Cycle 1
Health 2025-12-04 · Fire 2025-12-04
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Brainerd, MN
Good Samaritan Society - Bethany
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
804 Wright Street, Brainerd, MN
(218) 825-2593
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
79
Certified beds
Average residents
67
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
1988-01-01
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
1.61
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.33
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
1.82
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.76
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.95
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
1.27
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.65
CMS adjusted RN staffing hours
Adjusted total hours
3.86
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
18%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
461
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
69.4
Composite VBP score used to determine payment impact.
Payment multiplier
1.0221
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.63
Baseline 20.34% · Performance 17.89% · Measure score 7.63 · Achievement 7.63 · Improvement 6.89
Healthcare-associated infections
8.82
Baseline 7.20% · Performance 5.20% · Measure score 8.82 · Achievement 8.82 · Improvement 8.58
Total nurse turnover
8.64
Baseline 77.78% · Performance 29.41% · Measure score 8.64 · Achievement 8.38 · Improvement 8.64
Adjusted total nurse staffing
2.66
Baseline 3.95 hours · Performance 3.84 hours · Measure score 2.66 · Achievement 2.66 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.16% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 220 · Observed rate 7.73% · Lower 95% interval 6.99% |
| Discharge to community | 62.21% |
50.57%
11.6 pts better
|
Better than the National Rate · Eligible stays 218 · Observed rate 58.26% · Lower 95% interval 55.47% |
| Medicare spending per beneficiary | 0.69 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.29% |
95.27%
4 pts better
|
Numerator 140 · Denominator 141 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 141 |
| Discharge self-care score | 64.86% |
53.69%
11.2 pts better
|
Numerator 72 · Denominator 111 |
| Discharge mobility score | 46.85% |
50.94%
4.1 pts worse
|
Numerator 52 · Denominator 111 |
| Pressure ulcers or injuries, new or worsened | 2.13% |
2.29%
0.2 pts better
|
Numerator 3 · Denominator 141 · Adjusted rate 3.18% |
| Healthcare-associated infections requiring hospitalization | 5.2% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 132 · Observed rate 2.27% · Lower 95% interval 3.1% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 149 |
| Staff flu vaccination coverage | 82.35% |
42%
40.3 pts better
|
Numerator 224 · Denominator 272 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 74 · Denominator 111 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 99.02% |
96.28%
2.7 pts better
|
Numerator 101 · Denominator 102 |
| Resident COVID-19 vaccinations up to date | 28.57% |
25.2%
3.4 pts better
|
Numerator 24 · Denominator 84 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.1 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.0
1 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.2 · Expected 2.0 · Used in QM five-star |
| 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 | 88.7% |
96.1%
7.4 pts worse
|
95.5%
6.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.9%
0.6 pts better
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.3% · Q3 4.3% · Q4 2.4% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
4.3%
0.5 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 2.6% · Q3 4.7% · Q4 2.5% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 0.7% |
4.1%
3.4 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.2% |
12.4%
5.2 pts better
|
19.6%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.7% · Q3 8.1% · Q4 9.7% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.5% |
17.5%
1 pts better
|
16.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 22.7% · Q3 12.0% · Q4 19.0% · 4Q avg 16.5% · 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 | 31.6% |
22.5%
9.1 pts worse
|
16.3%
15.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 35.3% · 4Q avg 31.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.3% |
18.6%
1.7 pts worse
|
14.9%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 18.8% · Q3 14.7% · Q4 31.0% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.6% |
2.3%
1.3 pts worse
|
1.0%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 2.4% · Q3 0.0% · Q4 2.3% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.7% |
2.6%
3.1 pts worse
|
1.7%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 11.1% · Q3 0.0% · Q4 4.8% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.3% |
24.8%
1.5 pts worse
|
19.8%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 30.8% · Q3 25.8% · Q4 31.0% · 4Q avg 26.3% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
5.4%
1.6 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 2.7% · Q3 5.4% · Q4 2.9% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.6% |
88.6%
1 pts worse
|
81.7%
5.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.4% · Q2 85.3% · Q3 90.8% · Q4 89.8% · 4Q avg 87.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.6% |
14.0%
3.6 pts worse
|
12.0%
5.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 15.8% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.9%
1.2 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.7% · Q3 0.7% · Q4 0.7% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 57.5% |
82.7%
25.2 pts worse
|
79.7%
22.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 57.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.5% |
23.1%
5.4 pts worse
|
23.9%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.5% · Observed 21.8% · Expected 18.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-17 · Fire 2024-10-17
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-12-20 · Fire 2023-12-20
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-04
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2026-01-09
F · Potential for more than minimal harm
2025-12-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-09
D · Potential for more than minimal harm
2024-10-17
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-11-27
C · Minimal harm
2024-10-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-27
C · Minimal harm
2024-10-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-27
F · Potential for more than minimal harm
2023-12-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-20
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-01-19
C · Minimal harm
2023-12-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-01-02
D · Potential for more than minimal harm
2025-10-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-01-02
D · Potential for more than minimal harm
2025-02-14
F758 · Pharmacy Service Deficiencies
Health
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 2025-03-17
F · Potential for more than minimal harm
2024-10-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-10-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-10-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-10-17
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-10-17
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-10-17
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-06-12
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-01-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-12-20
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-03-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-28
Penalties and ownership
What sits behind the stars
Ownership
Sanford
5% Or Greater Direct Ownership Interest · Organization
The Evangelical Lutheran Good Samaritan Society
5% Or Greater Indirect 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 Director · Individual
Mccausland, Maureen
Corporate Director · Individual
Middleton, Aimee
Corporate Officer · Individual
Molbert, Lauris
Corporate Director · Individual
Morrison, Tony
Operational/Managerial Control · Individual
North, Andrew
Corporate Director · Individual
Olson, Julie
Operational/Managerial Control · Individual
Olson, Nicholas
Corporate Officer · Individual
Pederson, Justin
Operational/Managerial Control · Individual
Sandgren, Deeandra
Operational/Managerial Control · Individual
Schema, Nathan
Corporate Officer · Individual
Schieffer, Kevin
Corporate Director · Individual
Shulkin, David
Corporate Director · Individual
Teiken, Brent
Corporate Director · Individual
Ventling-Herrmann, Marnie
Corporate Director · Individual
Wenzel, Thomas
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Good Samaritan Society - Woodland
Brainerd, MN
5-star overall rating with 5-star inspections with 1 recent health deficiencies
#2
Heartwood
Crosby, MN
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Pierz Villa Inc
Pierz, MN
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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