Good Samaritan Society - Waconia and Westview Acre

In the surveyor’s words

From the most serious findings on record at Good Samaritan Society - Waconia and Westview Acre, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 12, 2026

  Based on interview, observation, and document review the facility failed to provide adequate supervision creating a likelihood for potential serious harm, injury, impairment, or death for 1 of 3 residents (R1) who was assessed to be at risk for elopement on [DATE] and wore a Wander Guard bracelet (security device that prevents alerts staff if a resident at risk of wandering attempts to leaving a designated area) and eloped from the facility on [DATE]. The immediate jeopardy began on [DATE], when R1 exited the facility front door at 12:54 a.m., then was found by a community member lying in the parking lot of an apartment building. […]

• Immediate jeopardy, isolatedF689Jul 24, 2025

  Based on observation, interview, and document review, the facility failed to maintain resident supervision and safety to prevent accidents for 1 of 1 resident (R2) who was at a high risk for elopement, left the facility unsupervised, and was found across the street in another assisted living (AL) parking lot. This resulted in an immediate Jeopardy (IJ) situation for R2. The IJ began on 7/18/25, when R2 was admitted to the facility and was identified to be a high risk for falls and elopement but the facility failed to implement safety measures and increased supervision resulting in an elopement from the facility on 7/19/25, when R2 wandered onto the elevator; walked through the attached assisted living, crossed the parking lot, crossed a busy street, and was found by police in the parking… […]

• Immediate jeopardy, isolatedF700Jun 29, 2023

  Based on observation, interview and document review, the facility failed to follow requirements to ensure safe use of a bed rail assist device resulting in a resident's neck becoming wedged between the assist bar and mattress while the rest of his body slid off the bed onto the floor preventing his ability to breathe for 1 of 4 residents (R1) reviewed for entrapment risk. This resulted in an immediate jeopardy (IJ) for R1. In addition, the facility failed to reduce the risk of bedrail entrapment when they did not attempt to use alternatives, ensure correct installation and maintenance, review risks and benefits, ensure bed dimensions were appropriate, and follow the manufacturers instructions resulting in the potential for harm for 57 of the 68 residents who utilized a bedrail assist bar… […]

• Actual harm, isolatedF628May 27, 2025

  Based on record review, staff interviews, and policy review, the facility failed to ensure that medications were accurately identified and dispensed upon discharge, resulting in one resident (R214) being sent home with another resident's (R221) medications. This failure led to R214 ingesting medications not prescribed to her. This resulted in actual harm when R214 required emergency medical intervention and hospitalization due to hypotension (low blood pressure). Findings include: R214's discharge Minimum Data Set (MDS) dated [DATE], indicated R214 had intact cognition, and had diagnoses of hypertension (high blood pressure), atrial fibrillation (irregular heartbeat that originates in the heart's upper chambers), anemia (low red blood cells) and depression. […]

• Actual harm, isolatedF686May 27, 2025

  Based on interview and document review the facility failed to assure that 1 of 3 residents (R213) reviewed for pressure ulcers received care and services to prevent occurrence of newly developed pressure ulcer. This failure resulted in actual harm to R213 when the facility failed to follow R213's care plan resulting in the development of a deep tissue injury (a type of pressure injury where the underlying tissue is damaged, but the skin may appear intact. It's characterized by a localized discoloration, often purple or maroon, and may have a blood-filled blister. deep tissue injury can develop into a larger, open wound, but it's initially a localized injury). […]