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🔎 Good Samaritan Society - Mountain Lake

Inspection Results


Inspection Overview

Good Samaritan Society - Mountain Lake has been cited for a total of 33 deficiencies since we began saving each survey.

In Minnesota, the average facility has **36.42 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: J

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2025-02-12
Correction Date: 2025-02-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Allow residents to self-administer drugs if determined clinically appropriate.

Survey Date: 2024-06-26
Correction Date: 2024-07-17
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2024-06-26
Correction Date: 2024-07-17
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-06-26
Correction Date: 2024-07-17
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2024-06-26
Correction Date: 2024-07-17
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: C

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-08-16
Correction Date: 2023-09-20
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2022-04-14
Correction Date: 2022-05-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2022-04-14
Correction Date: 2022-05-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Survey Date: 2022-04-14
Correction Date: 2022-05-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2022-04-14
Correction Date: 2022-06-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2022-04-14
Correction Date: 2022-05-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2022-04-14
Correction Date: 2022-05-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2022-04-14
Correction Date: 2022-05-20
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-04-14
Correction Date: 2022-05-20
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2022-04-14
Correction Date: 2022-05-20
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

Implement a program that monitors antibiotic use.

Survey Date: 2022-04-14
Correction Date: 2022-05-20
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2022-04-14
Correction Date: 2022-05-20
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Survey Date: 2022-04-14
Correction Date: 2022-05-20
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2022-04-14
Correction Date: 2022-05-20
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2021-07-29
Correction Date: 2021-09-09
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Survey Date: 2020-02-21
Correction Date: 2020-03-12
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2020-02-21
Correction Date: 2020-03-12
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2020-02-21
Correction Date: 2020-03-12
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2020-02-21
Correction Date: 2020-03-12
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2018-12-06
Correction Date: 2019-01-15
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2018-12-06
Correction Date: 2019-01-15
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Survey Date: 2018-12-06
Correction Date: 2019-01-15
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2018-12-06
Correction Date: 2019-01-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2018-12-06
Correction Date: 2019-01-15
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Survey Date: 2018-12-06
Correction Date: 2019-01-15
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2018-12-06
Correction Date: 2019-01-15
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2018-12-06
Correction Date: 2019-01-15
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Have a plan that describes the process for conducting QAPI and QAA activities.

Survey Date: 2018-12-06
Correction Date: 2019-01-15
Category: Administration Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**