Cycle 1
Health 2025-01-14 · Fire 2025-01-14
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Luverne, MN
Good Samaritan Society - Mary Jane Brown
1-star overall rating with 2-star inspections with $62,045 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
110 South Walnut Avenue, Luverne, MN
(507) 283-2375
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
51
Certified beds
Average residents
44
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
1991-07-01
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
0.91
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.49
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.60
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.87
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.97
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
33%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,927
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9864
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
5.02
Performance 6.34% · Measure score 5.02 · Achievement 5.02 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0.9
Baseline 56.82% · Performance 60.00% · Measure score 0.9 · Achievement 0.9 · Improvement 0
Adjusted total nurse staffing
3.47
Baseline 4.16 hours · Performance 4.07 hours · Measure score 3.47 · Achievement 3.47 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.36% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 1.96% · Lower 95% interval 6.03% |
| Discharge to community | 57.12% |
50.57%
6.5 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 58.06% · Lower 95% interval 38.47% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 54.17% |
95.27%
41.1 pts worse
|
Numerator 13 · Denominator 24 |
| Falls with major injury | 4.17% |
0.77%
3.4 pts worse
|
Numerator 1 · Denominator 24 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 24 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.34% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 0% · Lower 95% interval 2.86% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 83 |
| Staff flu vaccination coverage | 86.87% |
42%
44.9 pts better
|
Numerator 86 · Denominator 99 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · 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 | 99.3% |
97.3%
2 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.3% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
96.1%
1.5 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.9%
About the same
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.7% · Q3 5.1% · Q4 5.1% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.3% |
4.3%
2 pts worse
|
11.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 2.9% · Q3 2.8% · Q4 10.5% · 4Q avg 6.3% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
4.1%
0.2 pts worse
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.9% · Q3 3.0% · Q4 9.1% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.2% |
12.4%
12.8 pts worse
|
19.6%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 30.6% · Q3 20.6% · Q4 22.9% · 4Q avg 25.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.6% |
17.5%
9.1 pts worse
|
16.7%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.3% · Q2 26.7% · Q3 21.2% · Q4 22.6% · 4Q avg 26.6% · 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 | 37.2% |
22.5%
14.7 pts worse
|
16.3%
20.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 37.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.6% |
18.6%
14 pts worse
|
14.9%
17.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.9% · Q2 21.2% · Q3 30.3% · Q4 39.4% · 4Q avg 32.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
2.3%
0.8 pts better
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 3.8% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
2.6%
0.8 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 2.8% · Q3 2.6% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 37.4% |
24.8%
12.6 pts worse
|
19.8%
17.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 54.0% · Q2 35.4% · Q3 22.2% · Q4 37.4% · 4Q avg 37.4% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
5.4%
0.2 pts better
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 5.6% · Q3 6.7% · Q4 2.0% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
88.6%
3.1 pts better
|
81.7%
10 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 82.8% · Q3 89.3% · Q4 100.0% · 4Q avg 91.7% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.3% |
1.9%
4.4 pts worse
|
1.6%
4.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.7% |
82.7%
3 pts better
|
79.7%
6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.7% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-18 · Fire 2023-10-18
18 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-03-23 · Fire 2023-03-23
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-14
F · Potential for more than minimal harm
2025-01-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-14
F · Potential for more than minimal harm
2023-03-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-03-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-14
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 2025-02-14
D · Potential for more than minimal harm
2025-01-14
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-14
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 2025-02-14
D · Potential for more than minimal harm
2025-01-14
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 2025-02-14
D · Potential for more than minimal harm
2025-01-14
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 2025-02-14
D · Potential for more than minimal harm
2025-01-14
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
2025-01-14
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-02-14
D · Potential for more than minimal harm
2024-12-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-30
J · Immediate jeopardy
2024-08-06
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 2024-09-06
D · Potential for more than minimal harm
2024-08-06
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 2024-09-06
D · Potential for more than minimal harm
2024-02-08
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-02-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-02-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-02-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-06
F · Potential for more than minimal harm
2023-10-18
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-11-28
F · Potential for more than minimal harm
2023-10-18
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 2023-11-28
F · Potential for more than minimal harm
2023-10-18
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-11-28
F · Potential for more than minimal harm
2023-10-18
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-11-28
E · Potential for more than minimal harm
2023-10-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-28
E · Potential for more than minimal harm
2023-10-18
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-18
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-18
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-18
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 2023-11-28
D · Potential for more than minimal harm
2023-10-18
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 2023-11-28
D · Potential for more than minimal harm
2023-10-18
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-18
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 2023-11-28
D · Potential for more than minimal harm
2023-10-18
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 2023-11-28
D · Potential for more than minimal harm
2023-10-18
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-05-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-03-23
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-23
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-21
Penalties and ownership
What sits behind the stars
$57,045
2024-08-06
Fine
Fine · fine $57,045
Fine
$5,000
2023-03-23
Fine
Fine · fine $5,000
Fine
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
Chesley, Stephan
Operational/Managerial Control · 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, Nicholas
Corporate Officer · 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
Yeaton, Timothy
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Luverne, MN
4-star overall rating with 3-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Tuff Memorial Home
Hills, MN
5-star overall rating with 4-star inspections with $44,434 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Parkview Manor Nursing Home
Ellsworth, MN
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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