Good Samaritan Society Mountain Lake: Fall Fracture - MN
The resident, identified only as R5 in federal inspection records, had moderate cognitive impairment and needed substantial help getting to the toilet. After an earlier fall, her care team wrote a specific intervention into her plan: staff would offer toilet assistance during 4 a.m. rounds. The intervention never made it onto the Kardex, the quick-reference sheet nursing assistants use at the bedside.
At 6:15 a.m. on January 28, 2026, R5 was found on the floor. She told staff she had been trying to get to the bathroom on her own.
By 6:30 a.m. she was complaining of pain in her left hip, knee, and leg. She was transported to the emergency department before 8 a.m. By mid-morning, the facility learned she had a fractured left hip. The following day, surgeons performed a hemiarthroplasty, replacing the femoral head joint.
The nursing assistant on duty that night, identified as NA-A, told investigators she had checked on the resident between 2 a.m. and 4 a.m. but did not offer toilet assistance. She said she had no idea the toileting check was required. "It was not on R5's Kardex," she said. She acknowledged she had not looked at the care plan before her shift.
The nurse practitioner who reviewed the case was direct: the fall could have been prevented if staff had followed the care plan.
The director of nursing said she believed the toileting intervention had been added to the Kardex. It had not. The omission went undetected until after R5. was already in surgery.
When inspectors interviewed R5 in April, nearly three months after the fall, she remembered hurting her left leg and going to the hospital. She did not think anyone had offered to take her to the bathroom before she fell. She was right.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society - Mountain Lake from 2026-04-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 7, 2026 · Our methodology
GOOD SAMARITAN SOCIETY - MOUNTAIN LAKE in MOUNTAIN LAKE, MN was cited for violations during a health inspection on April 29, 2026.
The resident, identified only as R5 in federal inspection records, had moderate cognitive impairment and needed substantial help getting to the toilet.
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.