CCN 245476
Good Samaritan Society - Pine River
518 JEFFERSON AVENUE, Pine River, MN 56474 · Cass County
- Ownership
- Non profit - Corporation
- Certified beds
- 33
- Residents per day
- 29.1
- Health citations
- 8
- Penalties
- 0
- Fines
- 0 · $0
Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Staffing hours
Reported hours per resident per day come from the Payroll-Based Journal figures in the Provider Information file. Case-mix and adjusted hours account for how much care CMS expects given the residents’ needs. State and U.S. figures are averages from the same release.
- Measure
- This home
- State
- U.S.
- Nurse aide
- 1.69
- 2.52
- 2.32
- LPN/LVN
- 0.66
- 0.61
- 0.86
- Registered nurse
- 1.16
- 1.06
- 0.69
- Total nurse staff
- 3.51
- 4.19
- 3.86
- Weekend total
- 2.99
- 3.71
- 3.42
- Weekend RN
- 0.89
- 0.69
- 0.48
Adjusted total nurse hours: 3.75. Adjusted RN hours: 1.24. Case-mix total: 3.58. Case-mix index: 1.309.
Total nursing staff turnover: 44.1%. RN turnover: 36.4%. Administrators who left: 0.
How to read staffing hours
Payroll-Based Journal figures in Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Fines and penalties
CMS reports 0 fines totaling $0, and 0 payment denials.
The Penalties file has no individual penalty rows for this CCN.
Cycle 1 standard survey: March 25, 2026. Health deficiencies counted in cycle 1: 1. Cycle 1 total health score: 4. This was a Risk-Based Survey. Unlike a standard inspection, a risk-based inspection is a shorter visit with a smaller team and is used for higher-performing facilities.
Cycle 2 standard survey: February 5, 2025. Cycle 2/3 health deficiencies: 4. Total weighted health survey score: 12.
Penalties file and Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Health inspection citations
The Health Deficiencies file lists 8 citations for this home, including 0 at immediate jeopardy and 0 at actual harm. CMS may display some citations here that are not used in the health inspection rating, including citations under dispute.
March 25, 2026
1 citation. This was a Risk-Based Survey. Unlike a standard inspection, a risk-based inspection is a shorter visit with a smaller team and is used for higher-performing facilities.
| Tag | What CMS cited | Scope and severity | Status |
|---|
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 10, 2026 |
February 5, 2025
3 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|
| F801 | 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. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · March 11, 2025 |
| F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2 | F: widespread, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · March 11, 2025 |
| F732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Standard survey · Cycle 2 | C: widespread, no actual harm, with potential for minimal harm | Deficient, Provider has date of correction · March 12, 2025 |
April 5, 2024
1 citation
| Tag | What CMS cited | Scope and severity | Status |
|---|
| F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 5, 2024 |
January 9, 2024
3 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|
| F641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 29, 2024 |
| F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 29, 2024 |
| F695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 29, 2024 |
Health Deficiencies. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections