Cycle 1
Health 2025-04-24 · Fire 2025-04-24
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Sioux Falls, SD
Good Samaritan Society Sioux Falls Village
1-star overall rating with 1-star inspections with $72,644 in total fines with 14 recent health deficiencies
3901 S Marion Rd, Sioux Falls, SD
(605) 361-3311
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
177
Certified beds
Average residents
161
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
1990-07-01
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
0.66
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
3.68
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.74
CMS adjusted RN staffing hours
Adjusted total hours
4.10
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,687
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9840
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.80
Baseline 19.58% · Performance 19.20% · Measure score 4.80 · Achievement 4.80 · Improvement 0.98
Healthcare-associated infections
1.65
Baseline 6.56% · Performance 7.34% · Measure score 1.65 · Achievement 1.65 · Improvement 0
Total nurse turnover
0.64
Baseline 45.11% · Performance 61.05% · Measure score 0.64 · Achievement 0.64 · Improvement 0
Adjusted total nurse staffing
3.29
Baseline 4.28 hours · Performance 4.01 hours · Measure score 3.29 · Achievement 3.29 · 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 197 · Observed rate 7.61% · Lower 95% interval 6.54% |
| Discharge to community | 46.51% |
50.57%
4.1 pts worse
|
No Different than the National Rate · Eligible stays 205 · Observed rate 40.49% · Lower 95% interval 39.24% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 93.96% |
95.27%
1.3 pts worse
|
Numerator 171 · Denominator 182 |
| Falls with major injury | 1.65% |
0.77%
0.9 pts worse
|
Numerator 3 · Denominator 182 |
| Discharge self-care score | 57.75% |
53.69%
4.1 pts better
|
Numerator 82 · Denominator 142 |
| Discharge mobility score | 49.3% |
50.94%
1.6 pts worse
|
Numerator 70 · Denominator 142 |
| Pressure ulcers or injuries, new or worsened | 2.75% |
2.29%
0.5 pts worse
|
Numerator 5 · Denominator 182 · Adjusted rate 3.33% |
| Healthcare-associated infections requiring hospitalization | 7.34% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 117 · Observed rate 6.84% · Lower 95% interval 4.58% |
| Staff COVID-19 vaccination coverage | 5.2% |
8.2%
3 pts worse
|
Numerator 9 · Denominator 173 |
| Staff flu vaccination coverage | 88.05% |
42%
46 pts better
|
Numerator 199 · Denominator 226 |
| Discharge function score | 64.08% |
56.45%
7.6 pts better
|
Numerator 91 · Denominator 142 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 31 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 93 · Denominator 93 |
| Resident COVID-19 vaccinations up to date | 65.93% |
25.2%
40.7 pts better
|
Numerator 60 · Denominator 91 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.9
1.2 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
95.4%
4.2 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.3% |
96.9%
2.4 pts better
|
95.5%
3.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.1% |
5.1%
2 pts worse
|
3.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.4% · Q3 7.6% · Q4 7.6% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
4.6%
2.1 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.8% · Q3 3.8% · Q4 0.8% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
5.5%
3.1 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 1.6% · Q3 1.6% · Q4 2.3% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.9% |
17.8%
3.9 pts better
|
19.6%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 14.2% · Q3 12.4% · Q4 13.2% · 4Q avg 13.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 33.6% |
25.1%
8.5 pts worse
|
16.7%
16.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.9% · Q2 35.2% · Q3 32.3% · Q4 32.3% · 4Q avg 33.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 25.3% |
21.3%
4 pts worse
|
16.3%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.6% · Q2 22.7% · Q3 21.0% · Q4 22.1% · 4Q avg 25.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.2% |
21.6%
2.6 pts worse
|
14.9%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.9% · Q2 26.2% · Q3 18.0% · Q4 19.5% · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
2.0%
0.5 pts better
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 0.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.9% |
3.3%
0.6 pts worse
|
1.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 5.1% · Q3 2.1% · Q4 2.8% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.8% |
25.8%
About the same
|
19.8%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 29.6% · Q3 22.9% · Q4 26.1% · 4Q avg 25.8% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
4.6%
0.1 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 3.8% · Q3 4.8% · Q4 4.4% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
83.2%
12.3 pts better
|
81.7%
13.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.5% · Q2 94.2% · Q3 99.3% · Q4 99.2% · 4Q avg 95.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
11.7%
2.9 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 9.7% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.7%
0.2 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.9% · Q3 1.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.8% |
78.2%
16.6 pts better
|
79.7%
15.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.2% |
21.5%
8.7 pts worse
|
23.9%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.2% · Observed 32.7% · Expected 25.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-07 · Fire 2023-12-07
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-08 · Fire 2022-11-08
17 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
J · Immediate jeopardy
2025-04-24
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-04-24
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-04-24
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-04-24
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-04-24
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 2025-05-20
E · Potential for more than minimal harm
2025-04-24
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 2025-05-20
E · Potential for more than minimal harm
2025-04-24
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-04-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-24
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 2025-05-20
D · Potential for more than minimal harm
2025-04-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-24
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 2025-05-20
D · Potential for more than minimal harm
2025-04-24
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-24
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-05-20
G · Actual harm
2024-11-14
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 2024-11-01
G · Actual harm
2024-09-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-04
J · Immediate jeopardy
2024-06-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-28
G · Actual harm
2023-12-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-04
F · Potential for more than minimal harm
2023-12-07
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 2024-01-04
F · Potential for more than minimal harm
2023-12-07
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-12-07
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-12-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-07
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-07
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-07
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 2024-01-04
D · Potential for more than minimal harm
2023-07-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-10
F · Potential for more than minimal harm
2022-11-08
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 2022-12-08
F · Potential for more than minimal harm
2022-11-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-12-08
F · Potential for more than minimal harm
2022-11-08
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 2022-12-08
F · Potential for more than minimal harm
2022-11-08
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-12-08
F · Potential for more than minimal harm
2022-11-08
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2022-12-08
E · Potential for more than minimal harm
2022-11-08
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2022-12-08
E · Potential for more than minimal harm
2022-11-08
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-12-08
E · Potential for more than minimal harm
2022-11-08
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 2022-12-08
E · Potential for more than minimal harm
2022-11-08
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-12-08
E · Potential for more than minimal harm
2022-11-08
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 2022-12-08
E · Potential for more than minimal harm
2022-11-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-11-08
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-11-08
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-11-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-11-08
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 2022-12-08
D · Potential for more than minimal harm
2022-11-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-08
Penalties and ownership
What sits behind the stars
$14,472
2025-04-24
Fine
Fine · fine $14,472
Fine
$7,718
2024-11-14
Fine
Fine · fine $7,718
Fine
$9,256
2024-09-19
Fine
Fine · fine $9,256
Fine
$22,055
2024-06-04
Fine
Fine · fine $22,055
Fine
$19,143
2023-12-07
Fine
Fine · fine $19,143
Fine
Ownership
Sanford
5% Or Greater Direct Ownership Interest · Organization
The Evangelical Lutheran Good Samaritan Society
5% Or Greater Indirect Ownership Interest · Organization
Bachmeier, Dana
W-2 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
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
Orstad, Keri
Contracted Managing Employee · Individual
Rogers, Michael
Corporate Officer · Individual
Schema, Nathan
Corporate Officer · Individual
Shulkin, David
Corporate Director · Individual
Teiken, Brent
Corporate Director · Individual
Ventling-Herrmann, Marnie
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Bethany Home Sioux Falls
Sioux Falls, SD
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Good Samaritan Society Luther Manor
Sioux Falls, SD
2-star overall rating with 3-star inspections with $11,466 in total fines with 6 recent health deficiencies
#3
Avantara Norton
Sioux Falls, SD
0-star overall rating with 0-star inspections with Special Focus status with abuse icon flag with $191,055 in total fines with 19 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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