pass is inconsistent; residents still need to ask for evening snack.

*01/14/25, The snack cart remains problematic. One resident often wanders and touches the food on the cart. [Resident #15] reported inconsistency in passing snacks to residents in their rooms.

During an interview on 02/10/25 at 2:44 p.m., Resident #15 stated the snacks are delivered to the nurse's station and that's where they stay, they are not delivered to residents in their rooms. Resident #15 stated this happens way too often and I'm a diabetic and I sometimes need that snack.

Observations on 02/11/25 showed the following:

*3:04 p.m., Snacks delivered on a cart to the nursing station.

*3:11 p.m., Resident #12 removed the plastic wrap from the plate of snack bars and touched then while several staff members stood or walked nearby.

*3:15 p.m., An unidentified resident sat in the lounge and asked a certified nurse aide (CNA) (#11) for a snack. The CNA (#11) pulled the snack cart into the lounge and obtained a snack bar for the resident. Before

the CNA could give the resident the snack bar, this surveyor informed the CNA another resident had touched

the bars.

During an interview on the afternoon of 02/11/25, a dietary manager (#9) stated, The kitchen provides the snacks, and we usually put them by the nurse's station. But we are not responsible for delivering them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 23 355097 Department of Health & Human Services Printed: 09/08/2025 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 355097 B. Wing 02/13/2025

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

Good Samaritan Society - Larimore 501 E Front St Larimore, ND 58251

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 46477

Residents Affected - Some Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure food is stored in accordance with professional standards for food service sanitation in 1 of 1 kitchen. Failure to ensure food is stored, prepared, and served in a sanitary environment may result in contamination for residents, visitors, and staff.

Findings include:

Review of the facility policy titled Food-Supply Storage -Food and Nutrition Services occurred on 02/12/25.

This policy, revised on 05/07/24, stated, . Storeroom layout: 1. All food/supply items are stored six inches off

the floor. 20. Employee . food/fluids are not stored in the preparation kitchen cooler/freezer or dry storage.

Review of the facility policy titled Employee Hygiene and Dress Code occurred on 02/12/25. This policy, revised 06/12/24, stated, . Hairnets or hair restraints . are used: a. When cooking, preparing, assembling food or ingredients. This includes dish rooms and storage areas. Hair is to be covered completely .

The 2022 Food and Drug Administration (FDA) Food Code, Chapter 3-16, stated, . 3-305.11 Food Storage. FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination . Annex 3 Page 100, stated, . 3-305.12 Food Storage, Prohibited Areas. Pathogens can contaminate and/or grow in food that is not stored properly. Drips of condensate . can be sources of microbial contamination for stored food.

Observations of the kitchen showed the following:

* On 02/10/25 at 1:32 p.m., The walk-in freezer contained condensation and ice-build-up on the ceiling and floor and boxes of food sat directly on the iced floor. The walk-in refrigerator contained a closed medication box and an unopened bottle of cola. The dietary manager (#9) stated, the medication and cola belong to a dietary staff member and, should not be in here we have an employee refrigerator.

* On 02/13/25 at 10:03 a.m. Observation of the walk-in refrigerator at this time showed six large bundles of flowers.

During an interview on 02/13/25 at 10:49 a.m., two administrative staff members (#1 and #2) confirmed kitchen coolers are to remain free from personal items, medications, and flowers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 23 355097 Department of Health & Human Services Printed: 09/08/2025 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 355097 B. Wing 02/13/2025

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

Good Samaritan Society - Larimore 501 E Front St Larimore, ND 58251

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 0865 Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or 28398 potential for actual harm Based on review of the State Agency (SA) facility files, survey findings, and staff interview, the facility failed Residents Affected - Many to develop a Quality Assurance and Performance Improvement (QAPI) process to evaluate and identify problems and opportunities to improve services/outcomes, decrease or prevent likelihood of problems or occurrence of adverse events, and ensure compliance with federal requirements.

Findings include:

Review of the state agency files indicated the facility failed to maintain compliance at

F-F812 Food Procurement, Store/Prepare/Serve-Sanitary

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 23 355097 Department of Health & Human Services Printed: 09/08/2025 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 355097 B. Wing 02/13/2025

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

Good Samaritan Society - Larimore 501 E Front St Larimore, ND 58251

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 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in

the nursing home. Level of Harm - Minimal harm or potential for actual harm 31725

Residents Affected - Many Based on review of employee files, review of facility policy, and staff interview, the facility failed to employ an individual who has completed specialized training in infection prevention and control, to be responsible for

the facility's Infection Prevention and Control program. Failure to employ an Infection Control Preventionist (ICP) may affect all residents, staff, and visitors, placing them at risk for acquiring infectious diseases.

Findings include:

Review of the facility policy titled Infection Preventionist and Control Program occurred on 02/13/25. This policy, dated 12/02/24, stated, . The SNF [Skilled Nursing Facility] Infection Preventionist must . Have completed specialized training in infection prevention and control .

During an interview on 02/10/25 at 4:14 p.m., an administrative nurse (#1) confirmed the facility failed to have a staff member with specialized training in infection prevention and control.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 23 355097