Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - Blackduck during CMS and state inspections, most recent first.
A resident with multiple medical conditions and at moderate risk for pressure sores had inconsistent wound documentation, including varying descriptions and stages of pressure ulcers. An RN coded the MDS based on incomplete and conflicting nursing data, resulting in inaccurate staging of the resident's pressure ulcers.
A resident admitted with a pressure ulcer and at moderate risk for further skin breakdown did not have a baseline care plan developed to address pressure ulcer management. Multiple wounds were documented, but the care plan lacked specific interventions and instructions for pressure-relieving devices and wound care. The DON confirmed that required steps to link assessments to the care plan were not completed, resulting in incomplete care planning.
Two residents at risk for pressure ulcers did not receive ongoing and accurate wound assessments, with incomplete documentation and inconsistent implementation of interventions. One resident with multiple wounds and incontinence was frequently found uncleaned, while another high-risk resident had gaps in wound assessments and lacked regular skin checks. Facility policy requiring weekly evaluations and clear staff direction was not followed.
The facility failed to maintain sanitary conditions in the kitchen's dry storage, affecting all 29 residents. During a tour, a dented can and improperly managed plastic bins with opened bags of food were found. The food service manager acknowledged the lack of proper dating and closure of bags and noted the absence of formal direction for maintaining the dry storage area.
The facility failed to conduct ongoing quality assessment and assurance activities, impacting all 29 residents. It did not track infectious symptoms or implement timely precautions for COVID-19 and human metapneumovirus. The infection preventionist did not maintain the infection control program, and the administrator acknowledged a lack of training for the responsible RN. The QAPI plan lacked a continuous infection prevention program.
The facility failed to track and manage infectious symptoms, leading to inadequate implementation of transmission-based precautions and testing for respiratory illnesses. Several residents with symptoms of COVID-19 and HMPV were not properly isolated or tested, and staff interviews revealed confusion and inconsistency in following infection prevention protocols.
The facility failed to ensure a qualified infection preventionist was in place, affecting all residents, staff, and visitors. The Director of Nursing was on extended leave, and responsibilities were delegated to an RN without adequate training. This led to failures in tracking infectious symptoms and implementing precautions for residents with COVID-19 and HMPV. The administrator assumed tasks were completed based on dashboard presentations, but there was no plan to ensure proper training and support.
A facility failed to notify the Office of Ombudsman for LTC about a resident's hospital transfers. The resident, who had no cognitive impairment, was transferred to the hospital twice and returned without the required notification. The business office coordinator was unaware of the notification requirement, and the director of nursing confirmed the oversight. The facility's policy mandated such notifications.
A resident was hospitalized, and the facility failed to provide a written bed hold policy notice to the resident or their representative. The resident's family was informed of the hospitalization, but there was no documentation of the bed hold policy being communicated. Staff interviews confirmed the lack of verification and documentation, despite the facility's policy requiring such notice at the time of transfer.
Inaccurate MDS Coding for Pressure Ulcer Staging
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) was accurately coded to reflect the correct staging of pressure ulcers for a resident. The resident, who was admitted with diagnoses including dehydration, Parkinson's disease, anxiety, and weakness, was assessed as being at moderate risk for pressure sores according to the Braden Scale. Multiple wound assessments documented varying descriptions and stages of pressure ulcers, including an unstageable ulcer on the left buttock, a wound on the left iliac crest with tunneling and purulent drainage, and a stage I ulcer on the left buttock. There were inconsistencies in the wound documentation, such as incomplete wound characteristics and discrepancies in wound staging and descriptions across different assessments. During an interview, an RN responsible for coding the MDS stated that she relied on the nursing data collection, which indicated an unstageable pressure ulcer on admission, leading her to code it as such. The RN also acknowledged issues with the facility's wound charting. These actions and documentation inconsistencies resulted in the MDS not accurately reflecting the resident's pressure ulcer status, constituting a deficiency in the facility's assessment process.
Failure to Develop Baseline Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to develop a baseline care plan related to pressure ulcers for one resident who was admitted with an existing pressure ulcer and subsequently developed additional pressure ulcers. Upon admission, the resident had diagnoses including dehydration, Parkinson's disease, anxiety, and weakness, and was assessed as being at moderate risk for pressure sores according to the Braden Scale. Multiple wound assessments documented the presence of an unstageable decubitus ulcer on the left buttock, a wound on the left iliac crest with purulent drainage and tunneling, and later, a stage I pressure ulcer on the left buttock and a wound on the coccyx. The care plan identified a self-care deficit and potential impairment to skin integrity, but lacked specific instructions regarding pressure-relieving devices, their frequency of use, and did not specify interventions for all identified wounds. Interviews and document reviews revealed that the baseline care plan was not properly developed or implemented. The DON acknowledged that the initial care plan was created with assessments, but indicated that nurses did not complete the necessary steps to link interventions to the care plan. The facility's policy required individualized, person-centered care plans to address identified problems and needs, but this was not followed in the resident's case, resulting in incomplete documentation and lack of clear, actionable interventions for pressure ulcer management.
Failure to Perform Ongoing and Accurate Pressure Ulcer Assessment and Prevention
Penalty
Summary
The facility failed to perform ongoing and accurate assessment of pressure ulcers for two residents who were at risk for pressure ulcer development. For one resident with diagnoses including dehydration, Parkinson's disease, anxiety, and weakness, the Braden Scale indicated a moderate risk for pressure ulcers. Upon admission, this resident had multiple wounds, including a dehisced scar, an unstageable ulcer on the left buttock, and a scratch on the arm. Wound assessments documented changes in wound status, including the development of new pressure ulcers and worsening of existing wounds, but lacked consistent and complete documentation of wound characteristics, frequency of assessments, and specific interventions. The care plan and Kardex lacked clear directions for staff regarding mobility, transfers, repositioning, and toileting frequency, despite the resident's incontinence and need for assistance. Progress notes and interviews revealed that the resident was often found incontinent and not cleaned up, with reports of frequent exposure to feces and the development of additional sores during the facility stay. Another resident with diagnoses of dementia, heart disease, pain, and a history of falls was also identified as high risk for pressure ulcers based on the Braden Scale. The care plan directed staff to check for incontinence every two to three hours and to assist with frequent repositioning, but wound assessments were not consistently completed. There was a lack of documented wound assessments for a period of over three weeks, despite the presence of a pressure ulcer on the sacrum and an open area on the coccyx. Staff interviews confirmed that wound charting was inconsistent, and the facility did not have a process for regular wound rounds. The DON acknowledged that skin checks were supposed to be completed weekly but were not being done for this resident. Facility policy required that pressure ulcers be evaluated at least weekly, with RNs responsible for recording wound type and degree of tissue damage, and licensed nurses documenting location, measurements, and characteristics. However, the facility failed to adhere to these requirements, resulting in incomplete and infrequent wound assessments, lack of clear staff direction, and insufficient implementation of interventions to reduce the risk of new or worsening pressure ulcers for residents at risk.
Deficiency in Kitchen Dry Storage Sanitation
Penalty
Summary
The facility failed to maintain clean and sanitary conditions in the dry storage area of the kitchen, which had the potential to affect all 29 residents. During an initial tour, a dented can of tomato juice was found on the shelf, and two large covered plastic bins were improperly managed. One bin contained an opened 50 lb bag of cake mix with a gaping top, and the cover was left open. The second bin had its cover lying on a rack shelf, with two 50 lb opened bags inside, including a bag of biscuit mix with no opening date and a bag of sweet cornbread mix opened on 2/15/24. The kitchen staff member present was unaware of how long the items were good for, how often they were used, or if the cover should be on, and did not know who was responsible for the dry storage area. The food service manager (FSM) confirmed the lack of proper dating and closure of the bags and acknowledged that dented cans should be removed immediately. The FSM, who had been in the role for approximately six months, was working to standardize practices but noted that there was no formal direction for maintaining the dry storage area. The facility's cleaning policies did not include specific procedures for dry storage sanitation, and the existing policies on food supply storage and general sanitation did not adequately address the maintenance of a clean and sanitized dry storage area.
Failure in Infection Prevention and Quality Assurance Activities
Penalty
Summary
The facility failed to conduct ongoing quality assessment and assurance activities, and did not develop or implement appropriate plans of action to correct quality deficiencies identified during the survey. This failure had the potential to adversely affect all 29 residents residing in the facility. Specifically, the facility did not perform timely tracking and trending of potential infectious symptoms to prevent the spread of transmissible organisms. The facility also failed to implement timely transmission-based precautions and testing for COVID-19 according to CDC guidelines for four residents who were displaying COVID-19 symptoms, and did not implement timely precautions for two residents confirmed to have human metapneumovirus. The infection preventionist at the facility did not adequately assess, develop, implement, monitor, and maintain the infection prevention and control program, which had the potential to affect all residents, staff, and visitors. During an interview, the administrator acknowledged that the director of nursing, who was previously responsible for the infection prevention program, had delegated responsibilities to a registered nurse without ensuring the nurse received adequate training or support. The facility's Quality Assurance Performance Improvement plan did not include a plan for a continuous infection prevention program, indicating a disconnect between the assumed and actual understanding of infection prevention responsibilities.
Inadequate Infection Control and Documentation
Penalty
Summary
The facility failed to perform timely tracking and trending of potential infectious symptoms, which led to a deficiency in preventing the spread of transmissible organisms. This included a failure to implement timely transmission-based precautions (TBP) and testing for respiratory illnesses according to CDC guidelines for four residents displaying COVID-19 symptoms and two residents confirmed to have human metapneumovirus (HMPV). The infection logs failed to identify residents not treated with antimicrobials, and there was a lack of documentation regarding confirmatory COVID-19 tests and isolation measures for symptomatic residents. Several residents exhibited symptoms of respiratory illnesses, but their medical records did not reflect appropriate testing or isolation measures. For instance, one resident with a nonproductive cough and afebrile status was not placed in isolation, and there was no record of a confirmatory COVID-19 test. Another resident with cold symptoms and chest congestion was transferred to the emergency department after experiencing hypoxic respiratory failure due to HMPV, yet there was no documentation of isolation upon return to the facility. Similar lapses were noted for other residents, indicating a systemic issue in managing infectious symptoms. Interviews with facility staff revealed confusion and inconsistency in following infection prevention protocols. The Infection Prevention (IP) nurse was unsure of expectations and faced challenges in getting staff to use clinical monitoring forms. The Director of Nursing (DON) was unaware of CDC guidance for confirmatory testing and isolation, and staff interviews highlighted a lack of adherence to facility policies and CDC guidelines. The facility's infection prevention and control program was not effectively implemented, as evidenced by the absence of documentation and tracking of viral illnesses since January 2024.
Inadequate Infection Preventionist Training and Oversight
Penalty
Summary
The facility failed to ensure there was a qualified infection preventionist (IP) to adequately manage the infection prevention and control program, which had the potential to affect all 29 residents, staff, and visitors. The deficiency was identified through interviews and document reviews, revealing that the Director of Nursing (DON), who was initially responsible for the infection prevention program, had been on extended leave. During this period, the responsibilities were delegated to a registered nurse (RN-A) who had not received adequate training or support to fulfill the role effectively. The IP lead was unaware of this delegation and RN-A was not included in the training list, indicating a lack of communication and oversight. The facility's infection prevention and control program policy required the designation of a qualified individual to manage the program, which was not adhered to. The report highlighted specific failures, such as the lack of timely tracking and trending of infectious symptoms and the implementation of transmission-based precautions for residents displaying COVID-19 symptoms and those confirmed with human metapneumovirus (HMPV). Interviews with the DON, RN-A, and the administrator revealed that RN-A's only training was the corporate annual in-service and CDC Nursing Home Infection Preventionist Training, which was insufficient for the role. The administrator assumed infection prevention tasks were completed based on dashboard presentations at quality assurance meetings, but there was no plan to ensure RN-A received necessary training and support.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) regarding a facility-initiated transfer of a resident to the hospital. The resident, identified as R14, had no cognitive impairment according to their quarterly Minimum Data Set. The resident was admitted to the hospital on two occasions, once on 2/29/24 and again on 3/20/24, and returned to the facility each time. However, there was no evidence that the OOLTC was notified of these transfers. During interviews, the business office coordinator (BOC) stated that they were responsible for placing the bed hold form in the resident's chart but were unaware of the requirement to notify the OOLTC about hospital transfers. The director of nursing (DON) confirmed that the OOLTC should be notified of resident transfers and that the BOC was responsible for this task. The facility's Discharge and Transfer policy also indicated that notification to the OOLTC was required when a resident was hospitalized.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a written bed hold policy to a resident or their representative at the time of hospital transfer. This deficiency was identified for a resident, referred to as R14, who was hospitalized on March 21, 2024. The resident's progress notes indicated that the family was notified of the hospitalization, but there was no documentation regarding the bed hold policy. Interviews with the resident and staff revealed that the resident did not recall receiving a bed hold notice, and the registered nurse responsible for informing the resident or representative could not verify that the bed hold was communicated. Further investigation showed that the business office coordinator was responsible for ensuring bed hold forms were completed and scanned into the resident's chart, but no such documentation was found for R14's hospitalization. The director of nursing stated that it was expected for a bed hold form to be completed and documented for every resident transferred to the hospital. The facility's bed hold policy, dated December 2, 2023, required that a designated individual provide the bed hold policy notice to the resident or their representative at the time of transfer.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Blackduck
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Neilson Place | 22.3 mi | — | 19 | 0 |
| Havenwood Care Center | 23.2 mi | — | 18 | 0 |
| Jourdain Perpich Ext Care Fac | 24.5 mi | — | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.