Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 - Bethany during CMS and state inspections, most recent first.
A resident with cognitive impairment and dementia was left lying in bed wearing only a brief, with the door wide open, for an extended period while multiple staff members walked past without intervening. The resident received no ADL assistance, including dressing or repositioning, and later expressed discomfort about being seen in this state. Staff interviews confirmed this was a dignity concern and contrary to facility policy.
A resident with cognitive impairment and incontinence, dependent on staff for ADLs, was left exposed in bed wearing only a saturated brief for an extended period, with multiple staff members passing by without providing care or maintaining dignity. The resident was not repositioned or assisted with incontinence care as required by the care plan, resulting in prolonged exposure and soiled bedding.
The facility failed to document non-pharmacological interventions and symptoms before administering PRN psychotropic medication to two residents. Resident care plans included interventions like music and massages, but these were not documented as attempted before giving Lorazepam. Staff interviews confirmed expectations for documentation, but the EMR system lacked a place for it, and the facility's policy did not guide documenting reasons for PRN use.
The facility failed to implement proper transmission-based precautions for residents with COVID-19 and MDROs, leading to inconsistent PPE use and inadequate infection tracking. A resident with COVID-19 did not have their care plan updated, and staff were confused about PPE requirements. Another resident with MRSA was not placed on contact precautions, and PPE supplies were insufficient. The facility also failed to track infections accurately and did not conduct confirmatory COVID-19 testing for symptomatic residents.
A resident with severe cognitive impairment and a urinary catheter was observed multiple times with the catheter bag visibly hanging from the bed frame, lacking a privacy bag. Staff interviews revealed inconsistent practices regarding the use of privacy bags, contributing to the deficiency in maintaining the resident's dignity.
The facility failed to ensure clinical monitoring and documentation for two residents with COVID-19 infections. One resident with severe cognitive impairment and multiple diagnoses lacked monitoring records for over a week, while another with COPD had no documented vitals for three days. Interviews revealed inconsistencies in monitoring practices, with staff unaware of specific documentation forms. The facility's policy lacked clear guidelines on monitoring frequency and documentation, contributing to the deficiency.
A resident was admitted with an indwelling urinary catheter without a provider's order or rationale for its use. The resident's records indicated no cognitive impairment and bladder continence, yet the catheter was in place. Interviews with staff and the resident revealed a lack of documentation and understanding of the catheter's necessity, contrary to facility policy requiring medical necessity and a physician's order.
A facility failed to follow physician orders and care standards for a resident with a g-tube feeding. The resident's head of the bed was lowered during care while the feeding was running, contrary to orders requiring elevation to prevent aspiration. Staff interviews indicated that nursing assistants did not stop the feeding during care, as only licensed nurses could do so. The facility's policy required the head of the bed to be elevated during and after feeding, which was not consistently adhered to.
A resident with severe cognitive impairment was administered a discontinued Nystatin cream by a nursing assistant without a current order. The cream, with an old pharmacy label, was applied under the resident's breasts. Facility staff confirmed the absence of a current order and that nursing assistants were not authorized to apply prescription creams. The facility's policy required prescription creams to be kept in the medication cart unless ordered otherwise.
A facility failed to create an individualized discharge care plan for a resident with heart and respiratory failure, despite an active discharge plan to return to the community. The care plan lacked comprehensive details on the resident's goals, treatment preferences, and post-discharge needs. Social services staff admitted to not documenting the discharge plan, and the DON confirmed the expectation for such documentation. The facility could not provide a discharge planning policy when requested.
A resident with a pressure ulcer did not receive proper wound care as per physician orders. An RN failed to cover the wound with an ABD pad and tape, as required. The resident denied removing the dressing, and another nurse confirmed the need for proper coverage. The DON stated staff should review treatment orders before care, but the facility could not provide the relevant policy when requested.
A cognitively impaired resident with Alzheimer's was sent to an outpatient appointment unaccompanied, despite requiring assistance with daily activities and exhibiting aggressive behaviors. Facility staff failed to ensure proper supervision, leading to the resident being disoriented at the appointment. The director of nursing acknowledged the failure in the process, but no policy regarding supervision was provided.
Resident Left Undressed and Exposed, Dignity Not Maintained
Penalty
Summary
A deficiency occurred when a resident with moderate to mild cognitive impairment, anxiety, mood disturbance, and dementia was left lying in bed wearing only a brief, with the door to his room wide open for an extended period of time. Multiple staff members, including nursing assistants, an activity aide, a social worker, a registered nurse, and other facility personnel, walked past the resident's room without addressing his lack of clothing or closing the door. The resident was not provided with any activities of daily living (ADL) assistance, such as dressing, repositioning, or incontinence care, from the start of the shift until after 11:00 a.m., despite being assigned to a nursing assistant. The resident was observed calling for help and later stated he would not want others to see him only in his brief. Staff interviews confirmed that leaving a resident exposed in only a brief with the door open is a dignity concern and should not occur. The facility's policies on resident dignity and activities of daily living require staff to maintain or enhance each resident's dignity and provide appropriate care. Despite these policies, the resident was repeatedly left exposed and undressed, with staff acknowledging the lapse in maintaining the resident's privacy and dignity.
Failure to Provide Timely Repositioning, Incontinence Care, and Dignity for a Dependent Resident
Penalty
Summary
A resident with moderate to mild cognitive impairment, anxiety, mood disturbance, and dementia was admitted with a care plan requiring frequent turning, repositioning every two hours, and incontinence checks due to a moderate risk for skin breakdown. The resident was also to be assisted with activities of daily living (ADLs), including dressing and maintaining dignity. On the day of observation, the resident was found lying in bed in only a brief, with the door wide open, and was not covered by clothing or a blanket. Multiple staff members, including nursing assistants and a registered nurse, walked past the resident's room over a period of more than an hour without providing care or addressing the resident's exposure or needs. The resident was not assisted with repositioning, incontinence care, or dressing during the morning shift, despite being dependent on staff for these ADLs. When a hospice nursing assistant entered the room, the resident's brief was found to be saturated with urine and feces, and the bed sheets were also soaked. Interviews with staff confirmed that the resident had not received any care that morning, and the director of nursing acknowledged that such inaction increases the risk for skin breakdown. Facility policies required staff to follow individualized care plans for incontinence and repositioning, as well as to maintain resident dignity, but these were not followed in this instance.
Failure to Document Non-Pharmacological Interventions Before PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that acute, potentially distressing psychoactive symptoms were recorded and non-pharmacological interventions were attempted or documented for two residents before administering as-needed (PRN) psychotropic medication. For Resident 1, the care plan included non-pharmacological interventions such as classical music, essential oils, and massages, but these were not documented as attempted before administering Lorazepam. The progress notes for Resident 1 lacked documentation of anxiety symptoms at the time of PRN administration, and there was no evidence of non-pharmacological interventions being tried prior to medication. Resident 3's care plan also lacked non-pharmacological interventions for staff to implement when symptoms of agitation or anxiety were present. The progress notes for Resident 3 did not document the symptoms of agitation or anxiety at the time of PRN Lorazepam administration, nor did they show evidence of non-pharmacological interventions being attempted. Interviews with staff revealed that non-pharmacological interventions were expected to be attempted and documented, but the facility's electronic medical record (EMR) system did not have a place for such documentation. Interviews with nursing staff and the director of nursing confirmed that staff were expected to document non-pharmacological interventions and the symptoms exhibited by residents prior to administering PRN psychotropic medication. However, the facility's policy on medication administration did not provide clear guidance on documenting the reasoning for administering PRN psychotropic medication or the non-pharmacological interventions attempted. This lack of documentation and adherence to non-pharmacological intervention protocols contributed to the deficiency identified by the surveyors.
Inadequate Infection Control and Precaution Implementation
Penalty
Summary
The facility failed to implement appropriate transmission-based precautions for residents diagnosed with COVID-19 and those with multidrug-resistant organisms (MDROs). For instance, a resident with a COVID-19 diagnosis did not have their care plan updated to reflect the need for transmission-based precautions. Observations revealed that staff did not consistently use the required personal protective equipment (PPE) when entering the resident's room, and there was confusion about the necessity of certain PPE items, such as eye protection. Additionally, the facility did not conduct audits to ensure staff compliance with PPE guidelines during a COVID-19 outbreak. Another resident with a history of MRSA was not placed on the appropriate contact precautions upon admission, despite having an active MRSA infection. Staff were observed not wearing gowns as required, and there was a lack of PPE supplies near the resident's room, leading to improper doffing of gowns and gloves in the hallway. The Director of Nursing (DON) was unaware of the resident's MRSA status, and there was a lack of communication and documentation regarding the resident's infection status and necessary precautions. The facility also failed to track and trend potential or actual infections among residents, as evidenced by the absence of certain residents' symptoms in the infection control report. The DON relied on an electronic medical record system for infection surveillance, but the system's effectiveness was dependent on nursing staff entering data accurately. Additionally, the facility did not conduct confirmatory COVID-19 testing for symptomatic residents, and there was no consistent tracking of residents tested due to symptoms. The facility's policy required isolation and testing of residents with COVID-19 symptoms, but this was not consistently followed.
Failure to Maintain Resident Dignity with Catheter Privacy
Penalty
Summary
The facility failed to ensure the dignity of a resident with a urinary catheter by not placing the catheter bag in a privacy bag. The resident, who had severe cognitive impairment and a neurogenic bladder due to Huntington's disease, was observed multiple times with the catheter bag hanging visibly from the bed frame, which was clearly visible from the hallway. The care plan for the resident did not include instructions to keep the catheter bag in a privacy bag, which contributed to the oversight. Staff interviews revealed a lack of consistent practice regarding the use of privacy bags for catheter bags. Nursing assistants and registered nurses acknowledged the importance of using privacy bags for maintaining dignity and privacy but admitted that the practice was not consistently followed, especially when the resident was in bed. The facility had previously used a supply company that provided covers, but the current supplies did not include privacy bags for bed use, leading to the deficiency.
Failure in Clinical Monitoring for COVID-19 Infections
Penalty
Summary
The facility failed to ensure clinical monitoring was completed and documented for two residents with recent COVID-19 infections. Resident R37, who had severe cognitive impairment and multiple diagnoses including chronic respiratory failure and chronic kidney disease, tested positive for COVID-19. Despite the care plan directing staff to monitor and document symptoms, there was no record of clinical monitoring or vital signs from 9/26/24 to 10/3/24. Similarly, Resident R39, diagnosed with COPD and other conditions, tested positive for COVID-19 but lacked documented monitoring of vitals and symptoms from 9/28/24 to 9/30/24. Interviews with nursing staff revealed inconsistencies in the implementation and documentation of clinical monitoring. RN-C and RN-F stated that vitals and lung sounds should be documented every shift for COVID-19 positive residents, but RN-F was unaware of the specific assessment form used for documentation. Other staff members, including RN-A and RN-G, indicated that monitoring depended on the nurse on duty and the resident's condition, leading to a lack of consistent documentation. The Director of Nursing expressed disappointment over the absence of nursing assessments and expected staff to follow the facility's infection control process. The facility's policy on COVID-19 monitoring did not specify the frequency or documentation method for monitoring, contributing to the deficiency. Despite requests, a policy regarding illness monitoring and documentation was not provided. The administrator expected staff to adhere to policies and communicate effectively to ensure safety, but the lack of clear guidelines and documentation led to the failure in monitoring residents R37 and R39 during their COVID-19 infections.
Lack of Provider's Order and Rationale for Urinary Catheter Use
Penalty
Summary
The facility failed to ensure an appropriate provider's order and rationale for the use of an indwelling urinary catheter for a resident who was reviewed for catheter care. The resident, identified as R30, was admitted with an indwelling urinary catheter in place, but the medical records lacked any documentation of a provider's order or rationale for its use. The resident's Minimum Data Set indicated no cognitive impairment and that the resident was always continent of the bladder, raising questions about the necessity of the catheter. Interviews with the resident and staff revealed a lack of awareness and documentation regarding the catheter's purpose. The resident expressed uncertainty about the reason for the catheter's placement, and both a licensed practical nurse and a registered nurse confirmed the absence of an order or rationale in the medical records. The director of nursing stated that it is expected for every resident with a catheter to have a provider's order and a clear rationale for its use, which was not the case for this resident. The facility's policy also emphasized that catheters should only be used when medically necessary and with a physician's order.
Failure to Maintain Proper Head Elevation During Tube Feeding
Penalty
Summary
The facility failed to provide care according to standards of practice and physician orders for a resident with a gastrostomy tube (g-tube) feeding. The resident, identified as R15, had severe cognitive impairment and was dependent on staff for bed mobility. The physician's order required the head of the bed to be elevated greater than 30 degrees during tube feeding to prevent regurgitation or aspiration. However, during an observation, nursing assistants lowered the head of the bed to perform morning hygiene care while the tube feeding was running, contrary to the care plan and facility policy. Interviews with staff revealed that nursing assistants did not stop the tube feeding during care, as only licensed nurses were authorized to do so. The staff reported that lowering the head of the bed had not caused negative effects for the resident, although there were instances of vomiting during the night shift. The director of nursing stated that the expectation was for the head of the bed to be elevated if the resident could tolerate it, and the feeding could be stopped if extensive care was needed. The facility's policy directed staff to maintain the head of the bed elevated during and after feeding, which was not consistently followed.
Unauthorized Administration of Discontinued Medication
Penalty
Summary
The facility failed to ensure that a discontinued prescription topical antifungal medication was destroyed and not administered, and also failed to ensure that only authorized staff administered prescribed creams. This deficiency was observed in the case of a resident with severe cognitive impairment and multiple diagnoses, including traumatic brain dysfunction and non-Alzheimer's dementia. The resident was dependent on staff for all activities of daily living. Despite the discontinuation of the order for Nystatin cream, a nursing assistant was observed applying the cream under the resident's breasts without a current order, using a tube with an old pharmacy label. Interviews with facility staff, including registered nurses and the director of nursing, confirmed that the resident did not have a current order for the Nystatin cream and that nursing assistants were not authorized to apply prescription creams. The facility's policy required that prescription creams be kept in the medication cart unless there was a specific order to keep them at the bedside. The policy also mandated that medications be administered according to the Six Rights and that a provider's order must be legible and include specific details before administration.
Failure to Develop Individualized Discharge Plan
Penalty
Summary
The facility failed to create an individualized discharge care plan for a resident, identified as R3, who was reviewed during a survey. R3 had diagnoses of heart failure and respiratory failure and was cognitively intact. The resident's quarterly Minimal Data Set (MDS) indicated an active discharge plan for R3 to return to the community, with a referral made to the Local Contact Agency. However, the care plan dated 3/28/24 lacked evidence of a comprehensive discharge plan addressing the resident's goals, treatment preferences, and post-discharge needs such as nursing, therapy services, medical equipment, or activities of daily living (ADLs) assistance. During interviews, the social services staff member (SS-A) stated that discharge planning began upon the resident's admission and continued throughout their stay, but admitted to not including discharge planning in the resident's care plan, instead keeping the information mentally. The Director of Nursing (DON) confirmed that the social services staff was expected to develop a comprehensive discharge plan within the care plan, which was not done for R3. Additionally, the facility was unable to provide a policy related to discharge planning when requested.
Failure to Follow Wound Care Orders for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that physician treatment orders were followed for a resident with pressure ulcers. The resident, who was cognitively intact, had a pressure ulcer in the peri-anal area that required specific wound care instructions, including cleansing with saline, wet-dry dressing changes, and covering with an ABD pad secured with tape. However, during an observation, a registered nurse (RN-A) did not follow these instructions. RN-A performed the wound care without covering the wound with an ABD pad or using tape, contrary to the treatment order. RN-A admitted to not typically working on the resident's unit and did not review the treatment administration record (TAR) before performing the wound care. The resident denied removing any dressing or tape from the wound, and it was confirmed by another nurse (RN-D) that the wound needed to be covered to protect it. The Director of Nursing (DON) indicated that staff were expected to read each resident's wound treatment order before performing the treatment and could write down or print the order if it was complex. Despite this expectation, the facility failed to provide a copy of the pressure wound policy and treatment order policy when requested.
Inadequate Supervision for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate supervision for a cognitively impaired resident, who was diagnosed with Alzheimer's Disease and exhibited severe cognitive impairment and behavioral symptoms. The resident required assistance with all activities of daily living and was known to exhibit aggressive behaviors. Despite these needs, the resident was sent to an outpatient orthopedic appointment unaccompanied, where they were found to be disoriented and unable to verify their identity. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's appointment. The registered nurse and nursing assistant both confirmed the resident's cognitive impairments and aggressive behaviors, indicating that the resident was not safe to attend appointments alone. The health information staff, responsible for scheduling appointments, did not consult with the nurse manager about the resident's ability to attend the appointment unaccompanied, nor did they ensure that a family member or staff accompanied the resident. The director of nursing acknowledged the facility's policy that cognitively impaired residents should be accompanied to appointments and admitted that the process failed in this instance. The director was unaware of the situation until contacted by the clinic and had not investigated the incident or discussed the failure with the relevant staff. The facility did not provide a policy regarding appointments and supervision when requested.
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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 Brainerd
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Woodland | 0.7 mi | ★★★★★ | 1 | 0 |
| Heartwood | 16.2 mi | ★★★★★ | 0 | 0 |
| Pierz Villa Inc | 25.2 mi | ★★★★★ | 6 | 0 |
| Little Falls Care Center | 25.9 mi | ★★★★★ | 6 | 0 |
| Aicota Health Care Center | 26.4 mi | ★★★★★ | 11 | 0 |
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