Good Samaritan Society Bethany: ADL Care Failures - MN
Federal inspectors cited Good Samaritan Society Bethany following a complaint inspection completed October 2, 2025, documenting failures in basic daily care for residents who depend entirely on staff to move them.
The violation fell under F0677, which covers activities of daily living — the most fundamental category of nursing home care. Eating. Bathing. Moving. For residents who cannot do these things on their own, the nursing home is the only thing standing between them and harm. Inspectors determined the facility's failures affected a small number of residents and classified the level of harm as minimal or potential.
That classification matters, but it doesn't tell the whole story of what immobility does to a body left in one position too long.
Pressure ulcers, sometimes called bedsores, begin forming when sustained weight cuts off blood flow to skin and tissue. They can develop within hours. They start invisibly, as redness beneath the surface, and progress through stages that end in exposed bone and life-threatening infection. Repositioning — turning a resident every two hours, shifting weight, changing position — is the primary way to prevent them. It costs nothing except time and attention.
Good Samaritan Society Bethany's own Assessment Pressure Ulcer Prevention and Documentation Requirements policy, last reviewed in April 2025, spelled this out. Residents flagged as unable to reposition themselves on the facility's Sit-Stand-Walk Data Collection Tool were supposed to receive repositioning as often as their individual care plan directed. Each person was supposed to have a schedule built specifically for them.
The facility's Activities of Daily Living policy, last reviewed in December 2024, added that staff must provide appropriate treatment and services to maintain or improve residents' abilities in daily living tasks, for the well-being of "mind, body, and soul." The Resident Dignity policy, also reviewed in December 2024, committed the facility to care that maintains or enhances each resident's dignity and respect, recognizing their individuality.
Three policies. All recently reviewed. All pointing in the same direction.
Inspectors found the care didn't match the paperwork.
The gap between a facility's written policies and what actually happens on a given shift is one of the oldest problems in nursing home oversight. Policies get updated. They get signed off on by administrators and filed in binders. Then a night shift runs short-staffed, or a resident's call light goes unanswered too long, or the aide responsible for turning a resident gets pulled to help somewhere else. The policy doesn't change. The resident does.
What inspectors documented at Good Samaritan Society Bethany was exactly that kind of gap. The facility's own standards required individualized repositioning schedules for immobile residents. Those schedules were supposed to account for each person's specific vulnerabilities — whether they were incontinent, how well they were eating and drinking, what their skin looked like after being monitored over time. That level of individualization exists because no two residents break down the same way. A resident who is malnourished develops pressure injuries faster. A resident who is incontinent faces additional skin breakdown from moisture. The schedule has to account for the person.
Whether those schedules existed on paper but weren't followed, or whether they weren't developed at all, the inspection report does not specify. What it establishes is that the care residents received did not meet the standard the facility had set for itself.
Good Samaritan Society Bethany is part of the Good Samaritan Society, one of the largest nonprofit providers of senior care in the United States. The Brainerd facility serves residents in central Minnesota.
The complaint that triggered this inspection is not described in the publicly available portion of the report. Someone contacted regulators. Inspectors came. They found what they found.
For a resident who cannot roll over in bed, who cannot shift their weight, who cannot feel the pressure building in their hip or heel or tailbone, the difference between a staff member who comes and one who doesn't is not abstract. It is the difference between skin that stays intact and skin that doesn't. It is the difference between a wound that never opens and one that may take months to close, if it closes at all.
The violation was cited as minimal harm or potential for harm. For the residents it involved, the potential was the point.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society - Bethany from 2025-10-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 10, 2026 · Our methodology
GOOD SAMARITAN SOCIETY - BETHANY in BRAINERD, MN was cited for violations during a health inspection on October 2, 2025.
The violation fell under F0677, which covers activities of daily living — the most fundamental category of nursing home care.
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.