Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 - Howard Lake during CMS and state inspections, most recent first.
Unsafe food handling, dishwashing, and meal prep practices were observed during meal service and kitchen operations. Dietary aides delivered beverages without gloves, touched kitchen and dining room surfaces without hand hygiene, and placed bare fingers on the rims of drinking glasses before serving them to residents. A cook carried plated meals against his shirt and served them without re-plating, while dish machine logs showed repeated rinse temperatures below the required range. During food prep, a cook had hair outside the hairnet and used only one glove while scooping ice cream, with ungloved contact to the food container.
Failure to assist or remind residents to sanitize hands before meals: during dining room observations, residents ate while Sani-Hands wipes sat on the tables, but staff did not offer cues or assistance to residents who needed help. Staff interviews showed differing expectations about who was responsible for hand hygiene, and the DM stated hand sanitization was expected before meals, especially when finger foods were served.
A resident with moderately impaired cognition, dementia, and malnutrition was seated in the dining room with two other residents, but her meal was delayed while the tablemates were served and finished eating. The dietary aide could not explain the delay, and the cook stated he forgot to serve the resident initially. The resident said watching others eat while she waited made her feel increasingly hungry and left her wondering when her meal would be served.
Failure to Notify Provider of Weight Gain and Nitroglycerin Use A resident with CHF, heart failure, CAD, edema, and other chronic conditions had repeated weight gains above the provider’s notification threshold, but the chart did not show the MD/NP was notified as ordered. The resident also received Nitroglycerin on multiple occasions for chest pain/angina, yet documentation did not show provider notification after those administrations. Interviews confirmed staff were expected to report weight changes, edema, lung findings, and Nitroglycerin use, but this did not consistently occur.
The facility failed to notify the Office of the Ombudsman for Long-Term Care when a resident with impaired cognition, dementia, HTN, UTIs, hyponatremia, and malnutrition was transferred to the ER on two occasions. Transfer documentation, progress notes, and Ombudsman logs did not show notification, and the HIM confirmed both transfers were missing from the monthly reports faxed to the Ombudsman.
A resident’s Medicare 5-day MDS was started but not completed or closed after an emergent hospital transfer and subsequent death. The MDS tracking system showed the assessment remained open for more than 120 days, and the RN Manager stated it should have been closed or the ARD changed after the transfer; the manager also said a Medicare 5-day assessment should not have been completed.
Care plans for two residents were incomplete. One resident had severe cognitive impairment, used a wheelchair, and needed help with transfers, but the care plan did not address wheelchair use, foot pedals, or transfer assistance. Another resident had impaired cognition and a history of UTIs, but the care plan did not include a problem, goal, or interventions for UTI history. Nursing staff and the DON stated these needs should have been reflected in the care plans.
Unsafe Wheelchair Transport Without Care Plan Guidance: A resident with severe cognitive impairment, dementia, arthritis, malnutrition, and other diagnoses was observed being pushed in a wheelchair without foot pedals while his feet bounced or slid on the floor. The care plan did not address wheelchair mobility or foot pedal use, and staff gave differing accounts about whether pedals were required when pushing the resident.
A resident with severe cognitive impairment eloped from the facility by cutting a window screen and locking the door with a cell phone cord. The incident was reported to the State Agency 68 hours later, exceeding the 24-hour reporting requirement. The resident was not identified as an elopement risk, and the facility did not initially consider it an elopement due to prior discharge plans.
A facility failed to accurately complete a comprehensive MDS assessment for a resident with significant cognitive impairment, resulting in unaddressed dental issues. Despite observations of missing teeth and the resident's acknowledgment of needing dental care, the MDS assessments and care plan did not reflect these concerns. The facility's policy required dental assessments, but these were not accurately conducted, leading to a lack of appropriate care planning.
Unsafe Food Handling, Dishwashing, and Meal Prep Practices
Penalty
Summary
Food and beverages were not handled and served in a sanitary manner during evening meal service in the dining room. On 02/10/26, a dietary aide delivered beverages to multiple residents without gloves, repeatedly entered and exited the kitchen to obtain drinks, touched the kitchen keypad and door handle, and touched dining room tabletops, counters, water pitchers, and the ice machine between deliveries without performing hand hygiene. While carrying beverages, the aide placed bare fingers around the rims of drinking glasses, including the area where residents’ lips contact during consumption. On 02/11/26, a second dietary aide was observed performing the same actions, including delivering beverages without gloves, touching kitchen and dining room surfaces between deliveries without hand hygiene, and placing bare fingers around the rims of drinking glasses before serving them directly to residents. During meal service, a cook was observed transporting four plated meals at one time from the kitchen to the dining area without gloves. Two of the plates were in direct contact with the cook’s shirt while being carried, and the plates were then served to residents without being re-plated or discarded. In interview, the cook stated he typically carried multiple plates at one time and acknowledged he was not wearing gloves during the observation. The dietary manager stated staff did not routinely wear gloves when delivering food and beverages, and confirmed staff should not touch the tops or rims of drinking glasses and plates should not contact staff clothing during service. The facility also failed to consistently monitor dishwasher rinse temperatures and to ensure the process remained within the desired range. The dishwasher was described as a steam dishwasher with a wash temperature of 150 degrees Fahrenheit and a rinse cycle temperature of 180 degrees Fahrenheit. Review of temperature logs showed multiple morning rinse temperatures below 180 degrees Fahrenheit in February, and January logs showed 10 of 30 morning rinse temperatures below 180 degrees Fahrenheit. The contracted service technician stated the rinse water needed to reach 180 degrees Fahrenheit to achieve the desired surface temperature, and the dietary manager stated the high temperature was used to kill bacteria and germs. During meal preparation, a cook was observed with bangs outside the hairnet restraint, using only one glove while scooping strawberry ice cream, touching the container with an ungloved hand, and using the same gloved hand to scoop after the ungloved finger had contacted the container. The dietary manager stated gloves should be used on both hands during food preparation and that hairnets were important to prevent hair from getting into food items.
Failure to Assist Residents With Hand Sanitization Before Meals
Penalty
Summary
The facility failed to ensure staff implemented infection prevention practices by offering assistance, encouragement, or reminders for residents to sanitize their hands prior to dining. During observations of the dining room on 02/10/2026 at 4:35 p.m. and 02/11/2026 at 4:37 p.m., residents were seated at tables with containers of Sani-Hands hand sanitizing wipes placed in the center of each table, but residents proceeded to eat their meals without staff offering reminders or assistance to sanitize their hands before eating. No staff were observed directing residents to the hand sanitizer or assisting residents who required cues or help because of physical or cognitive limitations. During interview, the Dietary Aide stated the wipes were intended for use at every meal and that residents typically sanitized their hands independently, while dining room staff or staff who assisted residents into the dining room were responsible for dependent residents. The Cook stated the wipes were for resident use and that nursing assistants were expected to assist residents who required help, adding that hand sanitization should have occurred before the meal because it primarily consisted of finger foods and residents were using their hands to eat. A nursing assistant stated she did not assist any residents with hand sanitization prior to the meal and said assisting residents was the responsibility of all staff. The Dietary Manager stated staff were expected to encourage residents to use hand sanitizing wipes prior to meals, especially when meals included finger foods. A facility infection prevention and control policy related to hand hygiene during meals was requested but was not received.
Resident Left Waiting for Meal While Tablemates Ate
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during the dining experience for 1 of 1 resident reviewed for dignity. The resident had a quarterly MDS identifying moderately impaired cognition and a need for assistance with ADLs, with diagnoses including non-traumatic brain dysfunction, hypertension, UTI, hyponatremia, non-Alzheimer's dementia, and malnutrition. During continuous observation, the resident was assisted into the dining room and seated at a table with two other residents, but while the tablemates were served and began eating, the resident remained without a meal. The resident continued waiting while the other residents ate, and after they finished, the resident asked, "Was the food good?" The meal was not delivered until approximately 15 minutes or longer after the resident had been seated, by which time the other residents at the table had completed their meals. The dietary aide was unable to explain why the resident's meal was delayed, and the cook stated he forgot to serve the resident initially and did not realize the resident had not received a meal until later. The resident stated that watching other residents eat while waiting made her feel increasingly hungry and caused her to sit wondering when her meal would be served.
Failure to Notify Provider of Weight Gain and Nitroglycerin Administration
Penalty
Summary
The facility failed to ensure the resident’s physician was notified of significant changes in condition and provider-ordered parameters for one resident with intact cognition who required assistance with ADLs and had diagnoses including CHF, CAD, heart failure, GERD, hyperlipidemia, lymphedema, fluid overload, edema, hypokalemia, history of falls, and morbid obesity. The resident’s physician orders required daily morning weights for CHF protocol and notification of the provider for a weight increase of 3 or more pounds within 24 hours or 5 or more pounds within one week. The record showed the resident had weight gains greater than 3 pounds in one day on three occasions, but nursing notes, weight logs, and physician communication records did not document that the provider was notified as ordered. The resident’s record also showed Nitroglycerin 0.4 mg SL was administered on five separate occasions for chest pain or acute angina. The medical record, MARs, and physician communication documentation did not show evidence that the provider was notified after these administrations prior to 2/10/26. The provider order stated that if chest pain or acute angina was not relieved after three doses, staff were to contact the provider, and if the provider could not be contacted, call 911 unless contrary to advance directives. The nurse practitioner stated she had only been notified of one Nitroglycerin dose on 2/10/26 and was not aware the resident had received five doses before that date. Interviews with nursing staff and management confirmed that staff were expected to notify the provider when weight parameters were met and when Nitroglycerin was administered, but this did not consistently occur in practice. The nurse practitioner stated she expected nursing staff to follow provider-established parameters and include a nursing assessment with notification, including weight gain, lung findings, and edema. The DON stated staff were expected to obtain daily weights and notify the provider in accordance with the order, and that the provider should be notified when Nitroglycerin was administered. The DON also stated staff relied on the electronic order wording directing contact after three doses, rather than notifying the provider with each administration.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to ensure the Office of the Ombudsman for Long-Term Care was notified when a resident was transferred to the emergency room on two separate occasions. Record review showed the resident’s quarterly MDS identified moderately impaired cognition and a need for assistance with ADLs, and the resident’s diagnoses included non-traumatic brain dysfunction, hypertension, UTIs, hyponatremia, non-Alzheimer’s dementia, and malnutrition. The resident’s EMR showed transfers from the facility to the ER on 04/17/25 and 06/21/25. Review of the resident’s transfer documentation, progress notes, and the facility’s Ombudsman notification logs did not show that the Office of the Ombudsman for Long-Term Care was notified of either transfer. During interview, the HIM stated unplanned hospital transfers were faxed to the Ombudsman on a monthly basis and reviewed the records for both transfers, confirming they were missing from the system and were not included in the monthly reports faxed to the Ombudsman. The facility’s Discharge and Transfer policy stated that emergency transfer notices must be provided to the resident and resident representative as soon as practicable before transfer, and copies of notices for emergency transfers must also be sent to the Office of the Ombudsman for Long-Term Care.
Incomplete MDS Assessment Left Open After Hospital Transfer
Penalty
Summary
The facility failed to ensure an accurate MDS assessment was completed and closed for R26 after a Medicare 5-day MDS assessment was initiated but not finished. Record review showed R26 was transferred from the facility to the hospital and later expired without returning. The MDS tracking system showed the assessment remained open and exceeded 120 days without completion or closure, and there was no documented evidence that a required discharge assessment was completed or that action was taken to close the MDS after the hospital transfer and death. During interview, the RN Manager stated the assessment should have been closed or the ARD changed after the emergent hospitalization, that the resident was transferred emergently and the MDS should have been closed and left incomplete, and that a Medicare 5-day assessment should not have been completed. The RN Manager also stated being on vacation at the time may have contributed to the MDS not being closed appropriately.
Care Plans Failed to Address Wheelchair Mobility and UTI History
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and updated to address identified needs for 2 residents reviewed for care plan development. One resident had severe cognitive impairment, required assistance with ADLs including transfers, had diagnoses including pneumonia, arthritis, non-Alzheimer's dementia, malnutrition, adult failure to thrive, and disorientation, and used a wheelchair for mobility with occasional assistance needed for locomotion. The resident's comprehensive care plan did not address wheelchair use, foot pedals for safe mobility, or guidance for staff on how to assist with transfers or wheelchair mobility. Another resident had moderately impaired cognition, required assistance with ADLs, and had diagnoses including non-traumatic brain dysfunction, UTIs, non-Alzheimer's dementia, and malnutrition. The resident's MDS identified a history of UTIs and an ongoing clinical condition requiring monitoring and preventative interventions, but the comprehensive care plan did not include a problem, goal, or interventions related to the history of UTIs. During interviews, nursing staff and the DON stated that care plans should identify wheelchair mobility needs, including foot pedals when staff push a resident in a wheelchair, and that a resident's history of UTIs should be included for prevention purposes; however, the reviewed care plans did not contain those details.
Unsafe Wheelchair Transport Without Care Plan Guidance
Penalty
Summary
The facility failed to ensure safe wheelchair transport for one resident with severe cognitive impairment who required assistance with ADLs and used a wheelchair for mobility. The resident’s diagnoses included pneumonia, arthritis, non-Alzheimer’s dementia, malnutrition, localized edema, adult failure to thrive, and disorientation. During observation, nursing assistant and activity aide staff pushed the resident in a wheelchair without foot pedals in place, and the resident’s feet were observed bouncing off the floor and sliding on the floor while being transported in the hallway toward the dining room. The resident’s comprehensive care plan did not address locomotion status, wheelchair use, or whether foot pedals were required for safe mobility, and there was no documented guidance for staff on how to assist the resident when he was in a wheelchair. Staff interviews reflected differing practices: some stated foot pedals should be in place whenever staff pushed a resident in a wheelchair, while others noted the resident did not like foot pedals and typically self-propelled. The DON stated staff should not push a resident in a wheelchair while the resident’s feet were on the floor and confirmed that this expectation should have been addressed in the care plan.
Failure to Timely Report Elopement Incident
Penalty
Summary
The facility failed to report an elopement incident involving a resident with severe cognitive impairment to the State Agency within the required 24-hour timeframe. The resident, who had a history of amputated toes, peripheral vascular disease, diabetes, and muscle weakness, was not identified as an elopement risk. On the day of the incident, the resident refused medications and a blood sugar check, and later, staff discovered that the resident had left the facility through a window after cutting the screen. The resident used a cell phone cord to lock the door and placed pillows in the bed to make it appear as if he was still there. The incident was reported to the State Agency approximately 68 hours after it occurred. The Director of Nursing explained that the resident was supposed to be discharged the previous week, and the family had convinced him to stay longer. On the day of the incident, the resident believed he was going home after a morning appointment but was brought back to the facility by his family. The facility did not initially report the incident as an elopement because they believed the resident had a destination and arrived there safely. The facility's policy required non-abuse allegations without serious bodily injury to be reported within 24 hours, which was not adhered to in this case.
Inaccurate MDS Assessment for Resident's Dental Status
Penalty
Summary
The facility failed to accurately complete a comprehensive Minimum Data Set (MDS) assessment for a resident, identified as R23, who was reviewed for dental status. Upon admission, R23 was noted to have significant cognitive impairment but was reported to be independent with eating and oral hygiene. The MDS assessments conducted on 8/14/24, 10/30/24, and 12/18/24 did not identify any dental concerns, despite R23 having missing teeth on both the upper and lower jaw. Observations on 1/6/25 revealed that R23 had only partial teeth remaining, with no biting surfaces, and the resident acknowledged the need for dental care. However, these dental issues were not reflected in the MDS or the care plan. The care plan for R23, dated 8/8/24, indicated that the resident had his own teeth and could brush them independently once set up. However, the care plan did not address the missing teeth issue. The facility's policy required dental assessments upon admission, quarterly, and with the annual MDS, but these assessments failed to capture R23's dental status accurately. The registered nurse (RN-A) and the director of nursing (DON) acknowledged the oversight, noting that the MDS should have accurately reflected the resident's dental status and that the care plan should have been updated to direct staff on the resident's needs for assistance and care.
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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 Howard Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cokato Manor | 5.9 mi | ★★★★★ | 5 | 0 |
| The Gardens At Winsted Llc | 6.5 mi | ★★★★★ | 6 | 0 |
| The Estates At Delano Llc | 10.2 mi | ★★★★★ | 7 | 0 |
| Lakeside Generations Health Care Center | 11 mi | ★★★★★ | 5 | 0 |
| Park View Health Care Center | 12.3 mi | ★★★★★ | 1 | 0 |
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