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Nursing HomeMedicaid Investigative

Good Samaritan Society - Windom

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

705 Sixth Street, Windom, MN 5610163 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
2.0/5

based on 5 Google reviews

5
4
3
2
1
Good Samaritan Society - Windom Nursing Home in Windom, MN — Street View
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4/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Low staffing rating (1/5 stars)
  • Above-median deficiencies (22 vs median 6.5)

Bottom 25% in MN · Worst in GOOD SAMARITAN SOCIETY chain · No penalties on record

Source: Medicare data

What this means for your family

While the facility has been noted for providing care to hospice patients in the past, recent reviews contain alarming allegations of medication neglect and poor hygiene. If you choose this facility, you must be prepared to act as a constant advocate for your loved one to ensure their basic needs and medical requirements are met.

Google Reviews

Google Reviews

5 reviews on Google
Families should exercise extreme caution due to serious allegations regarding medication denial, hygiene neglect, and dishonest communication from staff. While one reviewer noted the facility provides good care for hospice patients, the most recent detailed feedback warns of a lack of responsiveness to resident needs without external advocacy.

Quality Themes

Tap a score for details
FoodN/AStaff1.0Clean1.0ActivitiesN/AMeds1.0MemoryN/AComms1.0ValueN/A

Strengths

  • Capable hospice care

Concerns

  • Neglect of hygiene and medication management
  • Unprofessional staff behavior and lack of responsiveness

Rating Trends

Tap a year to see what changed

2343.02017(1)1.02019(1)1.02025(1)2.52026(2)

Distribution · 5 analyzed

5
0
4
1
3
1
2
0
1
3

How They Respond to Reviews

40%response rate

This facility responds to some reviews.

Questions for Your Tour

  • 1What specific steps is the facility taking to improve the staffing levels and ensure residents have consistent care?
  • 2How does the nursing team manage medical emergencies or sudden changes in health during the overnight hours?
  • 3I noticed the facility is very active in responding to feedback; how does the administration use resident and family input to address recent inspection findings?
  • 4What kind of daily activities or social programs are available to help residents stay engaged and connected with one another?
  • 5With the recent state inspections, what specific improvements have been made to the facility's care protocols and safety standards?
  • 6How do you ensure that the care plan is updated and communicated effectively between the nursing staff and our family?

Personalized based on this facility's data


Key Review Excerpts

Senior living facility. Takes good care of hospice patients.

Local Guide · 2017★★★☆☆

never leave your loved one in the care of this facility, unless they can fully care of themselves and advocate for themselves with all of their needs. they will deny them their medication. they wont keep them clean.

Family member · 2026☆☆☆☆
Source: 5 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.65hrs
87%
Registered nurses for medical care
Total Nursing
3.69hrs
90%
All nurses + aides combined
Staff Turnover
44%
Lower is better (< 30% = good)
RN Turnover
44%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
2/ 5
Better Than Avg

7

measures

Worse Than Avg

8

measures

Mixed Results

2

measures

Long-Stay Residents
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility26.5%
Worse than Avg
Here
26.5%
US
14.4%
MN
18.6%
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.5%
Better than Avg
Here
0.5%
US
12.1%
MN
4.3%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility9.1%
Better than Avg
Here
9.1%
US
19.5%
MN
12.5%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility25.2%
Worse than Avg
Here
25.2%
US
15.3%
MN
21.4%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility27.5%
Worse than Avg
Here
27.5%
US
19.4%
MN
24.5%
⚖️

Residents who lost too much weight

↓ Lower is better
This Facility9.8%
Worse than Avg
Here
9.8%
US
5.3%
MN
4.1%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility69.4%
Worse than Avg
Here
69.4%
US
79.8%
MN
82.7%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility82.1%
Mixed vs Avgs
Here
82.1%
US
81.8%
MN
88.3%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility4.5%
Worse than Avg
Here
4.5%
US
1.6%
MN
1.8%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

22deficiencies
2penalties
Well above state avg (8.0)
8 complaint-triggered

This facility shows serious ongoing problems with families filing complaints about pressure ulcer care, resident rights, and dental services, and most recent deficiencies from 2026 remain uncorrected. The main recurring issues involve infection control, medication management, resident care planning, and fire safety systems. While some earlier problems were fixed, the recent pattern of unresolved deficiencies following family complaints raises significant concerns about current care quality.

Feb 12, 2026Routine
15
0868Potential for harm · WidespreadCorrected

Administration Deficiencies

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

0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0582Potential for harm · PatternCorrected

Resident Rights Deficiencies

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

0324Potential for harm · PatternCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0578Potential for harm · IsolatedCorrected

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.

0605Potential for harm · IsolatedCorrected

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.

0628Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

0638Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0645Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0685Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0756Potential for harm · IsolatedCorrected

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.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Feb 12, 2026Complaint
2
0609Potential for harm · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0610Potential for harm · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Jan 27, 2026Complaint
6
0686Immediate jeopardy · PatternCorrected

Quality of Life and Care Deficiencies

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

0657Potential for harm · PatternCorrected

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.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0580Potential for harm · IsolatedCorrected

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.

0791Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Dec 11, 2024Routine
8
0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0355Potential for harm · WidespreadCorrected

Smoke Deficiencies

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

0521Potential for harm · WidespreadCorrected

Services Deficiencies

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

0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0372Potential for harm · PatternCorrected

Smoke Deficiencies

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

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0688Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Nov 2, 2023Routine
11
0801Potential for harm · WidespreadCorrected

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.

0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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

0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0211Potential for harm · PatternCorrected

Egress Deficiencies

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

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0688Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0847Potential for harm · IsolatedCorrected

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

0554Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0521Potential for harm · IsolatedCorrected

Services Deficiencies

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

Federal Penalties

Fine

Jan 27, 2026

$194,680

Payment Denial

Jan 27, 2026

20-day denial

Ownership & Operations

Who Operates This Facility

Owner / Operator

Good Samaritan Society - Windom

Organization Type

nonprofit

Chain Affiliation

Chain Name

Good Samaritan Society

Chain Size

92 facilities nationwide

Chain avg rating: 3.0/5 · Rank 88 of 88 (Worst)

Ownership & Management

Owners

Sanford

Owner · Organization

100%

The Evangelical Lutheran Good Samaritan Society

Owner (parent company) · Organization

100%

Fluit, Joel

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Key personnel

Brown, GeorgeOfficer / DirectorDykhouse, DanaOfficer / DirectorEngbrecht, WesleyOfficer / DirectorGassen, WilliamOfficer / DirectorGulsvig, NeilOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 2 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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