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Missouri Slope

4916 N Washington St, Bismarck, ND 58503 · Non profit - Corporation · 192 certified beds · (701) 223-9407 Medicare & Medicaid certified

Call the home — (701) 223-9407 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Oct 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$39,404 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (5/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2024
  • it has 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $39,404 in federal fines (most recent 2024-10-15)
  • its payroll-based staffing score sits well above its independent inspection score

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4315 Ottawa St · (701) 530-3500 · Call to confirm hours
Pharmacy
900 43rd Ave NE · (701) 258-3736 · Call to confirm hours
Grocery
900 43rd Ave NE · (701) 223-6617 · Call to confirm hours
Park
500 Medora Ave · (701) 222-6455 · Typically dawn to dusk
Place of worship
4916 N Washington St · (701) 223-3753

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased20.7%19.8%15.4%worse
Long-stay residents who lose too much weight5.8%5.8%5.4%typical
Long-stay residents with a catheter left in their bladder2.4%1.6%0.9%worse
Long-stay residents with a urinary tract infection3.6%2.6%2.0%worse
Long-stay residents with depressive symptoms0.9%4.4%6.5%better
Long-stay residents who were physically restrained0.5%0.2%0.1%worse than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.6%5.1%3.3%better
Long-stay residents whose ability to walk worsened21.0%17.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication11.1%17.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.8%95.3%typical
Long-stay residents with pressure ulcers4.5%4.9%4.7%typical
Long-stay residents with worsening bladder/bowel control26.9%24.9%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table19.1%22.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.7%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine95.9%88.3%79.4%better
Short-stay residents rehospitalized after admission16.4%19.9%22.6%better
Short-stay residents with an outpatient ER visit13.1%11.4%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.001.491.67worse
Long-stay outpatient ER visits per 1,000 resident days1.221.861.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

53.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 317 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.4%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
61.1%U.S. median 56.6%
Met the expected recovery
0.18U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 61.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 193 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF53.4%CMS range 47.7–59.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 7.7–12.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge61.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge53.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge45.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified81.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting97.6%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.2%CMS range 4.5–10.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.861.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.90
RN hours/ resident / day
0.61
LPN hours/ resident / day
3.94
Aide hours/ resident / day
5.45
Total nurse hours/ resident / day
0.46
RN hoursweekends
52.2%
Total nursing turnover
28.6%
RN turnover

How full it usually is: this home is certified for 192 beds and averages 185.1 residents a day — about 96% occupied, or roughly 7 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.45 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.94 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.60 hrs/resident/day on weekends vs 5.79 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.08 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

3
deficiencies at the latest standard inspection (2026-05-14)
6
at the previous standard inspection (2025-03-27)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

20 citations, most serious first. The 12 most serious are shown; the remaining 8 are one tap away and print in full.

  • Actual harm · G2024-10-15 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility reported incident and investigation reports, record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from mental and/or physical abuse for 1 of 1 sampled resident (Resident #1) who was witnessed receiving physical and verbal abuse. Failure of facility staff to immediately report a witnessed incident of staff to resident abuse to the appropriate supervisor delayed the removal of the accused abuser, the start of the facility investigation, and assessment of the resident for injury. This delay placed Resident #1 at risk for further abuse, fear, anxiety, and/or psychosocial harm and placed other residents at risk for abuse. Findings include: Review of the facility policy titled Abuse occurred on 10/15/24. This policy, reviewed September 2024, stated, . All employees receive education during orientation and at least annually throughout their employment on what constitutes abuse, neglect . and their responsibilities to protect the resident from these crimes. Abuse is defined as . intimidation, or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-06-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of the facility reported incident (FRI), review of facility policy, and resident and staff interviews, the facility failed to prevent accidents for 1 of 1 sampled resident (Resident #1) who sustained a fall with fracture. Failure to utilize the whirlpool seat belt resulted in an avoidable fall and fracture for Resident #1 and placed all residents at risk for falls and/or injuries. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: Review of the facility policy titled Bathing Procedure occured on 06/12/24. The policy, dated November 2023, stated, Resident Safety - Safety Strap Usage Whirlpool: Transfer resident to whirlpool seat. Attach seat belt around resident. Ensure seat belt does not get caught in the door when closing the door. The facility failed to provide instruction on when it is safe to remove the bath chair seat belt. Review of the FRI report, submitted to the state agency on 06/10/24, identified Resident #1 . slipped from…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Ecited before2026-05-14 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 4 of 21 sampled residents (Resident #50, #61, #139, #154) and 1 supplemental resident (Resident #30) observed during cares. Failure to practice infection control standards related to glove use, hand hygiene, catheter care, equipment disinfection, and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Isolation, Standard Precautions, and Enhanced Barrier Precautions occurred on 05/14/26. This policy, revised December 2025, stated, . Perform hand hygiene with hand sanitizer or soap and water upon entering and leaving a resident's room . remove gloves after use, before touching noncontaminated items and environmental surfaces and environmental surfaces . Wash hands immediately after [glove] removal to avoid transfer of microorganisms . Linen should be bagged at the point of use. Enhanced Barrier Precautions . Use gowns and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of facility policy and staff interview, the facility failed to ensure adequate assistance for 1 of 1 sampled resident (Resident #61) observed during a mechanical sit to stand lift transfer. Failure to secure the leg strap and the abdominal strap of the lift sling placed the resident at risk for falls.Findings include:Review of the facility policy titled Transfer/Locomotion occurred on 05/14/26. This policy, revised September 2025, stated, . Slings are to be placed according to proper procedure.Review of Resident #61's medical record occurred on all days of survey. Diagnosis included left sided weakness and paralysis, history of falling, unsteadiness on feet and abnormal posture. The current care plan stated, Transfers with PAL [Patient Assist Lift] with assist x 2. Per shared risk agreement, [Resident #61's name] can choose where he wants the hook strap length at and where the abdominal strap is located (prefers it above abdomen).Observation on 05/11/26 at 11:39 a.m. showed two certified nurse aides (CNAs) (#8 and #9) assisted Resident #61…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, the facility failed to ensure drugs and biologicals were stored securely for 1 of 35 sampled residents (Resident #24) and 1 supplemental resident (Resident #109) with medications at the bedside. Failure to securely store medications may result in unauthorized use, adverse reactions, or ineffective treatment. Findings include: - Observation on 05/11/26 at 10:45 a.m. showed a tube of a topical analgesic (pain relief cream) on Resident #24's bedside table. - Observation on 05/12/26 at 8:15 a.m. showed three Refresh Tears eye drop bottles and one Systane eye drop bottle on Resident #24's bedside table. During an interview on 05/14/26 at 7:49 a.m., an administrative staff member (#5) confirmed nursing staff were not aware of the medications in Resident #24's room.- Observation on 05/11/26 at 11:55 a.m. showed a box of Lidocaine patches (topical pain relief patches) and Genteal eyes drops (lubricating eye drops) at Resident #109's bedside.- Observation on 05/12/26 at 10:08 a.m. showed Lidocaine patches, Genteal eyes drops, generic psyllium husk…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-27 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide care in a manner and environment that maintains or enhances residents' quality of life for 5 of 9 residents (Residents #3, #44, #45, #70, and #112) observed during medication administration and in 3 of 8 dining rooms (1st floor C/D wing, 2nd floor C/D wing, and 4th floor C/D wing). Failure to refer to residents by their preferred name and dispose of bags containing trash/dirty linens prior to entering dining rooms does not promote resident dignity or respect. Findings include: Review of the facility policy titled Promoting Dignity and Resident Rights occurred on 03/27/25. This policy, dated December 2024, stated, . All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . Staff members should converse with the resident while doing cares . Speak respectfully to residents . Observations of medication administration on 03/26/25…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-27 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, the facility failed to ensure food is stored in accordance with professional standards for food service sanitation in 6 of 8 nutrition stations (first floor A/B and C/D, second floor A/B and C/D, and third floor A/B and C/D). Failure to ensure food is safe from contamination by resident ice packs has the potential to result in a foodborne illness or adverse effects for residents, visitors, and staff. Findings include: When requested, the facility failed to provide a policy for storage of ice packs. Observation of the nutrition stations on 03/24/25 showed the following items stored with food items: - 2:25 p.m. First floor A/B nutrition station freezer, two blue gel cooling packs with a resident label, alongside ice cream cups. First floor C/D nutrition station freezer, two unlabeled blue gel cooling packs alongside a box of snack breads. - 2:38 p.m. Second floor A/B nutrition station freezer, one unlabeled blue gel cooling pack alongside ice cream cups. Second floor C/D nutrition station freezer, one unlabeled blue gel cooling pack alongside…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure the interdisciplinary team assessed the appropriateness to self-administer medications (SAM) for 1 of 9 residents (Resident #70) observed during medication administration. Failure to determine whether SAM is a safe practice has the potential to result in a medication error and/or harm to a resident. Findings include: Review of the facility policy titled Self-Administration of Medications occurred on 03/27/25. This policy, revised May 2024, stated, . Missouri Slope is committed to respecting resident's rights to self-administer medication, after an interdisciplinary assessment, when and if they desire and are able to. In order to facilitate this each resident will be evaluated for their ability to do so safely. Review of Resident #70's medical record occurred on 03/26/25 and identified a physician's order for Genteal Tear Solution (artificial tears) 1 drop in both eyes twice a day. The current care plan stated, . [Resident name] has impaired cognitive function/dementia .…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, policy review, professional reference, and staff interview, the facility failed to follow professional standards of practice for medication administration for 1 of 9 resident's observed during medication administration. Failure to document medications after administration, does not reflect the actual time of administration or any refusals which may cause adverse effects for the resident. Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 836, stated, . Administering Medications Safely . Document medication administration after giving it, not before. Review of the facility policy titled Medication Administration occurred on 03/27/25. This policy, dated December 2024, stated, . Proper steps for identification of medication and identification of resident should be carried out each time medications are administered. Medications should not be pre-dished for future medication passes . Right documentation . - Observation on 03/26/25 at 8:09 a.m.,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-27 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility policy, review of manufacturer's instructions, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 9 residents (Resident #44 and #70) observed during medication administration. Four medication errors occurred during staff administration of 41 medications, resulting in a nine percent error rate. Failure to properly prepare and administer medications may inhibit the effectiveness of the medication and may have a negative impact on the resident's overall health. Findings include: Review of the facility policy titled Medication Administration occurred on 03/27/25. This policy, dated December 2024, stated, . Medications included in this definition may include those administered orally . optic . c. right dosage d. right route. e. right time. f. right documentation . A resident may refuse a medication. This should be documented on the eMAR [electronic medication administration record] and the nurse notified. The physician should be notified of repeated refusals. Review of administration…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-27 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 14 sampled residents (Resident #116 and #164) requiring enhanced barrier precautions (EBP). Failure to practice infection control standards related to EBP and hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene, Artificial Nails occurred on 03/27/25. This policy, revised December 2024, stated, . Hand hygiene is considered the single most important procedure for preventing the spread of health-care associated infections. The use of gloves does not eliminate the need for hand hygiene. Indications for Hand Hygiene . 7. After removing gloves. Review of the facility policy titled Isolation, Standard Precautions, and Enhanced Barrier Precautions occurred on 03/27/25. This policy, dated September 2024, stated, . In addition to Standard Precautions, use Enhanced Barrier Precautions when providing high contact cares for residents at increased risk…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-15 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 2 of 36 sampled resident (Resident #69 and #138). Failure to review and revise the care plan limited staff's ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled, Care Plan (Plan of Care), occurred on 02/15/24. This policy, dated August 2023, stated, . The plan of care is reviewed at least monthly by nursing, quarterly with completion of MDS [Minimum Data Set] assessment and annually at interdisciplinary care conferences. Nursing plans of care are to be kept current by licensed staff members and remain consistent with the attending physician's plan of medical care, and the changing needs of the residents. - Review of Resident #138's medical record occurred on all days of survey. Diagnoses included hemiplegia. The current care plan identified the following: . Restorative therapy to Assist to move through tolerated range, supporting joints…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 8 citations
  • Potential for harm · D2024-02-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure appropriate care and services for 1 of 1 sampled resident (Resident #379) with orders for a knee immobilizer. Failure to follow physician's orders and the care plan for application, and report refusals of application, placed Resident #379 at risk for falls and discomfort/pain. Findings include: Review of the facility policy titled Care Plans (Plan of Care) occurred on 02/15/24. This policy, revised August 2023, stated, . develop and implement a baseline and/or comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events . Review of Resident #379's medical record occurred on all days of survey. Diagnoses included left patellar (kneecap) fracture. The current physician's orders stated, . Keep immobilizer in…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-15 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #138) reviewed for restorative therapy received the services developed by the therapy staff. Failure to follow up on a request to the provider for restorative nursing/therapy services may adversely affect the resident's ability to maintain range of motion (ROM), strength, and mobility. Findings include: Review of Resident #138's medical record occurred on all days of survey. Diagnosis included hemiplegia. The current care plan stated, . impaired functional mobility as evidenced by Inability to achieve full functional ROM, Decreased ability to self-perform ADLs [activities of daily living] R/T [related to] intracranial injury. A quarterly Minimum Data Set [MDS] dated 11/22/23 identified bilateral functional limitation in range of motion to upper and lower extremities. Random observations of cares during all days of survey showed Resident #138's knees in a bent position. Progress notes identified the following: * 01/20/24 at 1:57 p.m.: Update of resident's status given to wife.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide appropriate and sufficient supervision for 2 of 6 sampled residents (Resident #135 and #166) observed for safe transfers. Failure to provide appropriate and sufficient supervision during mechanical lift transfers (Resident t#166) and follow fall interventions (Resident #135) placed residents at risk for accidents, falls, and/or injuries. Findings include: Review of the facility policy titled Transfer/Locomotion occurred on 02/15/24. This policy, dated November 2023, stated, . 4. Always use 2 staff during transfer. Review of the facility policy titled Fall (Resident) Guidelines occurred on 02/15/24. This policy, revised June 2023, stated, . The nurse should make changes to the care plan and [NAME] as determined by the team to prevent further incidents of fall. - Review of Resident #166's medical record occurred on all days of survey and included a diagnoses of dementia. The current care plan stated,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of facility policy, and resident and staff interviews, the facility failed to provide respiratory care for 1 of 11 sampled residents (Resident #163) receiving oxygen by nasal cannula. Failure to administer oxygen according to the physician's order may result in complications and compromise the residents' respiratory status. Findings include: Review of a policy/procedure titled Oxygen occurred on 02/15/24. This policy/procedure, revised December 2023, stated, . Turn the oxygen on as ordered by the physician . Review of Resident #163's medical record occurred on all days of survey and identified a diagnoses of dependence on supplemental oxygen. A physician's order, dated 11/14/23, stated, Oxygen continuously at 1 LPM [liters per a minute] to maintain saturations above 88%. Observations on 02/12/24 at 11:11 a.m., 02/13/24 at 4:14 p.m., and 02/14/24 at 12:15 p.m. showed Resident #163 in a recliner without oxygen. During an interview on 02/12/24 at 11:14 a.m., Resident #163 reported facility staff removed their continuous oxygen on the morning…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-15 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and resident and staff interview, the facility failed to provide care and services to control pain for 1 of 3 sampled residents (Resident #17) investigated for pain management. Failure to administer pain medication as scheduled may have contributed to Resident #17 experiencing increased and/or unresolved pain. Findings include: Review of the facility policy titled Medication Administration occurred on 02/15/24. This policy, dated December 2023, stated, . Scheduled medications may be given up to 1 hour before and 1 hour after the designated time. Review of Resident #17's medical record occurred on all days of survey. The admission Minimum Data Set (MDS), dated [DATE], identified intact cognition and frequent pain rated 5 on a 0-10 scale, which affected her sleep and day to day activities occasionally and interfered with therapy activities almost constantly. Resident #17's care plan stated, . potential for pain R/T [related to] chronic back pain, diabetes, PVD [peripheral…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from unnecessary psychotropic medications for 1 of 2 sampled residents (Resident #286) who received an as needed (PRN) psychotropic. Failure to limit PRN psychotropic use to 14 days unless reevaluated by a practitioner placed the resident as risk of receiving unnecessary medications and experiencing adverse drug effects. Findings include: Review of the facility policy titled Medications-Psychotropic and Antipsychotic Medication Use occurred on 02/15/24. This policy, dated August 2023, stated, . The attending or prescribing health care provider must document the diagnosed specific condition and indication for the PRN medication in the medical record. When the extended use of a PRN psychotropic mediations is indicated (beyond 14 days), additional orders must be obtained. Nursing staff will automatically send Health Care Provider a pre-made PRN Psychotropic Fax prior to day 14 if indication for use continues and there is no specific time frame for the PRN.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-15 · tag F0825 — isolated
    Provide or get specialized rehabilitative services as required for a resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of facility policy, and staff and family interviews the facility failed to provide the required specialized rehabilitative services for 1 of 6 sampled residents (Resident #156) with orders for physical therapy evaluation and treatment. Failure to provide physical therapy services as ordered for Resident #156 may result in impaired strength, impaired mobility, and increased pain. Findings include: Review of the facility policy titled Physician Orders occurred on 02/15/24. This policy, revised April 2023, stated, . It is the policy of [Facility Name] to complete physician orders in a timely manner to ensure appropriate care . Review of the facility policy titled Physical Therapy, Occupational Therapy, and Speech Therapy occurred on 02/15/24. This policy, revised April 2024, stated, . To provide therapeutic environment for residents through written communication to Nursing staff to sustain functioning and/or prevent deterioration as able. During an interview on 02/12/24 at 4:40 p.m., Resident #156's representative indicated the resident was not getting…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-15 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of facility policy and staff interview, the facility failed to follow standards of infection control for 1 of 1 sampled resident (Resident #138) observed for medication administration via feeding tube and 1 of 1 sampled resident (Resident #91) on transmission-based precautions (TBP). Failure to follow infection control standards during medication administration and with TBP has the potential to transmit infections to residents, staff, and visitors. Findings include: MEDICATION ADMINISTRATION Review of the facility policy titled Medication Assistant Scope of Practice occurred on 02/14/24. This policy dated February 2023, stated, . If a medication is dropped, it should be discarded. Observation on 02/13/24 at 12:04 p.m., showed a staff nurse (#11) prepared medication for Resident #138. The staff nurse (#11) dropped a Guaifenesin tablet on the top of the cart. Using bare hand contact, picked up the pill, placed it into the medication cup, and administered it to the resident. TRANSMISSION BASED PRECAUTIONS Review of the facility policy titled…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$39,404 in federal fines across 2 penalties.

  • $30,580 — penalty dated 2024-10-15
  • $8,824 — penalty dated 2024-06-12

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
MISSOURI SLOPE LUTHERAN CARE CENTER, INC.Organization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 02/13/2025
ANDRIST, STEVEIndividualCORPORATE DIRECTORsince 11/06/2019
NITSCHKE, DARRELLIndividualCORPORATE DIRECTORsince 09/26/2022
SAUDE, JERRYIndividualCORPORATE DIRECTORsince 11/06/2019
THOMPSON, REIERIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/06/2019
HEBERT, BRIANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/23/2025

CMS files one row per role, so the 11 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$36.6M
Net patient revenuemost recent cost report
-2.3%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 61%Medicare 12%Other / private 27%

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$552per resident / day
operating cost
$16,768per month
≈ monthly operating cost
$539per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in ND

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the North Dakota Medicaid page.

Typical monthly cost in North Dakota
$11,528/mo
Nursing home (semi-private)
$12,304/mo
Nursing home (private)
$4,729/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 355128. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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