Cycle 1
Health 2026-02-12 · Fire 2026-02-12
22 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Windom, MN
Good Samaritan Society - Windom
1-star overall rating with 1-star inspections with 22 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
705 Sixth Street, Windom, MN
(507) 831-1788
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
63
Certified beds
Average residents
59
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
1991-05-01
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
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,549
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9894
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
2.19
Baseline 5.53% · Performance 7.18% · Measure score 2.19 · Achievement 2.19 · Improvement 0
Total nurse turnover
5.42
Baseline 40.35% · Performance 41.54% · Measure score 5.42 · Achievement 5.42 · Improvement 0
Adjusted total nurse staffing
3.14
Baseline 3.64 hours · Performance 3.97 hours · Measure score 3.14 · Achievement 3.14 · Improvement 1.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 5.77% · Lower 95% interval 6.92% |
| Discharge to community | 38.99% |
50.57%
11.6 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 32.61% · Lower 95% interval 28.07% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.24% |
95.27%
About the same
|
Numerator 20 · Denominator 21 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 21 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.18% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 6.45% · Lower 95% interval 3.43% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 108 |
| Staff flu vaccination coverage | 84.96% |
42%
43 pts better
|
Numerator 96 · Denominator 113 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.7
0.9 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.0
0.6 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
97.3%
1.2 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.1% · Q4 96.2% · 4Q avg 98.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.1% |
96.1%
2 pts worse
|
95.5%
1.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.9%
0.4 pts better
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 4.2% · Q3 3.8% · Q4 3.8% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
4.3%
3.8 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 10.1% |
4.1%
6 pts worse
|
5.4%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 7.1% · Q3 4.0% · Q4 14.0% · 4Q avg 10.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.6% |
12.4%
2.8 pts better
|
19.6%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 11.9% · Q3 8.0% · Q4 6.0% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.0% |
17.5%
2.5 pts better
|
16.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 12.5% · Q3 15.8% · Q4 15.0% · 4Q avg 15.0% · 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 | 21.7% |
22.5%
0.8 pts better
|
16.3%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.4% |
18.6%
0.2 pts better
|
14.9%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 20.5% · Q3 14.9% · Q4 22.2% · 4Q avg 18.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
2.3%
0.7 pts better
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
2.6%
1.1 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.9% |
24.8%
1.1 pts worse
|
19.8%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 21.7% · Q3 24.4% · Q4 32.1% · 4Q avg 25.9% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
5.4%
1.2 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 6.5% · Q3 4.4% · Q4 0.0% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.2% |
88.6%
6.4 pts worse
|
81.7%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 80.8% · Q2 78.8% · Q3 84.2% · Q4 86.8% · 4Q avg 82.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.6% |
14.0%
1.6 pts worse
|
12.0%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 13.8% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.6% |
1.9%
1.7 pts worse
|
1.6%
2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 4.2% · Q4 10.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.4% |
82.7%
13.3 pts worse
|
79.7%
10.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 8.4% |
23.1%
14.7 pts better
|
23.9%
15.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.4% · Observed 6.9% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-12-11 · Fire 2024-12-11
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-11-02 · Fire 2023-11-02
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2026-02-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Not marked corrected
F · Potential for more than minimal harm
2024-12-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-10
F · Potential for more than minimal harm
2024-12-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-01-27
E · Potential for more than minimal harm
2024-12-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-10
E · Potential for more than minimal harm
2024-12-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-10
E · Potential for more than minimal harm
2023-11-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-11-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-26
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-02-12
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Not marked corrected
F · Potential for more than minimal harm
2026-02-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Not marked corrected
E · Potential for more than minimal harm
2026-02-12
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Not marked corrected
E · Potential for more than minimal harm
2026-02-12
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Not marked corrected
E · Potential for more than minimal harm
2026-02-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
F578 · Resident Rights Deficiencies
Health
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.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Not marked corrected
D · Potential for more than minimal harm
2026-02-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Not marked corrected
K · Immediate jeopardy
2026-01-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Not marked corrected
E · Potential for more than minimal harm
2026-01-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Not marked corrected
D · Potential for more than minimal harm
2026-01-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Not marked corrected
D · Potential for more than minimal harm
2026-01-27
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Not marked corrected
D · Potential for more than minimal harm
2026-01-27
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Not marked corrected
D · Potential for more than minimal harm
2026-01-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Not marked corrected
F · Potential for more than minimal harm
2024-12-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-11
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-11
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-01-17
F · Potential for more than minimal harm
2023-11-02
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-12-18
F · Potential for more than minimal harm
2023-11-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-11-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-05
D · Potential for more than minimal harm
2023-11-02
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-11-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-11-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-02
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-02
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-12-08
Penalties and ownership
What sits behind the stars
Ownership
Sanford
5% Or Greater Direct Ownership Interest · Organization
Brown, George
Corporate Director · Individual
Dykhouse, Dana
Corporate Director · Individual
Dynes, Rodney
Operational/Managerial Control · Individual
Engbrecht, Wesley
Corporate Director · Individual
Fluit, Joel
Corporate Officer · Individual
Gassen, William
Corporate Director · Individual
Gassen, William
Corporate Officer · Individual
Gulsvig, Neil
Corporate Director · Individual
Herseth Sandlin, Stephanie
Corporate Director · Individual
Lundeen, Mark
Corporate Director · Individual
Mccausland, Maureen
Corporate Director · Individual
Middleton, Aimee
Corporate Officer · Individual
Molbert, Lauris
Corporate Director · Individual
Morrison, Tony
Operational/Managerial Control · Individual
North, Andrew
Corporate Director · Individual
Olson, Nicholas
Corporate Officer · Individual
Schema, Nathan
Corporate Officer · Individual
Schieffer, Kevin
Corporate Director · Individual
Shulkin, David
Corporate Director · Individual
Teiken, Brent
Corporate Director · Individual
The Evangelical Lutheran Good Samaritan Society
Operational/Managerial Control · Organization
Ventling-Herrmann, Marnie
Corporate Director · Individual
Wenzel, Thomas
Corporate Director · Individual
Wepplo, Nancy
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Good Samaritan Society - Mountain Lake
Mountain Lake, MN
4-star overall rating with 3-star inspections with $21,645 in total fines with 6 recent health deficiencies
#2
Colonial Manor Nursing Home
Lakefield, MN
1-star overall rating with 1-star inspections with 14 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Good Samaritan Society - Jackson
Jackson, MN
4-star overall rating with 3-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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