Inspection Reports for
Good Samaritan Society Waconia
433 5th Street West, Waconia, MN, 55387
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
15.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
292% worse than Minnesota average
Minnesota average: 3.9 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 24, 2025
Visit Reason
The inspection was conducted following an immediate jeopardy situation triggered by a resident (R2) eloping from the facility unsupervised shortly after admission, to assess compliance with safety and supervision requirements.
Complaint Details
The complaint investigation substantiated an immediate jeopardy situation beginning 2025-07-18 when resident R2 was admitted and identified as high risk for elopement. The resident eloped on 2025-07-19 due to failure to implement safety measures. The immediate jeopardy was removed on 2025-07-19 after corrective actions were taken.
Findings
The facility failed to maintain adequate supervision and safety measures for a high-risk resident, resulting in elopement and immediate jeopardy. The facility did not implement required safety interventions such as wanderguard application and increased monitoring until after the elopement occurred.
Deficiencies (1)
F 0689: The facility failed to ensure adequate supervision and accident hazard prevention for one resident at high risk for elopement, resulting in the resident leaving the facility unsupervised and being found offsite. Safety interventions including wanderguard application and 15-minute checks were not implemented prior to the elopement.
Report Facts
Residents affected: 1
Date of elopement: Jul 19, 2025
Date of admission: Jul 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN)-A | Admitted resident R2 and failed to apply wanderguard or implement safety measures. | |
| Nurse Manager (NM)-A | Responsible for wanderguard application; was not present to apply wanderguard on admission day. | |
| Director of Nursing (DON) | Notified of elopement and confirmed timeline and corrective actions. | |
| Registered Nurse (RN)-B | On duty during elopement; did not place wanderguard or implement increased safety checks. | |
| Registered Nurse (RN)-C | Indicated nurse managers applied wanderguards and was not trained on activation until after elopement. | |
| Dietary Aide (DA)-A | Observed resident wandering without walker and did not recognize resident. | |
| Nursing Assistant (NA)-A | Knew resident was at risk but confirmed wanderguard was not placed and safety checks were not implemented. | |
| Nursing Assistant (NA)-B | Not informed of elopement risk and noted resident packing personal items before elopement. |
Inspection Report
Routine
Deficiencies: 17
Date: May 27, 2025
Visit Reason
Routine inspection of Good Samaritan Society - Waconia and Westview Acre nursing home to assess compliance with healthcare regulations including resident care, medication management, infection control, and safety.
Findings
The facility had multiple deficiencies including improper use of physical restraints, failure to communicate pharmacy consultant recommendations, delayed reporting of incidents, medication errors at discharge, inaccurate Minimum Data Set (MDS) coding, incomplete baseline care plans, incomplete care plans for dialysis and other resident needs, failure to administer PRN medications as ordered, development of a pressure ulcer due to neglect, inadequate fall prevention interventions, failure to monitor antipsychotic medication side effects, improper hand hygiene during meal assistance, and failure to offer recommended pneumococcal vaccinations.
Deficiencies (17)
F0604: The facility failed to ensure pillows were not used as physical restraints for 1 of 1 resident (R21). Pillows were tucked under the fitted sheet to prevent the resident from getting out of bed without a physical restraint assessment.
F0605: The facility failed to communicate pharmacy consultant's gradual dose reduction recommendation for antipsychotic medication to the hospice prescriber for 1 of 5 residents (R43).
F0609: The facility failed to timely report suspected abuse and neglect incidents to the State agency for 2 of 4 residents (R213 and R214).
F0610: The facility failed to thoroughly investigate and protect residents from an allegation of neglect for 1 of 4 residents (R214).
F0628: The facility failed to ensure accurate medication reconciliation at discharge, resulting in 1 resident (R214) being sent home with another resident's medications, causing actual harm requiring hospitalization.
F0641: The facility failed to ensure accurate MDS assessments for 2 residents (R49 and R59), including failure to document falls and discharge status correctly.
F0644: The facility failed to notify the designated state mental health authority when 1 of 3 residents (R2) had a new onset of mental illness.
F0655: The facility failed to complete and implement baseline care plans within 48 hours of admission for 3 of 5 residents (R35, R41, and R215).
F0656: The facility failed to develop a comprehensive, person-centered care plan including dialysis for 1 of 2 residents (R35) reviewed for dialysis.
F0657: The facility failed to revise care plans to include current behaviors, toileting needs, discontinued medications, tube feeding status, and falls for multiple residents (R51, R20, R24, R7, and R55).
F0684: The facility failed to administer PRN torsemide as ordered for 1 resident (R41) with congestive heart failure despite documented weight gains over threshold, contributing to hospitalization.
F0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for 1 of 3 residents (R213), resulting in a deep tissue injury due to prolonged placement on a bedpan.
F0689: The facility failed to comprehensively assess and develop interventions to address repeated falls for 1 of 1 resident (R55).
F0756: The facility failed to ensure consulting pharmacist recommendations for PRN antipsychotic medications were acted upon timely for 1 of 5 residents (R43).
F0757: The facility failed to ensure residents receiving antipsychotic medications had routine orthostatic blood pressure monitoring and tardive dyskinesia assessments for 2 of 5 residents (R55 and R215).
F0880: The facility failed to ensure proper hand hygiene was performed during dining services for 1 of 1 resident (R1) assisted with meal set-up.
F0883: The facility failed to ensure recommended pneumococcal vaccinations were offered and/or provided timely for 2 of 6 residents (R20 and R49).
Report Facts
Number of falls: 18
Deep tissue injury size: 1.25
Deep tissue injury size: 24
Deep tissue injury size: 26
PRN torsemide doses missed: 7
Finger nail length: 0.25
Medication doses taken in error: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-A | Nurse Manager | Named in multiple findings including restraint assessment, medication errors, care plan deficiencies, and fall prevention |
| RN-E | Registered Nurse | Named in medication error and hospital transfer for R214 |
| NA-D | Nursing Assistant | Named in pressure ulcer neglect incident for R213 |
| NA-C | Nursing Assistant | Named in pressure ulcer neglect incident for R213 |
| RN-B | Registered Nurse | Named in toileting refusal and care plan deficiency for R20 |
| RN-D | Registered Nurse | Named in medication error reporting for R214 |
| RN-F | Registered Nurse | Named in restraint use interview for R21 |
| TMA-A | Trained Medication Aide | Named in restraint use interview for R21 |
| MD | Medical Director | Named in medication reconciliation and care plan interview |
| PT-A | Physical Therapist | Named in fall risk and wheelchair evaluation for R55 |
Inspection Report
Routine
Deficiencies: 11
Date: May 27, 2025
Visit Reason
Routine inspection of Good Samaritan Society - Waconia and Westview Acre nursing home to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to communicate pharmacy consultant recommendations, delayed reporting of incidents, medication errors leading to resident harm, inaccurate Minimum Data Set (MDS) assessments, incomplete baseline and revised care plans, failure to administer PRN medications as ordered, inadequate pressure ulcer care, inconsistent nurse staffing postings, and improper infection control during meal assistance.
Deficiencies (11)
F0605: Facility failed to communicate pharmacy consultant's gradual dose reduction recommendation to hospice prescriber for 1 of 5 residents reviewed for unnecessary medications.
F0609: Facility failed to timely report suspected abuse, neglect, or theft to the State agency for 2 of 4 residents reviewed, resulting in delayed investigations.
F0610: Facility failed to thoroughly investigate and protect residents from neglect allegations for 1 of 4 residents reviewed.
F0628: Facility failed to ensure accurate medication identification and dispensing upon discharge, resulting in a resident ingesting another resident's medications causing actual harm and hospitalization.
F0641: Facility failed to ensure accurate MDS assessments for 2 residents, risking inaccurate federal reimbursement and care planning.
F0655: Facility failed to complete and implement baseline care plans within 48 hours of admission for 3 of 5 residents reviewed.
F0657: Facility failed to revise care plans to include current behaviors, toileting needs, discontinued medications, tube feeding status, and falls for residents reviewed.
F0684: Facility failed to administer PRN torsemide as ordered for 1 resident with congestive heart failure despite documented weight gains, contributing to hospitalization.
F0686: Facility failed to provide appropriate pressure ulcer care and prevent new ulcers for 1 resident, resulting in a deep tissue injury and actual harm.
F0732: Facility failed to consistently post nurse staffing information and census in a location accessible to residents and visitors.
F0880: Facility failed to ensure proper hand hygiene and glove use during meal assistance for 1 resident, risking infection control breaches.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 69
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-A | Nurse Manager | Interviewed regarding multiple deficiencies including care plans, incident reporting, and medication administration |
| RN-D | Registered Nurse | Reported medication error involving resident R214 |
| RN-E | Registered Nurse | Notified nurse manager of medication error for resident R214 |
| NA-C | Nursing Assistant | Failed to check on resident R213 on bedpan leading to pressure injury |
| NA-D | Nursing Assistant | Failed to check/change resident R213 during shift |
| Administrator | Facility Administrator | Responsible for incident reporting and nurse staffing posting |
| RN-B | Registered Nurse | Reported resident R20's toileting refusal and care plan issues |
| RN-C | Registered Nurse | Checked resident R213 and found bedpan in place |
| RN-A | Registered Nurse | Reviewed care plans and medication administration records |
| RN-E | Registered Nurse | Reported medication error and hospital transfer of resident R41 |
| RN-B | Licensed Practical Nurse | Reported on resident R41's weight monitoring and medication orders |
| NA-D | Nursing Assistant | Assisted resident R1 with meal without proper hand hygiene |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control breach during meal assistance |
Inspection Report
Routine
Deficiencies: 3
Date: Feb 27, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pressure ulcer care, foot care, and fall prevention in the nursing home.
Findings
The facility failed to comprehensively assess and treat pressure ulcers, provide routine toenail care, and perform thorough fall assessments including root cause analysis and implementation of immediate interventions for residents reviewed.
Deficiencies (3)
F 0686: The facility failed to comprehensively assess wounds with measurements and consistently implement interventions to promote healing of a Stage 3 pressure ulcer for 1 of 3 residents. Daily wound data assessments and weekly RN wound assessments were not completed as required, and the off-loading boot was not consistently applied as ordered.
F 0687: The facility failed to ensure ongoing, routine toenail care was provided to prevent potential foot-related complications for 1 of 3 residents. Long, unkept toenails caused discomfort, and there was no documentation or timely podiatry follow-up.
F 0689: The facility failed to perform comprehensive fall assessments including root cause analysis and failed to implement immediate interventions to reduce fall risk for 2 of 3 residents. Fall huddle worksheets were not completed or located, and care plans lacked timely updates after falls.
Report Facts
Residents reviewed: 3
Falls reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-B | Registered Nurse | Interviewed regarding wound care and fall incident documentation |
| NM-A | Nurse Manager | Interviewed regarding wound data collection and nail care procedures |
| NP-A | Nurse Practitioner | Interviewed regarding wound care and fall prevention interventions |
| DON | Director of Nursing | Interviewed regarding wound assessments, nail care, and fall prevention policies |
| RN-C | Registered Nurse | Interviewed regarding fall incident and documentation |
| NM-B | Nurse Manager | Interviewed regarding fall incident reporting and follow-up |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 1, 2024
Visit Reason
The inspection was conducted due to complaints regarding quality of care and medication administration at the facility.
Complaint Details
The investigation was complaint-driven based on reports from residents R5 and R9 about quality of care issues, including staff refusal to complete care and dismissive behavior. The complaint was substantiated by findings of inadequate investigation and follow-up by the facility.
Findings
The facility failed to complete a thorough investigation of complaints from residents R5 and R9 about quality of care. Additionally, the facility failed to consistently administer time-sensitive medication within the required time frames for resident R2.
Deficiencies (2)
F 0610: The facility failed to complete a thorough investigation for 2 of 3 residents (R5, R9) who reported concerns related to quality of care. The director of nursing did not interview other residents or staff and had not followed up adequately with involved parties.
F 0684: The facility failed to consistently administer medication within the one-hour before or after assigned time frame for 1 of 2 residents (R2) receiving Parkinson's disease medication. Multiple instances of delayed medication administration were documented, potentially impacting resident health.
Report Facts
Instances of medication administration outside allowed time frame: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-B | Licensed Practical Nurse | Named in quality of care complaint and investigation for refusal to complete care and dismissive behavior. |
| NA-A | Nursing Assistant | Named in quality of care complaint and investigation for refusal to complete care and dismissive behavior. |
| RN-A | Registered Nurse, Clinical Manager | Provided interview regarding medication administration concerns and timing. |
| CP-A | Consultant Pharmacist | Provided expert opinion on medication timing and potential side effects. |
| DON | Director of Nursing | Responsible for investigation and follow-up of complaints; interviewed during inspection. |
Inspection Report
Routine
Deficiencies: 6
Date: Aug 15, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, infection control, and facility operations at Good Samaritan Society - Waconia and Westview Acre.
Findings
The facility was found deficient in maintaining clean wheelchairs and feeding equipment, timely reporting and investigating abuse allegations, monitoring orthostatic blood pressure for psychotropic medication use, implementing bowel movement protocols, cleaning kitchen fans regularly, and adhering to infection prevention and control practices including enhanced barrier precautions.
Deficiencies (6)
F 0584: The facility failed to maintain wheelchairs and feeding tube pumps in a clean and sanitary manner for multiple residents, with observed food debris and rust on equipment.
F 0609: The facility failed to immediately report an allegation of abuse within 2 hours and lacked investigation and documentation for the allegation involving a resident.
F 0610: The facility failed to thoroughly investigate abuse allegations and implement appropriate interventions for a resident.
F 0684: The facility failed to ensure orthostatic blood pressure monitoring for a resident on psychotropic medications and failed to implement bowel movement protocols for a resident with constipation.
F 0812: The facility failed to ensure 3 of 4 kitchen fans were free of lint buildup and cleaned on a regular schedule, posing a potential risk to residents and staff.
F 0880: The facility failed to ensure proper infection control practices for urinary catheter care and failed to utilize enhanced barrier precautions for a resident with wounds.
Report Facts
Days without bowel movement: 10
Medication doses: 2
Medication doses: 3
Wheelchair cleaning schedule: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-B | Registered Nurse | Named in relation to abuse allegation documentation and reporting. |
| DON | Director of Nursing | Named in relation to wheelchair cleaning policy, abuse reporting, and infection control findings. |
| RN-D | Registered Nurse | Named in relation to wound care and enhanced barrier precaution practices. |
| IP | Infection Preventionist | Named in relation to infection control practices and resident behavior affecting catheter care. |
Inspection Report
Routine
Deficiencies: 6
Date: Sep 14, 2023
Visit Reason
Routine state inspection of Good Samaritan Society - Waconia and Westview Acre nursing home to assess compliance with regulatory requirements including care planning, monitoring, dialysis care, medication administration, medication storage, and hospice coordination.
Findings
The facility had multiple deficiencies including failure to coordinate hospice care for a resident, inadequate monitoring of weights and vital signs for a resident receiving dialysis, failure to monitor dialysis access sites and include dialysis care in care plans, medication administration errors resulting in an 8% error rate, improper storage and removal of controlled medications, and lack of integrated care plans for hospice services.
Deficiencies (6)
F 0657: The facility failed to ensure coordination of care was integrated for hospice for 1 of 1 resident reviewed for care plan revisions. The care plan lacked hospice provider information, contact details, and an integrated care plan.
F 0684: The facility failed to appropriately monitor weights and vital signs for 1 of 6 residents reviewed for hospitalization, missing documentation of weights and vital signs on multiple days prior to hospitalization.
F 0698: The facility failed to ensure dialysis access sites were appropriately monitored and assessed for 2 of 2 residents receiving hemodialysis and failed to include dialysis care and coordination in care plans.
F 0759: The facility failed to administer medication according to manufacturer guidelines and physician orders for 2 of 25 observations, resulting in an 8.0% medication error rate.
F 0761: The facility failed to ensure two Fentanyl patches and one bottle of hydrocortisone were immediately removed after residents were discharged and lacked a written procedure for storing controlled medications no longer in use.
F 0849: The facility failed to coordinate hospice services between the facility and hospice agency for 1 of 1 resident, lacking hospice care plans, schedules, documentation, and communication with family and staff.
Report Facts
Medication error rate: 8
Dialysis runs: 35
Weight gain: 5
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