Inspection Report Summary
The most recent inspection on January 30, 2025, identified deficiencies related to updating care plans, insulin administration, kitchen sanitation, and infection control practices. Earlier inspections showed a pattern of medication administration issues, care plan inaccuracies, food safety concerns, and resident safety incidents, including a substantiated complaint about a medication error involving insulin that led to hospitalization. Inspectors cited recurring themes of medication management, infection prevention, and food service sanitation. Complaint investigations were mostly unsubstantiated except for the insulin error case, which was addressed with corrective actions. The facility’s deficiencies appear consistent over time, with ongoing challenges in medication administration and infection control.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
97% worse than North Dakota average
North Dakota average: 3.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 4
Date: Jan 30, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to care plan development, medication administration, food safety, and infection prevention and control in the nursing facility.
Findings
The facility was found deficient in updating care plans for residents, improper insulin administration technique, inadequate sanitization of kitchen surfaces, and failure to follow infection control protocols including hand hygiene, use of personal protective equipment, and equipment sanitation. These deficiencies posed risks of inaccurate medication dosing, foodborne illness, and infection spread.
Deficiencies (4)
Failure to update care plans to reflect residents' current status for 2 of 13 sampled residents.
Failure to ensure staff followed standards of practice for insulin preparation and administration for 1 of 2 residents observed.
Failure to sanitize kitchen surfaces with quaternary sanitizing solution at proper concentration.
Failure to follow infection control standards including enhanced barrier precautions, droplet precautions, and hand hygiene for 5 of 13 sampled residents and 1 supplemental resident.
Report Facts
Residents sampled: 13
Residents affected: 2
Residents affected: 1
Residents affected: 5
Supplemental residents affected: 1
Quat sanitizing solution concentration: 50
Quat sanitizing solution concentration: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse (#1) | Confirmed failure to revise care plans and stated expectations for insulin administration and infection control practices | |
| Staff nurse (#9) | Observed improperly priming insulin pen and administering insulin | |
| Dietary staff (#10) | Tested quat sanitizing solution with expired test strips | |
| Administrative staff (#2) | Tested quat sanitizing solution and stated expectations for proper testing and concentration | |
| Certified nurse aide (CNA) (#6) | Observed failing to follow enhanced barrier precautions and hand hygiene during resident cares | |
| Staff nurse (#4) | Observed failing to disinfect stethoscope after resident assessment | |
| Certified nurse aide (CNA) (#7) | Observed failing to wear gown during transfer of resident on enhanced barrier precautions | |
| Medication Aide (MA) (#8) | Observed failing to perform hand hygiene after administering eye drops | |
| Certified nurse aide (CNA) (#5) | Observed failing to remove mask after exiting droplet precautions room |
Inspection Report
Routine
Deficiencies: 4
Date: Jan 30, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to care plan development, medication administration, food safety, and infection prevention and control in a nursing facility.
Findings
The facility failed to update care plans for residents to reflect current medication orders, improperly administered insulin, inadequately sanitized kitchen surfaces, and did not consistently follow infection control protocols including hand hygiene, use of personal protective equipment, and equipment sanitation, posing risks of harm or infection spread.
Deficiencies (4)
Failed to review and revise care plans to reflect residents' current status for 2 of 13 sampled residents.
Failed to ensure staff followed standards of practice for insulin preparation and administration for 1 of 2 residents observed.
Failed to sanitize surfaces in 1 of 1 facility kitchen; quat sanitizing solution concentration below manufacturer's guidelines.
Failed to follow standards of infection control and prevention for 5 of 13 sampled residents and one supplemental resident, including improper hand hygiene, PPE use, and equipment sanitation.
Report Facts
Residents sampled: 13
Residents affected: 2
Residents affected: 1
Residents affected: 5
Supplemental residents affected: 1
Quat sanitizing solution concentration: 50
Quat sanitizing solution concentration: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse (#1) | Confirmed failure to revise care plans and stated expectations for insulin administration and infection control practices | |
| Staff nurse (#9) | Observed improperly priming and administering insulin | |
| Dietary staff (#10) | Tested quat sanitizing solution with expired test strips | |
| Administrative staff (#2) | Tested quat sanitizing solution and stated expectations for proper testing | |
| Certified nurse aide (CNA) (#6) | Observed failing to follow enhanced barrier precautions and hand hygiene | |
| Staff nurse (#4) | Observed failing to disinfect stethoscope after use | |
| Certified nurse aide (CNA) (#7) | Observed failing to wear gown during transfer of resident in enhanced barrier precautions | |
| Medication Aide (MA) (#8) | Observed failing to perform hand hygiene after administering eye drops | |
| Certified nurse aide (CNA) (#5) | Observed failing to remove mask after exiting droplet precautions room |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 30, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a significant medication error involving insulin administration to Resident #1.
Complaint Details
The complaint investigation found that Resident #1 received the wrong insulin type on 07/30/24, leading to elevated blood sugar levels and hospitalization. The noncompliance was substantiated and considered past noncompliance based on corrective actions taken.
Findings
The facility failed to ensure residents were free from significant medication errors, specifically administering the wrong type of insulin to Resident #1, which may have contributed to hyperglycemia and hospitalization. The facility implemented corrective actions including staff education, audits, and suspension of the involved nurse.
Deficiencies (1)
Failure to administer insulin according to physician's order, resulting in Resident #1 receiving multiple doses of Lantus instead of Humalog insulin.
Report Facts
Blood sugar level: 379
Blood sugar level: 456
Blood sugar level: 566
Insulin dosage: 22
Insulin dosage: 8
Insulin dosage: 10
Date range: 16
Inspection Report
Deficiencies: 1
Date: May 9, 2024
Visit Reason
The inspection was conducted due to an incident involving a resident who was injured by a hot beverage spill. The visit aimed to investigate the circumstances of the injury and assess the facility's compliance with safety regulations regarding accident hazards and supervision.
Findings
The facility failed to ensure an environment free of hazards for one resident who was injured by a hot beverage spill due to a staff member not securing the lid on the cup. The injury resulted in a burn with blistering on the resident's chest. The facility implemented corrective actions including staff education and supervision improvements.
Deficiencies (1)
Failure to ensure an environment free of hazards resulting in a resident injury from a hot beverage spill due to unsecured lid.
Report Facts
Residents Affected: 1
Burn size: 2
Burn size: 3
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Jan 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including accurate resident assessments, medication management, safety, and food service standards at Good Samaritan Society Augusta Place A Prospera CO.
Findings
The facility was found deficient in multiple areas including inaccurate coding of Minimum Data Set (MDS) assessments for residents, failure to complete required PASARR status change assessments, inadequate supervision during mechanical lift transfers, failure to monitor antipsychotic medication effects, improper medication labeling, serving food at unsafe temperatures, and unsanitary food service practices.
Deficiencies (7)
Failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 12 sampled residents and one supplemental resident, affecting comprehensive care planning.
Failed to complete a status change assessment for 1 of 2 sampled residents reviewed for PASARR after a new diagnosis of paranoia.
Failed to provide adequate supervision and assistive devices during a sit-to-stand mechanical lift transfer for 1 of 4 sampled residents, placing the resident at risk for accidents and injury.
Failed to ensure the resident's medication regimen remained free from unnecessary drugs by not completing required Abnormal Involuntary Movement Scale (AIMS) assessments for antipsychotic medication monitoring.
Failed to ensure appropriate labeling of medications for 1 of 6 residents, with discontinued PRN orders still labeled on medication cards.
Failed to serve hot foods at palatable and safe temperatures on 3 of 3 units, with multiple days of food temperatures recorded below 135 degrees Fahrenheit.
Failed to maintain sanitary food service in 1 of 3 kitchenettes by placing uncovered food trays on the floor and improper handling of dirty trays.
Report Facts
Days with food temperatures below 135 degrees: 20
Days with food temperatures below 135 degrees: 2
Days with food temperatures below 135 degrees: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff member (#2) | Confirmed failures to code MDS accurately for Residents #44, #29, and #12 | |
| Administrative nurse (#1) | Confirmed failure to complete AIMS assessment for Resident #44 and expected safe transfers by CNAs | |
| Certified Nurse Aides (#8 and #11) | Observed improperly applying sit-to-stand mechanical lift harness during Resident #9 transfer | |
| Nurse (#5) | Observed administering medications with incorrect labeling for Resident #45 | |
| Dietary staff member (#7) | Failed to maintain proper food temperature and reheated French toast inadequately | |
| Dietary manager (#3) | Reported expectations for food temperature monitoring and confirmed food safety violations | |
| Certified Nurse Aide (#9) | Observed placing uncovered food trays on floor and improper handling of dirty trays |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 28, 2023
Visit Reason
The inspection was conducted as an annual survey of the Good Samaritan Society Augusta Place A Prospera CO nursing home facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 6
Date: Jan 19, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident safety, medication administration, accurate resident assessments, accident prevention, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe and clean environment (unclean personal fan), inaccurate resident assessments (incorrect MDS coding), improper medication administration (delayed insulin administration and unlabeled insulin pens), inadequate resident repositioning techniques, and failure to provide required air gap for an ice machine.
Deficiencies (6)
Failure to ensure a safe, clean, comfortable, homelike environment for Resident #46 due to unclean personal fan.
Failure to ensure accurate coding of the Minimum Data Set (MDS) for Residents #26, #28, and #7.
Failure to follow standards of practice for administration of short acting insulin for Resident #23, resulting in delayed meal after insulin injection.
Failure to provide adequate assistance and correct technique in repositioning Resident #42.
Failure to label multi-dose insulin pens with the date opened for Resident #23.
Failure to provide an air gap for 1 of 4 ice machines in the main kitchen.
Report Facts
Residents sampled: 14
Units of insulin administered: 5
Minutes delay: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #6 | Nurse | Administered insulin to Resident #23 and confirmed insulin pen lacked open date |
| Administrative staff #1 | Provided expectations on cleaning equipment, confirmed ice machine lacked air gap, and repositioning technique expectations | |
| Administrative nurse #2 | Administrative Nurse | Confirmed incorrect MDS coding for Resident #28 and Resident #26 |
| Administrative staff #5 | Confirmed rapid-acting insulin administration timing and failure to date insulin pens |
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