Good Sam Westbrook

Inspection findings

1. Mar 19, 2026 Health · 11 findings
   • Not serious Scope/severity F

     F0868 Administration Deficiencies

     Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

     Corrected Apr 16, 2026 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 16, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

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

     Corrected Apr 16, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0291 Egress Deficiencies

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

     Corrected Apr 16, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Apr 16, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Apr 16, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Apr 16, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Apr 16, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0761 Miscellaneous Deficiencies

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

     Corrected Apr 16, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0914 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

     Corrected Apr 17, 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 Apr 16, 2026 · CMS fire safety

2. Jan 9, 2025 Health · 13 findings
   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

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

     Corrected Feb 14, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Feb 14, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected Feb 14, 2025 · 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 Feb 14, 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 Feb 14, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 14, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0881 Infection Control Deficiencies

     Implement a program that monitors antibiotic use.

     Corrected Feb 14, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0882 Infection Control Deficiencies

     Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

     Corrected Feb 14, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jan 10, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0372 Smoke Deficiencies

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

     Corrected Feb 10, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Feb 3, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0911 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the installation and maintenance of electrical systems.

     Corrected Feb 10, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Feb 10, 2025 · CMS fire safety

3. Dec 6, 2023 Fire Safety · 7 findings
   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Jan 4, 2024 · CMS fire safety

   • 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 17, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     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 Jan 11, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0851 Administration Deficiencies

     Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

     Corrected Jan 19, 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 2, 2024 · CMS health inspection

   • Not serious Scope/severity D

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Jan 11, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Jan 11, 2024 · CMS fire safety

4. Jan 27, 2022 MDH complaint investigation · 1 finding
   • Severity not stated

     H5595022C 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)

5. Jun 16, 2021 MDH complaint investigation · 1 finding
   • Severity not stated

     H5595020C 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. Mar 18, 2021 MDH complaint investigation · 3 findings
   • Severity not stated

     H5595014C 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

     H5595016C 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

     H5595017C 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 — corporate director, NOT APPLICABLE, since 01/01/2025
• BROWN, GEORGE — adp of the snf, 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 — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 04/30/2026
• FLUIT, JOEL — corporate officer, NOT APPLICABLE, since 10/01/2022
• FLUIT, JOEL — adp of the snf, NOT APPLICABLE, since 10/01/2022
• GASSEN, WILLIAM — corporate director, NOT APPLICABLE, since 05/30/2024
• GASSEN, WILLIAM — corporate officer, NOT APPLICABLE, since 05/30/2024
• GASSEN, WILLIAM — adp of the snf, 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 — adp of the snf, NOT APPLICABLE, since 05/30/2024
• HERSETH SANDLIN, STEPHANIE — corporate director, NOT APPLICABLE, since 05/30/2024
• KOPPERUD, ANDREW — operational/managerial control, NOT APPLICABLE, since 02/01/2023
• KOPPERUD, ANDREW — adp of the snf, NOT APPLICABLE, since 02/01/2023
• LUNDEEN, MARK — corporate director, NOT APPLICABLE, since 05/30/2024
• LUNDEEN, MARK — adp of the snf, 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
• 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 — corporate director, NOT APPLICABLE, since 05/30/2024
• NORTH, ANDREW — adp of the snf, 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 — adp of the snf, NOT APPLICABLE, since 07/16/2023
• SANDGREN, DEEANDRA — operational/managerial control, 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 — corporate director, NOT APPLICABLE, since 01/01/2025
• SCHIEFFER, KEVIN — adp of the snf, 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
• SWANSON, MARY — operational/managerial control, NOT APPLICABLE, since 11/20/2023
• SWANSON, MARY — adp of the snf, NOT APPLICABLE, since 11/20/2023
• 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 — corporate director, NOT APPLICABLE, since 05/30/2024
• VENTLING-HERRMANN, MARNIE — adp of the snf, 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 — 5% or greater direct ownership interest, 100%, since 01/01/2019
• SANFORD — adp of the snf, NOT APPLICABLE, since 11/26/2025
• THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY — 5% or greater indirect ownership interest, 100%, since 01/01/2019
• THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY — adp of the snf, NOT APPLICABLE, since 01/01/2019