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Good Samaritan Society - Devils Lake

Summary: Good Samaritan Society - Devils Lake is located in Devils Lake, North Dakota. It was first approved by Medicare and Medicaid to provide nursing home services on 1991-03-01. It currently has 48 certified beds and 47 residents in the certified beds. Good Samaritan Society - Devils Lake earned a 1-star overall rating in the lasted Medicare and Medicaid Health Inspections (2015-08-01) [1]. See following table for more details.

Information of Good Samaritan Society - Devils Lake

Nursing Home Profile
Address 302 7TH AVE NE, Devils Lake, ND 58301
Phone 701-662-6580
Number Certified Beds / Residents in Certified Beds 48 / 47
Certification Medicare and Medicaid
Ratings
Overall Rating ☆☆☆☆ (1)  
Health Inspection Rating ☆☆☆☆ (1)
Quality Rating ★★★ ☆☆ (3)
Staffing Rating ★★★ ☆☆ (3)
RN Staffing Rating ★★★★ (4)
Staff and Nurse Hour Statistics
Reported CNA Staffing Hours per Resident per Day 2.09043
Reported LPN Staffing Hours per Resident per Day 0.64787
Reported RN Staffing Hours per Resident per Day 0.68936
Reported Licensed Staffing Hours per Resident per Day 1.33723
Reported Total Nurse Staffing Hours per Resident per Day 3.42766
Reported Physical Therapist Staffing Hours per Resident Per Day 0.00426
Expected CNA Staffing Hours per Resident per Day 2.47463
Expected LPN Staffing Hours per Resident per Day 0.59438
Expected RN Staffing Hours per Resident per Day 0.86954
Expected Total Nurse Staffing Hours per Resident per Day 3.93855
Adjusted CNA Staffing Hours per Resident per Day 2.07275
Adjusted LPN Staffing Hours per Resident per Day 0.90469
Adjusted RN Staffing Hours per Resident per Day 0.59237
Adjusted Total Nurse Staffing Hours per Resident per Day 3.50803
Notes: CNA=Certified nurse attendant;   LPN=Licensed practical nurse
Health Deficiencies & Scores
Cycle 1 Total Number of Health Deficiencies 19
Cycle 1 Number of Standard Health Deficiencies 19
Cycle 1 Number of Complaint Health Deficiencies 0
Cycle 1 Health Deficiency Score 132
Cycle 1 Standard Survey Health Date 2014-12-18
Cycle 1 Number of Health Revisits 0
Cycle 1 Health Revisit Score 0
Cycle 1 Total Health Score 132
Cycle 2 Total Number of Health Deficiencies 10
Cycle 2 Number of Standard Health Deficiencies 10
Cycle 2 Number of Complaint Health Deficiencies 0
Cycle 2 Health Deficiency Score 60
Cycle 2 Standard Survey Health Date 2014-01-23
Cycle 2 Number of Health Revisits 2
Cycle 2 Health Revisit Score 30
Cycle 2 Total Health Score 90
Cycle 3 Total Number of Health Deficiencies 16
Cycle 3 Number of Standard Health Deficiencies 15
Cycle 3 Number of Complaint Health Deficiencies 1
Cycle 3 Health Deficiency Score 80
Cycle 3 Standard Survey Health Date 2013-01-16
Cycle 3 Number of Health Revisits 1
Cycle 3 Health Revisit Score 0
Cycle 2 Total Health Score 80
Total Weighted Health Survey Score 109.333
Complaints, Fines & Penalties
Number of Facility Reported Incidents 0
Number of Substantiated Complaints 1
Number of Fines 0
Total Amount of Fines in Dollars 0
Number of Payment Denials 0
Total Number of Penalties 0
Facility Information
Ownership Non profit - Corporation
Date First Approved to Provide Medicare and Medicaid 1991-03-01
Provider Resides in Hospital NO
Continuing Care Retirement Community N
Special Focus Facility N
Changed Ownership in Last 12 Months N
With a Resident and Family Council Resident
Automatic Sprinkler Systems in All Required Areas Yes
Processing Date 2015-08-01

Ownership Information

Owner NameOwner RoleOwner Type%
The Evangelical Lutheran Good Samaritan Society5% Or Greater Direct Ownership InterestOrganization100%
Brown, ElwinDirectorIndividualn/a
Connelly, LianeDirectorIndividualn/a
Deuth, MichaelDirectorIndividualn/a
Grindal, HaraldDirectorIndividualn/a
Gulsvig, NeilDirectorIndividualn/a
Gustafson, KariDirectorIndividualn/a
Halaas, GwenDirectorIndividualn/a
Hildebrandt, TeresaDirectorIndividualn/a
Holt, JohnDirectorIndividualn/a
Johnson, ChristopherDirectorIndividualn/a
Juffer, MicheleDirectorIndividualn/a
Matson, GuyDirectorIndividualn/a
Racek, JohnDirectorIndividualn/a
Samuelson, PhilipDirectorIndividualn/a
St Mary, SharonDirectorIndividualn/a
Gause, SylviaOfficerIndividualn/a
Ham-quick, MistyOfficerIndividualn/a
Herdina, JosephOfficerIndividualn/a
Horazdovsky, DavidOfficerIndividualn/a
Nylander, Raye NaeOfficerIndividualn/a
Bjelland, SusanManaging EmployeeIndividualn/a