Cycle 1
Health 2025-11-19 · Fire 2025-11-19
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Battle Lake, MN
Good Samaritan Society - Battle Lake
5-star overall rating with 5-star inspections with 1 recent health deficiencies
105 Glenhaven Drive, Battle Lake, MN
(218) 864-5231
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
51
Certified beds
Average residents
48
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
1986-12-01
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
1.06
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.07
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.32
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.26
CMS adjusted RN staffing hours
Adjusted total hours
4.84
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,367
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9857
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.37
Baseline 46.51% · Performance 54.00% · Measure score 2.37 · Achievement 2.37 · Improvement 0
Adjusted total nurse staffing
3.62
Baseline 3.85 hours · Performance 4.11 hours · Measure score 3.62 · Achievement 3.62 · Improvement 0.84
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.69% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 43 · Observed rate 9.3% · Lower 95% interval 7.11% |
| Discharge to community | 40.62% |
50.57%
10 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 33.33% · Lower 95% interval 30.26% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.15% |
95.27%
0.9 pts better
|
Numerator 25 · Denominator 26 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 26 |
| Discharge self-care score | 62.5% |
53.69%
8.8 pts better
|
Numerator 15 · Denominator 24 |
| Discharge mobility score | 70.83% |
50.94%
19.9 pts better
|
Numerator 17 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 3.85% |
2.29%
1.6 pts worse
|
Numerator 1 · Denominator 26 · Adjusted rate 8.62% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 4.12% |
8.2%
4.1 pts worse
|
Numerator 4 · Denominator 97 |
| Staff flu vaccination coverage | 84.47% |
42%
42.5 pts better
|
Numerator 87 · Denominator 103 |
| Discharge function score | 83.33% |
56.45%
26.9 pts better
|
Numerator 20 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
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 | 95.9% |
96.1%
0.2 pts worse
|
95.5%
0.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.9%
1.2 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.2% · Q3 2.1% · Q4 4.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.9% |
4.3%
4.6 pts worse
|
11.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 6.7% · Q3 4.5% · Q4 17.4% · 4Q avg 8.9% |
| Percentage of long-stay residents who lose too much weight | 0.6% |
4.1%
3.5 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.0% |
12.4%
3.4 pts better
|
19.6%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 8.1% · Q3 14.6% · Q4 5.3% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.2% |
17.5%
1.3 pts better
|
16.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 21.2% · Q3 16.2% · Q4 15.8% · 4Q avg 16.2% · 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 | 12.2% |
22.5%
10.3 pts better
|
16.3%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 12.3% · Q3 12.9% · Q4 16.1% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.5% |
18.6%
5.1 pts better
|
14.9%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 14.3% · Q3 12.8% · Q4 13.9% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
2.3%
1.8 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
2.6%
0.7 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.4% · Q3 4.2% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.9% |
24.8%
6.9 pts better
|
19.8%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 18.1% · Q3 17.4% · Q4 24.4% · 4Q avg 17.9% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
5.4%
2.8 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
88.6%
9.8 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · 4Q avg 98.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.9%
0.5 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-15 · Fire 2024-10-15
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-11-29 · Fire 2023-11-29
3 health deficiencies
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-10-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-01
F · Potential for more than minimal harm
2023-11-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-13
E · Potential for more than minimal harm
2023-11-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-28
C · Minimal harm
2023-11-29
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-12-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-19
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-12-17
F · Potential for more than minimal harm
2023-11-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-28
E · Potential for more than minimal harm
2023-11-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-28
E · Potential for more than minimal harm
2023-11-29
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-12-28
Penalties and ownership
What sits behind the stars
Ownership
Sanford
5% Or Greater Direct Ownership Interest · Organization
Cain, James
Corporate Director · Individual
Chisholm, Melissa
W-2 Managing Employee · 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 Director · Individual
Middleton, Aimee
Corporate Officer · Individual
Molbert, Lauris
Corporate Director · Individual
Morrison, Tony
W-2 Managing Employee · Individual
Mouser, Matthew
Contracted Managing Employee · Individual
North, Andrew
Corporate Director · Individual
Olson, Nicholas
Corporate Officer · Individual
Rogers, Michael
Corporate Officer · Individual
Schema, Nathan
Corporate Officer · 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
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#3
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