Good Samaritan Society - Pipestone
1311 North Hiawatha, Pipestone, MN 56164 · Pipestone County · 82 certified beds · avg 57 residents/day · certified since Dec 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: ★★★☆☆3/5 · CMS overall rating: 3/5
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 · Jan 7, 2026 · F-0805 · triggered by a complaint
The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.
Why it matters: Food served in the wrong texture can cause choking or lead residents to stop eating and lose weight.
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: Dec 30, 2025 (Past Non-Compliance)
All citations in the current public record (14)
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 |
|---|---|---|
| Jan 7, 2026 | ▲ J · Immediate jeopardy, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · from a complaint |
| May 21, 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. |
| May 21, 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. |
| May 21, 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. |
| May 21, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| May 21, 2025 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| May 21, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Mar 20, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Mar 20, 2024 | 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. |
| Mar 20, 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. |
| Mar 20, 2024 | D · Potential for harm, one-off | 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. |
| Apr 13, 2023 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Apr 13, 2023 | D · Potential for harm, one-off | 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. |
| Apr 13, 2023 | 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. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (4 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 3 | 0 | D |
| 2024 | 4 | 0 | D |
| 2025 | 6 | 0 | F |
| 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 $17,345.
| Date | Type | Amount / length |
|---|---|---|
| Jan 7, 2026 | Fine | $17,345 |
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) | 4.24 | 4.83 | 3.95 | bottom 26% in Minnesota; top 31% in the U.S. |
| Registered Nurse hours | 0.79 | 1.22 | 0.69 | bottom 13% in Minnesota; top 28% in the U.S. |
| Weekend total nurse staffing | 3.66 | 4.27 | 3.50 | bottom 21% in Minnesota; top 35% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.39 | 0.69 | 0.48 | bottom 17% in Minnesota; top 50% in the U.S. |
| Total nursing staff turnover (%) | 51.7 | 42.2 | 45.8 | bottom 24% in Minnesota; bottom 32% 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 3.70, RN 0.69, weekend 3.20. 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: 2/5 · short-stay residents: 2/5
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 |
| 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 | 12/18/2025 |
| 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 |
| 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 |
| Gulsvig, Neil | Individual | ADP of the SNF | NOT APPLICABLE | 05/30/2024 |
| Herseth Sandlin, Stephanie | 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 handle residents who need modified food textures, and how do you make those meals appetizing?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "Who oversees antibiotic use here, and how do you decide when an antibiotic is really needed?"
- "What percentage of your residents and staff are vaccinated against flu and pneumonia, and how do you offer the vaccines?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "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 |
|---|---|---|---|---|---|
| Edgebrook Care Center | 13.4 mi | Edgerton, MN | ★☆☆☆☆ | 2/5 | |
| Riverview Healthcare Center | 13.5 mi | Flandreau, SD | ★☆☆☆☆ | 1/5 | abuseSFF |
| Flandreau Santee Sioux Tribe Care Center | 14.2 mi | Flandreau, SD | ★★★☆☆ | 3/5 | |
| Avera Sunrise Manor | 19.6 mi | Tyler, MN | ★★★★☆ | 5/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 245591.