Cycle 1
Health 2025-12-31 · Fire 2025-12-31
5 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Mandan, ND
Good Samaritan Society Miller Pointe A Prospera Co
2-star overall rating with 1-star inspections with $35,535 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3500 21st St Se, Mandan, ND
(701) 323-1300
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
116
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
0.76
Registered nurse staffing · state 0.93 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.50 · national 0.87
Aide hours / resident day
3.01
Nurse aide staffing · state 2.99 · national 2.35
Total nurse hours
4.38
All reported nurse hours · state 4.41 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.03
Weekend nurse staffing · state 3.75 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.59 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
4.71
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
26%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,666
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.36
Composite VBP score used to determine payment impact.
Payment multiplier
0.9890
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.82
Baseline 19.83% · Performance 20.12% · Measure score 2.82 · Achievement 2.82 · Improvement 0
Healthcare-associated infections
0
Baseline 6.27% · Performance 7.99% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.28
Baseline 37.41% · Performance 38.02% · Measure score 6.28 · Achievement 6.28 · Improvement 0
Adjusted total nurse staffing
5.05
Baseline 4.49 hours · Performance 4.51 hours · Measure score 5.05 · Achievement 5.05 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.53% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 130 · Observed rate 11.54% · Lower 95% interval 7.79% |
| Discharge to community | 39.62% |
50.57%
11 pts worse
|
Worse than the National Rate · Eligible stays 124 · Observed rate 30.65% · Lower 95% interval 32.27% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.48% |
95.27%
3.2 pts better
|
Numerator 130 · Denominator 132 |
| Falls with major injury | 1.52% |
0.77%
0.8 pts worse
|
Numerator 2 · Denominator 132 |
| Discharge self-care score | 48.98% |
53.69%
4.7 pts worse
|
Numerator 48 · Denominator 98 |
| Discharge mobility score | 41.84% |
50.94%
9.1 pts worse
|
Numerator 41 · Denominator 98 |
| Pressure ulcers or injuries, new or worsened | 2.27% |
2.29%
About the same
|
Numerator 3 · Denominator 132 · Adjusted rate 2.64% |
| Healthcare-associated infections requiring hospitalization | 8% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 95 · Observed rate 10.53% · Lower 95% interval 5.37% |
| Staff COVID-19 vaccination coverage | 0.99% |
8.2%
7.2 pts worse
|
Numerator 2 · Denominator 203 |
| Staff flu vaccination coverage | 82.14% |
42%
40.1 pts better
|
Numerator 207 · Denominator 252 |
| Discharge function score | 59.18% |
56.45%
2.7 pts better
|
Numerator 58 · Denominator 98 |
| Transfer of health information to provider | 41.94% |
95.95%
54 pts worse
|
Numerator 13 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 33 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 33.73% |
25.2%
8.5 pts better
|
Numerator 28 · Denominator 83 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.4
1 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 3.9 · Expected 3.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.9
0.4 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.9 · Expected 2.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
98.3%
0.7 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 99.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
98.8%
0.6 pts worse
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
5.1%
1.3 pts better
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.9% · Q3 2.0% · Q4 4.1% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.3% |
4.4%
0.1 pts better
|
11.4%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 4.6% · Q3 5.1% · Q4 1.2% · 4Q avg 4.3% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
5.5%
1 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 4.3% · Q3 1.1% · Q4 4.3% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.4% |
17.4%
6 pts worse
|
19.6%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 22.4% · Q3 23.2% · Q4 25.0% · 4Q avg 23.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.6% |
23.4%
2.8 pts better
|
16.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 17.6% · Q3 20.3% · Q4 22.2% · 4Q avg 20.6% · 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 | 28.0% |
19.0%
9 pts worse
|
16.3%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.9% · Q2 22.0% · Q3 28.8% · Q4 27.5% · 4Q avg 28.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.7% |
20.1%
2.4 pts better
|
14.9%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 18.8% · Q3 19.4% · Q4 23.4% · 4Q avg 17.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.8%
1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.5% · Q3 0.8% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.7% |
3.1%
1.6 pts worse
|
1.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.1% · Q3 7.2% · Q4 3.2% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.7% |
25.2%
2.5 pts better
|
19.8%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 20.9% · Q3 23.7% · Q4 22.6% · 4Q avg 22.7% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
5.3%
1.2 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 5.3% · Q3 5.6% · Q4 5.9% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.1% |
93.6%
13.5 pts worse
|
81.7%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 70.2% · Q2 76.5% · Q3 83.2% · Q4 87.7% · 4Q avg 80.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
10.7%
0.1 pts worse
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 12.6% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 67.0% |
88.3%
21.3 pts worse
|
79.7%
12.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 67.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.7% |
20.5%
1.2 pts worse
|
23.9%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 25.2% · Expected 27.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-07 · Fire 2024-11-07
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-10-19 · Fire 2023-10-19
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-31
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2026-01-23
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-04
D · Potential for more than minimal harm
2025-12-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-02-04
D · Potential for more than minimal harm
2025-12-31
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 2026-02-04
D · Potential for more than minimal harm
2025-12-31
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2026-02-04
J · Immediate jeopardy
2025-03-06
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 2025-03-07
E · Potential for more than minimal harm
2024-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-12
G · Actual harm
2024-09-19
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 2024-09-16
D · Potential for more than minimal harm
2024-09-19
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 2024-10-24
E · Potential for more than minimal harm
2023-10-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-23
E · Potential for more than minimal harm
2023-10-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-23
D · Potential for more than minimal harm
2023-10-19
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-11-23
D · Potential for more than minimal harm
2023-10-19
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 2023-11-23
D · Potential for more than minimal harm
2023-10-19
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 2023-11-23
D · Potential for more than minimal harm
2023-10-19
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 2023-11-23
D · Potential for more than minimal harm
2023-10-19
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 2023-11-23
D · Potential for more than minimal harm
2023-09-14
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 2023-10-19
Penalties and ownership
What sits behind the stars
$35,535
2025-03-06
Fine
Fine · fine $35,535
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
Cartmill, Kayley
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
Johnson, Anthony
Operational/Managerial Control · 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
Nearby options
Other facilities in reach
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Sunset Drive - A Prospera Community
Mandan, ND
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $41,552 in total fines with 29 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Good Samaritan Society Augusta Place A Prospera Co
Bismarck, ND
4-star overall rating with 4-star inspections with $16,036 in total fines with 2 fire-safety deficiencies in the latest cycle
#3
Dakota Alpha
Mandan, ND
5-star overall rating with 5-star inspections with 2 recent health deficiencies
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