Good Samaritan Society - Ambassador
8100 Medicine Lake Road, New Hope, MN 55427


Good Samaritan Society - Ambassador is nursing home registered in the Centers for Medicare & Medicaid Services (CMS). The Provider Number is 245149. The address is 8100 Medicine Lake Road, New Hope, MN 55427. The zip code is 55427. The phone number is 7635444171.


Good Samaritan Society - Ambassador · 8100 Medicine Lake Road, New Hope, MN 55427

Federal Provider Number 245149
Provider Name GOOD SAMARITAN SOCIETY - AMBASSADOR
Address 8100 MEDICINE LAKE ROAD
NEW HOPE, MN 55427
Phone Number 7635444171
SSA County Code 260
County Name Hennepin
Ownership Type Non profit - Corporation
Certified Beds 77
Certified Beds Residents 77
Provider Type Medicare and Medicaid
Resides in Hospital false
Legal Business Name THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Date First Approved to Provide Medicare Medicaid Services 02/26/1968
Continuing Care Retirement Community false
Special Focus Facility false
Most Recent Health Inspection More Than 2 Years Ago false
Changed Ownership Last 12 Months false
With Resident Family Council Resident
Automatic Sprinkler Systems in All Required Areas Yes
Overall Rating 5
Health Inspection Rating 3
Quality Measure Rating 5
Staffing Rating 4
RN Staffing Rating 5
Reported CNA Staffing Hours per Resident per Day 2.1539
Reported LPN Staffing Hours per Resident per Day 0.49416
Reported RN Staffing Hours per Resident per Day 1.70974
Reported Licensed Staffing Hours per Resident per Day 2.2039
Reported Total Nurse Staffing Hours per Resident per Day 4.3578
Reported Physical Therapist Staffing Hours per Resident Per Day 0.15649
Expected CNA Staffing Hours per Resident per Day 2.29515
Expected LPN Staffing Hours per Resident per Day 0.62269
Expected RN Staffing Hours per Resident per Day 1.09127
Expected Total Nurse Staffing Hours per Resident per Day 4.00911
Adjusted CNA Staffing Hours per Resident per Day 2.30269
Adjusted LPN Staffing Hours per Resident per Day 0.65868
Adjusted RN Staffing Hours per Resident per Day 1.17067
Adjusted Total Nurse Staffing Hours per Resident per Day 4.38148
Cycle 1 Total Number of Health Deficiencies 3
Cycle 1 Number of Standard Health Deficiencies 3
Cycle 1 Number of Complaint Health Deficiencies 0
Cycle 1 Health Deficiency Score 8
Cycle 1 Standard Survey Health Date 01/26/2017
Cycle 1 Number of Health Revisits 1
Cycle 1 Health Revisit Score 0
Cycle 1 Total Health Score 8
Cycle 2 Total Number of Health Deficiencies 12
Cycle 2 Number of Standard Health Deficiencies 12
Cycle 2 Number of Complaint Health Deficiencies 0
Cycle 2 Health Deficiency Score 60
Cycle 2 Standard Health Survey Date 02/11/2016
Cycle 2 Number of Health Revisits 1
Cycle 2 Health Revisit Score 0
Cycle 2 Total Health Score 60
Cycle 3 Total Number of Health Deficiencies 7
Cycle 3 Number of Standard Health Deficiencies 7
Cycle 3 Number of Complaint Health Deficiencies 0
Cycle 3 Health Deficiency Score 40
Cycle 3 Standard Health Survey Date 01/08/2015
Cycle 3 Number of Health Revisits 1
Cycle 3 Health Revisit Score 0
Cycle 3 Total Health Score 40
Total Weighted Health Survey Score 30.667
Number of Facility Reported Incidents 0
Number of Substantiated Complaints 0
Number of Fines 0
Total Amount of Fines in Dollars $0.00
Number of Payment Denials 0
Total Number of Penalties 0
Processing Date 08/01/2017

Owner or Manager · Good Samaritan Society - Ambassador

Owner Name Role Association Date
BARTA, MARIE (Individual) MANAGING EMPLOYEE since 11/04/2005
BROWN, ELWIN (Individual) DIRECTOR since 06/14/2011
CONNELLY, LIANE (Individual) DIRECTOR since 06/25/2013
DEUTH, MICHAEL (Individual) DIRECTOR since 06/19/2012
GAUSE, SYLVIA (Individual) OFFICER since 07/20/1993
GRINDAL, HARALD (Individual) DIRECTOR since 06/19/2012
GULSVIG, NEIL (Individual) DIRECTOR since 06/23/2009
GUSTAFSON, KARI (Individual) DIRECTOR since 06/14/2011
HALAAS, GWEN (Individual) DIRECTOR since 06/25/2013
HAM-QUICK, MISTY (Individual) OFFICER since 12/11/2010
HERDINA, JOSEPH (Individual) OFFICER since 01/22/2012
HILDEBRANDT, TERESA (Individual) DIRECTOR since 06/23/2009
HOLT, JOHN (Individual) DIRECTOR since 06/22/2010
HORAZDOVSKY, DAVID (Individual) OFFICER since 07/02/2003
JOHNSON, CHRISTOPHER (Individual) DIRECTOR since 07/22/2008
JUFFER, MICHELE (Individual) DIRECTOR since 06/22/2010
MATSON, GUY (Individual) DIRECTOR since 06/25/2013
NYLANDER, RAYE NAE (Individual) OFFICER since 01/01/2002
RACEK, JOHN (Individual) DIRECTOR since 06/25/2013
SAMUELSON, PHILIP (Individual) DIRECTOR since 06/25/2013
ST MARY, SHARON (Individual) DIRECTOR since 06/14/2011
THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY (Organization) 5% OR GREATER DIRECT OWNERSHIP INTEREST
100%
since 10/31/1992

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