Cycle 1
Health 2025-06-03 · Fire 2025-06-03
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lakota, ND
Good Samaritan Society - Lakota
1-star overall rating with 2-star inspections with $74,283 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
608 4th Ave Sw, Lakota, ND
(701) 247-2902
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
38
Certified beds
Average residents
34
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
1991-04-01
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
1.00
Registered nurse staffing · state 0.93 · national 0.68
LPN hours / resident day
0.17
Licensed practical nurse staffing · state 0.50 · national 0.87
Aide hours / resident day
2.43
Nurse aide staffing · state 2.99 · national 2.35
Total nurse hours
3.59
All reported nurse hours · state 4.41 · national 3.89
Licensed hours
1.16
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.86
Weekend nurse staffing · state 3.75 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.59 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.06
CMS adjusted RN staffing hours
Adjusted total hours
3.83
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,350
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
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
2.06
Baseline 64.10% · Performance 55.26% · Measure score 2.06 · Achievement 2.06 · Improvement 1.75
Adjusted total nurse staffing
2.08
Baseline 4.30 hours · Performance 3.67 hours · Measure score 2.08 · Achievement 2.08 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.03% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 7.41% · Lower 95% interval 6.79% |
| Discharge to community | 36.46% |
50.57%
14.1 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 18.52% · Lower 95% interval 22.18% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 19 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.7% |
8.2%
4.5 pts worse
|
Numerator 2 · Denominator 54 |
| Staff flu vaccination coverage | 81.36% |
42%
39.4 pts better
|
Numerator 48 · Denominator 59 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · 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 | 98.6% |
98.3%
0.3 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 94.4% · Q4 100.0% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.5% |
98.8%
1.3 pts worse
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
5.1%
2.2 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 2.7% · Q3 2.8% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.7% |
4.4%
1.3 pts worse
|
11.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 6.7% · Q3 3.4% · Q4 4.3% · 4Q avg 5.7% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
5.5%
0.4 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.1% · Q3 6.5% · Q4 7.7% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.3% |
17.4%
9.1 pts better
|
19.6%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 6.1% · Q3 12.5% · Q4 7.4% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.4% |
23.4%
1 pts worse
|
16.7%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.0% · Q2 28.0% · Q3 17.4% · 4Q avg 24.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 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 | 30.2% |
19.0%
11.2 pts worse
|
16.3%
13.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.6% |
20.1%
8.5 pts worse
|
14.9%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 26.1% · 4Q avg 28.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.6% |
1.8%
3.8 pts worse
|
1.0%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 4.9% · Q3 6.1% · Q4 4.7% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
3.1%
1.6 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.9% |
25.2%
0.3 pts better
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.0% · Q2 17.4% · Q3 26.2% · Q4 16.0% · 4Q avg 24.9% |
| Percentage of long-stay residents with pressure ulcers | 13.7% |
5.3%
8.4 pts worse
|
5.1%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 13.2% · Q3 21.9% · Q4 12.1% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.6% |
93.6%
5 pts worse
|
81.7%
6.9 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 88.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-19 · Fire 2024-06-19
14 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-25 · Fire 2023-05-25
6 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
2025-06-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-15
F · Potential for more than minimal harm
2025-06-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-15
D · Potential for more than minimal harm
2025-06-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-07-15
F · Potential for more than minimal harm
2024-06-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-30
F · Potential for more than minimal harm
2024-06-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-09
L · Immediate jeopardy
2023-10-11
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 2023-11-28
E · Potential for more than minimal harm
2023-05-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-08
D · Potential for more than minimal harm
2023-05-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-08
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-07
E · Potential for more than minimal harm
2025-06-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-03
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 2025-07-07
D · Potential for more than minimal harm
2025-06-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-03
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 2025-07-07
D · Potential for more than minimal harm
2025-06-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-07
C · Minimal harm
2025-06-03
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-01-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-08
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 2025-02-21
G · Actual harm
2024-06-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-14
F · Potential for more than minimal harm
2024-06-19
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-07-25
E · Potential for more than minimal harm
2024-06-19
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 2024-07-25
D · Potential for more than minimal harm
2024-06-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-19
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-19
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
2024-06-19
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 2024-07-25
D · Potential for more than minimal harm
2024-06-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-19
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 2024-07-25
D · Potential for more than minimal harm
2024-06-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-25
G · Actual harm
2023-10-11
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 2023-10-31
E · Potential for more than minimal harm
2023-05-25
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-06-29
D · Potential for more than minimal harm
2023-05-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-29
D · Potential for more than minimal harm
2023-05-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-29
D · Potential for more than minimal harm
2023-05-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-29
D · Potential for more than minimal harm
2023-05-25
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-06-29
Penalties and ownership
What sits behind the stars
$48,445
2024-06-19
Fine
Fine · fine $48,445
Fine
$25,838
2023-10-11
Fine
Fine · fine $25,838
Fine
Ownership
Sanford
5% Or Greater Direct Ownership Interest · Organization
Berg, Jonathon
Contracted Managing Employee · Individual
Cain, James
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
Halvorson, Anna
W-2 Managing Employee · 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
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
Nearby options
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3-star overall rating with 2-star inspections with abuse icon flag with $36,855 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Eventide Heartland
Devils Lake, ND
2-star overall rating with 3-star inspections with 6 recent health deficiencies
#3
Aneta Parkview Health Ctr
Aneta, ND
5-star overall rating with 5-star inspections
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