Good Samaritan Society Sioux Falls Center
401 West Second Street, Sioux Falls, SD 57104 · Minnehaha County · 98 certified beds · avg 80 residents/day · certified since Jul 1, 1990
Abuse citation flag (CMS)
Part of chain: GOOD SAMARITAN SOCIETY (92 facilities, chain avg rating 3.0★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
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 · Mar 19, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
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 13, 2026 (Past Non-Compliance)
▲ Actual harm, one-off · Feb 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: Mar 6, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 7, 2023 · F-0686 · triggered by a complaint
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: Nov 27, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (18)
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 |
|---|---|---|
| Mar 19, 2026 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Mar 19, 2026 | E · Potential for harm, repeated | 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 |
| Feb 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 |
| Feb 4, 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 |
| Sep 5, 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. |
| Sep 5, 2025 | E · Potential for harm, repeated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Sep 5, 2025 | E · Potential for harm, repeated | The facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs. |
| Sep 5, 2025 | E · Potential for harm, repeated | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Sep 5, 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. |
| Sep 5, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Sep 5, 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. |
| Sep 5, 2025 | D · Potential for harm, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint |
| Sep 5, 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. |
| Jun 13, 2024 | 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. |
| Jun 13, 2024 | 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 13, 2024 | 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. |
| Jun 13, 2024 | D · Potential for harm, one-off | The facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs. |
| Nov 7, 2023 | ▲ 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. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (4 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 1 | G ▲ |
| 2024 | 4 | 0 | F |
| 2025 | 9 | 0 | F |
| 2026 | 4 | 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)
3 fines totaling $54,936.
| Date | Type | Amount / length |
|---|---|---|
| Mar 19, 2026 | Fine | $14,380 |
| Feb 4, 2026 | Fine | $29,295 |
| Nov 7, 2023 | Fine | $11,261 |
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) | 4.09 | 4.32 | 3.95 | bottom 50% in South Dakota; top 36% in the U.S. |
| Registered Nurse hours | 1.00 | 0.91 | 0.69 | top 35% in South Dakota; top 16% in the U.S. |
| Weekend total nurse staffing | 3.59 | 3.71 | 3.50 | top 46% in South Dakota; top 38% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.45 | 0.51 | 0.48 | bottom 44% in South Dakota; top 40% in the U.S. |
| Total nursing staff turnover (%) | 44.2 | 48.2 | 45.8 | top 43% in South Dakota; top 48% in the U.S. |
| RN turnover (%) | 14.3 | 34.7 | 42.9 | top 13% in South Dakota; top 7% 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 3.58, RN 0.87, weekend 3.14. 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: 3/5
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 | 02/09/2026 |
| Fluit, Joel | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2022 |
| Focusone Solutions | Organization | ADP of the SNF | NOT APPLICABLE | 03/04/2024 |
| 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.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "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?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "Can I see a sample menu, and how do you handle special diets like low-sodium or diabetic 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 |
|---|---|---|---|---|---|
| Dow Rummel Village | 0.8 mi | Sioux Falls, SD | ★★★☆☆ | 2/5 | |
| Bethany Home Sioux Falls | 2.3 mi | Sioux Falls, SD | ★★★☆☆ | 4/5 | |
| Good Samaritan Society Luther Manor | 2.8 mi | Sioux Falls, SD | ★★☆☆☆ | 2/5 | |
| Avantara Norton | 3.0 mi | Sioux Falls, SD | —/5 | abuseSFF | |
| Avera Prince of Peace | 4.3 mi | Sioux Falls, SD | ★★★★☆ | 3/5 | |
| Good Samaritan Society Sioux Falls Village | 4.4 mi | Sioux Falls, SD | ★★☆☆☆ | 2/5 | |
| Bethany Home - Brandon | 9.8 mi | Brandon, SD | ★☆☆☆☆ | 1/5 | abuse |
| Palisade Healthcare Center | 16.2 mi | Garretson, SD | ★☆☆☆☆ | 1/5 | abuse |
| Good Samaritan Society Canton | 18.5 mi | Canton, SD | ★★☆☆☆ | 3/5 | |
| Tuff Memorial Home | 19.1 mi | Hills, MN | ★★★★☆ | 5/5 | |
| Dells Nursing and Rehab Center INC | 19.1 mi | Dell Rapids, SD | ★★★★☆ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 435046.