Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - Windom during CMS and state inspections, most recent first.
The facility failed to consistently identify, comprehensively assess, and manage pressure ulcers for a high‑risk, paraplegic resident with diabetes, an indwelling catheter, and an ostomy. An existing heel wound was incompletely documented and not incorporated into the care plan, and later sacral and buttock skin changes, urinary meatus breakdown, and foot wounds were recorded with inconsistent locations, no staging, and missing measurements. Wound clinic records showed detailed staging and treatment recommendations that were not timely or fully reflected in the care plan, including catheter and brief management and measures to prevent recurrent shearing. The resident was not placed on a formal turning/repositioning schedule despite dependence for mobility, and staff documentation of refusals to get out of bed was repetitive and not linked to new interventions, while nursing assistants reported the resident usually accepted care when re‑approached. In late stages, buttock wounds with extensive eschar and slough and a dark lateral foot lesion were present without clear physician notification or evidence‑based treatment orders, and the resident ultimately required hospitalization for advanced, infected pressure ulcers with osteomyelitis and cellulitis.
A resident with paraplegia, diabetes, obesity, and existing right heel skin breakdown was admitted with high risk for pressure ulcers, but the initial care plan did not include a skin integrity focus or the documented heel wound, and the admission wound form lacked required descriptive details. Later, an RN wound assessment identified an unstageable right heel ulcer and subsequent documentation noted a new buttock pressure sore and a stage 3 ulcer at the urinary meatus related to catheter tension and incontinent brief use, yet the care plan was not promptly revised to include these new wounds or the wound clinic’s specific interventions for off-loading boots, catheter device positioning, brief removal, and barrier cream, despite the DON’s expectation that RN leaders update care plans with changes.
Two residents were not afforded appropriate dignity during care. One resident with cognitive impairment and a urinary catheter was twice observed with the catheter bag exposed and improperly placed, once hanging from a trash can and later on the floor in a wash basin, both times without a dignity cover despite staff acknowledging that covers should be used. Another resident who required assistance for bed mobility was left sitting on the edge of the bed in only a brief with pants at the knees, yelling for help, while the room door remained open and the privacy curtain was not drawn as staff provided support. Staff and leadership later confirmed expectations for covered catheter bags and closed doors during care, consistent with the facility’s dignity policy.
A resident with paraplegia and known risk for skin breakdown developed worsening shearing and open areas on the buttocks and impaired skin integrity at the coccyx/sacrum, while documentation of Wound Data Collections lacked measurements and wound type descriptions. Nursing orders and skin observations showed evolving buttock wounds, discoloration, and a left lateral foot issue, but there was no evidence that the physician was notified of new wounds or treatment changes, nor that the care plan was revised to address refusals and repositioning. The resident’s emergency contact reported not being informed of the buttock wounds and learned of their severity from a visitor, despite a facility policy requiring immediate notification of the resident, MD, and representative when treatment must be significantly altered.
A resident with paraplegia and type 2 DM, who was cognitively intact and had no documented dental issues on admission assessments, expressed a desire to pursue dental care, which was noted in the Nursing Admit/Re-admit Data. The resident later reported that no one had assisted in arranging a dental appointment, despite having informed the clinical care leader RN. The CCLRN stated that county case workers and the DON would need to approve dental appointments and described it as a process but could not explain the process or identify who should initiate it. Record review showed no documentation of any attempts to arrange dental services, contrary to facility policy that requires providing or obtaining routine and emergency dental services and assisting residents with making appointments and arranging transportation.
Two residents received wound care, catheter care, and personal care during which staff did not consistently follow infection prevention and control practices. For one resident with paraplegia, multiple pressure ulcers, an indwelling catheter, and an ostomy, nurses performed wound and wound vac care without reliably sanitizing hands between glove changes, placed supplies on undisinfected surfaces, reused gauze from an open package after contact with blood and other contaminated items, and allowed wound vac tubing to fall to the floor and leak secretions. Another nurse then provided IV care wearing gloves but no gown and left the room without hand hygiene. For a second resident with dementia, edema, and a history of pressure ulcers, a nursing assistant performed toileting, perineal care, catheter manipulation, and equipment handling while wearing the same gloves throughout, including into the hallway and bathroom. A nurse conducted leg wound care after dropping gauze on the floor and placing dressings on an uncleaned chair, with inconsistent hand hygiene. Later, a hospice nurse and an LPN performed buttock wound and catheter care without changing gloves or sanitizing hands between contact with the resident’s buttocks and clean supplies, despite staff acknowledging in interviews that such glove use and infection control lapses were problematic.
The facility failed to maintain a comprehensive infection prevention and control program, as the infection preventionist did not conduct formal surveillance or analyze infection data for trends. The DON confirmed the lack of comprehensive infection surveillance, which is crucial for identifying trends and implementing preventive interventions.
A resident with impaired cognition and incontinence was denied timely assistance to use the commode by an NA, leading to embarrassment due to incontinence. Other staff members confirmed that residents should be assisted when requested, and if busy, staff should seek help. The incident highlighted a failure in providing dignified care.
A resident with Parkinson's disease and other conditions experienced a deficiency in care as the facility failed to consistently implement a care plan for maintaining range of motion (ROM). Observations showed the resident's hands were often without the prescribed splint, and staff interviews revealed inconsistencies in applying passive range of motion (PROM) exercises. The occupational therapist confirmed the need for PROM and splinting, but documentation was insufficient to assess changes in the resident's condition.
A facility failed to follow standards of care for a resident with an indwelling catheter. The resident, with a history of UTIs and diagnoses including ulcerative proctitis, had a catheter placed without a clear medical justification. Staff were uncertain about the catheter's necessity, and the facility's policy requiring an order and indication was not met. The catheter was used as a permanent solution for incontinence without further evaluation or a urology consult.
Failure to Assess and Manage Pressure Ulcers Leading to Severe Wound Infection
Penalty
Summary
The deficiency involves the facility’s failure to identify, comprehensively assess, monitor, and implement effective interventions to prevent and manage pressure ulcers for multiple residents, with Immediate Jeopardy for one resident. One resident with paraplegia, diabetes, obesity, an indwelling catheter, and an ostomy was dependent for lower body care and transfers and was identified as at risk for pressure ulcers. On admission, the resident’s right heel wound was noted but not staged or fully described despite form instructions to document blanchability, size, color, odor, and discharge. The initial care plan did not include a skin integrity problem or the right heel wound, and subsequent skin checks failed to mention the heel wound. For an extended period after admission and readmission, the care plan was not revised to reflect existing and newly identified skin issues, including sacral redness, and pressure-relieving interventions were delayed or incompletely incorporated into the care plan. As time progressed, the resident developed multiple additional areas of impaired skin integrity, including buttocks, coccyx/sacrum, urinary meatus, and foot wounds. Wound clinic records showed comprehensive staging and measurements of the right heel and urinary meatus pressure ulcers and later buttock shearing injuries, while facility documentation (RN wound assessments, skin observations, and progress notes) was inconsistent and often lacked measurements, staging, wound type, and detailed descriptions. New wounds and changes in condition, such as buttock shearing and coccyx pressure areas, were not consistently or comprehensively assessed, and physician notification for new or worsening wounds was not evident for several documented changes. The care plan was not timely updated to include wound clinic recommendations, such as catheter and brief management for the urinary meatus ulcer and interventions to prevent recurrent shearing injuries to the buttocks. In the weeks leading up to the Immediate Jeopardy period, documentation of the resident’s buttock and coccyx wounds remained inconsistent, with alternating descriptions of coccyx versus buttock involvement and characterizations as shearing or pressure sores, without comprehensive wound assessments or clear identification of wound type. Skin observations and wound data collections around the end of the year showed black and blue tissue on the buttocks and new left lateral foot involvement, yet there was no documented physician notification or change in treatment orders for these developments. Wounds were not measured until early January, at which time large buttock wounds with significant eschar and slough, macerated and erythematous margins, and drainage were finally documented. Interviews with nursing staff revealed reliance on a clinical care lead RN to measure wounds and obtain orders, acknowledgment that wounds had not been measured for weeks, and use of treatments such as hydrofera blue and cleansing with soap and water or wet wipes without clear physician authorization or articulated evidence-based rationale. Throughout this period, the resident was not placed on a formal turning and repositioning schedule despite being at risk for pressure ulcers and dependent for repositioning. Staff and interdisciplinary team notes repeatedly referenced the resident’s refusals to get out of bed or reposition, but these notes were often verbatim over multiple entries and did not reflect new assessments or individualized interventions to address refusals. Nursing assistants reported that the resident rarely refused care and would usually accept care when re-approached, while a nurse later stated the resident had not received education on the risks of not repositioning prior to hospitalization. The clinical care lead RN stated that shearing was not a form of pressure, that the resident’s discolored buttocks were “always” monitored, and that larger protective dressings such as Mepilex were sometimes not used due to size or payor concerns, leading to use of ABD pads instead. By the time the resident was evaluated at the wound clinic in January, the buttock and foot wounds were classified as unstageable and stage 3 pressure ulcers, with the gluteal wound described as very advanced and infected, and subsequent hospital records documented sacral decubitus ulcer with osteomyelitis and cellulitis. Additional observations after the resident’s return from the hospital showed ongoing gaps in wound management and monitoring. Nursing staff could not initially locate dressing change orders, and the resident reported that no care had been provided to his heels over the weekend and that wedges for repositioning were only used if he requested them. On examination, facility leadership identified a dark, non-blanching area on the right lateral foot that was questioned as an unstageable pressure ulcer or suspected deep tissue injury, while the clinical care lead RN initially characterized it as a blister and a diabetic wound. Toenails pressing into adjacent toes and causing skin indentations were discovered only during surveyor observation, and improvised measures such as placing gauze between toes were initiated at that time. These documented inactions and inconsistent assessments, monitoring, and interventions for existing and developing wounds contributed to the progression of the resident’s buttock wound to a severe, infected pressure injury requiring hospitalization for osteomyelitis, cellulitis, and soft tissue infection.
Failure to Timely Update Care Plan for Multiple Pressure Ulcers and Catheter-Related Wound
Penalty
Summary
The deficiency involves the facility’s failure to timely and comprehensively update a resident’s care plan to reflect existing and newly developed pressure ulcers and related interventions. The resident was admitted with paraplegia, type 2 diabetes, obesity, and a documented right heel wound on the Nursing Admit/Re-admit Data Collection, but that form lacked required descriptive details such as staging, blanchability, size, color, odor, or discharge. The admission MDS identified the resident as at risk for pressure ulcers, with significant lower extremity impairment, dependence for lower body care and transfers, and use of pressure-reducing devices, but no pressure ulcers were documented at that time. The initial care plan dated the day after admission did not include a skin integrity focus or identify the right heel wound, although it did address assistance needs for turning and transfers. A subsequent care plan identified only potential for pressure ulcer development and general preventive interventions, without specifically addressing the existing right heel wound. As the resident’s condition evolved, the facility did not revise the care plan to reflect new pressure ulcers and specific wound-related interventions in a timely manner. An RN wound assessment later identified an unstageable right heel pressure ulcer, but the assessment did not address a red sacrum noted on the same date, and the care plan was not updated at that time to include off-loading boots, which were only added months later. A progress note documented a new pressure sore on the right buttock and the resident’s refusal to get up in a chair at mealtimes despite education on repositioning, yet there was no indication the care plan was revised to address this new wound. A wound clinic report then identified a stage 3 right heel ulcer and a stage 3 ulcer at the urinary meatus related to catheter tension and incontinent brief use, with specific directions regarding catheter device positioning, removal of the brief, and use of barrier cream. The record showed no corresponding care plan revisions to include the new urinary meatus ulcer or the clinic’s catheter and incontinent garment interventions until a later date, and interventions for prevention/minimization of recurrent buttock shearing injuries were also delayed, contrary to the DON’s stated expectation that RN nurse leaders update care plans with changes.
Failure to Maintain Resident Dignity for Catheter Care and Privacy During Personal Care
Penalty
Summary
The deficiency involves failure to maintain resident dignity related to catheter management and privacy during personal care for two residents. One resident with Alzheimer's disease and dementia, who had a urinary catheter placed by hospice on 1/2/26, was observed on two separate occasions with the catheter collection bag exposed and improperly positioned. On one occasion, the catheter bag was hanging from a garbage can next to the resident's recliner without a dignity cover, despite the resident's care plan identifying self-care deficits and the need for staff assistance. On another occasion, the same resident was observed in bed with the catheter bag placed on the floor in a wash basin, again without a dignity cover, even though a dignity bag was available in the closet. Staff, including an RN and an LPN, acknowledged that urine collection bags should be covered for dignity and should not be hung from garbage cans. The second resident, who had anxiety disorder and required two staff for bed mobility, was left without adequate privacy during care. During morning care, a nursing assistant exited the resident's room without shutting the door, leaving the resident sitting on the edge of the bed wearing only a brief secured at the waist with pants pulled down to the knees, while two other nursing assistants supported the resident in a seated position. The resident was yelling for help while the door remained open and the privacy curtain was not drawn. Staff later stated that the door should have been shut during this care. The DON reported that she expected doors to be shut during cares and that catheter bags should have covers, and the facility's Resident Dignity policy directed staff to maintain the dignity of every resident.
Failure to Notify Physician and Representative of Wound Changes and Inadequate Wound Assessment
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and the resident’s representative of changes in a resident’s skin integrity and related treatment orders, and failure to comprehensively assess new and evolving wounds. The resident, who was paraplegic and chair/bedbound, had a care plan identifying shearing on both buttocks and high risk for skin breakdown, with interventions including barrier cream, dressings when areas were open and draining, and monitoring for signs of shearing and infection with reporting of abnormalities to the health care provider. Early faxed communications to the physician noted intermittent shearing on the buttocks and later increased skin breakdown and open sores associated with the resident’s refusal to get out of bed, but there was no evidence that the care plan was revised to address refusals or a repositioning program. Wound Data Collections from mid-December documented impaired skin integrity at the coccyx/sacrum but were not comprehensive, lacking wound measurements and type descriptions, and a physician note during this period did not mention shearing injury. Subsequent nursing orders directed cleansing of the buttocks and application of zinc oxide and ABD pads, and later documentation described shearing on both buttocks, darkened and reddened areas, and black and blue tissue, as well as a dried calloused area on the left lateral foot treated with iodine. However, between early and late December, records did not show that the physician was notified of new wounds or changes in treatment orders, and from late December through the end of the month there was no indication that the buttock wounds and left lateral heel were comprehensively assessed. The resident’s family member, listed as emergency contact, reported not being informed by the facility about the buttock wound and instead learning of its severity from a visitor who assisted with care. A certified wound NP reported that all prior wounds had been healed and that the wound clinic later received a referral for pressure ulcers on the right lateral foot and both buttocks. The DON stated that nurses should notify the physician of any change in condition, and the facility’s Notification of Change policy required immediate notification of the resident, physician, and resident representative when treatment needed to be significantly altered, but the records did not show such notifications occurred for these wound changes.
Failure to Assist Resident in Obtaining Requested Dental Services
Penalty
Summary
The deficiency involves the facility’s failure to assist a resident in obtaining requested dental services, as required by facility policy. The resident, who had paraplegia and type 2 diabetes, was cognitively intact and had no documented dental issues such as cavities, broken teeth, dentures, or bridges on the admission MDS and Nursing Admit/Re-admit Data collection. However, the Nursing Admit/Re-admit Data form included a comment that the resident would like to pursue dental care. Despite this documented request, there was no evidence in the medical record of any attempts to arrange a dental appointment. During interviews, the resident reported that no one at the facility had worked with him to make a dental appointment, although he stated he had informed the clinical care leader RN. The clinical care leader RN confirmed she completed the Nursing Admit/Re-admit Data and acknowledged that county case workers managed the resident and that either they or the DON would have to approve a dental appointment, describing it as a process. She was unable to articulate the process for obtaining a dental appointment when requested by a resident and was unsure who was responsible for initiating it. Review of the resident’s record by the clinical care leader RN did not reveal any documentation of efforts to set up a dental visit, despite the facility’s policy stating that the location provides or obtains routine and 24-hour emergency dental services and assists residents, when necessary, in making appointments and arranging transportation and referrals.
Failure to Follow Infection Control Practices During Wound, Catheter, and Personal Care
Penalty
Summary
The deficiency involves the facility’s failure to follow infection prevention and control practices during wound care and other direct care for two residents. For one resident with paraplegia, multiple pressure ulcers, an indwelling catheter, and an ostomy, staff performed extensive wound and wound vac care without consistently sanitizing hands between glove changes, moved and placed wound supplies on undisinfected surfaces, and handled clean and dirty items interchangeably. During the wound care, staff removed and applied dressings to multiple wounds, manipulated the wound vac, and cleaned blood using gauze taken repeatedly from the same package, sometimes after touching contaminated items, and without always performing hand hygiene between glove changes. The suction tubing from the wound vac fell to the floor and leaked secretions, and the canister was discarded, while staff continued to work in the area. After this care, another nurse entered the room wearing gloves but no gown, removed IV medication, flushed the IV, and left the room without performing hand hygiene. For a second resident with Alzheimer’s, dementia, edema, and a history of pressure ulcers, staff also failed to adhere to infection control practices during toileting, catheter care, and wound care. A nursing assistant performed perineal care, manipulated the mechanical lift, wheelchair, catheter bag and tubing, moved equipment in and out of the room, handled a blanket and pillow, and went into the bathroom and hallway, all while wearing the same pair of gloves and without changing them until the end of the sequence. During wound care to the resident’s legs, a nurse removed heel protectors soaked in bodily fluids, dropped gauze on the floor and picked it up, and placed dressings on a chair that had not been disinfected, while intermittently changing gloves and sometimes sanitizing hands, but not consistently between all clean and dirty contacts. In a subsequent wound assessment of the second resident’s buttocks, a hospice nurse and an LPN initially provided care such as obtaining vital signs and administering medications without gowns or gloves, then donned gowns and gloves to perform wound care and catheter care. During this care, they removed dressings, washed the buttocks with wet wipes obtained from the bathroom sink, applied cream, and handled wound care supplies and the catheter cover without removing gloves or sanitizing hands between touching the resident’s buttocks and clean surfaces. Staff interviews confirmed awareness that gloves should be changed when soiled, between different tasks, and that wearing dirty gloves was an infection control issue. The DON stated that following enhanced barrier precautions and infection control was confusing.
Inadequate Infection Surveillance and Data Analysis
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program, as evidenced by the lack of analysis of monthly surveillance data for trends and patterns. The infection preventionist, RN-B, was responsible for overseeing the infection control program and maintaining the surveillance log. However, RN-B admitted that while infections were tracked and documented, there was no formal surveillance or monitoring of trends and breaks in infection practices. The infection data was reviewed informally and not tracked or analyzed comprehensively, which was confirmed by RN-B during an interview. The Director of Nursing (DON) verified that the facility's infection surveillance was not comprehensive, and residents were not tracked or compared for trends or patterns. The DON acknowledged the importance of monthly analysis to identify trends and implement interventions to prevent infections, including staff education and system process review. Despite the facility's policy indicating the need for a robust infection prevention and control program, the facility had not completed the necessary infection surveillance, data collection, analysis, or tracking and trending of infections among residents or staff.
Failure to Provide Dignified Care for Resident's Toileting Needs
Penalty
Summary
The facility failed to provide care in a dignified and respectful manner to a resident with moderately impaired cognition and a history of bowel incontinence. The resident, who was dependent on staff for toilet transfers and hygiene, requested to use the commode but was denied assistance by a nursing assistant (NA-E) who stated she was too busy. NA-E told the resident she should have asked to use the commode earlier and accused the resident of seeking attention out of jealousy. As a result, the resident was taken to the dining room without being assisted to the commode, leading to embarrassment due to incontinence. Interviews with other staff members, including another nursing assistant (NA-D), a registered nurse (RN-C), a licensed practical nurse (LPN-A), and the director of nursing (DON), revealed that the facility's expectation was for residents to be assisted to use the commode when requested. They indicated that if a staff member was too busy, they should seek help from another NA or a nurse. The incident was observed when NA-D later assisted the resident to the commode, where it was noted that the resident had been incontinent of urine in her brief. NA-E's training record showed she had been trained in person-centered care and effective communication.
Failure to Maintain Resident's Range of Motion
Penalty
Summary
The facility failed to provide adequate services to maintain and prevent the loss of range of motion (ROM) for a resident diagnosed with Parkinson's disease, dementia, polyneuropathy, and peripheral vascular disease. The resident, identified as having severely impaired cognition and limited ROM in both upper and lower extremities, was dependent on staff for all activities of daily living. The care plan required passive range of motion (PROM) exercises and the use of a palm splint for the resident's left hand to prevent complications related to immobility. Observations revealed that the resident's left hand was often found without the prescribed splint, and both hands were noted to be in a contracted position. Interviews with nursing assistants and licensed practical nurses indicated a lack of clarity and consistency in the application of the resident's care plan. The nursing assistant responsible for restorative duties reported being frequently pulled from these duties, resulting in inconsistent application of PROM exercises and splinting. Additionally, there was confusion among staff regarding the resident's need for a splint and ROM exercises for the right hand, which was also observed to be contracted. The occupational therapist confirmed that the resident should receive PROM for both hands and wear a splint on the left hand throughout the day. However, the therapist noted a lack of documentation on the progression of the resident's condition, making it difficult to assess changes in the resident's ROM. The facility's failure to consistently implement the care plan and provide necessary interventions contributed to the deficiency in maintaining the resident's ROM.
Failure to Justify Indwelling Catheter Use for Resident
Penalty
Summary
The facility failed to adhere to standards of care and practice for the use of an indwelling catheter for a resident with a history of urinary tract infections (UTIs). The resident, who has diagnoses including ulcerative proctitis, insomnia, and hypothyroidism, was found to have an indwelling catheter without a clear medical diagnosis justifying its use. The resident's care plan indicated the catheter was related to an overactive bladder and hygiene issues, but there was no documentation of post-void residuals or a urology consult to support the necessity of the catheter. Interviews with staff revealed uncertainty about the reason for the catheter, and the resident reported frequent UTIs despite the catheter placement. The facility's urinary catheter policy requires an order and indication for an indwelling Foley insertion, with consideration of alternatives. However, the resident's documentation lacked a specific indication for the catheter, and the director of nursing acknowledged that the resident's diagnosis did not meet the standard of care for a Foley catheter. Despite this, the catheter was placed as a permanent solution to the resident's incontinence, based on a provider's note and order, without further evaluation or consultation with a urologist.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Windom
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Mountain Lake | 10.8 mi | — | 3 | 0 |
| Colonial Manor Nursing Home | 12.5 mi | — | 21 | 0 |
| Good Samaritan Society - Jackson | 17.6 mi | — | 0 | 0 |
| Good Samaritan Society - Westbrook | 20.1 mi | — | 11 | 0 |
| Seasons Healthcare | 21.5 mi | — | 0 | 0 |
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