Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - Albert Lea during CMS and state inspections, most recent first.
Kitchen staff failed to properly date-mark, store, and discard food items, with multiple opened or undated foods found in a walk-in refrigerator past the facility’s 7-day limit or otherwise not labeled. Surveyors also observed wet stacked pans, uncovered utensils with crumbs, and staff personal items such as a cell phone, keys, snacks, and drinks in food prep and storage areas. The MNFS-C stated foods should be dated when opened and discarded after 7 days, and acknowledged concerns about contamination.
Failure to provide adequate visual assistance for meal selection. A resident with severe vision loss, including blindness in one eye and macular degeneration in the other, was observed struggling to read a weekly menu using two very small magnifying glasses. Records showed highly impaired vision, but the care plan did not fully reflect the resident’s blindness, and staff interviews showed inconsistent awareness of his needs. The resident stated no one had offered a larger magnifier or helped him select meals, despite a policy requiring accessible communication and assistance for persons with low vision.
The facility did not ensure the high-temperature dishwashing machine consistently reached the required wash and rinse temperatures, as observed by the dietary manager and confirmed by temperature logs and staff interviews. This failure occurred despite facility policy requiring compliance checks and staff notification when temperatures are out of range.
Staff failed to use required PPE, such as gowns or aprons, when sorting soiled laundry, and transported clean resident clothing in uncovered carts, leaving items exposed to dust and dirt. Facility policy required both PPE for soiled laundry handling and covered carts for clean laundry, but these practices were not followed.
A resident with severely impaired cognition and a high risk for falls was found sitting in a recliner with the call light out of reach, contrary to facility policy and the resident's care plan. Staff confirmed that call lights should be accessible unless otherwise documented, but no such documentation existed for this resident.
A resident with severe cognitive impairment and incontinence was left in urine-soaked sheets for several hours, with staff failing to offer toileting or change incontinence products as required by the care plan. Documentation showed long gaps without care, and staff did not consistently re-approach or document refusals, despite facility policy and expectations.
A male resident with severe cognitive impairment and a history of sexually inappropriate behaviors was not adequately supervised, leading to incidents of sexual abuse involving two female residents. The facility failed to update the care plan or implement effective measures to prevent these incidents, resulting in immediate jeopardy for the affected residents.
A facility failed to report an alleged abuse incident involving two residents with dementia in a timely manner. One resident was found in another's bed, possibly attempting to masturbate. The incident was reported to the DON, family, and provider, but the report to the State Agency was delayed by 40 hours due to an initial assessment that it did not require reporting.
A resident, who required assistance with a gait belt for ambulation, fell and fractured their hip when a nursing assistant let go of the gait belt to secure a wheelchair. The resident, who was legally blind and had diabetes, lost balance and fell, resulting in a need for surgical intervention. The incident was initially reported as a slip, but video evidence later showed the care plan was not followed.
The facility failed to implement enhanced barrier precautions for two residents with implanted medical devices. One resident, dependent on staff for daily activities, was assisted by a nursing assistant without the necessary PPE. Another resident's care plan lacked specific instructions for G-tube care, leading an LPN to administer medications without proper PPE. The director of nursing confirmed the need for PPE, which was not followed.
The facility failed to conduct routine weekly skin assessments for two residents with impaired skin integrity. One resident with severe cognitive impairment had inconsistent wound assessments for a non-healing lesion, while another resident with multiple diagnoses had incomplete wound data for a deep tissue injury and a pressure ulcer. Staff interviews revealed that the required twice-weekly assessments were not consistently performed.
A resident with severe cognitive impairment and a non-healing head lesion experienced a lapse in accurate medical record-keeping. Maggots were found in the wound, but documentation was delayed and incomplete. The resident frequently removed dressings, complicating care. Despite observations and treatment attempts, the facility failed to document the extent of the infestation and subsequent monitoring.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
Food stored in the kitchen refrigerators was not labeled, dated, or discarded in accordance with facility policy and professional standards. During the kitchen tour, surveyors observed opened foods in a walk-in refrigerator that were past the facility’s seven-day window or were undated, including facility-made strawberry frost dated 3/19, chopped red onion dated 4/25, red grapes dated 10/14 with a cloudy whitish/grayish liquid in the bag, Chef Grade hard boiled peeled eggs dated 4/21, lettuce with no date and brown leaves, and an undated sour cream container that was about half full. A sign on the refrigerator stated that all dated food items must be tossed at the end of 7 days. The MNFS-C removed the items and stated foods were to be dated when opened and prepared foods were to be discarded after seven days. The MNFS-C also stated staff date-mark foods when opened with the month and day and do not include the year. Additional kitchen observations showed two stacked stainless steel pans with water on the inner surfaces, three containers of utensils left uncovered on a wire cart with crumbs in one container, and personal items belonging to staff on or in food preparation counters and storage areas, including a cell phone, car keys, a pink mini wallet, a small bag of chips, plastic water bottles, and a thermal mug. A cell phone was also observed in a drawer with utensils. The MNFS-C stated the pans should have been completely dry before stacking and was unaware utensils should be in a drawer or covered container. The FSA-A stated personal items such as cell phones, keys, and snacks were not appropriate in food prep areas and could lead to distractions. The RD-F stated monthly audits had identified staff not dating opened food, and the administrator stated she expected the MNFS-C to oversee the kitchen and ensure staff adhered to policies and regulations.
Failure to Provide Adequate Visual Assistance for Meal Selection
Penalty
Summary
The facility failed to ensure services and assistance were provided to preserve the independence of a resident with highly impaired vision. The resident’s significant change MDS dated 4/16/26 indicated intact cognition, clear speech, and that he was understood and able to understand, but also showed highly impaired vision. The resident was independent in some ADLs, dependent in others, and able to walk short distances such as to the bathroom. His care plan identified impaired visual function related to macular degeneration and stated he could see very large print/newspaper headlines with a magnifying glass and glasses, but it did not identify blindness in his left eye. Records reviewed showed the resident had age-related macular degeneration in the right eye and blindness in the left eye, with later provider documentation noting progressive vision loss, blindness in the left eye from a prior injury, and severe macular degeneration in the right eye. During a care conference, the resident was noted to have blurry vision even with a magnifying glass. A progress note later documented that the social worker met with the resident about referral options for vision services and that the resident voiced interest in a referral to services for the blind. During observation, the resident was seen holding two very small magnifying glasses up to his right eye while trying to read a weekly menu printed in approximately 11-point font; the menu had to be held close to his nose for him to make out one or two words at a time. The resident stated no one had offered him a larger magnifying glass and that no one had ever asked him or helped him make meal selections before. Staff interviews showed inconsistent awareness of his impairment: one NA said staff were supposed to sit with him and go through the menu, while the cook, manager of nutrition and food services, social worker, and DON stated they were not aware of his visual impairment or how he was being assisted. The RN stated the resident used his own small magnifying glass, had not asked for help, and she had not approached him to ask how staff could assist him with meal selection. The facility’s auxiliary aids policy stated that persons who were blind or had low vision would be provided accessible communication and assistance, but the resident’s menu-reading support was not consistently provided or documented.
Failure to Maintain Proper Dishwashing Temperatures in Kitchen
Penalty
Summary
The facility failed to ensure the high-temperature dishwashing machine operated at the required temperatures for effective sanitization. During an observation, the dietary manager (DM) ran several empty dish racks through the machine and consistently recorded wash and rinse temperatures of approximately 140 degrees Fahrenheit, which is below the required 150 degrees for wash and 180 degrees for rinse. The DM also noted a flashing red light on the booster, which was unusual, and stated that maintenance would be notified. Temperature logs indicated that a dietary aide (DA-A) had documented proper temperatures earlier, but during interview, DA-A referenced the dials on the machine and reported temperatures that did not align with the observed readings. The DA-A also described the process for checking temperatures and the protocol for notifying staff if temperatures were out of range. Further observation on the following day showed the dish machine reaching appropriate temperatures, but the initial failure to meet required standards was not addressed before equipment was used. Facility policy requires compliance checks for wash and rinse cycles at each meal service and mandates staff notification if temperatures are outside acceptable parameters. The policy also references the use of an irreversible registering temperature indicator to ensure proper surface temperature is achieved during the rinse cycle, as per the food code.
Failure to Use Appropriate PPE and Cover Clean Laundry During Transport
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in the handling of both soiled and clean laundry. Observations showed that a laundry aide transported clean resident clothing in an uncovered metal cart and carried multiple shirts by hand and on her arm into resident rooms. The clean clothing was not protected from dust or dirt during transport and delivery. The laundry aide confirmed that this was the standard practice and that the carts used did not have covers. The Ancillary Department Manager also acknowledged that the carts in use were not laundry carts and lacked covers, and that clean laundry was not being adequately protected during transport. Additionally, the facility did not ensure that appropriate personal protective equipment (PPE) was used when sorting soiled laundry. The laundry aide reported that only gloves were used during sorting, and there was no PPE such as gowns or aprons available nearby in the soiled laundry area. The Infection Preventionist and Ancillary Department Manager were both unsure if gowns were required, despite the facility's policy stating that at a minimum, a disposable apron and gloves should be worn when handling soiled laundry. The policy also directed that clean clothes should be transported and stored in a manner that reasonably protects them from dust and soil, and that clean linen carts should be covered at all times during storage and distribution.
Failure to Ensure Call Light Accessibility for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident identified as high risk for falls had their call light within reach, as required by facility policy. The resident had a history of chronic kidney disease, altered mental status, severely impaired cognition, and a history of falls, and was assessed as high risk for falls. The care plan included interventions such as reminding the resident to call for staff assistance and ensuring the call light was accessible. However, during observation, the call light was found removed from the wall and placed on a bedside table, out of the resident's reach while she was sitting in a recliner at the back of the room. Staff interviews confirmed that call lights should always be placed within easy reach of residents unless a specific preference is documented, which was not the case for this resident. The facility's policy also required that call lights be accessible to residents at all times. The failure to ensure the call light was within reach was verified by both nursing and administrative staff, and there was no documentation indicating the resident had requested the call light be placed elsewhere.
Failure to Provide Timely Incontinence Care and Document Refusals
Penalty
Summary
The facility failed to provide timely incontinence care for a resident with severely impaired cognition, dementia, and epilepsy, who was frequently incontinent of bladder and always incontinent of bowel. The resident's care plan required staff to check and change incontinence products every shift and as needed, maintain consistency in ADL routines, and re-approach the resident if care was refused, documenting each refusal. Despite these interventions, continuous observation revealed that the resident remained in urine-soaked sheets for an extended period, with a strong odor of urine present in the room, and staff did not offer toileting or change the resident's clothing or bedding during multiple interactions over several hours. Documentation in the facility's electronic health record indicated that the resident had only been toileted three times during the day in question, with no record of toileting or incontinence care for approximately eight hours. Staff interviews confirmed that the expectation was to offer toileting and check/change incontinence products every two hours, even if the resident refused, and to document each refusal. However, staff failed to follow these protocols, as evidenced by the lack of documented offers and the resident remaining in soiled conditions for an extended period. Family and staff interviews further corroborated that the resident would not have wanted to remain in urine-soaked clothing or bedding, and that staff were aware of the need to re-approach and document refusals. The facility's policy required necessary services for residents unable to perform ADLs, including maintaining personal hygiene. The observed failure to provide timely incontinence care and to document care refusals as required led to the identified deficiency.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect two female residents from sexual abuse and inappropriate behaviors by a male resident. The male resident, who had severe cognitive impairment and a history of wandering, displayed sexually inappropriate behaviors towards staff and other residents. These behaviors included exposing himself, making sexual advances, and inappropriate touching. Despite these behaviors being documented in progress notes, the facility did not notify the physician promptly or update the resident's care plan to address the risk to other residents. The male resident's inappropriate behaviors escalated, leading to two incidents involving female residents. In one incident, the male resident was found in bed with a female resident, possibly attempting to masturbate. In another incident, he was found in a common area touching another female resident inappropriately. Both female residents had severe cognitive impairments and were unable to protect themselves or report the abuse effectively. The facility's interventions, such as placing a mesh stop sign banner and conducting more frequent checks, were insufficient to prevent these incidents. The facility's lack of a comprehensive assessment and failure to implement effective measures to supervise the male resident contributed to the incidents. The interventions in place were not adequately assessed for their effectiveness, and the facility did not ensure that the male resident was supervised to prevent further inappropriate behaviors. The facility's actions were deemed insufficient, resulting in an immediate jeopardy situation for the affected residents.
Removal Plan
- The facility implemented a plan to ensure R3 had direct 1:1 supervision.
- All nursing staff were provided with education and expectations pertaining to R3's care plan interventions and supervision.
- Audits have been initiated to ensure R3 had direct 1:1 supervision.
- Facility updated R1, R2, and R3's care plan and provided education to staff on changes and updates.
Delayed Reporting of Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner to the State Agency for one of the residents reviewed for allegations of abuse. The incident involved two residents, both diagnosed with dementia. One resident was found lying next to another in bed, with the former possibly attempting to masturbate. The incident was discovered by an LPN who responded to a call light and found the resident in question with his pants halfway down. The LPN notified the Director of Nursing (DON), the family, and the provider about the incident. Despite the facility's policy requiring allegations of abuse to be reported within 24 hours if there is no serious bodily injury, the report was submitted approximately 40 hours after the incident. The delay occurred because the DON and regional clinical service nurse initially determined that the incident did not need to be reported due to the absence of willful intent or injury. However, after further discussion, the administrator instructed the DON to submit the report to the State Agency, which was then finalized and submitted two days after the incident.
Failure to Follow Care Plan Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide safe transfers and adhere to the care plan for a resident, resulting in a fall and a left hip fracture that required surgical intervention. The resident, who was legally blind and had diabetes, required one staff assist with a gait belt for ambulation. On the day of the incident, a nursing assistant (NA) was assisting the resident from the bathroom to a wheelchair using a gait belt. The NA let go of the gait belt to secure the wheelchair, causing the resident to lose balance and fall, hitting their head and expressing pain in the hip. The incident was initially reported as a slip by the NA, and the care plan was believed to have been followed. However, a video later revealed that the NA had let go of the gait belt, leading to the fall. The director of nursing (DON) and the administrator reviewed the video with the resident's family, confirming the lapse in following the care plan. The facility's policy required staff to maintain hold of the gait belt until the resident was safely seated, which was not adhered to in this case.
Removal Plan
- Re-educate all staff on safe transfers and expectations for using the gait belt during transfers.
- Check the Kardex/care plan prior to assisting residents with mobility, including transfers and/or ambulation.
- Ensure the Kardex/care plan includes use of gait belt for transfers/ambulation, and staff hold on to the gait belt until the resident is safely seated on the destination surface.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBPs) for two residents with implanted medical devices, leading to a deficiency in infection prevention and control. Resident R4, who was dependent on staff for all activities of daily living and had a supra pubic catheter and ostomy, required staff to wear gowns and gloves during high-contact care activities. However, during an observation, a nursing assistant (NA-E) assisted another nursing assistant (NA-M) in transferring R4 without wearing the necessary personal protective equipment (PPE), despite the supplies being readily available. Similarly, Resident R6, who had an indwelling urinary catheter and a feeding tube, required EBPs during high-contact care activities. However, the care plan did not specify the need for EBPs during G-tube care and medication administration. An LPN was observed administering medications via the feeding tube without wearing a gown and initially without gloves, indicating a lack of awareness of the need for PPE in such situations. The director of nursing confirmed that PPE should be worn as per facility policy, which was not adhered to in these instances.
Failure to Conduct Routine Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure routine weekly skin assessments for two residents with impaired skin integrity. Resident 1, who had severe cognitive impairment and a non-healing lesion on the top of his head, did not receive consistent weekly comprehensive wound assessments. The care plan for Resident 1 included monitoring the location, size, and treatment of the skin injury, but the record showed missed weekly measurements on several dates. The wound data collection lacked initial measurements and descriptions, and the clinical manager acknowledged missing measurements due to her absence. Resident 2, diagnosed with hemiplegia, hemiparesis, and other conditions, had a suspected deep tissue injury on the right great toe and a stage 3 pressure ulcer on the left lower leg. The care plan required daily and weekly wound assessments, but the wound data collection did not consistently include descriptions or measurements. Missed assessments were noted on specific dates. Interviews with staff revealed that wounds were supposed to be assessed twice weekly, but this protocol was not followed consistently, leading to the deficiency.
Failure to Maintain Accurate Medical Records for Wound Management
Penalty
Summary
The facility failed to maintain accurate medical records for a resident with severe cognitive impairment and a non-healing lesion on the head. The resident's care plan required monitoring of the lesion, but a change in the skin condition was identified on July 8, 2024, and not documented until July 10, 2024. During this period, maggots were found in the wound, and the family was notified, but the time of notification was not recorded. The nurse practitioner was informed, and the lesion was irrigated, but there was no documentation of the extent of the maggot infestation or subsequent monitoring. Interviews revealed that the resident frequently removed dressings, complicating wound management. A nursing assistant noted the dressing was intact on the morning of July 8, 2024, but a registered nurse found maggots during a dressing change. The clinical manager confirmed the presence of maggots and attempted treatment without initial orders. Despite these observations, there was a lack of documentation regarding the treatments and findings. The assistant director of nursing acknowledged the importance of timely documentation, which was not adhered to in this case.
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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 Albert Lea
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Johns On Fountain Lake | 2.6 mi | ★★★★★ | 15 | 0 |
| Thorne Crest Retirement Center | 3 mi | ★★★★★ | 26 | 0 |
| New Richland Care Center | 14.9 mi | ★★★★★ | 2 | 0 |
| Parkview Care Center | 18.5 mi | ★★★★★ | 12 | 0 |
| Lutheran Retirement Home | 18.7 mi | ★★★★★ | 8 | 0 |
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