Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - Jackson during CMS and state inspections, most recent first.
Improper food handling and hand hygiene were observed during meal prep and service. A cook measured salt by shaking it into her bare hand and dumping it into noodles, then used her bare hand to return noodles from the counter and from the edge of plated meals back onto the food. The cook also left the steam table area and returned to plating meals without hand hygiene. The CDM stated bare-hand contact with food was not acceptable and that utensils and proper hand hygiene were expected.
The facility failed to document RTW decisions for 3 staff members with GI illness symptoms. An NA with diarrhea, another NA with fever and diarrhea, and an LPN with vomiting and diarrhea were removed from work, but the illness logs did not consistently record RTW dates, and time punches showed they returned before the forms were completed. The IP stated she did not track RTW well, and the regional clinical services director said the illness forms should be filled out thoroughly and used to guide work restrictions for staff with symptoms.
Failure to properly investigate and report allegations of verbal abuse and involuntary seclusion. Multiple grievances described an RN yelling at residents, blocking a resident from his room, and scolding residents for self-transferring, while an LPN made rude and inappropriate comments to a resident and his representative. The facility’s investigations were limited, with little evidence of broader interviews, incomplete documentation, delayed escalation, and no immediate suspension of the involved RN or timely reporting to the SA as required by policy.
A facility failed to identify and thoroughly investigate multiple grievances alleging verbal abuse, rude and unprofessional comments, and threats of involuntary seclusion by an RN and an LPN toward several residents. The record shows repeated complaints that staff yelled at residents, blocked a resident from entering his room, and used a “time-out” approach, but the facility often interviewed only the directly involved parties, left grievance sections blank, did not document timely reporting to the administrator and SA, and did not remove the staff from direct care pending investigation.
Failure to Report Allegations of Verbal Abuse and Involuntary Seclusion: The facility did not report multiple grievances involving an RN and an LPN to the SA, including resident complaints of rude and disrespectful comments, yelling, scolding, and blocking residents from entering their rooms when they tried to self-transfer. Documentation showed incomplete grievance investigations, delayed administrator sign-off, and no timely reporting of the allegations as verbal abuse or involuntary seclusion.
A resident with bipolar disorder was not referred to the SMHA for a PASRR level II review after the diagnosis was added to the record but not identified on the PAS level I. The SSD said she had not been reviewing the PAS for level II needs and had not notified the county, even though the resident was being seen by psychiatry.
A resident with multiple cardiac, pulmonary, and GI diagnoses was discharged with only two topical meds, while active non-controlled meds such as diltiazem, apixaban, pantoprazole, and a lidocaine patch were not sent home and were instead routed to a local pharmacy for new prescriptions. The MDS nurse confirmed the resident did not leave with the other current meds, and the facility policy addressed medication disposal but did not direct staff to send remaining non-controlled meds with the resident at discharge.
Failure to fully explain the arbitration agreement and the right to refuse signing. A resident with moderately impaired cognition and two other residents had arbitration agreements signed by their representatives or themselves, but interviews showed they did not understand what arbitration was, did not recall receiving a clear explanation, and did not receive a copy in their admission packet. The SSD said paperwork was sometimes reviewed quickly and copies were not routinely provided unless asked, and the ADM was unsure whether a copy was required.
A facility failed to ensure that 1 of 8 sampled staff members completed the required annual Alzheimer's Disease and Related Disorders training. Review of the training records showed that an NA had not completed the annual Alzheimer's and dementia training, and the administrator confirmed the omission during interview, stating the training is usually assigned through the facility's online program.
The facility failed to ensure beverageware and metal pans were completely dry before storing, potentially promoting bacterial growth. A cook was observed stacking wet metal pans and drink cups, which was acknowledged as improper practice. The dietary manager confirmed that dishes should air dry completely, but the facility's policy lacked instructions for drying.
The facility failed to ensure proper infection prevention and control practices, including hand hygiene and equipment cleaning. An Environmental Service Technician did not perform hand hygiene when entering and exiting resident rooms. Additionally, a mechanical lift was not cleaned after use with residents requiring enhanced barrier precautions. Nursing assistants also failed to wear gowns while providing care to a resident with a wound, despite the need for enhanced barrier precautions.
The facility had a medication error rate of 6.9% due to incorrect insulin administration. Two residents received insulin from nurses who primed the Kwikpens with only 1 unit instead of the required 2 units, as per manufacturer instructions. This deviation from protocol was confirmed by the director of nursing and the clinical nurse educator.
Improper Food Handling and Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure infection control measures were followed during meal preparation and service for 1 of 1 observed meal services. During observation of the noon meal preparation, cook-A placed food onto the steam table, then opened a cabinet, removed a saltshaker, shook salt into her bare hand, and dumped the salt from her hand into the cooking noodles. When questioned, she stated she had measured the salt that way and said that was how she always did it. She then set the pot into the sink and prepared a fresh pot of noodles. During plating, cook-A used a large slotted spoon to scoop noodles onto plates, then used her bare hand to scoop noodles hanging off the side of the plate back onto the plate. She repeated this while serving several plates. Later, after leaving the steam table area and going into the dining room to identify room trays, she returned to the steam table without hand hygiene and continued plating meals. The certified dietary manager stated that touching food with bare hands was not acceptable and that staff were expected to use utensils and appropriate hand hygiene. The infection preventionist stated her expectation that all departments follow appropriate infection control practices by utilizing hand hygiene. The facility policy identified that food items were not to be touched using bare hands and that utensils or gloves were to be used when handling food items.
Incomplete staff illness tracking and return-to-work documentation
Penalty
Summary
The facility failed to identify when employees with symptoms consistent with possible norovirus could return to work for 3 of 3 sampled staff members. Review of the Employee Illness Tracking logs showed that NA-A called in with diarrhea and was removed from work, but the return-to-work date was left blank even though time punches showed the employee returned to work two days later. NA-F called in with fever and diarrhea on two consecutive days, was removed from work, and the return-to-work date was also left blank, although time punches showed a return to work the next day. LPN-A called in with vomiting and diarrhea, was removed from work, and the form identified a return-to-work date the next day. The report cited norovirus guidance stating that the virus is spread through the fecal-oral route, causes symptoms such as diarrhea and vomiting, and that infected individuals can shed the virus after recovery. It also noted that staff with gastrointestinal illness should be restricted from patient care and food handling duties until 72 hours after vomiting or diarrhea has ended. The facility’s Employee Illness Tracking log included fields for symptoms, onset date, prevention measures, and return-to-work date, but the April and May 2026 forms were not completed thoroughly and did not document when employees returned to work. During interview, the infection preventionist stated she did not track when employees returned to work very well and agreed the April and May forms lacked return-to-work documentation. The regional clinical services director also stated the employee illness forms should be filled out thoroughly and that the facility should establish a baseline for when to implement more stringent precautions based on staff symptoms. The facility’s infection control policy required employees with symptoms of infection to consult with a supervisor to determine whether they could return to work or needed restriction, and stated that employees with vomiting or diarrhea should be referred before being permitted to perform food handling or resident care duties.
Failure to Properly Investigate and Report Allegations of Verbal Abuse
Penalty
Summary
The facility failed to follow its abuse and neglect policy when multiple grievances described verbal abuse and threats of involuntary seclusion involving two nurses and six residents. The grievances included reports that an LPN spoke rudely and made inappropriate comments to a resident and his representative, and that an RN yelled at residents, scolded them for self-transferring, blocked a resident from entering his room, and told residents they were going into a “time-out.” The report also described concerns that residents were upset by the RN’s tone, volume, and behavior, including statements that she was bossy, assertive, and made residents feel inadequate. The facility’s responses were limited to interviews with the residents directly named in the grievances and the involved nurses, with little evidence of broader fact gathering. In one grievance, the investigation noted the LPN admitted her word choice was not the best, but there was no documentation of interviews with other residents, representatives, or staff to determine whether similar conduct had occurred or whether the resident experienced any psychosocial or physical effects. In another grievance, the RN denied yelling, but the record did not show that the facility explored the reported comments to another resident, interviewed additional witnesses, or documented whether the resident who complained felt safe or had any psychosocial impact. The report also identified that the facility did not handle the allegations as abuse-related concerns under its policy. The policy required allegations of employee-to-resident abuse to be reported immediately, no later than 2 hours after the allegation, and required the employee to be removed from direct care and placed on suspension pending investigation. Instead, the grievances were not promptly escalated, the administrator’s sign-off was delayed on some reports, and the investigations were incomplete or left with blank resolution and follow-up sections. The report further noted that the facility did not immediately suspend the RN during the recurring complaints, did not timely report the allegations to the SA, and did not complete thorough investigations that included broader interviews and documented follow-up.
Failure to Investigate Abuse and Verbal Abuse Grievances
Penalty
Summary
The facility failed to identify allegations of verbal abuse and threats of involuntary seclusion that were reported through grievances involving multiple residents and two nurses. The report describes grievances and interviews involving an RN and an LPN, including concerns that the LPN made rude and unprofessional comments to a resident and the resident’s representative, and that the RN yelled at residents, used a harsh tone, blocked a resident from entering his room, and told residents they were going into a “time-out.” The grievances also described residents becoming upset, feeling inadequate, refusing meals, and reporting that staff were scolding them for self-transferring or attempting to enter their rooms. The facility did not complete timely and thorough investigations of these concerns. In several instances, only the directly involved resident or representative was interviewed, with no documentation of broader interviews with other residents, witnesses, or staff who may have had knowledge of the events. The report notes missing or blank sections on grievance forms, including resolution and follow-up, and no documented assessment of whether residents felt safe or experienced psychosocial effects after the incidents. One grievance involving the LPN was signed off by the DON, but the administrator did not sign off until months later. Another grievance involving the RN was not reported to the administrator and State agency immediately as an allegation of verbal abuse, and the report states there was no documented re-education about what constitutes verbal abuse or timely reporting requirements. The facility also failed to immediately remove the RN and LPN from direct care pending investigation, despite its policy stating that allegations of employee-to-resident abuse required immediate reporting and suspension pending investigation. The report identifies a pattern of recurring complaints about the RN across multiple residents, including reports from staff that the RN was bossy, yelled at residents, blocked a resident from his room, and upset residents who were attempting to self-transfer. The administrator and regional clinical service director acknowledged that the grievance forms lacked thorough investigation and follow-up, and that additional interviews should have been completed, but the report documents that these deficiencies had already occurred across multiple grievances involving six residents.
Failure to Report Allegations of Verbal Abuse and Involuntary Seclusion
Penalty
Summary
The facility failed to report allegations of verbal abuse and threats of involuntary seclusion involving an RN and an LPN to the State Agency. One grievance involved a resident who reported the LPN was rude, stern, and spoke in a manner the resident felt was not nice. During the related interview, the LPN acknowledged making comments about the resident not taking direction well from women and said her word choice was not the best, while the concern was addressed only as unprofessional communication and education on professional conversation was documented. The administrator did not sign off on the report until months later, and there was no report made to the State Agency. A second grievance involved a resident who reported hearing the RN yelling loudly at another resident and then entering the resident’s room and saying she did not like him and that he was not a good patient. The RN denied yelling and said she was reminding the resident to ask for help. The resident who heard the exchange later stated she had no concerns about how the RN treated her, and the resident who was the subject of the yelling said he felt safe and that staff were treating him well. The grievance documentation did not identify the yelling as an allegation of verbal abuse, and it was not reported immediately to the State Agency or the administrator at the time it occurred. A third grievance involved a resident who reported the RN told her she was going into a time-out and said, "you don't know what you are doing," which made the resident feel inadequate. Additional interviews and an email described multiple residents being upset by the RN’s tone, yelling, and blocking residents from entering their rooms when they attempted to self-transfer. Staff described the RN as assertive and bossy, and one staff member reported the RN stood in front of a resident’s door and scolded him while preventing him from entering. The grievance record contained incomplete interviews, blank resolution and follow-up sections, and no indication that the allegations of verbal abuse or involuntary seclusion were reported to the State Agency as required.
Failure to Refer Resident With Bipolar Disorder for PASRR Level II Review
Penalty
Summary
The facility failed to notify the designated State Mental Health Authority for 1 sampled resident who had a diagnosis of bipolar disorder that was not identified on the Pre-admission Screen. The resident’s quarterly MDS assessment dated 5/23/26 showed cognition was intact and no behaviors were displayed during the assessment period. The resident’s PAS level I completed on 10/09/2020 indicated there was no diagnosis of bipolar disorder or other mental illness, and a level II assessment was not required at that time. A diagnosis report dated 7/29/26 showed bipolar disorder had been added to the resident’s record on 4/29/21, but the medical record did not contain evidence that the resident was referred to the SMHA after that diagnosis was identified. During interview, the social service designee stated she had not been reviewing the PAS to ensure a level II screening was completed when needed and confirmed she had not notified the county for a level II referral, although the resident was being seen by psychiatry. The regional clinical service director stated the facility should review the PAS for accuracy and follow up with the mental health authority if a mental illness diagnosis was identified and not reflected on the PAS for level II screening.
Discharge Medication Omission
Penalty
Summary
The facility failed to ensure that one resident was discharged home with all non-controlled medications that were active at the time of discharge. The resident had been re-admitted in early April 2026 for rehabilitation after a surgical procedure and had diagnoses including a wedge compression fracture, pulmonary fibrosis, heart disease, high blood pressure, Barrett’s esophagus, ventricular tachycardia, supraventricular tachycardia, pneumonia, and pulmonary embolism. The resident’s MAR at discharge showed active orders for diltiazem ER 120 mg daily, a lidocaine 4% patch daily for lower back pain related to the fracture, pantoprazole 20 mg daily, apixaban 5 mg twice daily, mupirocin ointment every 12 hours, and trolamine salicylate cream. The discharge notes showed the resident was only sent home with mupirocin ointment and trolamine salicylate ointment, while the other current prescriptions were sent to a local pharmacy for new prescriptions. Email correspondence from the MDS nurse confirmed the resident had not been sent home with the other medications and that only what was listed in the discharge notes was provided. The nurse also relayed that staff may send bottled medications that are ordered and being used at discharge, including OTC medications, lotions, and creams, and document what was sent. Review of the facility’s Medication: Disposition policy showed it addressed disposal of medications under applicable guidelines or with pharmacist consultation, but did not direct staff to send remaining non-controlled medications home with the resident at discharge.
Failure to Fully Explain Arbitration Agreement
Penalty
Summary
The facility failed to ensure the binding arbitration agreement was fully explained in a manner understood by residents or their representatives, including the right to refuse to sign. Review of the resident listing showed that R31, R6, and R40 had an arbitration agreement response of yes. R31’s MDS identified moderately impaired cognition, and her representative/family member signed the arbitration agreement. During interview, the representative stated she did not know what arbitration was, did not recall the facility explaining it, did not recall signing an agreement, and said the admission folder did not contain a copy of the arbitration agreement. She also stated she wanted a copy to review before the 30-day period ended. R6’s MDS identified intact cognition, and her representative/family member signed the arbitration agreement on the day of admission. During interview, the representative stated she was not sure arbitration had been explained, was not aware she agreed not to use the courts in a dispute, and described the admission day as hectic and overwhelming with many papers to sign. R40’s MDS identified admission to the facility, and she signed an arbitration agreement on the day of admission. During interview, R40 stated she was not aware of what arbitration was, did not recall receiving an explanation, did not recall signing the agreement, and did not receive a copy in her admission folder. The social service designee stated she sometimes went through admission paperwork quickly, did not go into detail, and did not provide a copy unless asked. The administrator stated staff were trained to explain arbitration as using a third party to resolve disputes outside court, but he was not sure whether residents or representatives were required to receive a copy of the agreement, and no policy was provided by the end of the survey period.
Failure to Complete Required Annual Dementia Training
Penalty
Summary
The facility failed to ensure that 1 of 8 sampled staff members reviewed for annual required Alzheimer's Disease and Related Disorders training had completed the training. Review of the requested annual Alzheimer's and dementia training on 8/30/26 identified that nursing assistant (NA)-E had not completed the required annual training. During an interview on 8/30/26 at 1:30 p.m., the administrator confirmed that NA-E had failed to complete the annual training and stated that the facility typically assigns the training through its online training program, but he had not realized NA-E had not completed the required training. A policy was requested, but none was provided by the end of the survey period.
Improper Drying of Beverageware and Pans
Penalty
Summary
The facility failed to ensure that beverageware and metal pans were completely dry before storing, which could lead to bacterial growth. During an observation and interview, a cook was seen stacking multiple metal steam table pans upside down on a shelving rack, with visible water on the inside surfaces of the pans. Additionally, multiple drink cups were stacked upside down on a solid plastic tray, with condensation visible in the clear tumblers. The cook acknowledged that staff should not have put pans and drink cups away while still wet, as this could promote bacterial growth. In a subsequent interview, the certified dietary manager confirmed that dishes should be allowed to air dry completely before being put away. The facility's policy on the safe handling of personal and outside food, revised earlier in the year, did not include instructions for drying dishes.
Infection Control Deficiencies in Hand Hygiene and Equipment Cleaning
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, specifically in hand hygiene and equipment cleaning/disinfection. An Environmental Service Technician was observed entering and exiting multiple resident rooms without performing hand hygiene, despite touching various surfaces and clean clothing. This was confirmed by a registered nurse who stated that hand hygiene should be performed upon entering and exiting resident rooms, before and after donning gloves, and when hands are visibly dirty. The facility also failed to clean and disinfect a mechanical lift after use with residents who required enhanced barrier precautions (EBP). Two nursing assistants were observed using a mechanical lift for a resident with moderate cognitive impairment and osteoporosis, and another resident with severe cognitive impairment and a wound requiring EBP. In both instances, the lift was not cleaned after use and was left in the hallway, which was confirmed by the nursing assistants and the director of nursing. The facility's policy requires that lifts be cleaned after each use to prevent cross-contamination. Additionally, the facility did not adhere to EBP protocols for a resident with a wound. Nursing assistants failed to wear gowns while providing care, despite the resident being on EBP due to a burn wound. This was confirmed by the infection preventionist, who stated that gowns and gloves should be worn during high-contact care activities for residents on EBP. The facility's protocol requires PPE to be set up outside the resident's room and staff to be notified of the need for EBP during specific care activities.
Insulin Administration Errors Due to Incorrect Priming Procedure
Penalty
Summary
The facility failed to ensure insulin was administered according to standard practice and manufacturer recommendations, resulting in a medication error rate of 6.9%, which is above the acceptable threshold of 5%. During observations, a registered nurse (RN) and a licensed practical nurse (LPN) were seen administering insulin to two residents using Kwikpens. Both nurses primed the insulin pens with only 1 unit of insulin, contrary to the manufacturer's instructions, which require priming with 2 units to ensure proper dosing. The nurses confirmed that they were taught to prime with 1 unit, indicating a deviation from the correct procedure. The residents involved had specific physician orders for insulin administration. One resident was to receive Humalog solution with meals, with additional units based on a sliding scale for blood glucose levels. The other resident was prescribed a daily dose of Humulin N insulin. The manufacturer's instructions and the facility's policy both specify that the insulin pen should be primed with 2 units, and insulin should be visible at the needle tip before administration. The director of nursing and the clinical nurse educator confirmed the correct priming procedure, highlighting a gap in staff training and adherence to protocol.
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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 Jackson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Manor Nursing Home | 9.4 mi | ★★★★★ | 23 | 0 |
| Accura Healthcare Of Spirit Lake | 15.1 mi | ★★★★★ | 2 | 0 |
| Seasons Healthcare | 17.2 mi | — | 0 | 0 |
| Good Samaritan - Estherville | 17.4 mi | ★★★★★ | 10 | 0 |
| Good Samaritan Society - Windom | 17.6 mi | ★★★★★ | 23 | 1 |
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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 October 2026) and official state health department websites.