Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 - Pine River during CMS and state inspections, most recent first.
Hand hygiene was not performed appropriately during personal care for a resident with severe cognitive impairment, incontinence, and total ADL dependence. Two NAs were providing incontinence care while wearing gloves; after one NA cleaned feces from the resident’s skin, she continued with clean brief placement and dressing before removing the dirty gloves and washing her hands. The NA and DON both stated hand hygiene should have occurred after the dirty task and before any clean task, consistent with the facility’s hand hygiene policy.
The facility failed to ensure dietary staff were educated on required dishwasher temperatures, leading to improper sanitization of dishes. The dishwasher's rinse temperature was consistently below the required 180 degrees Fahrenheit, and staff were not instructed on alternative sanitization methods. The dietary manager did not verify repairs or review temperature logs, and staff training lacked critical information on temperature requirements.
The facility failed to maintain the dishwasher rinse cycle at the required temperature of 180°F, potentially affecting 26 residents. The dietary aide and manager were unaware of the significance of the temperature readings and did not take corrective actions. Temperature logs showed consistent non-compliance, and staff interviews revealed a lack of training on minimum temperature requirements and alternative sanitization methods.
The facility failed to consistently post accurate daily nurse staffing information, with postings often incomplete or not updated to reflect changes due to call-ins or staff shortages. Interviews revealed a lack of clarity in responsibilities between the DON and staffing coordinator, contributing to the deficiency. The facility's policy emphasized the importance of updating staffing changes, but this was not adhered to, potentially affecting care for 26 residents.
The facility failed to ensure timely reporting of abuse allegations for two residents. One resident with dementia reported being groped by a nursing assistant, and another resident with depression and stroke was found naked by a family member who suspected abuse. The director of nursing did not report these allegations to the state agency as required by facility policy.
Hand Hygiene Not Performed Between Dirty and Clean Tasks
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff failed to use appropriate hand hygiene during personal care for a resident with severe cognitive impairment. The resident’s quarterly MDS identified diagnoses of dementia with mood disturbance, anxiety, and PTSD, and noted the resident was always incontinent of bowel and bladder and dependent on staff for ADLs including toileting and transfers. The care plan stated the resident was non-ambulatory and required two staff and a total mechanical lift for transfers. During observation, two nursing assistants were checking the resident’s brief while both wore disposable gloves. One assistant helped turn the resident, cleaned feces from the resident’s skin with a disposable wipe and gloved hands, then placed and fastened a clean brief and pulled up the resident’s pants. The assistant did not remove the dirty gloves after cleaning feces and before assisting with the clean brief and dressing; she removed the gloves and washed her hands only after the resident was fully dressed and ready for transfer. In interview, the assistant stated she should have removed the dirty gloves and washed her hands right after cleaning feces from the resident’s skin, and the DON stated staff should have removed dirty gloves and washed their hands prior to completing any other tasks. The facility’s Hand Hygiene policy stated hand hygiene was to be performed upon entering a room, before a clean task, after bodily fluid/glove removal, and upon exiting a room.
Inadequate Staff Training on Dishwasher Temperatures
Penalty
Summary
The facility failed to ensure that dietary staff were adequately educated on the required dishwasher temperatures, which affected the sanitization process for dishes used by all 26 residents. During an inspection, it was observed that the dishwasher's rinse temperature was consistently below the required 180 degrees Fahrenheit, with recorded temperatures ranging from 164 to 176 degrees over several months. Despite this, staff continued to use the dishwasher without implementing alternative sanitization methods, as they were not instructed on the appropriate actions to take when temperatures were insufficient. The dietary manager (DM) acknowledged that the dishwasher had not been reaching the necessary rinse temperature and had contacted a repairman to replace the thermostat. However, the DM did not verify the effectiveness of the repair or review the temperature logs afterward. The DM also failed to provide clear guidance to the staff on using the three-compartment sink process when temperatures were inadequate. Staff members, including dietary aides, were uncertain about the correct procedures and had not been given specific instructions on handling low rinse temperatures. The facility's policy required adherence to the manufacturer's instructions for dishwasher temperatures and completion of a competency checklist for mechanical warewashing, but these were not followed. The DM was unaware of the policy details and the importance of maintaining proper sanitization temperatures. Additionally, the staff training did not cover the critical temperature requirements for dishwashing, leading to a lack of understanding and compliance among the dietary staff.
Dishwasher Rinse Cycle Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the dishwasher rinse cycle reached the required temperature to effectively sanitize dishes, potentially affecting 26 residents who consumed food from the kitchen. During an initial kitchen tour, it was observed that the commercial dishwasher's rinse cycle temperature was consistently below the required 180 degrees Fahrenheit, ranging from 173 to 178 degrees since January 2025. The dietary aide responsible for monitoring the temperatures was unaware of the significance of these numbers and had not been instructed on corrective actions other than documenting them. A review of the Dish Machine Temperature Logs revealed that from January 1, 2025, to February 2, 2025, the rinse temperature only reached the minimum 180 degrees four times. In December 2024, 72 out of 93 recorded temperatures were below 180 degrees, and in November 2024, 66 out of 90 were below the required temperature. The dietary manager acknowledged the issue and stated that a repairman had been contacted on January 19, 2025, to replace the thermostat. However, the manager did not verify the rinse temperature post-repair and assumed the machine was functioning correctly. Interviews with kitchen staff revealed a lack of understanding and training regarding the minimum rinse temperature requirements and alternative sanitization methods. The dietary manager and staff were unaware of the extent of the temperature issue, and the infection control logs did not identify any gastrointestinal illnesses or outbreaks during the period. The facility's policy required staff to follow manufacturer instructions for minimum temperatures, but this was not adhered to, leading to the deficiency.
Inconsistent Daily Nurse Staffing Information Posting
Penalty
Summary
The facility failed to consistently post the required nurse staffing information on a daily basis, as observed during multiple days. On several occasions, the staffing information was either incomplete or not updated to reflect changes due to call-ins, vacations, or staff shortages. For instance, on one day, the posting did not accurately reflect the total hours worked by nursing assistants (NAs) and registered nurses (RNs), and the shifts were not updated to show changes in staffing due to call-ins. Interviews with the Director of Nursing (DON) and the staffing coordinator revealed a lack of clarity and responsibility in ensuring the accuracy of the staffing postings. The DON admitted to not updating the postings due to time constraints, while the staffing coordinator was unaware that the postings needed to be updated throughout the day to reflect real-time changes. This lack of communication and understanding of responsibilities contributed to the deficiency. The facility's policy on Nurse Staff Daily Posting Requirements emphasized the importance of keeping the report updated with staffing changes as they occur. However, the failure to adhere to this policy resulted in inaccurate and outdated staffing information being available to residents, staff, and visitors, potentially affecting the care provided to the 26 residents in the facility.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse to the state agency (SA) for two residents who alleged abuse. Resident 2 (R2), who had dementia and insomnia, reported that a nursing assistant (NA-A) tried to take her clothes off and groped her. This incident was communicated internally via email by a licensed practical nurse (LPN-A) to the director of nursing (DON), but there was no immediate report to the SA as required by the facility's policy. The policy mandates that any allegation of abuse must be reported to the SA immediately, but no later than two hours after the allegation is made. The DON acknowledged the delay and cited issues with the reporting system as a reason for the failure to report promptly. Resident 3 (R3), who had depression, stroke, and anxiety, was found naked in his room by a family member, who suspected that R3 had been molested or raped by staff. The family member reported this to a hospice social worker (SW-A), who then informed the facility. However, the DON did not report the allegation to the SA, assuming that the hospice social worker would handle the reporting. This miscommunication and failure to adhere to the facility's policy resulted in a delay in reporting the abuse allegation to the SA, which is a clear deficiency in the facility's handling of abuse allegations.
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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 Pine River
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heartwood | 27.5 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Bethany | 28.4 mi | ★★★★★ | 4 | 0 |
| Good Samaritan Society - Woodland | 28.5 mi | ★★★★★ | 1 | 0 |
| Lakewood Health System | 30.3 mi | ★★★★★ | 3 | 0 |
| Green Pine Acres Nursing Home | 32.3 mi | ★★★★★ | 6 | 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.