South Dakota ›Sioux Falls

Good Samaritan Society Luther Manor

1500 W 38th St, Sioux Falls, SD 57105 · Minnehaha County · 92 certified beds · avg 86 residents/day · certified since Jun 1, 1990

Part of chain: GOOD SAMARITAN SOCIETY (92 facilities, chain avg rating 3.0★)

2/5

Health inspection rating (on-site)

6

Serious findings on record

$92,066

Fines, last 3 years

4.33

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5

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 4, 2026 · 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: Jun 30, 2026 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Apr 1, 2026 · F-0760 · triggered by a complaint

The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.

Why it matters: A serious medication error can cause real harm, hospitalization, or worse.

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: Mar 23, 2026 (Past Non-Compliance)

▲ Actual harm, one-off · Mar 5, 2026 · F-0686

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.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

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: Apr 1, 2026 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Mar 5, 2026 · 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: Apr 1, 2026 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jun 18, 2025 · 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: Jul 18, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Oct 17, 2024 · F-0689

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: Nov 12, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (22)

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 4, 2026	▲ 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
Jun 4, 2026	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. · from a complaint
Apr 1, 2026	▲ G · Actual harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Apr 1, 2026	E · Potential for harm, repeated	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
Mar 5, 2026	▲ G · Actual 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.
Mar 5, 2026	▲ 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
Mar 5, 2026	E · Potential for harm, repeated	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
Mar 5, 2026	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.
Mar 5, 2026	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Mar 5, 2026	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.
Mar 5, 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.
Mar 5, 2026	D · Potential for harm, one-off	The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from.
Jul 23, 2025	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. · from a complaint
Jun 18, 2025	▲ 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
Jun 18, 2025	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. · from a complaint
Jan 23, 2025	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. · from a complaint
Oct 17, 2024	▲ 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.
Oct 17, 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.
Oct 17, 2024	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.
Sep 8, 2023	E · Potential for harm, repeated	The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Sep 8, 2023	E · Potential for harm, repeated	The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have.
Sep 8, 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.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (3 → 7).

Year	Citations	Serious (G–L)	Worst severity that year
2023	3	0	E
2024	3	1	G ▲
2025	4	1	G ▲
2026	12	4	G ▲

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)

3 fines totaling $92,066.

Date	Type	Amount / length
Mar 5, 2026	Fine	$70,980
Jun 18, 2025	Fine	$9,620
Oct 17, 2024	Fine	$11,466

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	South Dakota avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	4.33	4.32	3.95	top 39% in South Dakota; top 28% in the U.S.
Registered Nurse hours	1.04	0.91	0.69	top 31% in South Dakota; top 14% in the U.S.
Weekend total nurse staffing	3.64	3.71	3.50	top 44% in South Dakota; top 36% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.53	0.51	0.48	top 41% in South Dakota; top 29% in the U.S.
Total nursing staff turnover (%)	43.5	48.2	45.8	top 39% in South Dakota; top 46% in the U.S.
RN turnover (%)	34.8	34.7	42.9	bottom 40% in South Dakota; top 38% 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 3.94, RN 0.95, weekend 3.32. 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: 2/5 · long-stay residents: 1/5 · short-stay residents: 3/5

Who owns this facility

For 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
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	03/04/2024
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	06/01/2026
Fluit, Joel	Individual	ADP of the SNF	NOT APPLICABLE	10/01/2022
Focusone Solutions	Organization	ADP of the SNF	NOT APPLICABLE	03/04/2024
Fraser, Thomas	Individual	Operational/Managerial Control	NOT APPLICABLE	04/25/2022
Fraser, Thomas	Individual	ADP of the SNF	NOT APPLICABLE	04/25/2022
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
Grape Tree Medical Staffing LLC	Organization	ADP of the SNF	NOT APPLICABLE	04/13/2018
Gulsvig, Neil	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.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"What systems do you use to prevent medication errors, and what happens when one occurs?"
"How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
"If my family member is able to manage their own medications, would you allow it, and how is that decided?"
"When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
"Who completes resident assessments here, and how do you check them for accuracy?"
"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
Avantara Norton	0.6 mi	Sioux Falls, SD		—/5	abuseSFF
Bethany Home Sioux Falls	0.9 mi	Sioux Falls, SD	★★★☆☆	4/5
Good Samaritan Society Sioux Falls Village	2.4 mi	Sioux Falls, SD	★★☆☆☆	2/5
Good Samaritan Society Sioux Falls Center	2.8 mi	Sioux Falls, SD	★★☆☆☆	2/5	abuse
Dow Rummel Village	2.9 mi	Sioux Falls, SD	★★★☆☆	2/5
Avera Prince of Peace	3.1 mi	Sioux Falls, SD	★★★★☆	3/5
Bethany Home - Brandon	11.3 mi	Brandon, SD	★☆☆☆☆	1/5	abuse
Good Samaritan Society Canton	16.4 mi	Canton, SD	★★☆☆☆	3/5
Palisade Healthcare Center	18.6 mi	Garretson, SD	★☆☆☆☆	1/5	abuse
Tuff Memorial Home	19.6 mi	Hills, MN	★★★★☆	5/5

Compare this facility with the 3 closest →

All facilities in Sioux Falls →

Facility data as of CMS processing date 2026-08-01. CCN 435044.

The Care File

Visit checklist — Good Samaritan Society Luther Manor

1500 W 38th St, Sioux Falls, SD 57105 · 6053361997

Health inspection rating 2/5 · CMS overall 2/5· Fines (3y): $92,066

Most serious findings on record:

▲ Jun 4, 2026 (F-0689, 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.
▲ Apr 1, 2026 (F-0760, Actual harm, one-off): The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
▲ Mar 5, 2026 (F-0686, Actual 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.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "What systems do you use to prevent medication errors, and what happens when one occurs?"
☐ "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
☐ "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
☐ "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
☐ "Who completes resident assessments here, and how do you check them for accuracy?"
☐ "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?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 435044 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)