Good Sam Inver Grove Heights

Inspection findings

1. Feb 19, 2026 Health · 10 findings
   • Not serious Scope/severity D

     F0578 Resident Rights Deficiencies

     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.

     Corrected Mar 20, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0582 Resident Rights Deficiencies

     Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

     Corrected Mar 20, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0605 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

     Corrected Mar 20, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Mar 20, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0698 Quality of Life and Care Deficiencies

     Provide safe, appropriate dialysis care/services for a resident who requires such services.

     Corrected Mar 20, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Mar 20, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Mar 20, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0346 Smoke Deficiencies

     Follow proper procedures when the fire alarm was out of service for more than 4 hours.

     Corrected Mar 30, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0354 Smoke Deficiencies

     Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

     Corrected Mar 30, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Mar 30, 2026 · CMS fire safety

2. Apr 10, 2025 MDH complaint investigation · 1 finding
   • Severity not stated

     H52852121C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

3. Apr 2, 2025 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected May 5, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected May 5, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0770 Administration Deficiencies

     Provide timely, quality laboratory services/tests to meet the needs of residents.

     Corrected May 5, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 5, 2025 · CMS health inspection

4. Dec 12, 2024 Health · 14 findings
   • Not serious Scope/severity E

     F0553 Resident Rights Deficiencies

     Allow resident to participate in the development and implementation of his or her person-centered plan of care.

     Corrected Jan 13, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jan 13, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Jan 13, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Jan 13, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Jan 13, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0685 Quality of Life and Care Deficiencies

     Assist a resident in gaining access to vision and hearing services.

     Corrected Jan 13, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Jan 13, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

     Corrected Jan 13, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jan 13, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jan 14, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jan 14, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Jan 14, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Jan 14, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jan 14, 2025 · CMS fire safety

5. Jul 12, 2024 MDH complaint investigation · 5 findings
   • Severity not stated

     H52855061C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

   • Severity not stated

     H52855122C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

   • Severity not stated

     H52855123C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

   • Severity not stated

     H52855124C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

   • Severity not stated

     H52855125C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

6. May 6, 2024 MDH complaint investigation · 1 finding
   • Severity not stated

     H52853446C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

7. Apr 9, 2024 Health · 2 findings
   • Serious Scope/severity G Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Mar 28, 2024 · CMS health inspection

   • Severity not stated

     H52852900C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

8. Nov 6, 2023 MDH complaint investigation · 1 finding
   • Severity not stated

     H52856689C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

9. Oct 30, 2023 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Nov 24, 2023 · CMS health inspection

10. Oct 5, 2023 Fire Safety · 31 findings
    • Not serious Scope/severity C

      E0023 Emergency Preparedness Deficiencies

      Establish policies and procedures for medical documentation.

      Corrected Oct 27, 2023 · CMS fire safety

    • Not serious Scope/severity C

      E0025 Emergency Preparedness Deficiencies

      Create arrangements with other facilities to receive patients.

      Corrected Oct 27, 2023 · CMS fire safety

    • Not serious Scope/severity C

      E0037 Emergency Preparedness Deficiencies

      Establish staff and initial training requirements.

      Corrected Oct 27, 2023 · CMS fire safety

    • Not serious Scope/severity F

      E0041 Emergency Preparedness Deficiencies

      Implement emergency and standby power systems.

      Corrected Oct 27, 2023 · CMS fire safety

    • Not serious Scope/severity D

      F0550 Resident Rights Deficiencies

      Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0554 Resident Rights Deficiencies

      Allow residents to self-administer drugs if determined clinically appropriate.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity C

      F0577 Resident Rights Deficiencies

      Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0578 Resident Rights Deficiencies

      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.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0636 Resident Assessment and Care Planning Deficiencies

      Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0638 Resident Assessment and Care Planning Deficiencies

      Assure that each resident’s assessment is updated at least once every 3 months.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0645 Resident Assessment and Care Planning Deficiencies

      PASARR screening for Mental disorders or Intellectual Disabilities

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0657 Resident Assessment and Care Planning Deficiencies

      Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0676 Quality of Life and Care Deficiencies

      Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0684 Quality of Life and Care Deficiencies

      Provide appropriate treatment and care according to orders, resident’s preferences and goals.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0686 Quality of Life and Care Deficiencies

      Provide appropriate pressure ulcer care and prevent new ulcers from developing.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0695 Quality of Life and Care Deficiencies

      Provide safe and appropriate respiratory care for a resident when needed.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0698 Quality of Life and Care Deficiencies

      Provide safe, appropriate dialysis care/services for a resident who requires such services.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity C

      F0732 Nursing and Physician Services Deficiencies

      Post nurse staffing information every day.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0757 Pharmacy Service Deficiencies

      Ensure each resident’s drug regimen must be free from unnecessary drugs.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0758 Pharmacy Service Deficiencies

      Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0759 Pharmacy Service Deficiencies

      Ensure medication error rates are not 5 percent or greater.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Oct 27, 2023 · CMS health inspection

    • Not serious Scope/severity D

      K0211 Egress Deficiencies

      Keep aisles, corridors, and exits free of obstruction in case of emergency.

      Corrected Oct 27, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0291 Egress Deficiencies

      Install emergency lighting that can last at least 1 1/2 hours.

      Corrected Oct 27, 2023 · CMS fire safety

    • Not serious Scope/severity D

      K0321 Smoke Deficiencies

      Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

      Corrected Oct 27, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0324 Smoke Deficiencies

      Provide properly protected cooking facilities.

      Corrected Oct 27, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0345 Smoke Deficiencies

      Have approved installation, maintenance and testing program for fire alarm systems.

      Corrected Oct 27, 2023 · CMS fire safety

    • Not serious Scope/severity C

      K0353 Smoke Deficiencies

      Inspect, test, and maintain automatic sprinkler systems.

      Corrected Oct 27, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0521 Services Deficiencies

      Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

      Corrected Oct 27, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0901 Electrical Deficiencies

      Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

      Corrected Oct 27, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0918 Gas, Vacuum, and Electrical Systems Deficiencies

      Have generator or other power source capable of supplying service within 10 seconds.

      Corrected Oct 27, 2023 · CMS fire safety

11. Nov 30, 2022 MDH complaint investigation · 2 findings
    • Severity not stated

      H52855717C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

    • Severity not stated

      H52855960C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

Owners and managers (as published by CMS)

• BROWN, GEORGE — adp of the snf, NOT APPLICABLE, since 01/01/2025
• BROWN, GEORGE — corporate director, NOT APPLICABLE, since 01/01/2025
• DYKHOUSE, DANA — corporate director, NOT APPLICABLE, since 05/30/2024
• DYKHOUSE, DANA — adp of the snf, NOT APPLICABLE, since 05/30/2024
• ENGBRECHT, WESLEY — adp of the snf, NOT APPLICABLE, since 05/30/2024
• ENGBRECHT, WESLEY — corporate director, NOT APPLICABLE, since 05/30/2024
• FLUIT, JOEL — adp of the snf, NOT APPLICABLE, since 10/01/2022
• FLUIT, JOEL — corporate officer, NOT APPLICABLE, since 10/01/2022
• FLUIT, JOEL — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 01/15/2026
• GASSEN, WILLIAM — adp of the snf, NOT APPLICABLE, since 05/30/2024
• GASSEN, WILLIAM — corporate director, NOT APPLICABLE, since 05/30/2024
• GASSEN, WILLIAM — corporate officer, NOT APPLICABLE, since 05/30/2024
• GULSVIG, NEIL — adp of the snf, NOT APPLICABLE, since 05/30/2024
• GULSVIG, NEIL — corporate director, NOT APPLICABLE, since 05/30/2024
• HERSETH SANDLIN, STEPHANIE — adp of the snf, NOT APPLICABLE, since 05/30/2024
• HERSETH SANDLIN, STEPHANIE — corporate director, NOT APPLICABLE, since 05/30/2024
• JANUSZ, ANTHONY — operational/managerial control, NOT APPLICABLE, since 07/01/2025
• JANUSZ, ANTHONY — adp of the snf, NOT APPLICABLE, since 07/01/2025
• LUNDEEN, MARK — adp of the snf, NOT APPLICABLE, since 05/30/2024
• LUNDEEN, MARK — corporate director, NOT APPLICABLE, since 05/30/2024
• MCCAUSLAND, MAUREEN — adp of the snf, NOT APPLICABLE, since 01/01/2025
• MCCAUSLAND, MAUREEN — corporate director, NOT APPLICABLE, since 01/01/2025
• MIDDLETON, AIMEE — adp of the snf, NOT APPLICABLE, since 01/27/2022
• MIDDLETON, AIMEE — corporate officer, NOT APPLICABLE, since 01/27/2022
• MITTAL, VIKAS — adp of the snf, NOT APPLICABLE, since 02/01/2019
• MITTAL, VIKAS — operational/managerial control, NOT APPLICABLE, since 02/01/2019
• MOLBERT, LAURIS — adp of the snf, NOT APPLICABLE, since 05/30/2024
• MOLBERT, LAURIS — corporate director, NOT APPLICABLE, since 05/30/2024
• MORRISON, TONY — adp of the snf, NOT APPLICABLE, since 01/01/2019
• MORRISON, TONY — operational/managerial control, NOT APPLICABLE, since 01/01/2019
• NORTH, ANDREW — adp of the snf, NOT APPLICABLE, since 05/30/2024
• NORTH, ANDREW — corporate director, NOT APPLICABLE, since 05/30/2024
• OLSON, NICHOLAS — corporate officer, NOT APPLICABLE, since 04/08/2024
• OLSON, NICHOLAS — adp of the snf, NOT APPLICABLE, since 04/08/2024
• SANDGREN, DEEANDRA — operational/managerial control, NOT APPLICABLE, since 07/16/2023
• SANDGREN, DEEANDRA — adp of the snf, NOT APPLICABLE, since 07/16/2023
• SCHEMA, NATHAN — adp of the snf, NOT APPLICABLE, since 01/01/2022
• SCHEMA, NATHAN — corporate officer, NOT APPLICABLE, since 01/01/2022
• SCHIEFFER, KEVIN — adp of the snf, NOT APPLICABLE, since 01/01/2025
• SCHIEFFER, KEVIN — corporate director, NOT APPLICABLE, since 01/01/2025
• SHULKIN, DAVID — adp of the snf, NOT APPLICABLE, since 05/30/2024
• SHULKIN, DAVID — corporate director, NOT APPLICABLE, since 05/30/2024
• TEIKEN, BRENT — corporate director, NOT APPLICABLE, since 05/30/2024
• TEIKEN, BRENT — adp of the snf, NOT APPLICABLE, since 05/30/2024
• VENTLING-HERRMANN, MARNIE — adp of the snf, NOT APPLICABLE, since 05/30/2024
• VENTLING-HERRMANN, MARNIE — corporate director, NOT APPLICABLE, since 05/30/2024
• WENZEL, THOMAS — corporate director, NOT APPLICABLE, since 01/01/2025
• WENZEL, THOMAS — adp of the snf, NOT APPLICABLE, since 01/01/2025
• DTN STAFFING INC — adp of the snf, NOT APPLICABLE, since 08/02/2024
• FOCUSONE SOLUTIONS — adp of the snf, NOT APPLICABLE, since 03/04/2024
• GRAPE TREE MEDICAL STAFFING LLC — adp of the snf, NOT APPLICABLE, since 04/13/2018
• SANFORD — adp of the snf, NOT APPLICABLE, since 12/02/2025
• SANFORD — 5% or greater direct ownership interest, 100%, since 01/01/2019
• THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY — adp of the snf, NOT APPLICABLE, since 01/01/2019
• THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY — 5% or greater indirect ownership interest, 100%, since 01/01/2019
• THRIFTY DRUG STORES INC — adp of the snf, NOT APPLICABLE, since 08/01/2017