Cycle 1
Health 2025-01-09 · Fire 2025-01-09
2 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
New Hope, MN
Good Samaritan Ambassador
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
8100 Medicine Lake Road, New Hope, MN
(763) 417-4171
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
77
Certified beds
Average residents
75
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
1968-02-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
89 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.78
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.66
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
2.25
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.07
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
1.26
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.81
CMS adjusted RN staffing hours
Adjusted total hours
4.73
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
774
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.94
Composite VBP score used to determine payment impact.
Payment multiplier
1.0185
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.51
Baseline 20.49% · Performance 17.95% · Measure score 7.51 · Achievement 7.51 · Improvement 6.83
Healthcare-associated infections
8.40
Baseline 5.80% · Performance 5.33% · Measure score 8.40 · Achievement 8.40 · Improvement 5.40
Total nurse turnover
4.60
Baseline 49.48% · Performance 44.90% · Measure score 4.60 · Achievement 4.60 · Improvement 1.36
Adjusted total nurse staffing
5.08
Baseline 4.55 hours · Performance 4.52 hours · Measure score 5.08 · Achievement 5.08 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.06% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 264 · Observed rate 9.47% · Lower 95% interval 8.26% |
| Discharge to community | 55.03% |
50.57%
4.5 pts better
|
No Different than the National Rate · Eligible stays 254 · Observed rate 53.15% · Lower 95% interval 48.72% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.43% |
95.27%
1.2 pts better
|
Numerator 135 · Denominator 140 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 140 |
| Discharge self-care score | 47.15% |
53.69%
6.5 pts worse
|
Numerator 58 · Denominator 123 |
| Discharge mobility score | 50.41% |
50.94%
0.5 pts worse
|
Numerator 62 · Denominator 123 |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 5 · Denominator 140 · Adjusted rate 4.79% |
| Healthcare-associated infections requiring hospitalization | 5.33% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 138 · Observed rate 2.17% · Lower 95% interval 2.98% |
| Staff COVID-19 vaccination coverage | 10.29% |
8.2%
2.1 pts better
|
Numerator 14 · Denominator 136 |
| Staff flu vaccination coverage | 91.76% |
42%
49.8 pts better
|
Numerator 167 · Denominator 182 |
| Discharge function score | 49.59% |
56.45%
6.9 pts worse
|
Numerator 61 · Denominator 123 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 88.99% |
96.28%
7.3 pts worse
|
Numerator 97 · Denominator 109 |
| Resident COVID-19 vaccinations up to date | 44.12% |
25.2%
18.9 pts better
|
Numerator 30 · Denominator 68 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.3%
2.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.9%
1.6 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.2% · Q3 2.3% · Q4 2.3% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.3%
4.3 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.0% |
4.1%
2.1 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 5.9% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.4% |
12.4%
7 pts better
|
19.6%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 5.1% · Q3 8.1% · Q4 5.9% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.2% |
17.5%
4.3 pts better
|
16.7%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 11.4% · Q3 14.3% · Q4 16.1% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.4% |
22.5%
10.1 pts better
|
16.3%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.2% |
18.6%
2.4 pts better
|
14.9%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 28.2% · Q3 11.1% · Q4 8.8% · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
2.3%
0.9 pts better
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.7% · Q3 1.6% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
2.6%
0.3 pts better
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.3% · Q3 2.3% · Q4 2.3% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.0% |
24.8%
13.8 pts better
|
19.8%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 10.2% · Q3 9.6% · Q4 16.4% · 4Q avg 11.0% |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
5.4%
3.1 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 8.9% · Q3 12.2% · Q4 5.0% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
88.6%
9.4 pts better
|
81.7%
16.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 97.8% · Q3 98.4% · Q4 97.7% · 4Q avg 98.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.5% |
14.0%
8.5 pts better
|
12.0%
6.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.5% · Observed 5.1% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.9%
0.3 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.8% · Q3 0.0% · Q4 1.7% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.0% |
82.7%
14.3 pts better
|
79.7%
17.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.8% |
23.1%
2.7 pts worse
|
23.9%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 20.6% · Expected 19.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-03-16 · Fire 2023-03-16
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-27
C · Minimal harm
2025-01-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-28
B · Minimal harm
2025-01-09
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-02-21
E · Potential for more than minimal harm
2024-03-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-04-30
F · Potential for more than minimal harm
2023-03-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-16
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-04
E · Potential for more than minimal harm
2023-03-16
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-04-27
E · Potential for more than minimal harm
2023-03-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-05-04
E · Potential for more than minimal harm
2023-03-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-03
C · Minimal harm
2023-03-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-05-04
B · Minimal harm
2023-03-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-09
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-14
D · Potential for more than minimal harm
2023-03-16
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-05-04
D · Potential for more than minimal harm
2023-03-16
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-05-04
Penalties and ownership
What sits behind the stars
Ownership
Sanford
5% Or Greater Direct Ownership Interest · Organization
Brown, George
Corporate Director · Individual
Dykhouse, Dana
Corporate Director · Individual
Engbrecht, Wesley
Corporate Director · Individual
Fluit, Joel
Corporate Officer · Individual
Gassen, William
Corporate Director · Individual
Gassen, William
Corporate Officer · Individual
Gulsvig, Neil
Corporate Director · Individual
Herseth Sandlin, Stephanie
Corporate Director · Individual
Lundeen, Mark
Corporate Officer · Individual
Mccausland, Maureen
Corporate Director · Individual
Middleton, Aimee
Corporate Officer · Individual
Minske, Anna
Operational/Managerial Control · Individual
Molbert, Lauris
Corporate Director · Individual
Morrison, Tony
Operational/Managerial Control · Individual
Mujir, Ibrahim
Operational/Managerial Control · Individual
North, Andrew
Corporate Director · Individual
Olson, Nicholas
Corporate Officer · Individual
Schema, Nathan
Corporate Officer · Individual
Schieffer, Kevin
Corporate Director · Individual
Shulkin, David
Corporate Director · Individual
Teiken, Brent
Corporate Director · Individual
The Evangelical Lutheran Good Samaritan Society
Operational/Managerial Control · Organization
Ventling-Herrmann, Marnie
Corporate Director · Individual
Wenzel, Thomas
Corporate Director · Individual
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#2
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5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
The Terrace at Crystal LLC
Crystal, MN
0-star overall rating with 0-star inspections with Special Focus status with $174,044 in total fines with 31 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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