Good Samaritan Society Westbrook: Infection Control Failures - MN
That is what federal inspectors found when they reviewed infection control records at Good Samaritan Society Westbrook, a nursing home on First Street in this small southwestern Minnesota city. The inspection, completed January 9, 2025, documented months of surveillance failures, an unmonitored antibiotic, and an infection prevention program that had effectively gone dark.
The facility's infection preventionist, identified in inspection records only by her title, told inspectors she tracked staff illness through illness and absence forms that charge nurses were supposed to complete whenever a staff member called in sick, whether for their own illness or a child's. Copies went to her, to the director of nursing, and to the office manager who handled scheduling. At the end of each month, she compiled everything into a report for the Quality Assurance committee.
The system sounded orderly. It wasn't working.
When inspectors reviewed infection surveillance logs from September through December 2024, they found infections that had never been tracked to resolution, no trending or pattern analysis of any kind, and December's surveillance had simply not been done at all. The infection preventionist told inspectors she had not been including documentation on surveillance or resolution of infections. She could not explain why.
One resident, identified in the report as R23, had been tested for Norovirus. The infection preventionist said she remembered this. But R23 was not on her log. No initial clinical monitoring had been completed. When inspectors asked about the gap between the hospitalized resident and the staff members calling in with the same gastrointestinal symptoms, the picture got worse: the infection preventionist had never correlated the illnesses, had never put measures in place to prevent potential spread, and had not ensured that sick staff stayed home for 72 hours after their symptoms resolved. She told inspectors she was unaware she needed to report a potential Norovirus outbreak.
The administrator told inspectors she had no idea there might be a connection between the resident hospitalized with Norovirus and the staff reporting the same symptoms. She said she would have expected that kind of investigation to happen automatically, and she would have expected documentation confirming that sick staff were kept away from residents for the appropriate period. Then she added something that explained part of the problem: the infection preventionist had been on vacation, and no one had been designated to cover infection control surveillance while she was gone.
The director of nursing confirmed what should have been happening. Antibiotics should not start until a culture comes back. Forty-eight hours after an antibiotic is started, a timeout is supposed to occur, with a form completed and sent to the physician for review. The physician then determines whether the antibiotic should continue or be changed. That process exists to slow the spread of antibiotic resistance and ensure drugs are only used when genuinely needed.
For a resident identified as R7, none of it happened. R7 had been admitted to the facility already on a prophylactic antibiotic. There was no documentation showing anyone had investigated whether the antibiotic was still necessary. No attempt to explore alternate treatments. No antibiotic timeout. The infection preventionist told inspectors that when a resident arrived with orders for a prophylactic antibiotic, she had not investigated or questioned the order. She made no follow-up to confirm antibiotic stewardship had occurred.
The infection preventionist had completed her training certification and provided inspectors a copy of the certificate. But she also told them she wanted more education on what she needed to investigate and document, and that she was still looking for a format that captured the necessary information. She said she was sometimes told about antibiotic use verbally by staff, or learned of it through notes left for her, which she recorded on her log. Whether the electronic reporting system captured antibiotic use depended entirely on whether staff completed the documentation correctly.
The director of nursing told inspectors her expectation was that the infection preventionist would correlate potential outbreak concerns, investigate root causes, and put interventions in place. She said there was a checklist that was supposed to be completed and sent to both her and the infection preventionist. She expected the facility's own infection control policy to be followed.
That policy, reviewed by inspectors from a December 2, 2024 document, described a program designed to prevent, identify, investigate, and report infections and communicable diseases affecting residents, staff, and visitors. It called for nationally accepted standards, an acceptable system to monitor and document infection control, and annual review to ensure compliance. Results were to be communicated to the Quality Assurance and Performance Improvement committee.
The gap between that document and what inspectors actually found ran across four months of records.
A resident had been hospitalized. Staff had been sick with matching symptoms. December's surveillance was never completed. An antibiotic was running in a resident's body with no one checking whether it belonged there. And when the person responsible for watching all of it left for vacation, she left no one watching in her place.
The infection preventionist told inspectors she didn't have an explanation for why R23 hadn't made it onto her log. She said she would like more training. She said she was still figuring out the format.
In the meantime, the logs from the final months of 2024 showed infections that opened and closed with nothing recorded in between, and one month with nothing recorded at all.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society - Westbrook from 2025-01-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 5, 2026 · Our methodology
GOOD SAMARITAN SOCIETY - WESTBROOK in WESTBROOK, MN was cited for violations during a health inspection on January 9, 2025.
Copies went to her, to the director of nursing, and to the office manager who handled scheduling.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.