Good Samaritan Society-Scandia Village

Good Samaritan Society-Scandia Village was recognized and ceritified in 1992 by Centers for Medicare & Medicaid Services as one of model nursing home providers promoting health and improving quality of life. Good Samaritan Society-Scandia Village which is located in 10560 Applewood Rd Sister Bay, is scientifically measured and assessed by Centers for Medicare & Medicaid Services and is shown to provide good nursing home services or products under the Medicare program. Good Samaritan Society-Scandia Village is being offered ceritified services and products in Wisconsin.
Address:   10560 Applewood Rd
       Sister Bay, WI 54234

Phone:   (920) 854-2317

County: Door
Federal Provider Number: 525494
Participates in: Medicare And Medicaid
Certified Date: Sunday, October 11, 1992 (32 years certified)
Certified Agency: Centers for Medicare & Medicaid Services
Legal Business Name: The Evangelical Lutheran Good Samaritan Society
Ownership Type: Non Profit - Corporation
Provider Changed Ownership in Last 12 Months: No



TypeNameRole Description
OrganizationThe Evangelical Lutheran Good Samaritan Society5% Or More Ownership Interest
PersonGuy MatsonDirector/officer
PersonMichele JufferDirector/officer
PersonChristopher JohnsonDirector/officer
PersonDavid HorazdovskyDirector/officer
PersonJohn HoltDirector/officer
PersonTeresa HildebrandtDirector/officer
PersonJoseph HerdinaDirector/officer
PersonMisty Ham-QuickDirector/officer
PersonGwen HalaasDirector/officer
PersonKari GustafsonDirector/officer
PersonNeil GulsvigDirector/officer
PersonHarald GrindalDirector/officer
PersonSylvia GauseDirector/officer
PersonMichael DeuthDirector/officer
PersonLiane ConnellyDirector/officer
PersonElwin BrownDirector/officer
PersonMichele NotzW-2 Managing Employee
PersonRaye Nae NylanderDirector/officer
PersonJohn RacekDirector/officer
PersonPhilip SamuelsonDirector/officer
PersonMark ScharnbergW-2 Managing Employee
PersonSharon St MaryDirector/officer

Provider Resides in Hospital: No
Number of Federally Certified Beds: 60
Number of Residents in Federally Certified Beds: 52 (87% occupied)
Continuing Care Retirement Community: No
Special Focus Facility: No
With a Resident and Family Council: Resident
Automatic Sprinkler Systems in All Required Areas: Yes


Survey Date: Tuesday, July 22, 2014
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 1, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, July 22, 2014
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, July 23, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, July 17, 2014
Survey Type: Health
Deficiency: F0318 (Ensure that residents with limited range of motion receive appropriate treatment and services to inc)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, July 17, 2014
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, July 17, 2014
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, July 17, 2014
Survey Type: Health
Deficiency: F0280 (Allow residents the right to participate in the planning or revision of care and treatment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, July 17, 2014
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, July 17, 2014
Survey Type: Health
Deficiency: F0502 (Give or get quality laboratory services/tests in a timely manner to meet the needs of residents.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, July 17, 2014
Survey Type: Health
Deficiency: F0314 (Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.)
Scope Severity Code: G
Deficiency Corrected: Deficient, Provider Has No Plan Of Correction
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 23, 2013
Survey Type: Health
Deficiency: F0157 (Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decl)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, June 13, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 23, 2013
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, June 13, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, May 23, 2013
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, June 13, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, May 22, 2013
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 5, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, May 22, 2013
Survey Type: Fire Safety
Deficiency: K0043 (Rooms that can be unlocked from inside without a key.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, June 7, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, May 22, 2013
Survey Type: Fire Safety
Deficiency: K0056 (An approved automatic sprinkler system connected to the fire alarm system.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, June 10, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Monday, May 7, 2012
Survey Type: Fire Safety
Deficiency: K0051 (A fire alarm system that can be heard throughout the facility.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, June 20, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, May 7, 2012
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 8, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, May 7, 2012
Survey Type: Fire Safety
Deficiency: K0022 (Signs that state that exit doors are to be kept closed.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 8, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, May 7, 2012
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, June 20, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, May 7, 2012
Survey Type: Fire Safety
Deficiency: K0011 (A two-hour-resistant firewall separation.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, June 20, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, April 27, 2012
Survey Type: Health
Deficiency: F0465 (Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staf)
Scope Severity Code: B
Deficiency Corrected: Deficient, Provider Has Plan Of Correction
Date the deficiency was corrected: Friday, May 25, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, April 27, 2012
Survey Type: Health
Deficiency: F0314 (Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, May 25, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, April 27, 2012
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, May 25, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, April 27, 2012
Survey Type: Health
Deficiency: F0425 (Provide routine and emergency drugs through a licensed pharmacist and only under the general supervi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 15, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, April 27, 2012
Survey Type: Health
Deficiency: F0334 (Develop policies and procedures for influenza and pneumococcal immunizations.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, May 15, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Number of Facility Reported Incidents: 0
Number of Substantiated Complaints: 0
Number of Fines: 0
Number of Payment Denials: 0
Total Number of Penalties: 0
Total Amount of Fines in Dollars: USD 0
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This data was updated by using data source from Centers for Medicare and Medicaid Services (CMS) which is publicized on Wednesday, October 1, 2014. If you found out that something incorrect and want to change it, please follow this Update Data guide.

The Five Star Quality Rating System is not a substitute for visiting the nursing home. This system can give you important information, help you compare nursing homes by topics you consider most important, and help you think of questions to ask when you visit the nursing home. Use the Five-Star ratings together with other sources of information.

items rating
Health Inspection Rating (3 out of 5 stars)
Quality Rating (5 out of 5 stars)
Staffing Rating (4 out of 5 stars)
RN Staffing Rating (4 out of 5 stars)
Overall Rating (5 out of 5 stars)
Nursing homes vary in the quality of care and services they provide to their residents. Reviewing health inspection results, staffing data, and quality measure data are three important ways to measure nursing home quality. This information gives you a "snap shot" of the care individual nursing home give.


Patients experiences Provider State Nation
Percent of High Risk Long Stay Residents With Pressure Ulcers
N/A
4%
6%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury
N/A
3%
3%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain
N/A
9%
8%
Percent of Long Stay Residents Who Were Physically Restrained
N/A
1%
1%
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased
N/A
15%
16%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder
N/A
4%
3%
Percent of Long Stay Residents With a Urinary Tract Infection
N/A
5%
6%
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain
N/A
21%
19%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened
N/A
1%
1%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
98%
94%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
96%
94%
Percent of Long Stay Residents Who Have Depressive Symptoms
N/A
6%
6%
Percent of Long Stay Residents Who Lose Too Much Weight
N/A
7%
7%
Percent of Long Stay Residents Who Received an Antipsychotic Medication
N/A
15%
20%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder
N/A
44%
44%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
91%
83%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication
N/A
1%
2%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
90%
84%

N/A
Data not available.

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Good Samaritan Society-Scandia Village [Federal No:525494] near 10560 Applewood Rd, Sister Bay WI

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