Good Samaritan Society - Blackduck
172 Summit Avenue West, Blackduck, MN 56630 · Beltrami County · 30 certified beds · avg 28 residents/day · certified since Apr 1, 1992
Part of chain: GOOD SAMARITAN SOCIETY (92 facilities, chain avg rating 3.0★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jul 1, 2026 · F-0803 · triggered by a complaint
The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
Why it matters: When menus aren't planned and followed properly, residents may not get the nutrition their health depends on.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jun 11, 2026 (Past Non-Compliance)
All citations in the current public record (23)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jul 1, 2026 | ▲ J · Immediate jeopardy, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint |
| Oct 31, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Oct 31, 2025 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Oct 31, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Aug 20, 2025 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Jun 13, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 13, 2024 | F · Potential for harm, facility-wide | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
| Jun 13, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 13, 2024 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Jun 13, 2024 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Jun 13, 2024 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Feb 7, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 10, 2023 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Aug 10, 2023 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · from a complaint |
| Aug 10, 2023 | D · Potential for harm, one-off | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Aug 10, 2023 | D · Potential for harm, one-off | When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. |
| Aug 10, 2023 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Aug 10, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Aug 10, 2023 | B · Minimal risk, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (6 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 7 | 0 | E |
| 2024 | 7 | 0 | F |
| 2025 | 8 | 0 | D |
| 2026 | 1 | 1 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $22,205.
| Date | Type | Amount / length |
|---|---|---|
| Jul 1, 2026 | Fine | $22,205 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Minnesota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.44 | 4.83 | 3.95 | bottom 34% in Minnesota; top 25% in the U.S. |
| Registered Nurse hours | 0.82 | 1.22 | 0.69 | bottom 17% in Minnesota; top 26% in the U.S. |
| Weekend total nurse staffing | 4.13 | 4.27 | 3.50 | bottom 45% in Minnesota; top 19% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.46 | 0.69 | 0.48 | bottom 29% in Minnesota; top 39% in the U.S. |
| Total nursing staff turnover (%) | 53.7 | 42.2 | 45.8 | bottom 19% in Minnesota; bottom 28% in the U.S. |
| RN turnover (%) | 50.0 | 38.6 | 42.9 | bottom 32% in Minnesota; bottom 39% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.01, RN 0.74, weekend 3.73. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: —/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Sanford | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/01/2019 |
| The Evangelical Lutheran Good Samaritan Society | Organization | 5% or Greater Indirect Ownership Interest | 100% | 01/01/2019 |
| Billups, Sherry | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/14/2018 |
| Billups, Sherry | Individual | ADP of the SNF | NOT APPLICABLE | 08/14/2018 |
| Bjerke, Brandon | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/12/2021 |
| Bjerke, Brandon | Individual | ADP of the SNF | NOT APPLICABLE | 04/12/2021 |
| Brown, George | Individual | Corporate Director | NOT APPLICABLE | 01/01/2025 |
| Brown, George | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| DTN Staffing INC | Organization | ADP of the SNF | NOT APPLICABLE | 08/02/2024 |
| Dykhouse, Dana | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Dykhouse, Dana | Individual | ADP of the SNF | NOT APPLICABLE | 05/30/2024 |
| Engbrecht, Wesley | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Engbrecht, Wesley | Individual | ADP of the SNF | NOT APPLICABLE | 05/30/2024 |
| Fluit, Joel | Individual | Corporate Officer | NOT APPLICABLE | 10/01/2022 |
| Fluit, Joel | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 04/13/2026 |
| Fluit, Joel | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2022 |
| Focusone Solutions | Organization | ADP of the SNF | NOT APPLICABLE | 03/04/2024 |
| Gassen, William | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Gassen, William | Individual | Corporate Officer | NOT APPLICABLE | 05/30/2024 |
| Gassen, William | Individual | ADP of the SNF | NOT APPLICABLE | 05/30/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Who reviews your menus, and can I see this week's menu and join my family member for a meal?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Neilson Place | 22.3 mi | Bemidji, MN | ★☆☆☆☆ | 1/5 | |
| Havenwood Care Center | 23.2 mi | Bemidji, MN | ★★☆☆☆ | 1/5 | |
| Jourdain Perpich Ext Care Fac | 24.5 mi | Redlake, MN | ★★★★★ | 5/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 245600.