Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 - Mountain Lake during CMS and state inspections, most recent first.
A resident with dementia, moderate cognitive impairment, poor vision, unsteady gait, and high fall risk had a care plan requiring staff to toilet her during 4:00 a.m. rounds due to prior falls and need for extensive assistance with toileting and toilet transfers. A CNA checked on the resident during the night but did not offer toileting assistance, stating she was unaware of the toileting intervention because it was not on the Kardex and she had not reviewed the care plan. The resident later attempted to get up to use the bathroom independently, was found on the floor complaining of left leg pain, and was sent to the ED where a closed displaced left femoral neck fracture was diagnosed, requiring a left hip hemiarthroplasty. The NP stated the fall could have been prevented if the care-planned toileting intervention had been followed.
A resident with dementia and Alzheimer's disease ingested another resident's crushed medications after an RN prepared the medications in a glass, placed it in front of the intended resident, and walked away, leaving it unattended. The cognitively impaired resident took the glass, drank the contents, and became lethargic, with her pulse dropping from her usual rate to the 30s–40s bpm. She was sent to the ED, where it was determined she had ingested multiple medications, including metoprolol, and was diagnosed with a medication overdose and bradycardia requiring IV fluids and glucagon.
The facility failed to incorporate identified vulnerable adult risks into the care plans of three cognitively impaired residents, despite MVAA findings that they could not report abuse/neglect, defend themselves from verbal/physical attacks, or manage financial affairs. Staff, including NAs, reported relying on the care plan or Kardex to understand resident needs and interventions. One NA reported finding two residents in a room during an inappropriate physical interaction and did not immediately stop it, instead leaving to get a nurse. Social Services reported completing the MVAA but not specifically care planning vulnerabilities, assuming all residents were vulnerable adults, while the DON stated all identified vulnerabilities should be care planned under the facility’s comprehensive care plan policy.
A resident with a history of stroke and fragile skin developed a deep tissue injury on the coccyx. Although the provider was notified and wound care orders were obtained after the wound opened, there was no documentation of family notification until nearly two weeks later. The family only became aware of the wound after observing it during a visit, and the wound progressed to infection requiring hospitalization. Facility policy required immediate notification of significant changes, but this was not followed.
A resident with impaired mobility and poor nutritional intake developed an unstageable pressure ulcer to the coccyx after staff failed to promptly assess and implement pressure-relieving interventions when a red area was first noted. Despite risk factors and facility policy requiring immediate preventative measures, there was a delay in both assessment and intervention, resulting in the wound progressing to a severe, infected state requiring hospitalization.
A resident with diabetes type 1 was admitted to the ICU with a blood sugar level over 1000 mg/dl due to the facility's failure to properly assess and monitor blood sugar levels. The staff relied on inaccurate CGM readings without confirming with finger stick tests, leading to inappropriate treatment. The resident exhibited symptoms of hyperglycemia, which were not identified, resulting in a diagnosis of diabetic ketoacidosis.
The facility failed to ensure beverageware and metal pans were completely dry before storing, risking bacterial growth. Observations revealed wet metal steam table pans and drinking cups with condensation were improperly stacked. Staff acknowledged the items should have been dry before storage, contrary to the facility's warewashing policy.
A resident with colon cancer and other conditions was found with medications at her bedside without an assessment or physician's order for self-administration. Despite no cognitive impairment, the facility did not document her ability to self-administer medications, contrary to policy. Staff acknowledged the oversight, and the Director of Nursing confirmed the lack of required documentation.
The facility failed to follow professional standards during eye drop administration for two residents. An LPN did not ask the residents to tilt their heads back and placed the drops in the inner corner of the eyes instead of the conjunctival sac. The LPN confirmed she was not trained on proper instillation, and the DON acknowledged the lack of training. An undated document from Elsevier online training was provided, which included proper administration instructions.
A resident was not offered the PCV20 vaccine as recommended by the CDC, despite being eligible. The immunization record lacked evidence of shared clinical decision-making with the physician, and there was no documentation that the resident was informed about the vaccine. The resident expressed interest in receiving the vaccine, highlighting a lapse in the facility's immunization policy.
Failure to Follow Care-Planned Toileting Intervention Resulting in Fall and Hip Fracture
Penalty
Summary
The facility failed to follow a care-planned fall intervention for a resident with dementia, moderate cognitive impairment, poor vision, unsteady gait, and a high risk for falls. The resident’s MDS indicated a need for substantial to maximal assistance with toileting and partial to moderate assistance with toilet transfers. After an actual fall without injury, the care plan was revised to include an intervention for staff to toilet the resident during 4:00 a.m. rounds. On the date of the incident, progress notes documented that at 6:15 a.m. the resident was found on the floor after attempting to use the bathroom, and the resident later reported she had been trying to get up to go to the bathroom before the fall and did not think staff had offered to take her to the bathroom beforehand. A nursing assistant reported that between 2:00 a.m. and 4:00 a.m. she checked on the resident but did not offer toileting assistance and was not aware the resident needed to be toileted during 4:00 a.m. rounds because this intervention was not on the resident’s Kardex. The nursing assistant also stated she did not review the care plan prior to her shift. The DON stated that staff are expected to follow resident care plans and that the toileting intervention had been added to the care plan but was not on the Kardex. The NP stated that the fall could have been prevented if staff had followed the care plan and toileted the resident during 4:00 a.m. rounds. As a result of the fall, the resident sustained a closed displaced left femoral neck fracture requiring a left hip hemiarthroplasty.
Resident Overdose After Ingestion of Another Resident’s Crushed Medications
Penalty
Summary
The facility failed to ensure medications were administered to the correct resident, resulting in a resident with dementia and Alzheimer's disease ingesting another resident's medications. The resident was seated at a dining table across from another resident whose medications had been crushed and placed in a glass of liquid. The administering RN prepared the other resident's medications in the glass, set the cup in front of that resident, and then walked away, leaving the medications unattended. During this time, the resident with dementia took the glass containing the crushed medications and drank from it. After ingesting the medications, the resident became sleepy at the dining room table within about ten minutes. Vital signs showed the resident's pulse decreased to 47 bpm and then to 40 bpm, compared to her usual pulse of around 60 bpm. Poison control was contacted due to concern that the resident had received an unknown amount of high-dose blood pressure medication, and guidance was given to send her to the ED if her pulse dropped below 45 consistently. The resident's pulse continued to decrease, at times dropping into the upper 30s, and she was sent to the ED. In the ED, it was determined that she had ingested valproic acid, carbidopa/levodopa, glycopyrrolate, metoprolol, and mirtazapine, and she was diagnosed with a medication overdose with bradycardia consistent with metoprolol ingestion, requiring IV normal saline and glucagon therapy.
Failure to Integrate Vulnerable Adult Assessment Findings Into Resident Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans that incorporated identified vulnerabilities from the Minnesota Vulnerable Adult Assessments (MVAA) for three residents with dementia or mild cognitive impairment. One resident’s face sheet showed dementia and mild cognitive impairment, and the MVAA documented that this resident was unable to report abuse/neglect concerns, defend herself from verbal or physical attacks, and manage financial affairs. Another resident with mild cognitive impairment was assessed as unable to defend himself from verbal and physical attacks and unable to manage financial affairs. A third resident with dementia, disorientation, and Alzheimer’s disease was assessed as unable to report abuse/neglect concerns, defend herself from verbal or physical attacks, and manage financial affairs. Despite these documented vulnerabilities, each resident’s care plan dated 4/29/26 did not include the specific MVAA findings related to inability to report abuse/neglect, defend against verbal/physical attacks, or manage finances. Nursing assistants reported that they rely on the care plan or Kardex to identify resident needs and how to meet those needs. One NA described entering a resident’s room and finding another resident in a wheelchair at the bedside, with the resident in bed having her pants down and brief to the side, while the other resident was touching her vaginal area; the NA stated she was surprised, left both residents in the room, and went to get the nurse without stopping the interaction. Social Services staff stated they complete the MVAA and then address the findings in the care plan, but acknowledged there was nothing in the care plans about vulnerabilities specifically, explaining it was assumed everyone was a vulnerable adult and treated as such. The DON stated that Social Services was responsible for completing the MVAA and that all vulnerabilities should be care planned, while the facility’s Comprehensive Care Plan policy required development of a person-centered care plan to meet residents’ physical, mental, spiritual, and psychosocial well-being.
Failure to Timely Notify Family and Provider of Deep Tissue Injury
Penalty
Summary
The facility failed to notify the resident's representative and medical provider in a timely manner following the discovery of a deep tissue injury (DTI) for a resident with a history of cerebral infarction and fragile skin. The resident was initially assessed as not being at risk for pressure ulcers, but developed a dark red area on the coccyx, which was first noted by an LPN. Documentation shows that the provider was notified and wound care orders were obtained after the wound opened, but there was no documentation of family notification until nearly two weeks later, despite the facility's policy requiring immediate notification of significant changes. Interviews and record reviews revealed that the family was not informed of the wound until they observed it themselves during a visit, and subsequent communication with the facility did not result in timely updates about the wound's progression. The resident's condition deteriorated, with decreased therapy progress, increased weakness, and decreased appetite, and the wound eventually became infected, requiring hospitalization. The DON confirmed that both the family and provider should have been notified at the initial discovery of the wound and again when it opened, but this did not occur as required. The facility's own policy mandates immediate notification of the resident, physician, and representative in the event of significant changes or injuries. However, documentation and interviews confirm that this protocol was not followed, resulting in a delay in communication regarding the resident's DTI and subsequent decline.
Failure to Implement Timely Pressure Ulcer Prevention and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to assess, monitor, and implement pressure-relieving interventions for a resident who developed an unstageable pressure ulcer to the coccyx area. The resident was admitted with a history of stroke, impaired mobility, and skin fragility, but was initially assessed as being at low to moderate risk for pressure ulcers, with no pressure injuries present on admission. Despite the presence of risk factors such as immobility, poor nutritional intake, and incontinence, the care plan did not include comprehensive pressure ulcer prevention measures until after a red area was discovered on the coccyx. When a red area was first noted on the resident's coccyx, there was a delay in both assessment and the implementation of preventative interventions. Documentation and interviews revealed that no interventions to prevent further skin breakdown were put in place between the initial discovery of the red area and the subsequent assessment, during which the wound had already opened. The facility's own policy required immediate preventative measures and individualized repositioning plans for residents unable to reposition themselves, but these were not initiated in a timely manner. Additionally, there was a lack of consistent wound assessment and documentation, with significant gaps between assessments and no evidence of a repositioning assessment being completed. As the resident's condition deteriorated, the pressure ulcer progressed to an unstageable wound with necrotic tissue and infection, ultimately requiring hospitalization for cellulitis and advanced wound care. Interviews with staff and providers confirmed that preventative measures were not implemented promptly after the initial signs of skin breakdown, and that the severity of the wound could have been mitigated with earlier intervention. The facility's failure to follow its own protocols for pressure ulcer prevention and timely intervention directly contributed to the development and worsening of the resident's pressure ulcer.
Failure to Monitor Blood Sugar Levels Leads to Resident's ICU Admission
Penalty
Summary
The facility failed to properly assess and monitor blood sugar levels for a resident with diabetes type 1, who was admitted to the intensive care unit with a blood sugar level exceeding 1000 mg/dl. The resident's continuous glucose monitor (CGM) showed low blood sugar readings, but these were not confirmed with finger stick tests as recommended by the CGM manufacturer. The resident exhibited symptoms of hyperglycemia, such as confusion and lethargy, which were not identified by the staff due to reliance on the CGM readings. The resident's care plan did not address the use of the CGM, and there was a lack of comprehensive assessments and monitoring for hypo/hyperglycemia. The facility's staff, including licensed practical nurses, were not adequately trained on the use of CGMs and did not follow the manufacturer's recommendations to confirm low or high readings with a finger stick test. This oversight led to the resident receiving inappropriate treatment, such as glucose tablets, based on inaccurate CGM readings. The situation escalated when the resident's condition deteriorated, showing increased confusion and somnolence. Despite the CGM indicating low blood sugar, manual blood sugar tests revealed extremely high levels. The resident was eventually sent to the emergency room, where they were diagnosed with diabetic ketoacidosis and admitted to the ICU. The facility's failure to properly monitor and respond to the resident's blood sugar levels resulted in immediate jeopardy to the resident's health.
Removal Plan
- Review policy on blood sugar monitoring to include the use of CGM's and management of CGM's per manufacturer's recommendations
- Educate staff on correct placement of CGM's that the facility uses
- Educate staff on the signs and symptoms of hyper- and hypo- glycemia
- Educate staff on when to do a finger stick BGM to verify the CGM's readings
- Review with staff when to alert the physician of low and high blood sugars
Improper Storage of Wet Beverageware and Pans
Penalty
Summary
The facility failed to ensure that beverageware and metal pans were completely dry before storing, which could promote bacterial growth. During an observation and interview, a cook was seen stacking wet metal steam table pans upside down on a wire shelving rack. The cook acknowledged that the pans should not have been put away while still wet. In another instance, a different cook was observed with multiple drinking cups stacked upside down on a plastic tray, with visible condensation inside the tumblers and water pooling on the tray. The cook confirmed that the tumblers should have been allowed to dry completely before stacking. The facility's policy on warewashing indicated that dishes are to air-dry before storage or use.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R196, was appropriately assessed and deemed suitable to self-administer medications. R196, who has diagnoses including malignant neoplasm of the colon, polyneuropathy, and pain, was found to have various medications at her bedside, including Tylenol, Systane eye drops, Voltaren gel, and Neosporin ointment. Despite having no cognitive impairment as per her admission Minimum Data Set assessment, there was no documentation in her care plan or physician's orders indicating her ability to self-administer these medications. During interviews, both a registered nurse and a licensed practical nurse acknowledged the presence of medications in R196's room but confirmed that there was no completed self-administration assessment or physician's order authorizing this. The Director of Nursing also verified the absence of such an assessment or order, which is contrary to the facility's policy that requires an interdisciplinary team to determine and document a resident's ability to safely self-administer medications, along with obtaining a physician's order and updating the care plan accordingly.
Improper Eye Drop Administration for Two Residents
Penalty
Summary
The facility failed to ensure professional standards of practice were followed during the administration of eye drops for two residents. Resident R197, who was admitted with a primary diagnosis of pancreatitis, had a physician's order for Alphagen P ophthalmic solution eye drops to be administered three times a day. However, during an observation, the LPN did not ask R197 to tilt her head back and placed the eye drops at the inner corner of each eye instead of the conjunctival sac. Similarly, Resident R7, diagnosed with unspecified macular degeneration, had a physician's order for brinzolamide ophthalmic solution eye drops to be administered twice a day. The LPN also failed to ask R7 to tilt his head back and instilled the drops in the inner corner of each eye. During interviews, the LPN confirmed that she was taught to instill eye drops in the inner corner of the eye and had not received any education from her employer on proper eye drop instillation. The Director of Nursing (DON) stated that nurses are expected to instill eye drops in the pocket of the lower lid and not in the corner of the eye, as this could lead to infection or improper administration. The DON acknowledged that no training on eye drop instillation had been completed. The facility provided an undated document from Elsevier online training, which included instructions on proper eye drop administration, such as asking the patient to look at the ceiling.
Failure to Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident was offered and/or provided the pneumococcal vaccine series as recommended by the CDC. The resident, who was over the age of 65, had previously received the PPSV23 and PCV13 vaccines but had not been offered the PCV20 vaccine, which should have been considered at least five years after the last pneumococcal dose. The immunization record lacked evidence of shared clinical decision-making with the physician regarding the PCV20 vaccine, and there was no documentation that the resident was offered or declined the vaccine. Interviews with the infection preventionist and the director of nursing revealed that immunizations are reviewed upon admission, and eligible vaccines are supposed to be offered to residents. However, in this case, there was no documentation to confirm that the resident was informed about the PCV20 vaccine. The resident expressed interest in receiving the PCV20 vaccine, indicating that she usually receives all recommended vaccines. The facility's policy stated that residents should be provided the opportunity to receive immunizations, but the process was not followed in this instance, leading to the deficiency.
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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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mountain Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Windom | 10.8 mi | ★★★★★ | 23 | 1 |
| Good Samaritan Society - St James | 15.2 mi | ★★★★★ | 0 | 0 |
| Seasons Healthcare | 16.8 mi | — | 0 | 0 |
| St John Lutheran Home | 20.5 mi | ★★★★★ | 10 | 0 |
| Colonial Manor Nursing Home | 21.2 mi | ★★★★★ | 21 | 0 |
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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 July 2026) and official state health department websites.