MinnesotaLuverne

Good Samaritan Society - Mary Jane Brown

110 South Walnut Avenue, Luverne, MN 56156 · Rock County · 51 certified beds · avg 46 residents/day · certified since Jul 1, 1991

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

2/5
Health inspection rating (on-site)
1
Serious findings on record
$57,045
Fines, last 3 years
4.29
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: 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 · Aug 6, 2024 · 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 (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: Sep 6, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (32)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Apr 1, 2026F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Apr 1, 2026F · Potential for harm, facility-wideThe facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records.
Apr 1, 2026D · Potential for harm, one-offThe 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.
Jan 14, 2025E · Potential for harm, repeatedThe 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.
Jan 14, 2025D · Potential for harm, one-offThe facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately.
Jan 14, 2025D · Potential for harm, one-offThe 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.
Jan 14, 2025D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jan 14, 2025D · Potential for harm, one-offThe 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.
Jan 14, 2025D · Potential for harm, one-offThe 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.
Jan 14, 2025D · Potential for harm, one-offThe facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs.
Dec 27, 2024D · Potential for harm, one-offThe 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
Aug 6, 2024▲ J · Immediate jeopardy, one-offThe 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 6, 2024D · Potential for harm, one-offThe 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
Feb 8, 2024D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint
Feb 8, 2024D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Feb 8, 2024D · Potential for harm, one-offThe 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
Feb 8, 2024D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint
Oct 18, 2023F · Potential for harm, facility-wideThe 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
Oct 18, 2023F · Potential for harm, facility-wideThe 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 18, 2023F · Potential for harm, facility-wideThe facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Oct 18, 2023F · Potential for harm, facility-wideThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Oct 18, 2023E · Potential for harm, repeatedThe 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 18, 2023E · Potential for harm, repeatedThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Oct 18, 2023D · Potential for harm, one-offThe facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out.
Oct 18, 2023D · Potential for harm, one-offThe 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.
Oct 18, 2023D · Potential for harm, one-offThe 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.
Oct 18, 2023D · Potential for harm, one-offThe 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.
Oct 18, 2023D · Potential for harm, one-offThe facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. · from a complaint
Oct 18, 2023D · Potential for harm, one-offThe 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.
Oct 18, 2023D · Potential for harm, one-offThe 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.
Oct 18, 2023D · Potential for harm, one-offThe 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.
Oct 18, 2023D · Potential for harm, one-offThe facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months.

Inspection trend by year

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

YearCitationsSerious (G–L)Worst severity that year
2023150F
202471J ▲
202570E
202630F

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 $57,045.

DateTypeAmount / length
Aug 6, 2024Fine$57,045

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

MeasureThis facilityMinnesota avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)4.294.833.95bottom 30% in Minnesota; top 29% in the U.S.
Registered Nurse hours1.071.220.69bottom 44% in Minnesota; top 13% in the U.S.
Weekend total nurse staffing3.404.273.50bottom 9% in Minnesota; top 47% in the U.S.
Weekend RN hours (not acuity-adjusted)0.430.690.48bottom 23% in Minnesota; top 43% in the U.S.
Total nursing staff turnover (%)60.042.245.8bottom 13% in Minnesota; bottom 17% in the U.S.
RN turnover (%)50.038.642.9bottom 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 3.88, RN 0.97, weekend 3.08. 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 / managerTypeRoleStakeSince
SanfordOrganization5% or Greater Direct Ownership Interest100%01/01/2019
The Evangelical Lutheran Good Samaritan SocietyOrganization5% or Greater Indirect Ownership Interest100%01/01/2019
Brown, GeorgeIndividualCorporate DirectorNOT APPLICABLE01/01/2025
Brown, GeorgeIndividualADP of the SNFNOT APPLICABLE01/01/2025
Chesley, StephanIndividualOperational/Managerial ControlNOT APPLICABLE07/09/2018
Chesley, StephanIndividualADP of the SNFNOT APPLICABLE07/09/2018
DTN Staffing INCOrganizationADP of the SNFNOT APPLICABLE08/02/2024
Dykhouse, DanaIndividualCorporate DirectorNOT APPLICABLE05/30/2024
Dykhouse, DanaIndividualADP of the SNFNOT APPLICABLE05/30/2024
Engbrecht, WesleyIndividualCorporate DirectorNOT APPLICABLE05/30/2024
Engbrecht, WesleyIndividualADP of the SNFNOT APPLICABLE05/30/2024
Fluit, JoelIndividualCorporate OfficerNOT APPLICABLE10/01/2022
Fluit, JoelIndividualADP of the SNFNOT APPLICABLE10/01/2022
Focusone SolutionsOrganizationADP of the SNFNOT APPLICABLE03/04/2024
Gassen, WilliamIndividualCorporate DirectorNOT APPLICABLE05/30/2024
Gassen, WilliamIndividualCorporate OfficerNOT APPLICABLE05/30/2024
Gassen, WilliamIndividualADP of the SNFNOT APPLICABLE05/30/2024
Grape Tree Medical Staffing LLCOrganizationADP of the SNFNOT APPLICABLE04/13/2018
Gulsvig, NeilIndividualCorporate DirectorNOT APPLICABLE05/30/2024
Gulsvig, NeilIndividualADP of the SNFNOT APPLICABLE05/30/2024

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

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Facility data as of CMS processing date 2026-08-01. CCN 245568.