Good Sam Pine River

Inspection findings

1. Mar 25, 2026 Health · 2 findings
   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 15, 2026 · CMS fire safety

2. Feb 5, 2025 Health · 12 findings
   • Not serious Scope/severity C

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Mar 12, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0801 Nutrition and Dietary Deficiencies

     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 Mar 11, 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 Mar 11, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0281 Egress Deficiencies

     Install proper backup exit lighting.

     Corrected Feb 10, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0291 Egress Deficiencies

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

     Corrected Feb 10, 2025 · 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 Feb 10, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0345 Smoke Deficiencies

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

     Corrected Feb 14, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Feb 17, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Feb 11, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Feb 11, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0711 Miscellaneous Deficiencies

     Provide a written emergency evacuation plan.

     Corrected Feb 12, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Feb 13, 2025 · CMS fire safety

3. Dec 3, 2024 MDH complaint investigation · 1 finding
   • Severity not stated

     H54761390C 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)

4. Apr 5, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     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 May 5, 2024 · CMS health inspection

5. Jan 9, 2024 Fire Safety · 10 findings
   • Not serious Scope/severity F

     E0015 Emergency Preparedness Deficiencies

     Address subsistence needs for staff and patients.

     Corrected Jan 29, 2024 · CMS fire safety

   • Not serious Scope/severity C

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Jan 29, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0041 Emergency Preparedness Deficiencies

     Implement emergency and standby power systems.

     Corrected Jan 29, 2024 · CMS fire safety

   • Not serious Scope/severity E

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Jan 29, 2024 · 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 Jan 29, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Jan 29, 2024 · CMS health inspection

   • 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 26, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0711 Miscellaneous Deficiencies

     Provide a written emergency evacuation plan.

     Corrected Jan 26, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Jan 26, 2024 · 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 Jan 26, 2024 · CMS fire safety

6. Jun 2, 2023 MDH complaint investigation · 1 finding
   • Severity not stated

     H54768160C 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 29, 2022 MDH complaint investigation · 1 finding
   • Severity not stated

     H5476028C 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. Jun 14, 2021 MDH complaint investigation · 1 finding
   • Severity not stated

     H5476022C 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)

• AHLF, CIERRA — adp of the snf, NOT APPLICABLE, since 01/15/2024
• AHLF, CIERRA — operational/managerial control, NOT APPLICABLE, since 01/15/2024
• BROWN, GEORGE — corporate director, NOT APPLICABLE, since 01/01/2025
• BROWN, GEORGE — adp of the snf, NOT APPLICABLE, since 01/01/2025
• DYKHOUSE, DANA — adp of the snf, NOT APPLICABLE, since 05/30/2024
• DYKHOUSE, DANA — corporate director, NOT APPLICABLE, since 05/30/2024
• ENGBRECHT, WESLEY — corporate director, NOT APPLICABLE, since 05/30/2024
• ENGBRECHT, WESLEY — adp of the snf, 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
• GASSEN, WILLIAM — corporate director, NOT APPLICABLE, since 05/30/2024
• GASSEN, WILLIAM — adp of the snf, NOT APPLICABLE, since 05/30/2024
• GASSEN, WILLIAM — corporate officer, NOT APPLICABLE, since 05/30/2024
• GULSVIG, NEIL — corporate director, NOT APPLICABLE, since 05/30/2024
• GULSVIG, NEIL — adp of the snf, NOT APPLICABLE, since 05/30/2024
• HERSETH SANDLIN, STEPHANIE — corporate director, NOT APPLICABLE, since 05/30/2024
• HERSETH SANDLIN, STEPHANIE — adp of the snf, NOT APPLICABLE, since 05/30/2024
• 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 — corporate officer, NOT APPLICABLE, since 01/27/2022
• MIDDLETON, AIMEE — adp of the snf, NOT APPLICABLE, since 01/27/2022
• 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, JULIE — adp of the snf, NOT APPLICABLE, since 10/16/2018
• OLSON, JULIE — operational/managerial control, NOT APPLICABLE, since 10/16/2018
• OLSON, NICHOLAS — corporate officer, NOT APPLICABLE, since 04/08/2024
• OLSON, NICHOLAS — adp of the snf, NOT APPLICABLE, since 04/08/2024
• SANDGREN, DEEANDRA — adp of the snf, NOT APPLICABLE, since 07/16/2023
• SANDGREN, DEEANDRA — operational/managerial control, NOT APPLICABLE, since 07/16/2023
• SCHEMA, NATHAN — corporate officer, NOT APPLICABLE, since 01/01/2022
• SCHEMA, NATHAN — adp of the snf, NOT APPLICABLE, since 01/01/2022
• SCHIEFFER, KEVIN — corporate director, NOT APPLICABLE, since 01/01/2025
• SCHIEFFER, KEVIN — adp of the snf, NOT APPLICABLE, since 01/01/2025
• SHULKIN, DAVID — corporate director, NOT APPLICABLE, since 05/30/2024
• SHULKIN, DAVID — adp of the snf, 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
• GUARDIAN PHARMACY OF MINNESOTA LLC — adp of the snf, NOT APPLICABLE, since 09/26/2024
• SANFORD — 5% or greater direct ownership interest, 100%, since 01/01/2019
• THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY — operational/managerial control, NOT APPLICABLE, since 01/01/2019