Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 - Mary Jane Brown during CMS and state inspections, most recent first.
Unmonitored resident food refrigerator contained multiple unlabeled and expired food items, dried spills, and mold-like food. Dietary staff had no cleaning or checking schedule, and the cook stated he did not know when it had last been inspected. The admin reported the facility did not currently have a CDM or anyone Serve Safe certified.
Incorrect PBJ Staffing Submission: The facility failed to submit complete and accurate PBJ staffing data to CMS because weekday RNs with administrative duties were coded as direct care RN staff. Review of PBJ reports and staffing schedules showed multiple RNs were counted as direct care when they were scheduled for administrative duties, and the DON and corporate manager acknowledged the coding error.
Failure to Confirm G-Tube Placement Before Enteral Feeding: A resident with a G-tube, dysphagia, and severe cognitive impairment received enteral feeding without the LPN confirming tube placement first. The LPN prepared the formula and flush, connected the feeding, and started the pump without checking whether the tube was still in the stomach, and later stated she had not been trained to do so. The DON said staff were expected to follow the tube-feeding policy, which required placement and patency checks before feeding or giving fluids or meds.
The facility failed to store discontinued controlled narcotic medications separately from in-use medications, as observed during a survey. Discontinued medications for five residents were found in two medication carts alongside active medications. Nursing staff were unaware of proper storage procedures, and the facility's policy lacked documentation on controlled medication storage. The interim DON and consultant pharmacist were also unaware of the improper practice.
The facility failed to consistently deliver mail to residents on Saturdays, affecting two residents with intact cognition. Mail delivery was dependent on the presence of activity staff, who were only available for a limited time on Saturdays. If mail arrived after staff had left, it was not delivered until Monday. The facility lacked a specific policy for mail delivery in long-term care.
A resident with cognitive impairments and multiple diagnoses was served fish despite a documented dislike, due to the facility's failure to update his care plan and communicate dietary preferences effectively. Staff interviews revealed that menu slips were often returned blank, and the dietary manager confirmed the oversight, highlighting a communication breakdown in the facility's meal service process.
An LPN administered levothyroxine to a resident along with calcium and iron supplements, contrary to the medication's label instructions. The LPN did not notice the label's precaution and the instructions were not included in the MAR, leading to the oversight. The IDON confirmed that the medications had likely been administered together for the past three days, contrary to the facility's medication administration policy.
A facility failed to conduct required bi-annual AIMS assessments for a resident on psychotropic medication, as per its policy. The resident, with diagnoses of dementia and depression, was on Seroquel and sertraline. Despite an initial AIMS assessment in September 2023, no further assessments were documented, contrary to the facility's policy requiring such evaluations every six months to monitor for Tardive Dyskinesia.
A resident with a neurogenic bladder had her urinary drainage bag improperly hung from a trash can, contrary to infection control practices. Despite being informed of the risk, the resident continued this practice due to limited placement options. Staff confirmed the practice was inappropriate, highlighting a need for further education on proper infection control techniques.
The facility failed to ensure a newly hired NA received initial training on Alzheimer's disease, ADL assistance, problem-solving with challenging behaviors, and communication skills. The interim DON confirmed the expectation for such training, as outlined in the facility's assessment. However, the facility did not provide a copy of the NA's training policy during the survey.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a urinary catheter and feeding tube. Staff did not wear gowns and gloves during high contact activities, such as transferring the resident, despite care plan instructions and a doorframe magnet indicating the need for EBP. Interviews revealed staff misunderstandings about EBP application, and the facility's policy supports EBP use to prevent infection spread.
The facility failed to assess falls for root cause and implement interventions for two residents with a history of falls. One resident sustained multiple injuries after an unwitnessed fall due to inadequate supervision and care plan implementation. Another resident experienced multiple falls without a comprehensive analysis or updated care plan interventions.
The facility failed to conduct comprehensive bladder assessments and develop individualized toileting programs for two residents, leading to deficiencies in continence care. One resident experienced a change in mobility and required more assistance with ADLs but did not have a toileting program. Another resident experienced a decline in continence and required assistance with clothing management, yet their care plan did not include a toileting program. The facility's policy did not specify timing for assessments or protocols for changes in condition.
A resident with quadriplegia and dysphagia required a two-handled cup for drinking thickened liquids, as specified in their care plan. However, staff were unaware of this requirement, and the resident's bedside table was not positioned within reach, resulting in the resident being unable to access water without assistance.
A facility failed to consistently assess and monitor a quadriplegic resident's heel wound, which was first noted on 1/21/24. Despite the resident's care plan requiring heel protectors, the wound progressed without proper documentation or new interventions. The DON was informed by the family on 1/17/24 but did not document staff interviews or update the care plan as required by facility policy.
A resident with quadriplegia and a neck fracture developed a heel wound that was inconsistently monitored and documented by the facility staff. Despite the care plan requiring heel protectors, the wound's progress was not consistently assessed, leading to inadequate monitoring. Interviews with staff revealed a lack of adherence to the facility's policy on skin assessment and documentation.
A resident with dementia, diabetes, and dysphagia was served the incorrect diet due to staff failing to follow the facility's process for verifying diet orders. The resident required a pureed diet but was served mashed potatoes and pasta noodles. The error was identified and corrected, but not before the resident was offered the incorrect food.
Unmonitored Resident Food Refrigerator
Penalty
Summary
The facility failed to monitor, clean, and properly maintain the refrigerator in the dining room that was designated for food brought in for residents by family members. During observation, the refrigerator contained multiple bags, bottles, takeout containers, and condiment containers with dried spills on the lids and outside surfaces, dried red liquid and food particles on the shelves, and a red dried liquid substance puddled on the second shelf and extending into the lower freezer compartment. The refrigerator also had a posted log for resident food items, but the dates listed did not identify the year, and the log did not reflect consistent monitoring of the contents. Inside the refrigerator were numerous items that were not labeled with a resident name or date, including cocktail sauce with dried buildup under the lid, heavy cream past its manufacturer expiration date, opened sausage, egg nog, coffee creamer, iced coffee, sour cream, snack items, deli meat, bagels, baby carrots, and an avocado that was black, soft, and mushy. One takeout container was labeled with the name of a resident no longer at the facility, another was dated but had no resident name, and one opened taco dip platter had a white mold-like, furry substance on the surface. A small bowl of applesauce was dated from the kitchen, but had no resident name, and the freezer below also contained spilled food items, including ice cream containers and a partially frozen red liquid container with no resident name or date. Cook-A stated dietary staff were responsible for monitoring and cleaning the resident food refrigerator, but there was no schedule or assignment list for cleaning and checking the refrigerator and freezer, and he did not know when it had last been checked. The administrator stated the facility did not currently have a certified dietary manager or anyone certified as Serve Safe, and reported that the previous CDM had left the facility shortly before the observation. The administrator confirmed the resident refrigerator and other kitchen items had included a newly developed cleaning schedule and would be monitored for compliance, and a policy for cleaning the resident-designated refrigerator was requested but not provided at survey exit.
Incorrect PBJ Staffing Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS based on payroll and other verifiable and auditable data during Quarter 4 of 2025. Review of the PBJ report identified excessively low staffing, and review of the 1702D report along with staffing schedules showed that, during an average Monday through Friday day shift, multiple RNs had been working and their hours were submitted to PBJ as direct care RN hours rather than as RN hours with administrative duties. Specific examples included 8/26/25 and 8/27/25, when 6 RNs were coded as direct care RNs on the report, but staffing schedules showed 4 of those RNs were assigned administrative duties and should not have been coded as direct care staff. On 9/30/25, 5 RNs were coded as direct care RNs, but staffing schedules showed 3 of those RNs were assigned administrative duties and should not have been coded as direct care staff. During interview on 4/1/26, the DON stated the facility had not separated weekday RNs with administrative duties from RNs who provide direct care on the PBJ submission, and a corporate manager stated they were unaware that RNs with administrative duties should be coded by job type and category rather than as direct care RNs.
Failure to Confirm G-Tube Placement Before Enteral Feeding
Penalty
Summary
The facility failed to ensure enteral feeding tube placement was confirmed before a feeding was started for a resident with a G-tube. The resident had diagnoses of hemiplegia and hemiparesis following cerebral infarction, dysphagia, and severe cognitive impairment. His MDS identified that he received 51% or more of his total calories through tube feeding and 501 cc/day or more fluid intake by tube feeding. His care plan and physician orders directed staff to provide Osmolyte 1.5 calorie via pump through the G-tube, flush the tube with water during the feeding, and administer medications through the G-tube or with pudding. During observation, an LPN prepared the tube feeding, filled one feeding bag with tap water and another with formula, flushed the G-tube with 30 cc of water, and connected the feeding to the tube. Before starting the pump at 80 cc/hour, she did not perform any checks to determine whether the G-tube was still in the resident's stomach. In interview, the LPN stated she followed her usual procedure and had not been trained to check placement before administering the flush or starting the feeding. The DON stated nursing staff received tube feeding training at orientation and were expected to follow the facility policy, which required checking tube placement and patency before beginning a feeding or administering fluids or medications.
Improper Storage of Discontinued Controlled Medications
Penalty
Summary
The facility failed to ensure that discontinued controlled narcotic medications were stored separately from in-use medications, as observed during a survey. Specifically, five residents had discontinued medications stored in two medication carts alongside active medications. For instance, a box of Fentanyl patches sent in error by the pharmacy was left in the medication cart until destruction, and several blister packs of Lorazepam and bottles of Morphine Sulfate belonging to deceased or discharged residents were found in the narcotic box. These medications were not removed from the in-use narcotic storage, contrary to proper procedures. Interviews with nursing staff revealed a lack of awareness regarding the proper storage of discontinued medications. Both a registered nurse and a licensed practical nurse admitted that discontinued medications continued to be counted and stored with active medications until they could be destroyed. The interim director of nursing and the consultant pharmacist were also unaware of this practice, which was not documented in the facility's medication administration policy. The consultant pharmacist confirmed that discontinued medications should not be stored with in-use medications to prevent errors or diversion.
Inconsistent Mail Delivery on Saturdays
Penalty
Summary
The facility failed to ensure consistent delivery of mail to residents on Saturdays, affecting two residents who expressed concerns about this issue. Both residents had intact cognition, as indicated by their Brief Interview for Mental Status (BIMS) scores of 15. One resident reported not receiving mail on Saturdays because the activity staff, responsible for mail delivery, were only present for a limited time on that day. The other resident also noted irregular mail delivery on Saturdays, attributing it to the limited presence of activity staff who left after assisting with noon meals. Interviews with facility staff revealed that mail was typically picked up by the maintenance director and delivered by activity staff from Monday to Saturday, with no delivery on Sundays. However, if mail arrived after the activity staff had left on Saturdays, it was not delivered until Monday. The administrator in training expected that mail delivered by the post office on Saturdays should reach residents the same day. Despite this expectation, the facility lacked a specific policy for mail delivery in long-term care, as the provided policy did not cover this aspect.
Failure to Revise Care Plan for Resident's Meal Preferences
Penalty
Summary
The facility failed to revise the care plan of a resident, identified as R11, to reflect his meal preferences, specifically his dislike for fish. R11, who has a diagnosis of dementia, diabetes, Parkinson's disease, and anxiety disorder, was observed eating a tuna fish sandwich, which he described as tasting like slop. Despite family members informing the staff multiple times about R11's dislike for fish, the care plan did not include this preference. The resident's nutritional assessment also failed to mention his request not to be served fish. Interviews with staff revealed that R11's menu slips were often returned blank to the kitchen, and his dietary preferences, including his dislike for fish, were not communicated effectively. The dietary manager confirmed that R11's dietary card noted 'NO FISH,' yet he still received fish during a meal. The facility did not provide a policy regarding the handling of dietary preferences by the end of the survey, indicating a lack of proper documentation and communication regarding resident meal preferences.
Improper Administration of Levothyroxine with Calcium and Iron
Penalty
Summary
The facility failed to administer levothyroxine according to labeled instructions for a resident. During an observation, an LPN was seen administering levothyroxine along with calcium and iron supplements, despite the medication label advising against taking levothyroxine with these substances. The LPN did not notice the additional instructions on the medication label and had been administering all of the resident's morning medications simultaneously. The instructions to avoid taking levothyroxine with calcium and iron were not included in the electronic medical record (MAR), leading to the oversight. The interim director of nursing (IDON) confirmed that the medications had likely been administered together for the past three days, as documented in the MAR. The facility's policy on medication administration requires staff to follow the Six Rights of medication administration and to avoid significant medication interactions. However, the LPN did not adhere to these guidelines, as she failed to notice the label precaution and did not verify the instructions with the charge nurse or pharmacy. This oversight resulted in the improper administration of levothyroxine, contrary to the facility's medication administration policy.
Failure to Conduct Required AIMS Assessments for Resident on Psychotropic Medication
Penalty
Summary
The facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident, identified as R12, who was on psychotropic medication. R12 was admitted with diagnoses of dementia, depression, and heart failure, and was prescribed Seroquel and sertraline for these conditions. The facility's policy required an initial AIMS assessment and subsequent assessments every six months to monitor for signs of Tardive Dyskinesia, a potential side effect of psychotropic medications. However, after an initial AIMS assessment in September 2023, there was no evidence of any further assessments being conducted. The interim director of nursing acknowledged during an interview that staff were expected to perform updated AIMS assessments for residents on psychotropic medications as per facility policy. The facility's policy on psychotropic medications required staff to complete these assessments bi-annually and to notify the primary care physician and family if any changes were identified. Despite these requirements, the facility did not adhere to its policy, resulting in a deficiency in monitoring the resident's condition while on psychotropic medication.
Inadequate Infection Control for Urinary Drainage Bag
Penalty
Summary
The facility failed to adhere to proper infection control practices concerning the management of a urinary drainage bag for a resident with a neurogenic bladder. The resident, who was cognitively intact, had a urinary drainage bag due to her condition. Observations revealed that the urinary drainage bag was repeatedly hung from a trash can, which is not an appropriate practice for infection control. This improper placement was noted during multiple observations, including when the resident was seated in her recliner and when assisted by the interim director of nursing. Interviews with various staff members, including registered nurses and a trained medication aide, confirmed that the placement of the urinary drainage bag on the trash can was not acceptable and posed a risk of contamination. Despite being informed of the inappropriate practice, the resident continued to hang the bag from the trash can due to limited options for placement. The facility's policy required that catheters be maintained and properly secured, and any contaminated systems should be replaced immediately. However, the staff and the resident needed further education on proper infection control practices to prevent complications.
Failure to Provide Required Training for New Nursing Assistant
Penalty
Summary
The facility failed to ensure that a newly hired nursing assistant (NA-D) received initial training on Alzheimer's disease or related disorders, assistance with activities of daily living (ADL), problem-solving with challenging behaviors, and communication skills. This deficiency was identified during an interview and document review, which revealed that NA-D, hired on 10/29/24, did not complete the required training. The interim director of nursing confirmed the expectation that all staff caring for vulnerable adults should complete Alzheimer/Dementia training. The facility's August 2024 assessment indicated that staff would be trained on dementia and behavioral health during general orientation, with annual in-services on Federal and State requirements for continuity of care and resident safety. However, the facility failed to provide a copy of NA-D's training policy during the survey.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with indwelling medical devices, including a urinary catheter and feeding tube. The resident's care plan required staff to don gown and gloves during high contact care activities such as transferring, dressing, and device care. However, during an observation, a registered nurse (RN) and a nursing assistant (NA) entered the resident's room and transferred the resident from a wheelchair to a recliner without wearing the required gown and gloves, despite a magnet on the doorframe indicating the need for EBP. Interviews with the staff revealed a misunderstanding of when EBP should be applied. The NA believed EBP was not necessary during transfers, while the RN acknowledged the need for EBP during device care but not for transfers. The medical doctor emphasized that failing to use EBP could spread infections, especially among residents with indwelling devices. Another RN confirmed that EBP should be worn during all transfers and when working with catheters or feeding tubes. The facility's policy on Standard and Transmission-Based Precautions supports the use of EBP during high contact activities to prevent the transfer of multi-drug resistant organisms.
Failure to Prevent Falls and Implement Care Plans
Penalty
Summary
The facility failed to comprehensively assess falls for root cause, implement appropriate interventions, and follow the care plan to prevent and/or reduce the risk of falls with major injury for two residents with a history of falls. One resident, identified as R2, sustained multiple left rib fractures, a left clavicle fracture, and a subdural hematoma after an unwitnessed fall. The facility did not implement R2's care plan for close supervision, which resulted in R2's fifth unwitnessed fall, a major head injury, and subsequent admission to the intensive care unit. R2 had a history of falls prior to admission and experienced multiple falls with injury since admission. Despite being at medium risk for falls, the facility did not conduct a comprehensive fall analysis to identify root causes and implement effective interventions. R2's care plan lacked a toileting routine, and interventions were not consistently updated or followed. The facility's failure to provide adequate supervision and assess the effectiveness of interventions contributed to R2's repeated falls and injuries. Another resident, identified as R3, was at low risk for falls but experienced multiple unwitnessed falls. The facility did not complete a comprehensive analysis of causal factors or root causes to determine appropriate interventions to prevent falls or reduce the risk of falls with major injury. R3's care plan was not updated with interventions to address the identified risk factors, and staff failed to provide the necessary assistance and supervision, leading to repeated falls.
Deficiency in Continence Care and Toileting Programs
Penalty
Summary
The facility failed to conduct a comprehensive bladder assessment and develop individualized toileting programs for two residents, leading to deficiencies in continence care. Resident 3, who was initially admitted with severe cognitive impairment and was continent of bowel and bladder, experienced a change in mobility and required more assistance with activities of daily living (ADLs) after some falls. Despite these changes, Resident 3 did not have a toileting program, and staff relied on the resident to communicate the need to use the bathroom or observed self-transferring attempts. Interviews with nursing assistants revealed that Resident 3 was not on a scheduled toileting program, and the care plan did not address the resident's toileting needs. Similarly, Resident 2, who had intact cognition and was initially continent, experienced a decline in continence and required assistance with clothing management. The resident's care plan did not include a toileting program, and staff were responsible for changing briefs. Interviews indicated that Resident 2 was frequently incontinent and not on a scheduled toileting or check and change program. The facility's policy on bowel and bladder evaluation did not specify timing for assessments outside of the Care Area Assessment, nor did it provide protocols for changes in condition. The Director of Nursing stated that if a resident was continent, it would not trigger a care plan focus for bowel and bladder, which contributed to the lack of individualized interventions for these residents.
Failure to Accommodate Resident's Drinking Needs
Penalty
Summary
The facility failed to accommodate the needs of a resident (R1) who required a two-handled cup for drinking liquids. R1, diagnosed with quadriplegia, a neck fracture, and dysphagia, had a care plan that specified the need for moderately thick water to be placed in a double-handled cup with a lid on a bedside table within reach. However, observations revealed that R1's bedside table was placed in the middle of the room with a one-handled water pitcher, and a plastic disposable cup with thickened water was placed on the nightstand, both out of R1's reach. R1 confirmed that he could not reach either cup without staff assistance. Nursing assistants (NA-A and NA-B) and other staff members were unaware of the specific requirements outlined in R1's care plan, and the bedside table was not adjusted to be within R1's reach during the observation period. Interviews with various staff members, including nursing assistants, a licensed practical nurse (LPN), a registered nurse (RN), and the director of nursing (DON), confirmed that R1 required thickened liquids in a two-handled cup due to limited arm movement. Despite this, the staff failed to provide the necessary accommodations as specified in the care plan. The facility's policy on individualized, person-centered care plans was not followed, resulting in R1's needs not being met. The deficiency was identified through a combination of observation, interviews, and record reviews, highlighting a failure in communication and adherence to the care plan.
Failure to Monitor and Assess Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure an injury of unknown origin was consistently assessed and monitored for healing progress for a resident with quadriplegia, a neck fracture, and dysphagia. The resident's care plan indicated the need for heel protectors while in bed to prevent pressure ulcers. Despite this, a small brown area was noted on the resident's left heel on 1/21/24, and subsequent documentation on 1/28/24 lacked evidence of the heel's progress. By 2/4/24, the area had developed into a small, scabbed wound. The wound was formally documented on 2/6/24, noting its size and condition, but there was no evidence of new or revised interventions to address the wound or ensure proper use of heel protectors. The Director of Nursing (DON) was informed of the wound by the resident's family on 1/17/24 and assessed it the same day, but was unsure how the wound occurred given the resident's immobility and use of heel protectors. The DON only interviewed staff on shift the evening of 1/17/24 and did not document these interviews. The resident's records lacked evidence of an incident between the physician's assessment on 1/9/24 and the family's report on 1/17/24. Additionally, there was no documentation of new interventions or staff monitoring to prevent further wounds, contrary to the facility's policy on abuse and neglect, which requires thorough investigation and care plan updates following incidents.
Inconsistent Monitoring and Documentation of Resident's Heel Wound
Penalty
Summary
The facility failed to ensure consistent assessment and monitoring of an injury of unknown origin for a resident with quadriplegia, a neck fracture, and dysphagia. The resident's care plan indicated the need for heel protectors while in bed to prevent pressure ulcers. Despite this, the resident developed a small brown area on the left heel, which later scabbed over. Documentation of the wound's progress was inconsistent, with no evidence of assessment on certain dates. Family members and staff reported the wound, but there was a lack of consistent monitoring and documentation by the nursing staff. The wound was eventually noted to be healing, but the initial lack of documentation and monitoring was evident. Interviews with various staff members, including nursing assistants, licensed practical nurses, and the director of nursing, revealed that the wound was not consistently assessed or documented. The facility's policy required weekly monitoring and documentation of any skin impairments, but this was not followed. The director of nursing confirmed that the wound should have been assessed weekly until healed, but there was uncertainty about whether this was done. The deficiency highlights a failure in adhering to the facility's skin assessment and documentation policy, leading to inadequate monitoring of the resident's wound.
Failure to Provide Prescribed Altered Diet
Penalty
Summary
The facility failed to provide an altered diet as prescribed for a resident with dementia, diabetes, and dysphagia. The resident required a pureed textured diet as per physician orders. However, during an observation, the resident was served mashed potatoes and pasta noodles instead of pureed food. The nursing assistant assisting the resident was unaware of the diet requirement and attempted to feed the resident the incorrect food. The error was identified, and the plate was replaced with the correct pureed food, but not before the resident had been offered the incorrect diet. Interviews with various staff members revealed that the facility's process for verifying diet orders was not consistently followed. Dietary staff were expected to reference dietary cards to ensure the correct diet was served, but on the evening in question, the process was chaotic, and the double-check verification was not completed. The facility's policy on diet orders lacked specific directions for the meal delivery process to ensure residents received the correct diet per physician orders.
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Illustrative
What surveyors actually found near you
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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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Illustrative
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Nursing homes near Luverne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mn Veterans Home - Luverne | 1.1 mi | ★★★★★ | 5 | 0 |
| Tuff Memorial Home | 11 mi | ★★★★★ | 9 | 0 |
| Parkview Manor Nursing Home | 13.8 mi | ★★★★★ | 10 | 0 |
| Palisade Healthcare Center | 14.3 mi | ★★★★★ | 5 | 1 |
| Edgebrook Care Center | 16 mi | ★★★★★ | 12 | 1 |
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