Good Samaritan Society - Clearbrook
305 3rd Avenue Southwest, Clearbrook, MN 56634


Good Samaritan Society - Clearbrook is nursing home registered in the Centers for Medicare & Medicaid Services (CMS). The Provider Number is 245523. The address is 305 3rd Avenue Southwest, Clearbrook, MN 56634. The zip code is 56634. The phone number is 2187763157.


Good Samaritan Society - Clearbrook · 305 3rd Avenue Southwest, Clearbrook, MN 56634

Federal Provider Number 245523
Provider Name GOOD SAMARITAN SOCIETY - CLEARBROOK
Address 305 3RD AVENUE SOUTHWEST
CLEARBROOK, MN 56634
Phone Number 2187763157
SSA County Code 140
County Name Clearwater
Ownership Type Non profit - Church related
Certified Beds 43
Certified Beds Residents 32
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 02/01/1988
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 2.1375
Reported LPN Staffing Hours per Resident per Day 0.94219
Reported RN Staffing Hours per Resident per Day 0.81719
Reported Licensed Staffing Hours per Resident per Day 1.75938
Reported Total Nurse Staffing Hours per Resident per Day 3.89688
Reported Physical Therapist Staffing Hours per Resident Per Day 0.00625
Expected CNA Staffing Hours per Resident per Day 2.34223
Expected LPN Staffing Hours per Resident per Day 0.59033
Expected RN Staffing Hours per Resident per Day 0.82998
Expected Total Nurse Staffing Hours per Resident per Day 3.76253
Adjusted CNA Staffing Hours per Resident per Day 2.23923
Adjusted LPN Staffing Hours per Resident per Day 1.32472
Adjusted RN Staffing Hours per Resident per Day 0.73569
Adjusted Total Nurse Staffing Hours per Resident per Day 4.17483
Cycle 1 Total Number of Health Deficiencies 5
Cycle 1 Number of Standard Health Deficiencies 5
Cycle 1 Health Deficiency Score 20
Cycle 1 Standard Survey Health Date 02/24/2017
Cycle 1 Number of Health Revisits 1
Cycle 1 Total Health Score 20
Cycle 2 Total Number of Health Deficiencies 9
Cycle 2 Number of Standard Health Deficiencies 9
Cycle 2 Health Deficiency Score 40
Cycle 2 Standard Health Survey Date 04/21/2016
Cycle 2 Number of Health Revisits 1
Cycle 2 Total Health Score 40
Cycle 3 Total Number of Health Deficiencies 9
Cycle 3 Number of Standard Health Deficiencies 9
Cycle 3 Health Deficiency Score 68
Cycle 3 Standard Health Survey Date 02/20/2015
Cycle 3 Number of Health Revisits 1
Cycle 3 Total Health Score 68
Total Weighted Health Survey Score 34.667
Total Amount of Fines in Dollars $0.00
Processing Date 08/01/2017

Owner or Manager · Good Samaritan Society - Clearbrook

Owner Name Role Association Date
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
PECK, ADRIANA (Individual) MANAGING EMPLOYEE since 01/09/2017
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 02/01/1988
TRIBBLE, GEORGE (Individual) OFFICER since 12/01/2014

street_number: 305
route: 3rd Avenue (3rd Ave)
locality, political: Clearbrook
admin_level_2, political: Clearwater County
admin_level_1, political: Minnesota (MN)
country, political: United States (US)
postal_code: 56634
types : street_address
latitude: 47.6919403
longitude: -95.424504
latlng: (47.6919403, -95.424504)


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