Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 - St James during CMS and state inspections, most recent first.
The facility failed to follow physician and hospice orders for bowel management for a resident on hospice, did not administer eye drops according to professional standards for two residents, and did not comprehensively assess or monitor significant bruising and a contusion for a resident on anticoagulation therapy. Additionally, the facility did not perform required quality control checks on glucometers for a resident receiving insulin, despite frequent use and abnormal blood sugar readings.
The facility did not hold required admission or quarterly care conferences or involve residents and their family representatives in care planning for three residents. One resident had no care conferences during her stay, another had only an initial conference with no further involvement, and a third had a delayed conference months after admission. Staff shortages and lack of rescheduling contributed to missed conferences, and documentation did not reflect resident or family participation as required by facility policy.
Two residents did not receive required assistance with personal hygiene, including oral care and shaving, as outlined in their care plans. One resident was not assisted with brushing teeth despite needing help, and documentation of oral care was almost entirely absent. Another resident, who needed help with shaving, was left with long chin hair because staff did not provide a razor or assist as needed. Staff interviews and observations confirmed these lapses in care.
A resident with multiple chronic conditions and limited mobility did not receive restorative nursing care to maintain or improve range of motion, as recommended by therapy and outlined in the care plan. After the departure of the restorative aide, the facility did not communicate or train NAs to continue the restorative program, resulting in the resident spending most of the day inactive and not receiving prescribed exercises or ambulation support.
A resident with an indwelling urinary catheter was observed to have the tip of their urinary drainage tubing repeatedly left uncapped and in contact with the bathroom floor, and the overnight drainage bag was not cleaned or stored according to facility policy. Staff used a tap water and vinegar solution to clean the bag, but the process and storage did not follow infection control protocols, and the infection preventionist was unaware of this practice. Facility documentation did not address the cleaning or use of the leg bag, and required procedures for maintaining a closed system and preventing contamination were not followed.
A resident with severe cognitive impairment experienced two falls, resulting in pain and inability to bear weight. The facility did not notify the resident's representative or the medical provider after the first fall, nor did they update the provider about the resident's ongoing pain and mobility issues as ordered. The family was not given the opportunity to decide on further evaluation, such as an x-ray, despite the resident's declining condition. This failure to communicate and follow notification policies led to a deficiency finding.
A resident with dementia and severe cognitive impairment, who was dependent on staff and receiving hospice care, did not have a care plan addressing constipation despite multiple medical orders and documented periods without bowel movements. Staff and family observed signs of discomfort, and the DON confirmed the care plan lacked necessary interventions for bowel management.
The facility failed to communicate resident rights effectively, as resident council meetings from January to July 2024 did not include discussions on this topic. Four residents attending these meetings were unaware of their rights and their posting location. Interviews with staff revealed that resident rights had not been reviewed in meetings since 2022, and there was no policy guiding these discussions.
A facility failed to ensure enhanced barrier precautions were followed for a resident with an indwelling catheter. Two nursing assistants entered the resident's room without donning the required gown or gloves, despite indicators and available PPE supplies. One assistant acknowledged the mistake, confirming the expectation to wear PPE due to the resident's catheter. The facility's policy required enhanced barrier precautions for residents with catheters during high-contact care activities.
The facility failed to ensure that SA survey results were accessible to residents, affecting four residents who attended council meetings. The survey results binder was located at an unmanned reception desk, not easily accessible to residents. Interviews revealed that staff did not inform residents of their right to review the results or the binder's location. The facility lacked a policy on resident council meetings, and the resident handbook only mentioned the council as a communication method.
Failure to Follow Physician Orders, Medication Administration Standards, Skin Monitoring, and Glucometer Quality Control
Penalty
Summary
The facility failed to implement physician and hospice orders for bowel management for a resident with dementia and on hospice care. Despite clear orders to administer laxatives and notify the provider if there were three days without a significant bowel movement (BM), documentation showed multiple extended periods without a BM, and no evidence of provider notification or escalation of interventions. The resident's care plan and assessments did not address bowel issues, and staff interviews confirmed a lack of awareness and follow-through on bowel protocols, resulting in the resident being sent to the emergency room for constipation-related discomfort. In addition, the facility did not follow professional standards for eye drop administration for two residents. Observations revealed that a trained medication aide failed to use proper technique, including not pulling down the lower eyelid and allowing the tip of the bottle to touch the eye, which is contrary to accepted practice. The aide also administered more drops than ordered in one case. The DON confirmed there was no specific training or policy for eye drop administration, and the medication aide was unaware of proper procedures. The facility also failed to comprehensively assess and monitor significant bruising and a contusion for a resident on anticoagulation therapy. Weekly skin assessments lacked documentation of measurements or characteristics of bruises, and new contusions were not promptly identified or documented. Staff interviews indicated there was no expectation or process for ongoing monitoring of bruises, and the DON was unaware of new injuries until informed by surveyors. Additionally, the facility did not perform required quality control checks on glucometers used for blood glucose monitoring, with logs showing no quality control for nearly two months despite frequent use and unusually high blood sugar readings. Manufacturer and facility policy required quality control with each new bottle of test strips and when abnormal readings occurred, but this was not followed.
Failure to Conduct and Document Resident Care Conferences
Penalty
Summary
The facility failed to conduct admission or quarterly care conferences and did not invite or involve residents and/or their family representatives in the care planning process for three residents reviewed. For one resident admitted in January, there was no documentation of any care conference or evidence that the resident was included in the development or revision of the care plan. The resident confirmed in interviews that she had not participated in any care conference or been asked for input regarding her care plan during her stay. Another resident, admitted in July, reported never being invited to a care conference or having input into his plan of care. The electronic medical record showed only one care conference, which the resident was invited to but did not attend, and there was no evidence of additional care conferences. The social service director acknowledged that only an initial care conference had occurred and that subsequent conferences were missed due to staff absences. A third resident, admitted in January, had only one care conference several months after admission, with no documentation of an initial care conference or early family involvement. The social service director explained that scheduled care conferences were not conducted or rescheduled due to her absence. The facility's policy required timely care conferences with resident and representative involvement, but this was not followed, as confirmed by staff and documentation review.
Failure to Provide Assistance with Personal Hygiene and Oral Care
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene, specifically oral care and shaving, as directed by the care plans for two residents. One resident, with diagnoses including chronic kidney disease and high blood pressure, required assistance with most activities of daily living (ADLs) and was care planned for set-up and clean-up assistance with oral care. However, the care plan and Kardex did not specifically address oral care, and documentation showed that out of 60 opportunities in the past 30 days, oral care was only documented once as refused. Observations confirmed that staff did not offer or provide oral care during morning routines, and the resident reported never being asked or assisted with brushing teeth. Another resident, with chronic kidney disease, depression, morbid obesity, and diabetes, required setup assistance for personal hygiene, including shaving. Despite expressing a preference for having chin hair shaved and being unable to stand at the mirror, the resident was observed with long chin hair over multiple days. The resident stated that staff were often too busy to assist, and staff interviews revealed that the resident did not have a razor and that this need had not been communicated to nursing staff. The DON was unaware of the resident's unmet need for shaving assistance. The facility's policy on activities of daily living required that residents unable to perform ADLs receive necessary services to maintain grooming and personal hygiene, including oral care and shaving. Despite this policy, both residents did not receive the required assistance, as evidenced by lack of documentation, staff interviews, and direct observations.
Failure to Maintain Resident's Range of Motion Due to Lapse in Restorative Nursing Program
Penalty
Summary
The facility failed to provide services to maintain or prevent loss of range of motion (ROM) for a resident with multiple diagnoses, including chronic kidney disease, diabetes, dementia, Alzheimer's disease, muscle weakness, and difficulty walking. The resident's care plan identified a need for restorative intervention related to activity intolerance, limited ROM, and limited mobility, with a goal to maintain the current level of function. Recommendations from physical therapy included specific exercises and ambulation routines to be completed five times per week. However, there was no current physician order for physical therapy evaluation or treatment, and the resident's Point of Care (POC) documentation did not list any restorative nursing functions, including ROM or ambulation. Interviews with staff revealed that the facility previously had a restorative aide, but the position was eliminated due to low census, and the responsibility for restorative care was not clearly communicated or assigned to nursing assistants (NAs). NAs reported not being instructed or trained to perform restorative nursing care, and the director of nursing (DON) and administrator acknowledged that the restorative nursing program had stopped when the restorative aide left. Observations showed the resident spent most of the day in a recliner and expressed a desire to walk in the hallway to stay limber, but this was not being facilitated. The facility's policy required restorative nursing care to be provided based on individual needs, but this was not implemented for the resident in question.
Failure to Maintain Infection Control for Urinary Drainage System
Penalty
Summary
The facility failed to ensure proper infection control practices for a resident with an indwelling urinary catheter. The resident, who had diagnoses including urinary retention, hydronephrosis, and a flaccid neuropathic bladder, required supervision with most activities of daily living and had a physician's order for a catheter but not for a leg bag. Observations revealed that the tip of the resident's urinary drainage tubing was repeatedly found lying uncapped on the bathroom floor, and the overnight urinary drainage bag was not maintained according to facility policy. The care plan and Kardex did not address the use or cleaning of the leg bag or overnight drainage bag, nor did they specify techniques to minimize infection risk. Staff interviews and observations showed that the overnight urinary drainage bag was cleaned daily using a solution of tap water and vinegar, which was injected into the bag with a catheter-tip syringe. The bag, along with the tubing, was then placed in a basin on the bathroom floor, and the tubing was often left uncapped and in contact with unclean surfaces. The cleaning supplies, including a jug of vinegar and a urinal, were stored together in the same basin as the drainage bag, contrary to policy. The graduate used for cleaning was not changed weekly as required, and the practice of using tap water and vinegar was not known to the infection preventionist. Facility policy required that catheter tubing should never touch the floor, that contaminated closed collection systems be replaced immediately, and that cleaning of drainage bags be performed with specific solutions and techniques, including proper drying and capping of tubing. These procedures were not followed, and the facility's documentation did not reflect the actual practices observed. The DON acknowledged the potential for infection due to these lapses and confirmed that the observed practices did not align with facility policy.
Failure to Notify Family and Provider After Resident Fall with Injury
Penalty
Summary
The facility failed to notify a resident's representative and medical provider following a fall with potential injury. The resident, who had diagnoses including dementia with agitation, psychosis, anxiety, and delusional disorder, experienced a fall during a power outage and was found on the floor with pain in the left leg. Documentation indicated that the administrator and DON were notified, and an information sheet was prepared for the certified nurse practitioner (CNP). However, the progress notes stated that the resident's family would be notified during business hours, and there was no follow-up documentation confirming that the family was actually notified after the first fall. The family member later reported learning about the first fall only after being notified of a second fall the following day. After the falls, the resident exhibited increased pain and inability to bear weight on the left leg. Hospice was notified and recommended comfort measures, including morphine administration, but there was no documentation that the CNP was updated about the resident's ongoing pain and weight-bearing difficulties as previously ordered. The CNP later stated that if she had been informed of these changes, she would have considered ordering an x-ray and discussing options with the family. The family was not given the opportunity to decide on further diagnostic evaluation, such as an x-ray, despite the resident's worsening condition. The facility's own policy required immediate notification of the resident, physician, and representative in the event of an accident with potential injury or significant change in condition. Interviews with staff and review of documentation confirmed that there was no evidence the family or CNP were properly notified as required. The resident's condition deteriorated following the falls, and he passed away a few days later. The lack of timely notification and communication with both the family and medical provider constituted the deficiency identified by surveyors.
Failure to Develop Comprehensive Care Plan for Constipation
Penalty
Summary
The facility failed to develop and maintain a comprehensive care plan addressing constipation for a resident with dementia, severe cognitive impairment, and who was receiving hospice and palliative care. Despite multiple physician and hospice orders for bowel management, including scheduled and as-needed laxatives and suppositories, the resident's care plan did not include interventions for bowel or bladder incontinence or constipation. The care plan did address other areas such as hospice, opioid use, and pain management, but omitted bowel issues, even though the resident was dependent on staff for all activities of daily living and had severely impaired communication abilities. Observations and interviews revealed that the resident experienced multiple extended periods without a documented bowel movement, and family members and staff noted signs of discomfort and pain that were not verbally communicated by the resident. The family reported an emergency room visit due to constipation, and staff acknowledged the need for a care plan to address constipation, especially given the resident's opioid use. The director of nursing confirmed the absence of a care plan for constipation, and facility policy required individualized care plan interventions for bowel management based on assessment and resident response.
Failure to Communicate Resident Rights
Penalty
Summary
The facility failed to provide ongoing communication to residents about their rights, as evidenced by the lack of discussion on resident rights during resident council meetings. The review of meeting minutes from January through July 2024 revealed that resident rights were not included in the discussions. During a resident council meeting, four residents who regularly attended these meetings stated they did not recall any discussions about their rights and were unaware of where the resident rights were posted within the facility. This indicates a gap in communication and education regarding resident rights. Interviews with facility staff further highlighted the deficiency. A licensed social worker, who facilitated the monthly resident council meetings, admitted that resident rights had not been reviewed in these meetings since 2022. The director of nursing confirmed the absence of a policy on resident council meetings and provided an undated page from the resident handbook, which mentioned the purpose of the resident council but did not ensure the inclusion of resident rights in discussions. This lack of structured communication and policy adherence contributed to the residents' unawareness of their rights.
Failure to Follow Enhanced Barrier Precautions for Resident with Catheter
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were followed for a resident with an indwelling catheter. The resident, identified as having moderately impaired cognition and dependent on staff for transfers, was observed on a specific date when two nursing assistants entered the room without donning the required gown or gloves, despite a magnet indicating EBP and personal protective equipment (PPE) supplies being available outside the room. The nursing assistants were observed completing a brief change for the resident without wearing a gown, and one of them confirmed the omission, acknowledging the expectation to wear a gown and gloves due to the resident's catheter. The facility had provided training on PPE usage in EBP resident rooms, and the director of nursing confirmed the expectation for staff to wear PPE when providing care to residents on EBP. The facility's policy on Standard and Transmission Based Precautions, dated earlier in the year, indicated that enhanced barrier precautions are necessary for residents with indwelling urinary catheters, especially during high-contact care activities such as transfers, dressing, providing hygiene, changing briefs, or assisting with toileting.
Inaccessible Survey Results for Residents
Penalty
Summary
The facility failed to ensure that state agency (SA) survey results were accessible to residents, specifically affecting four residents who regularly attended resident council meetings. During an observation, the survey results binder was found at the main entrance on an unmanned reception desk, which was not a common area for residents. This location made the results generally accessible only to family members and legal representatives, not to the residents themselves unless they were entering or exiting the building or meeting with staff in the offices. During a resident council meeting, the four residents in attendance were unaware of the SA survey results and did not know where they were located. Interviews with facility staff revealed that the licensed social worker, who facilitated the resident council meetings, did not recall informing residents of their right to review the SA survey results or the location of the survey binder. Additionally, the director of nursing stated that the facility did not have a policy on resident council meetings, and the resident handbook only mentioned that the council was a way for residents to communicate with the facility. The administrator, upon being informed of the findings, relocated the binder to a more accessible location in the dining room.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 69 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near St James
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Living Meadows At Luther - Madelia | 11.6 mi | ★★★★★ | 3 | 0 |
| Truman Senior Living | 14.2 mi | ★★★★★ | 13 | 0 |
| Good Samaritan Society - Mountain Lake | 15.2 mi | ★★★★★ | 3 | 0 |
| Seasons Healthcare | 15.5 mi | — | 0 | 0 |
| Sleepy Eye Rehabilitati Center | 22.1 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Good Samaritan Society - St James.
100% money-back within 48 hours.
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.