19 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Waconia, MN
1-star overall rating with 1-star inspections with $12,649 in total fines with 19 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
333 Fifth Street West, Waconia, MN
(952) 442-5111
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
75
Certified beds
Average residents
67
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
1980-01-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
89 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
1.21
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.49
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.11
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.71
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.59
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.82
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.32
CMS adjusted RN staffing hours
Adjusted total hours
4.48
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Program rank
4,274
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9935
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0.94
Baseline 18.85% · Performance 21.00% · Measure score 0.94 · Achievement 0.94 · Improvement 0
Healthcare-associated infections
7.24
Baseline 7.30% · Performance 5.67% · Measure score 7.24 · Achievement 7.24 · Improvement 6.56
Total nurse turnover
4.62
Baseline 61.91% · Performance 44.78% · Measure score 4.62 · Achievement 4.62 · Improvement 4.12
Adjusted total nurse staffing
3.45
Baseline 4.25 hours · Performance 4.06 hours · Measure score 3.45 · Achievement 3.45 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.26% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 160 · Observed rate 8.13% · Lower 95% interval 7.42% |
| Discharge to community | 62.21% |
50.57%
11.6 pts better
|
Better than the National Rate · Eligible stays 163 · Observed rate 61.35% · Lower 95% interval 54.98% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 78.95% |
95.27%
16.3 pts worse
|
Numerator 60 · Denominator 76 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 76 |
| Discharge self-care score | 65.15% |
53.69%
11.5 pts better
|
Numerator 43 · Denominator 66 |
| Discharge mobility score | 68.18% |
50.94%
17.2 pts better
|
Numerator 45 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 3.95% |
2.29%
1.7 pts worse
|
Numerator 3 · Denominator 76 · Adjusted rate 5.09% |
| Healthcare-associated infections requiring hospitalization | 5.67% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 93 · Observed rate 2.15% · Lower 95% interval 3.19% |
| Staff COVID-19 vaccination coverage | 3.15% |
8.2%
5 pts worse
|
Numerator 4 · Denominator 127 |
| Staff flu vaccination coverage | 78.03% |
42%
36 pts better
|
Numerator 206 · Denominator 264 |
| Discharge function score | 77.27% |
56.45%
20.8 pts better
|
Numerator 51 · Denominator 66 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 47 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 48.57% |
25.2%
23.4 pts better
|
Numerator 17 · Denominator 35 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
97.3%
1.1 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 100.0% · Q3 100.0% · Q4 95.3% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
96.1%
1.9 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
3.9%
2 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 6.5% · Q3 6.5% · Q4 7.0% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.2% |
4.3%
0.9 pts worse
|
11.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 7.5% · Q3 6.8% · Q4 0.0% · 4Q avg 5.2% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
4.1%
0.7 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.9% · Q3 5.6% · Q4 3.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.1% |
12.4%
8.3 pts better
|
19.6%
15.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 5.7% · Q3 5.6% · Q4 3.0% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.9% |
17.5%
5.6 pts better
|
16.7%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 13.0% · Q3 9.1% · Q4 16.7% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.0% |
22.5%
0.5 pts better
|
16.3%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.8% |
18.6%
6.2 pts worse
|
14.9%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 25.0% · Q3 29.0% · Q4 36.4% · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.0% |
2.3%
3.7 pts worse
|
1.0%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 10.7% · Q3 5.4% · Q4 0.0% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.5% |
2.6%
3.9 pts worse
|
1.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 8.7% · Q3 6.5% · Q4 4.7% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.1% |
24.8%
10.3 pts worse
|
19.8%
15.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 45.3% · Q3 44.6% · Q4 30.5% · 4Q avg 35.1% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
5.4%
2.6 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 6.4% · Q3 11.7% · Q4 9.4% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.9% |
88.6%
1.3 pts better
|
81.7%
8.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.4% · Q2 91.4% · Q3 93.8% · Q4 87.6% · 4Q avg 89.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.4% |
14.0%
4.6 pts better
|
12.0%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.4% · Observed 8.5% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.9%
0.9 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 4.0% · Q3 1.9% · Q4 2.1% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.3% |
82.7%
1.6 pts better
|
79.7%
4.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.9% |
23.1%
8.2 pts better
|
23.9%
9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.9% · Observed 12.7% · Expected 20.2% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (5 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-07-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-01
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-31
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-01
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-01
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-07-01
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-01
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-01
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-10-01
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-01
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2024-10-01
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-01
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-10
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-10-13
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-13
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-13
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-05
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-10-13
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-13
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-19
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-04
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-06
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-07-04
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-07-04
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-04
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-04
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-04
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-04
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-07-04
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-07-04
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-04
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-04
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-04
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-07-04
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-07-04
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-04
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-07-04
Health
Post nurse staffing information every day.
Corrected 2025-07-04
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-24
Health
Provide appropriate foot care.
Corrected 2025-04-24
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-24
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-06
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-06
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-09
Health
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.
Corrected 2024-09-09
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-09-09
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-09
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-09
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-09
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-13
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-13
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-10-13
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-13
Health
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.
Corrected 2023-10-13
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-10-13
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-07-24
Penalties and ownership
Fine · fine $12,649
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Nearby options
Waconia, MN
1-star overall rating with 1-star inspections with Special Focus status with $15,940 in total fines with 18 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Spring Park, MN
5-star overall rating with 4-star inspections with $8,827 in total fines
Chaska, MN
1-star overall rating with 1-star inspections with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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