Good Samaritan Society - Lakota
608 4th Ave SW, Lakota, ND 58344 · Nelson County · 38 certified beds · avg 35 residents/day · certified since Apr 1, 1991
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)
▲ Actual harm, one-off · Jun 19, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 14, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 11, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 31, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (30)
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 |
|---|---|---|
| Jun 16, 2026 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Jun 16, 2026 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Jun 16, 2026 | 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 |
| Jun 3, 2025 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jun 3, 2025 | E · Potential for harm, repeated | 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 3, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jun 3, 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. |
| Jun 3, 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. |
| Jun 3, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jun 3, 2025 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Jan 8, 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 |
| Jan 8, 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. · from a complaint |
| Jun 19, 2024 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jun 19, 2024 | F · Potential for harm, facility-wide | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Jun 19, 2024 | E · Potential for harm, repeated | 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. · from a complaint |
| Jun 19, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jun 19, 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. · from a complaint |
| Jun 19, 2024 | 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 |
| Jun 19, 2024 | 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 |
| Jun 19, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Jun 19, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Jun 19, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jun 19, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint |
| Jun 19, 2024 | D · Potential for harm, one-off | 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. · from a complaint |
| Oct 11, 2023 | ▲ G · Actual 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 |
| May 25, 2023 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| May 25, 2023 | 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. |
| May 25, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 25, 2023 | 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. |
| May 25, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (12 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 6 | 1 | G ▲ |
| 2024 | 12 | 1 | G ▲ |
| 2025 | 9 | 0 | E |
| 2026 | 3 | 0 | E |
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)
2 fines totaling $74,283.
| Date | Type | Amount / length |
|---|---|---|
| Jun 19, 2024 | Fine | $48,445 |
| Oct 11, 2023 | Fine | $25,838 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | North Dakota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.90 | 5.15 | 3.95 | bottom 6% in North Dakota; top 44% in the U.S. |
| Registered Nurse hours | 1.08 | 1.09 | 0.69 | top 43% in North Dakota; top 13% in the U.S. |
| Weekend total nurse staffing | 2.95 | 4.43 | 3.50 | bottom 1% in North Dakota; bottom 28% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.58 | 0.59 | 0.48 | top 43% in North Dakota; top 25% in the U.S. |
| Total nursing staff turnover (%) | 44.7 | 48.8 | 45.8 | top 35% in North Dakota; top 49% in the U.S. |
| RN turnover (%) | 55.6 | 40.3 | 42.9 | bottom 22% in North Dakota; bottom 28% 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 3.83, RN 1.06, weekend 2.90. Staffing rating: 3/5.
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 |
| Berg, Jonathon | Individual | Contracted Managing Employee | NOT APPLICABLE | 01/01/2019 |
| Cain, James | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Dykhouse, Dana | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Engbrecht, Wesley | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Fluit, Joel | Individual | Corporate Officer | NOT APPLICABLE | 10/01/2022 |
| Gassen, William | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Gassen, William | Individual | Corporate Officer | NOT APPLICABLE | 05/30/2024 |
| Gulsvig, Neil | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Halvorson, Anna | Individual | W-2 Managing Employee | NOT APPLICABLE | 01/02/2015 |
| Herseth Sandlin, Stephanie | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Lundeen, Mark | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Middleton, Aimee | Individual | Corporate Officer | NOT APPLICABLE | 01/27/2022 |
| Molbert, Lauris | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Morrison, Tony | Individual | W-2 Managing Employee | NOT APPLICABLE | 01/01/2019 |
| North, Andrew | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Olson, Nicholas | Individual | Corporate Officer | NOT APPLICABLE | 04/08/2024 |
| Rogers, Michael | Individual | Corporate Officer | NOT APPLICABLE | 06/13/2022 |
| Schema, Nathan | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2022 |
| Shulkin, David | Individual | Corporate Director | 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.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "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 |
|---|---|---|---|---|---|
| Nelson County Health System Care Center | 20.7 mi | McVille, ND | ★★☆☆☆ | 2/5 | abuse |
| Eventide Heartland | 23.4 mi | Devils Lake, ND | ★★★★☆ | 3/5 | |
| Aneta Parkview Health Ctr | 30.3 mi | Aneta, ND | ★★★★★ | 5/5 | |
| Good Samaritan Society - Park River | 33.5 mi | Park River, ND | ★★☆☆☆ | 2/5 | |
| Good Samaritan Society - Larimore | 35.1 mi | Larimore, ND | —/5 | SFF |
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Facility data as of CMS processing date 2026-08-01. CCN 355104.