Good Samaritan Society - Mountain Lake
GOOD SAMARITAN SOCIETY - MOUNTAIN LAKE in MOUNTAIN LAKE, MN — inspection on April 29, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
actions that can be measured.
vulnerabilities for 3 of 3 residents (R1, R2, R3) who's care plans were reviewed for
impairment. R1's Minnesota Vulnerable Adult Assessment (MVAA) dated 2/19/26, indicated R1 was unable to report abuse/ neglect concerns, defend self from verbal/physical attacks, and manage financial affairs. R1's care plan dated 4/29/26, did not identify or include the following vulnerability findings for R1: unable to report abuse/ neglect concerns, defend self from verbal/physical attacks, and manage financial affairs.R2R2's Face Sheet dated 10/9/2023, indicated R2 had mild cognitive impairment.R2'S MVAA dated 2/27/26, indicated R2 was unable to defend self from verbal and physical attacks and was unable to manage financial affairs. R2's care plan dated 4/29/26, did not identify or include the following vulnerability findings for R2: unable to defend self from verbal/physical attacks and manage financial affairs. R3R3's Face Sheet dated 10/23/25, indicated R3 had dementia, disorientation, and Alzheimer's Disease.R3's MVAA dated 4/8/26, indicated R3 was unable to report abuse/ neglect concerns, defend self from verbal/physical attacks, and manage financial affairs.R3's care plan dated 4/29/26, did not identify or include the following vulnerability findings for R3: unable to report abuse/ neglect concerns, defend self from verbal/physical attacks, and manage financial affairs.
During an interview on 4/23/26 at 12:30 p.m., nursing assistant (NA)-A stated she would look at the resident care plan or Kardex for needs a resident might have and how to meet those needs.
During an interview on 4/23/26 at 1:23 p.m., NA-B stated on 4/11/26 around 10:00 p.m., she went into R1's room and found R2 in his wheelchair on the right side of R1's bed, with R1 lying in bed with R1's pants down and brief to the side. R2 was touching R1's vaginal area with his left hand. R1 had her eyes closed but R1's eyebrows were scrunched together. NA-B stated she was surprised by this observation. NA-B stated she left R1 and R2 in the room to get the nurse. NA-B did not stop the interaction. NA-B stated she would look in a resident care plan or Kardex for any resident needs or interventions.
During an interview on 4/29/26 at 1:45 p.m., Social Services (SS)-A stated she would complete the MVAA and once complete she would address the findings in the care plan. SS-A stated there was nothing in the care plan about vulnerabilities specifically because it was assumed everyone was a vulnerable adult and the facility treated all residents as such.
During an interview on 4/29/26 at 3:42 p.m., director of nursing (DON) stated SS-A would be responsible for completing the MVAA.
All vulnerabilities should be care planned.The facility Comprehensive Care Plan policy revised 12/29/25, indicated the facility would develop a person-centered care plan that would meet the residents physical, mental, spiritual, and psychosocial well-being.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
245549 04/29/2026
Good Samaritan Society - Mountain Lake 745 Basinger Memorial Drive Mountain Lake, MN 56159
prevent accidents.
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on
residents (R5) reviewed for falls.
This resulted in actual harm when R5 fell and required a visit to the emergency department resulting in a fractured left femur and needed surgical intervention.
The facility had implemented appropriate corrective action prior to the onsite investigation, so the deficiency is being cited at past non-compliance.ˆ Findings include:R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 had moderate cognitive impairment, needed substantial to maximal assistance with toileting, and needed partial to moderate assistance with toilet transfersR5's Face Sheet dated 6/23/23, indicated R5 had dementia.R5's care plan with intervention revision dated 7/16/25, indicated R5 had an actual fall with no injury related to poor vision and unsteady gait.
Intervention included: staff to toilet resident during 4:00 a.m. rounding. R5's fall tool dated 8/31/25, indicated R5 was at high risk for falls.R5's Emergency Department (ED) note dated 1/28/26, indicated R5 had a fall resulting in a closed fracture of left hip.R5's [NAME] Accountability For Excellence (SAFE) Event- Incident Report dated 1/28/26, indicated at 6:15 a.m., R5 had a fall, was sent to the ED and X-ray verified a left hip fracture.R5's progress notes dated 1/28/26:6:15 a.m., R5 was found on the floor and stated she was trying to use the bathroom.6:30 a.m., indicated R5 was complaining of left hip, knee, and leg pain.7:51 a.m. R5 was sent into the ED.9:58 a.m., facility was notified R5 had a left hip fracture. R5's Orthopedic Surgery note dated 1/29/26, indicated R5 had a closed displaced left femoral neck fracture and needed a left hip hemiarthroplasty (femoral head joint replacement).During an interview on 4/22/26 at 3:15 p.m., R5 stated she had a fall in 1/2026 but could not recall the date.
R5 hurt her left leg and had to go to the hospital.
Before the fall R5 was trying to get up to go to the bathroom. R5 did not think staff offered to take her to the bathroom before her fall.On 4/23/26 at 12:30 p.m., nursing assistant (NA)-A stated on 1/28/26 between 2:00 a.m. and 4:00 a.m., NA-A checked on R5 but did offer toilet assistance to R5. NA-A stated she was not aware R5 needed to be toileted during 4:00 a.m. rounds because it was not on R5's Kardex. NA-A stated she did not look at the care plan prior to her shift. NA-A stated she should have looked at R5's care plan prior to caring for R5.On 4/29/26 at 2:40 p.m., nurse practitioner (NP)-A stated the fall R5 had could have been prevented if staff would have followed the care plan and toileted R5 during 4:00 a.m. rounds.On 4/29/26 at 3:42 p.m., director of nursing (DON) stated staff are expected to follow resident care plans. DON put the intervention to toilet R5 during 4:00 a.m. rounds in R5's care plan. DON thought the intervention was on R5's Kardex but it was not.
The facility now double checks the Kardex to ensure all interventions are in place.On 4/29/26 at 4:07 p.m., administrator stated staff are expected to follow the care plan.
The administrator was made aware R5's toileting intervention was not on the Kardex after discussion with the DON.The facility Fall Prevention and Management policy revised 3/31/26, indicated the facility would communicate fall interventions to prevent a fall per the 24-hour report, care plan and Kardex.The facility implemented corrective action to prevent recurrence by 2/3/26 when the facility completed the following: provided education to all nursing staff on updating interventions, following care plans, and fall risks, reviewed all high fall risk residents and updated care plans, and completed high fall risk audits to ensure fall interventions were care planned and pulling to the resident Kardex.
Verification of corrective action was confirmed by observation, interview, and document review on 4/22/26 and 4/29/26.
245549 04/29/2026
Good Samaritan Society - Mountain Lake 745 Basinger Memorial Drive Mountain Lake, MN 56159
During an interview on 4/22/26 at 4:13 p.m., registered nurse (RN)-A stated he got R4's medications ready in a glass of liquid and set the cup in front of R4 then RN-A walked away. R3 grabbed R4's glass of crushed medications and drank out of the glass. R3's pulse started to decrease so R3 was sent to the ED. RN-A stated he should not have left R4 alone with his medications. RN-A stated he should have stayed with R4 until all of his medications were taken. On 4/29/26 at 2:40 p.m., nurse practitioner (NP)- A stated if the facility would have followed the medication administration policy and procedure R3 would not have ingested R4's medications and would not have been sent to the ED. R3's pulse was normally around 60 bpm so a pulse of 37 bpm was concerning. On 4/29/26 at 3:01 p.m., consultant pharmacist (CP)-A stated R3's pulse being above 50 bpm would not have been concerning but a pulse of 37 bpm was concerning.
Glucagon was given to R3 to reverse the effects of the metoprolol overdose.ˆ On 4/29/26 at 3:42 p.m., director of nursing (DON) stated staff would be expected to stay with the resident when taking medications unless they were assessed and had orders to take medications alone. RN-A should have never left R4's medications on the table, RN-A should have stayed with R4 until his medications were taken. On 4/29/26 at 4:07 p.m., administrator stated staff were expected to stay with residents when giving medications until they were taken, unless the resident was assessed and safe to take medications alone. R4 was not safe to take medications alone.
The facility Medication Administration policy revised 3/30/26, indicated staff would not leave medications with a resident unless a specific physician order was in place to do so and the resident was evaluated for self- administration of medications.
The facility implemented corrective action to prevent recurrence by 3/31/26, when the facility completed the following: provided education to all staff members responsible for medication administration, which included administration of medications and self-administration of medication, observed all residents with self- administration of medication orders and updated care plans, and completed medication administration audits.
Verification of corrective action was confirmed by observation, interview, and document review on 4/22/26 through 4/29/26.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.