Good Samaritan Society - Blackduck
172 Summit Avenue West, Blackduck, MN 56630


Good Samaritan Society - Blackduck is nursing home registered in the Centers for Medicare & Medicaid Services (CMS). The Provider Number is 245600. The address is 172 Summit Avenue West, Blackduck, MN 56630. The zip code is 56630. The phone number is 2188353410.


Good Samaritan Society - Blackduck · 172 Summit Avenue West, Blackduck, MN 56630

Federal Provider Number 245600
Provider Name GOOD SAMARITAN SOCIETY - BLACKDUCK
Address 172 SUMMIT AVENUE WEST
BLACKDUCK, MN 56630
Phone Number 2188353410
SSA County Code 30
County Name Beltrami
Ownership Type Non profit - Corporation
Certified Beds 30
Certified Beds Residents 25
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 04/01/1992
Continuing Care Retirement Community true
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 4
Quality Measure Rating 2
Staffing Rating 5
RN Staffing Rating 5
Reported CNA Staffing Hours per Resident per Day 2.9
Reported LPN Staffing Hours per Resident per Day 0.358
Reported RN Staffing Hours per Resident per Day 0.968
Reported Licensed Staffing Hours per Resident per Day 1.326
Reported Total Nurse Staffing Hours per Resident per Day 4.226
Reported Physical Therapist Staffing Hours per Resident Per Day 0.028
Expected CNA Staffing Hours per Resident per Day 2.39331
Expected LPN Staffing Hours per Resident per Day 0.54196
Expected RN Staffing Hours per Resident per Day 0.78192
Expected Total Nurse Staffing Hours per Resident per Day 3.71719
Adjusted CNA Staffing Hours per Resident per Day 2.97318
Adjusted LPN Staffing Hours per Resident per Day 0.54827
Adjusted RN Staffing Hours per Resident per Day 0.92501
Adjusted Total Nurse Staffing Hours per Resident per Day 4.58265
Cycle 1 Total Number of Health Deficiencies 6
Cycle 1 Number of Standard Health Deficiencies 6
Cycle 1 Health Deficiency Score 28
Cycle 1 Standard Survey Health Date 03/30/2017
Cycle 1 Number of Health Revisits 1
Cycle 1 Total Health Score 28
Cycle 2 Total Number of Health Deficiencies 1
Cycle 2 Number of Standard Health Deficiencies 1
Cycle 2 Health Deficiency Score 4
Cycle 2 Standard Health Survey Date 04/21/2016
Cycle 2 Number of Health Revisits 1
Cycle 2 Total Health Score 4
Cycle 3 Total Number of Health Deficiencies 4
Cycle 3 Number of Standard Health Deficiencies 4
Cycle 3 Health Deficiency Score 16
Cycle 3 Standard Health Survey Date 05/01/2015
Cycle 3 Number of Health Revisits 1
Cycle 3 Total Health Score 16
Total Weighted Health Survey Score 18
Total Amount of Fines in Dollars $0.00
Processing Date 08/01/2017

Owner or Manager · Good Samaritan Society - Blackduck

Owner Name Role Association Date
CONNELLY, LIANE (Individual) DIRECTOR since 06/25/2013
DEUTH, MICHAEL (Individual) DIRECTOR since 06/19/2012
GARD, ALAN (Individual) DIRECTOR since 06/24/2014
GAUSE, SYLVIA (Individual) OFFICER since 07/20/1993
GRINDAL, HARALD (Individual) DIRECTOR since 06/19/2012
GULSVIG, NEIL (Individual) DIRECTOR since 06/23/2009
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) DIRECTOR since 07/19/2007
HORAZDOVSKY, DAVID (Individual) OFFICER since 07/02/2003
HORMANN, GORDON (Individual) MANAGING EMPLOYEE since 05/25/2014
MARCH-CURTIS, CONNIE (Individual) DIRECTOR since 06/24/2014
MATSON, GUY (Individual) DIRECTOR since 06/25/2013
PETERSON, BERGEN (Individual) OFFICER since 01/17/2015
RACEK, JOHN (Individual) DIRECTOR since 06/25/2013
SAMUELSON, PHILIP (Individual) DIRECTOR since 06/25/2013
SCHARNBERG, MARK (Individual) OFFICER since 12/27/2010
ST MARY, SHARON (Individual) DIRECTOR since 06/14/2011
STENE, DENNIS (Individual) DIRECTOR since 06/24/2014
THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY (Organization) 5% OR GREATER DIRECT OWNERSHIP INTEREST
100%
since 04/01/1992
TRIBBLE, GEORGE (Individual) OFFICER since 12/01/2014
TROUT, CARLA (Individual) DIRECTOR since 06/24/2012

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