Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 - Woodland during CMS and state inspections, most recent first.
Care plans for two residents did not accurately reflect contact precautions. One resident had cellulitis and MDRO in a lower extremity wound, and the other had MRSA with a lower leg wound and moderate cognitive impairment. Both had contact precaution signs on their doors, and staff were observed using gowns and gloves, but the care plans listed enhanced barrier precautions instead of contact precautions. Interviews with nursing staff and the DON/infection preventionist confirmed the residents should have been on contact precautions and that the care plans were not accurate.
A resident who required maximum assistance for transfers and toileting activated the call light for help but was left waiting for 38 minutes while staff prioritized other residents. The resident, unable to ambulate and not wearing appropriate footwear, attempted to transfer independently to use the bathroom, resulting in a fall and a head laceration that required emergency care. Staff interviews confirmed the delay in response and failure to follow care plan interventions, leading to actual harm.
A resident dependent on staff for all toileting needs was not assisted for over three hours, despite being care planned for check and change every two hours. Staff acknowledged the lapse, citing shift change and other duties as reasons for the missed care.
Care plans did not reflect contact precautions for residents with MRSA wounds
Penalty
Summary
The facility failed to update the care plans for 2 residents to reflect contact precautions. One resident had an admission MDS identifying cognitive intactness, a diagnosis of non-pressure chronic ulcer of the right lower extremity, and MDRO; the resident received ointment/medication and nonsurgical dressings for two venous/arterial ulcers and was not in isolation or quarantine for active infection during the assessment period. The resident’s care plan, revised 1/29/25, identified cellulitis and MDRO in the right lower extremity and stated the resident was on enhanced barrier precautions, with staff to wear gowns and gloves during high-contact care and perform hand hygiene. The second resident’s admission MDS identified moderate cognitive impairment and diagnoses including MRSA, with risk for pressure ulcers and open lesions other than ulcers, rashes, or cuts; the resident was also not in isolation or quarantine for active infection during the assessment period. The resident’s care plan dated 1/8/26 identified enhanced barrier precautions due to MRSA, with staff to wear gowns and gloves during high-contact care and perform hand hygiene. Observation showed contact precaution signs on both residents’ doors, and staff were observed wearing gowns and gloves before entering one resident’s room. Interviews with nursing staff and the DON/infection preventionist confirmed both residents had MRSA in their wounds and should have been on contact precautions, but the care plans did not accurately reflect that information.
Failure to Respond Timely to Call Light Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to respond in a timely manner to a resident's request for toileting assistance, resulting in the resident attempting to transfer independently and sustaining a head laceration that required emergency medical care. The resident, who had intact cognition, was occasionally incontinent of bladder, required maximum assistance for transfers and toileting, and was unable to ambulate. The care plan specified that the resident needed assistance of one staff member and a mechanical stand aid for transfers and should be toileted every three hours. On the day of the incident, the resident had last been toileted several hours prior and had used the call light to request assistance, which was not promptly answered. Staff interviews and documentation revealed that the resident activated the call light and was told she would be the next to receive assistance, but staff prioritized assisting two other residents who were considered high fall risks. The call light remained on for 38 minutes before staff responded, at which point the resident was found on the floor with a significant head injury. The resident was not wearing appropriate footwear at the time of the fall, as required by her care plan, and was found to be incontinent of urine. Staff acknowledged that the unit was busy and that the resident had to wait a long time for help, leading her to attempt to go to the bathroom on her own. The facility's policies required prompt response to call lights and implementation of care-planned interventions to prevent falls. Despite these policies, staff did not respond to the resident's call light in a timely manner, nor did they ensure the resident was wearing appropriate footwear. The failure to provide timely assistance and adhere to the resident's care plan directly contributed to the resident's fall and subsequent injury.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to ensure timely toileting assistance for a resident (R16) who was dependent on staff for all toileting needs and was always incontinent of bowel and bladder. Continuous observations revealed that R16 was not assisted with toileting from 2:00 p.m. to 5:05 p.m., despite being care planned for check and change every two hours. R16 was observed sitting in his wheelchair during this period, attending an activity program, and later at the nurse's station and dining room without any staff offering toileting assistance. The documentation indicated that R16 was last checked and changed at 1:53 p.m., and was due for toileting at 3:00 p.m., which was not completed. When interviewed, staff members acknowledged the lapse in care, with the trained medication assistant (TMA)-A admitting that the task might have been missed due to shift change and other duties. The registered nurse (RN)-A confirmed that it was a problem if R16 went longer than two hours without being checked and changed, as per the care plan. The director of nursing (DON) stated that it was expected for nursing assistants to follow the care plan and seek help if they were unable to meet the expectations. The facility's policy on Activities of Daily Living emphasized the importance of providing necessary services to maintain good hygiene, including timely toileting assistance.
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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 Brainerd
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Bethany | 0.7 mi | ★★★★★ | 4 | 0 |
| Heartwood | 16.8 mi | ★★★★★ | 0 | 0 |
| Pierz Villa Inc | 24.9 mi | ★★★★★ | 6 | 0 |
| Little Falls Care Center | 25.4 mi | ★★★★★ | 6 | 0 |
| St Ottos Care Center | 26.2 mi | ★★★★★ | 1 | 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.