Good Samaritan Society New Underwood
412 South Madison, New Underwood, SD 57761 · Pennington County · 41 certified beds · avg 37 residents/day · certified since Jul 1, 1997
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: 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 10, 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: Jun 30, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 30, 2025 · 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: Feb 27, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (29)
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 |
|---|---|---|
| Dec 8, 2025 | 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. |
| Dec 8, 2025 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Dec 8, 2025 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Dec 8, 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. |
| Dec 8, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Dec 8, 2025 | 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. |
| Dec 8, 2025 | 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. |
| Dec 8, 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. |
| Dec 8, 2025 | D · Potential for harm, one-off | 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. |
| Dec 8, 2025 | D · Potential for harm, one-off | 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. |
| Jul 9, 2025 | 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 |
| Jun 10, 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 |
| Jan 30, 2025 | ▲ 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. |
| Jan 30, 2025 | F · Potential for harm, facility-wide | 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. |
| Jan 30, 2025 | F · Potential for harm, facility-wide | 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. |
| Jan 30, 2025 | 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. |
| Jan 30, 2025 | 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. |
| Jan 30, 2025 | 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. |
| Jan 30, 2025 | 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. |
| Jan 30, 2025 | 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. |
| Jan 30, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jan 30, 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. |
| Jan 30, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jan 30, 2025 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Nov 16, 2023 | F · Potential for harm, facility-wide | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. |
| Nov 16, 2023 | 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. |
| Nov 16, 2023 | 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. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (12 → 10).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 0 | F |
| 2025 | 24 | 2 | 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)
2 fines totaling $26,595.
| Date | Type | Amount / length |
|---|---|---|
| Jun 10, 2025 | Fine | $11,190 |
| Jan 30, 2025 | Fine | $15,405 |
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) | 3.41 | 4.32 | 3.95 | bottom 14% in South Dakota; bottom 32% in the U.S. |
| Registered Nurse hours | 0.95 | 0.91 | 0.69 | top 41% in South Dakota; top 18% in the U.S. |
| Weekend total nurse staffing | 2.70 | 3.71 | 3.50 | bottom 7% in South Dakota; bottom 16% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.37 | 0.51 | 0.48 | bottom 31% in South Dakota; bottom 47% in the U.S. |
| Total nursing staff turnover (%) | 64.7 | 48.2 | 45.8 | bottom 12% in South Dakota; bottom 10% in the U.S. |
| RN turnover (%) | 50.0 | 34.7 | 42.9 | bottom 24% in South Dakota; 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 2.82, RN 0.79, weekend 2.23. 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: 3/5 · long-stay residents: 1/5 · short-stay residents: 5/5
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 |
| Cain, James | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Diamond, Kenneth | Individual | Contracted Managing Employee | NOT APPLICABLE | 08/01/2021 |
| 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 |
| Herseth Sandlin, Stephanie | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Hubbeling, Paul | Individual | W-2 Managing Employee | NOT APPLICABLE | 08/23/2023 |
| 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 |
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?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Does your facility have an active resident council, and how does management respond to its concerns?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "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 |
|---|---|---|---|---|---|
| Westhills Village Health Care Facility | 19.6 mi | Rapid City, SD | ★★★★★ | 4/5 | |
| Avantara North | 19.9 mi | Rapid City, SD | ★★★☆☆ | 3/5 | |
| Avantara Saint Cloud | 19.9 mi | Rapid City, SD | ★☆☆☆☆ | 2/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 435104.