Deficiencies (last 3 years)
Deficiencies (over 3 years)
15.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
292% worse than North Dakota average
North Dakota average: 3.9 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Jun 3, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and ensure the facility provides appropriate care and services to residents.
Findings
The facility was found to have multiple deficiencies including inaccurate coding of Minimum Data Set (MDS) assessments, failure to provide scheduled bathing and wound care, delayed procurement of a CPAP device, failure to post nurse staffing information timely, and inadequate infection prevention and control practices.
Deficiencies (7)
Failure to ensure accurate coding of the Minimum Data Set (MDS) for 5 of 13 sampled residents, affecting assessment accuracy and care planning.
Failure to provide scheduled bathing for 3 residents, resulting in poor personal hygiene and decreased self-esteem.
Failure to provide appropriate pressure ulcer care and wound dressing changes as ordered for 1 resident, resulting in delayed healing and risk of infection.
Failure to provide necessary toileting assistance for 1 resident, resulting in urinary incontinence and risk of skin breakdown.
Failure to obtain and follow up on a CPAP device order for over 3 months for 1 resident with severe obstructive sleep apnea.
Failure to post nurse staffing information timely on 2 of 3 days of survey.
Failure to follow infection prevention and control standards including improper use of PPE, hand hygiene, and cleaning of equipment for 4 of 5 sampled residents.
Report Facts
Residents sampled: 13
Days bathing not provided: 15
Days bathing not provided: 15
Days bathing not provided: 13
Days dressing changes missed: 3
Days staff failed to post nurse staffing info: 2
Months delay in CPAP order follow-up: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse (#3) | Confirmed staff failed to code MDS assessments correctly | |
| Administrative nurse (#4) | Confirmed staff failed to code MDS assessments correctly | |
| Certified nurse aide (#2) | Reported working short staffed and not providing baths | |
| Administrative staff member (#1) | Confirmed lack of bathing documentation and failure to post staffing info | |
| Nurse (#10) | Confirmed wound dressing change dates and refusals | |
| Certified nurse aides (#8 and #9) | Observed failing to wear PPE during wound and perineal care | |
| Certified nurse aides (#2 and #5) | Observed failing to wear gowns and perform hand hygiene properly during care | |
| Certified nurse aides (#7 and #8) | Observed failing to sanitize mechanical lift after use | |
| Administrative staff member (#6) | Confirmed delay in ordering CPAP device |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 8, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations related to pressure ulcer care, catheter care, and prevention of urinary tract infections in the nursing home.
Findings
The facility failed to provide appropriate pressure ulcer care and prevention, including failure to complete weekly wound assessments and measurements for residents with pressure ulcers. Additionally, the facility failed to follow physician orders for pressure relief interventions and did not obtain a physician order for an indwelling urinary catheter for one resident.
Deficiencies (2)
Failure to provide necessary treatment/services to promote healing or prevent development of pressure ulcers for 2 of 3 sampled residents, including failure to apply pressure relieving devices and complete weekly assessments with measurements.
Failure to ensure appropriate care and services for 1 resident with an indwelling urinary catheter, including failure to obtain a physician order for the catheter and catheter change frequency.
Report Facts
Wound measurements: 7
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff member #1 | Verified facility failed to ensure interventions were followed and medical record lacked weekly wound measurements and catheter order |
Inspection Report
Routine
Deficiencies: 13
Date: Jun 19, 2024
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements for nursing home care and facility operations.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of changes in resident conditions, failure to provide timely transfer notices to the ombudsman, inaccurate resident assessments, inadequate care and monitoring of residents with respiratory distress and positioning needs, improper wound care, failure to follow tube feeding orders, respiratory care deficiencies, medication management errors including tampering and administration errors, food safety and sanitation violations, infection control breaches, and plumbing code violations related to food-preparation sink air gap.
Deficiencies (13)
Failed to notify the resident's physician of a change in condition for 1 resident with missed blood tests.
Failed to provide the State Long Term Care Ombudsman a notice of transfer for 1 resident.
Failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 residents.
Failed to provide care and services to maintain the highest level of well-being for 1 resident with respiratory distress, resulting in hospital transfer.
Failed to provide proper positioning device and follow physician orders for devices to control edema for 2 residents.
Failed to provide appropriate pressure ulcer care for 1 resident with a stage IV pressure ulcer.
Failed to ensure appropriate gastrostomy tube care and discontinue tube feeding as recommended for 2 residents.
Failed to provide safe and appropriate respiratory care including oxygen flow and tubing changes for 3 residents.
Failed to recognize tampered controlled medication packaging for 1 resident.
Medication error rate exceeded 5 percent with 2 errors during administration for 2 residents.
Failed to prepare, store, and serve food in a sanitary manner including unlabeled food, expired test strips, and improper storage in kitchen and nutrition center.
Failed to follow infection control standards by not using proper PPE for residents on enhanced barrier precautions.
Failed to provide an air gap for the main kitchen food-preparation sink as required by plumbing code.
Report Facts
Medication error rate: 8
Tube feeding frequency: 4
Oxygen flow rates: 1
Oxygen flow rates: 3
Oxygen flow rates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse (#2) | Confirmed multiple deficiencies including failure to notify physicians, medication errors, respiratory care issues, and infection control breaches. | |
| Medication aide (#4) | Observed administering medication incorrectly and identified tampered medication packaging. | |
| Nutrition services director (#11) | Confirmed food safety and sanitation deficiencies. | |
| Administrative nurse (#9) | Observed failing to wear PPE during tube feeding. |
Inspection Report
Routine
Deficiencies: 13
Date: Jun 19, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements for the nursing home facility.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of changes in resident conditions, failure to provide timely transfer notices to the ombudsman, inaccurate resident assessments, inadequate care and monitoring of residents with respiratory distress, failure to follow physician orders for positioning and edema management, improper wound care, failure to discontinue tube feedings as recommended, improper respiratory care and oxygen tubing maintenance, medication management errors including tampering and administration errors, food safety and sanitation violations, failure to follow infection control precautions, and plumbing code violations related to food-preparation sink air gap.
Deficiencies (13)
Failed to notify the resident's physician of a change in condition for missed blood tests.
Failed to provide timely notification to the State Long Term Care Ombudsman of resident transfer.
Failed to ensure accurate coding of the Minimum Data Set (MDS) for residents.
Failed to provide care and services to maintain resident's highest level of well-being resulting in delay in treatment and hospital admission.
Failed to apply positioning device and follow physician orders for edema management.
Failed to provide appropriate pressure ulcer care as ordered.
Failed to ensure appropriate gastrostomy tube care and discontinue tube feeding as recommended.
Failed to provide safe and appropriate respiratory care including oxygen tubing changes and adherence to oxygen flow orders.
Failed to recognize tampered controlled medication packaging.
Medication errors occurred during administration resulting in an 8% error rate.
Failed to prepare, store, and serve food in a sanitary manner including unlabeled food, expired test strips, and improper storage.
Failed to follow infection control standards by not using proper PPE for residents on enhanced barrier precautions.
Failed to provide required air gap for food-preparation sink per plumbing code.
Report Facts
Medication error rate: 8
Tube feeding frequency: 4
Oxygen flow rates: 1
Oxygen flow rates: 2
Oxygen flow rates: 3
Weight gain: 8
Weight gain: 144
Medication doses: 5
Date of survey completion: Jun 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #2 | Administrative Nurse | Confirmed failures in physician notification, respiratory care, medication administration, and infection control |
| Nurse #4 | Medication Aide | Observed administering medication incorrectly and medication tampering |
| Nurse #3 | Medication Aide | Observed medication administration without proper assessments |
| Nurse #7 | Certified Nurse Aide | Observed assisting resident without positioning device |
| Nurse #9 | Nurse | Observed failing to wear PPE during tube feeding |
| Nurse #10 | Nurse | Observed wound care not following physician orders |
| Nutrition Services Director #11 | Nutrition Services Director | Confirmed food safety and sanitation deficiencies |
| Environmental Services Director #12 | Environmental Services Director | Confirmed lack of air gap in kitchen sink plumbing |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 11, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure resident safety related to smoking, specifically concerning Resident #1 who sustained an injury while smoking outdoors.
Complaint Details
Based on observation, record review, facility policy review, staff interviews, and information from a complainant, the facility failed to ensure resident safety for Resident #1 who sustained injury from fire while smoking and later died. The complaint was substantiated with findings of inadequate monitoring and failure to ensure alarms alerted staff when the resident left the building.
Findings
The facility failed to adequately monitor Resident #1 while smoking in the designated smoking area, resulting in a fire injury that led to the resident's death. Surveillance monitors were not consistently observed, and no alarm sounded when the resident left the building, indicating inadequate supervision and safety measures.
Deficiencies (1)
Failure to ensure resident safety for 1 of 1 resident related to smoking safety, resulting in actual harm.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Multiple staff members (#1 through #6) interviewed regarding surveillance monitoring and response to the incident; no full names provided. |
Inspection Report
Routine
Deficiencies: 5
Date: May 25, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, medication management, physical restraints, fluid restrictions, and medication labeling at Good Samaritan Society - Lakota nursing home.
Findings
The facility was found deficient in accurately coding Minimum Data Set (MDS) assessments, updating comprehensive care plans to reflect residents' current status, ensuring appropriate fluid restriction management, labeling multi-dose insulin vials, and correctly identifying physical restraints. These deficiencies posed risks to resident care and safety.
Deficiencies (5)
Failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 12 sampled residents, affecting assessment accuracy and care planning.
Failed to review and revise comprehensive care plans to reflect current resident status for 4 of 12 sampled residents, limiting staff communication and continuity of care.
Failed to provide appropriate treatment and care for a resident on fluid restriction, resulting in risk of adverse effects from fluid overload.
Failed to accurately label 3 of 8 opened multi-dose insulin vials with the opened date, increasing risk of administering outdated medications.
Incorrectly coded physical restraint use for residents, failing to identify assist/grab bars as restraints when applicable.
Report Facts
Residents sampled: 12
Residents affected by MDS coding deficiency: 3
Residents affected by care plan deficiency: 4
Fluid restriction amount: 1500
Fluid intake days exceeding restriction: 11
Multi-dose insulin vials unlabeled: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse (#1) | Confirmed incorrect coding of restraints and MDS, and care plan deficiencies | |
| Staff Nurse (#2) | Observed unlabeled insulin vials and confirmed labeling policy | |
| Dietary Manager (#6) | Provided information on fluid restriction compliance and fluid distribution | |
| Certified Nurse Aide (#7) | Reported on fluid passing practices and documentation |
Inspection Report
Routine
Deficiencies: 5
Date: May 25, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, medication management, physical restraints, fluid restrictions, pressure ulcer care, and medication labeling at Good Samaritan Society - Lakota nursing home.
Findings
The facility failed to ensure accurate coding of resident assessments, timely revision of care plans, appropriate fluid restriction management, proper pressure ulcer care, and correct labeling of multi-dose insulin vials. These deficiencies posed risks to resident care and safety but were generally classified as minimal harm or potential for actual harm.
Deficiencies (5)
Failure to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 12 sampled residents (Residents #28, #32, and #34).
Failure to review and revise comprehensive care plans to reflect current status for 4 of 12 sampled residents (Residents #4, #26, #29, and #32).
Failure to provide appropriate care and monitoring for fluid restrictions for Resident #25, resulting in risk of fluid overload.
Failure to provide necessary treatment and prevent worsening of pressure ulcers for Resident #34, including delayed physician notification and treatment orders.
Failure to label 3 of 8 opened multi-dose insulin vials with the opened date, increasing risk of administering outdated medications.
Report Facts
Residents sampled: 12
Residents with inaccurate MDS coding: 3
Residents with care plan deficiencies: 4
Fluid restriction daily limit: 1500
Days fluid intake exceeded restriction: 11
Days fluid intake not documented: 25
Open insulin vials unlabeled: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse (#1) | Confirmed inaccurate MDS coding, care plan deficiencies, fluid restriction issues, and pressure ulcer treatment delays | |
| Staff Nurse (#2) | Observed unlabeled insulin vials and confirmed labeling policy | |
| Certified Nurse Aide (#5) | Notified nurse about pressure ulcer wound | |
| Staff Nurse (#4) | Assessed and treated pressure ulcer wound | |
| Dietary Manager (#6) | Provided information on fluid restriction compliance and fluid distribution | |
| Certified Nurse Aide (#7) | Reported fluid passing practices and documentation issues |
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