Eventide Heartland
620 14th Ave NE, Devils Lake, ND 58301 · Non profit - Corporation · 78 certified beds · (701) 662-4905 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2026
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its facility-reported quality-measure rating is low (2/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 2 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 improved from 1 to 3 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 15.6% | 19.8% | 15.4% | typical |
| Long-stay residents who lose too much weight | 6.6% | 5.8% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.7% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 4.4% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.6% | 5.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 14.5% | 17.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 7.5% | 17.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.5% | 98.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 4.9% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.2% | 24.9% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 26.3% | 22.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.1% | 88.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 32.5% | 19.9% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.3% | 11.4% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.86 | 1.49 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 4.05 | 1.86 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
31.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 47.5% 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 40 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 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 31.4%CMS range 20.0–45.6 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 6.2–14.2 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 47.5% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 27.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 55.0% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 75.9% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.1–13.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 78 beds and averages 72.1 residents a day — about 92% occupied, or roughly 6 beds typically open. It runs fairly full. 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 4.28 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.02 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 3.87 hrs/resident/day on weekends vs 4.44 on weekdays — 13% thinner on weekends. RN hours go from 0.86 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% 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
Deficiencies are more than at the previous inspection — worsening. 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.
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.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · D2026-05-20 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
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 fully inform the resident or resident's representative regarding treatment with psychotropic medications for 1 of 5 residents (Resident #8) reviewed for unnecessary medications. Failure to fully inform the resident or resident's representative of the risks, benefits, or alternative options for psychotropic medications does not allow residents the right to choose treatment options.Findings include:Review of the facility policy titled Psychotropic Medication Use occurred on 05/20/26. This policy, dated 02/16/26, stated, . Informed consent for psychotropic medications will be obtained from the resident/resident representative prior to initiation. The resident/resident representative will be provided with information on the medication . will document this information in the medical record.Review of Resident #8's medical record occurred on 05/20/26. Diagnosis list includes insomnia. Physician orders included Mirtazapine (an antidepressant) one time a day related for insomnia.The medical record…
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.
- Potential for harm · D2026-05-20 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 provide privacy for 2 of 3 sampled residents (Resident #15 and #27) observed during personal cares while positioned in a mechanical sit-to-stand lift. Failure to ensure privacy during personal care infringes on the resident's rights and does not enhance their quality of life. Findings include: Review of the facility policy titled Standards of Care occurred on 05/20/26. This policy, dated 02/17/26, stated, . Dignity . Privacy curtain/door to be closed anytime cares are being completed. -Observation on 05/18/26 at 4:24 p.m. showed Resident #27 upright in the sit to stand lift and two CNAs (certified nurse aides) (#3 and #5) completed a brief change. The CNA's failed to close the blinds in the resident's room and the resident's buttocks were exposed to the courtyard. -Observation on 05/19/26 at 1:05 p.m. showed Resident #15 positioned in a sit-to-stand lift and seated on the toilet. A CNA (#13) raised the resident from the toilet, performed perineal care, and wheeled the resident out of the…
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.
- Potential for harm · D2026-05-20 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 a safe, clean, comfortable, and homelike environment for 1 of 1 supplemental residents (Resident #60) on oxygen. Failure to clean personal fans does not provide a safe and clean environment and may place the resident at risk for illness.Findings include:Review of facility policy titled Proper Cleaning of a Room occurred on 05/20/26. This policy, dated 02/09/26, stated, . Clean all surfaces .Review of Resident #60's medical record occurred on 05/20/26. Diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, shortness of breath, and obstructive sleep apnea.Observations on all days of survey showed a layer of dust on the cover/grate and blades of the personal fan in Resident #60's room.Observation on 05/19/26 at 5:00 p.m. showed Resident #60 seated in the room, oxygen administered via nasal cannula, and the dusty, circulating fan blowing air directly on the resident.During an interview on 05/20/26 at 8:17 a.m., a…
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.
- Potential for harm · Dcited before2026-05-20 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 17 sampled residents (Resident #5 and #9). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION A: IDENTIFICATION INFORMATION The Long-Term Care Facility RAI User's Manual, revised October 2025, pages A-30-32, stated, . Section A1500: Preadmission Screening and Resident Review (PASRR) . Coding Instructions . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . and continue to A1510 . Section A1510 . Coding instructions Code A, Serious mental illness: if resident has been diagnosed with a serious mental illness . - Review of…
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.
- Potential for harm · Dcited before2026-05-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 properly utilize assistive devices necessary to prevent accidents for 3 of 5 sampled residents (Resident #8, #15, and #27) observed during transfers with a mechanical sit-to-stand lift. Failure to properly utilize a mechanical sit-to-stand lift during transfers placed the residents at risk for injury and falls.Findings include: Review of the policy titled Standing Lifts occurred on 05/20/26. This policy, dated 02/17/26, stated, Use of this lift is [a] participatory process on the part of the resident, and they must be able to balance and bear-weight. place the sling behind their back. Position the wings of the sling under the resident's arms . Secure the buckle around the lower abdomen . and pull it snug. -Review of Resident #8's medical record occurred on all days of survey. The current care plan stated, . Proper footwear with all transfers . Prevalon [heel support] boots to both feet at all times. To be removed only with transfers. Observation on 05/20/2026 at 8:17 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.
- Potential for harm · D2026-05-20 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, review of the dialysis contract, review of the dialysis communications forms, and staff interview, the facility failed to provide care and services consistent with professional standards of practice for 1 of 1 sampled resident (Resident #7) receiving hemodialysis. Failure to complete dialysis treatment communications may result in an unidentified change in the resident's condition.Findings include: Review of the dialysis contract between the facility and the dialysis center occurred on 05/20/26. This contract, dated 05/10/19, stated, . Collaboration. Both the ESRD [end-stage renal disease center] and SNF [skilled nursing facility] are responsible for ensuring collaboration necessary to provide dialysis care coordination to each SNF resident receiving dialysis treatments. Review of Resident #7's medical record occurred on all days of survey. A physician's order, date 11/13/25, identified hemodialysis three times weekly on Mondays, Wednesdays, and Fridays. Review of Resident #7's dialysis communication forms between the facility and the dialysis…
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.
- Potential for harm · D2026-05-20 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, review of facility policy, review of professional reference and staff interviews, the facility failed to label over the counter (OTC) medications in accordance with professional standards for 2 of 2 medication carts. Failure to ensure appropriate and legible labels placed residents at risk for potential medication errors.Findings include:Review of facility policy titled Medication Administration and Storage occurred on 05/20/26. This policy, dated 02/16/26, stated, . Purpose: To provide safe and effective drug therapy . Medications will be labeled according to accepted pharmacy standards.Kozier & Erb's Fundamentals of Nursing, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 841, stated, . Always check the medication label to make sure the correct medication is being taken.Observation on 05/19/26 at 10:52 a.m. showed a medication aide (MA) (#10) administered AZO D-Mannose, an OTC medication for urinary tract health, with an illegible pharmacy label over the drug facts and dosage information. Review of the physician's order stated, AZO D-Mannose…
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.
- Potential for harm · Dcited before2026-05-20 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 professional references, and staff interview, the facility failed to follow professional standards of infection control and prevention for 2 of 9 sampled residents (Resident #15 and #30) observed during cares. Failure to practice infection control standards related to hand hygiene, glove use, and when emptying catheter bags has the potential to spread infection throughout the facility. Findings include: Information found at https://medlineplus.gov/ency/patientinstructions/000142.htm, reviewed 01/01/25, stated, . Urine drainage bags collect urine. Follow these steps for emptying your bag . Hold the bag over the toilet, or special container . Open the spout at the bottom of the bag, and empty it [the urine] into the toilet or container. Clean the spout with rubbing alcohol . Close the spout tightly. Information found at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, dated 02/27/24, stated, . Know when to clean your hands . After touching a patient . Know when to wear (and change) gloves. Gloves are not a substitute for hand hygiene.…
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.
- Potential for harm · D2026-04-09 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 (FRI) investigation, record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from physical abuse for 1 of 1 sampled resident (Resident #1) who displayed physical and verbal aggression toward other residents. Failure to ensure an environment free from physical and verbal abuse placed all residents at risk for injury, fear, anxiety, and/or psychosocial harm. Findings Include:Review of the facility policy titled Vulnerable Adult - North Dakota occurred on 04/08/26. This policy, dated February 2026, stated, . Vulnerable Adult - Every resident of the facility . Abuse - the willful infliction of injury . Physical abuse - conduct that produces pain or injury and is not accidental . Examples of abuse . resident to resident abuse . A FRI report, dated 02/14/26, stated, . Staff heard [resident name] yelling out and went to where he was. When they arrived, [resident name] was on the floor in the hallway . [Resident #1] was seen scurrying away from the area . Mgr [manager] on call…
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.
- Potential for harm · Dcited before2026-04-09 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 2 of 3 sampled residents (Resident #3 and #6) observed during cares and 1 of 1 sampled resident (Resident #7) observed during a dressing change. Failure to practice infection control standards related to glove usage and hand hygiene has the potential to spread infection throughout the facility. Findings Include:Review of the facility policy titled Hand Hygiene occurred on 04/09/26. This policy, dated February 2026, stated, . Hand hygiene will be done: A. Before and after resident contact (before you leave the room). B. Before every clean procedure. C. After every dirty procedure. The purpose is to prevent the spread of infection.-Observation on 04/08/26 at 1:00 p.m. showed a nurse (#2) performed hand hygiene, applied a gown, mask, and gloves, and entered Resident #7's room to complete a dressing change. The nurse cleansed the bedside table with a disinfecting wipe, and removed the resident's sock and soiled dressing. The…
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.
Show the remaining 13 citations
- Potential for harm · E2025-04-30 · tag F0759 — failed to keep medication error rate low — patternEnsure 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, record review, review of facility policy, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 5 of 7 residents (Resident #2, #19, #20, #21, and #58) observed during medication administration. Thirteen medication errors occurred during staff administration of 37 medications, resulting in a 35% error rate. Failure to properly prime insulin pens and administer medications at the correct time may result in residents receiving an ineffective and/or inaccurate dose and experience adverse reactions. Findings include: Review of the facility policy titled Medication - Administration and Storage occurred on 04/30/25. This policy, dated March 2025, stated, . POLICY: Medications will be administered according to the following directives. Medications will be considered as given at the correct time if administered one hour before or one hour after the scheduled time. Review of the facility policy titled Insulin - Subcutaneous occurred on 04/30/25. This policy, dated September 2024, stated, . Remove cap from insulin pen .…
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.
- Potential for harm · Dcited before2025-04-30 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 record review, facility policy review, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 2 of 20 sampled residents (Resident #29 and #58). Failure to revise the care plan limited the ability of staff to communicate care needs and ensure continuity of care for each resident. Findings include: Review of the facility policy titled Care Plans occurred on 04/28/25. This policy, revised November 2021, stated, . develop a person-centered care plan . that reflects the actual care, condition. The comprehensive care plan . will be reviewed and updated monthly and as needed. Review of the facility policy titled Smoking/Tobacco Free occurred on 04/29/25. This policy, revised January 2024, stated, . maintain a policy where all buildings, grounds . are free of tobacco products. Use of tobacco products . are not permitted. - Review of Resident #29's medical record occurred on all days of survey. The care plan, dated 02/24/25, stated, . Will be assessed to be safe to smoke if she does engage in this activity.…
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.
- Potential for harm · D2025-04-30 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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
1. 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 7 residents (Resident #19) observed during medication administration. Failure to document medications at the time of administration does not reflect the actual time of administration and may cause adverse effects for the resident. Findings include: Review of the facility policy titled Medication - Administration and Storage occurred on 04/30/25. This policy, dated March 2025, stated, . documentation . immediately following administration. Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 836, stated, . Ten Rights of Medication Administration . Right Documentation . Document medication administration after giving it . The record [medication administration record] should . include the exact time of administration . Observation on 04/29/25 at 4:15 p.m. showed a medication aide (MA) (#3) administered…
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.
- Potential for harm · Dcited before2025-04-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, review of operator's instructions, and staff interview, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 1 of 4 residents (Resident #9) observed during a sit-to-stand mechanical lift transfer. Failure to utilize a mechanical lift properly, complete a nursing assessment, and implement a safe transfer method placed Resident #9 at risk for pain and/or injury. Findings include: Review of the EZ Way Smart Stand [type of sit-to-stand mechanical lift] 400, 500 & 800 lb [pound] Capacities Operator's Instructions occurred on 04/30/25. The operator's instructions, revised 09/29/23, on page 2-6, stated, . Patients should be able to bear some weight, have upper body strength and be able to follow simple commands. Review of the facility policy titled Standing Lifts occurred on 04/30/25. This policy, dated January 2024, stated . Use of this lift is participatory on the part of the resident and they must be…
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.
- Potential for harm · Dcited before2025-04-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
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, and review of facility policy, the facility failed to follow standards of infection control and prevention for 3 of 14 sampled residents (Resident #19, #25 and #46) observed during cares. Failure to practice infection control standards related to hand hygiene and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Infection Control - Enhanced Barrier Precautions occurred on 04/30/25. This policy, revised December 2024, stated, . Enhanced barrier precautions are used to limit or prevent the spread of resistant organisms during high-contact resident care activities. These may be indicated for residents with . chronic wounds that include pressure ulcers . venous ulcers . gown and gloves must be worn during high-contact resident care activities such as . wound care for chronic wounds requiring a dressing . Review of the facility policy titled Hand Hygiene occurred on 04/30/25.…
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.
- Potential for harm · D2024-12-04 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 provide the resident and/or the resident's representative a written bed hold notice for 1 of 1 closed record (Resident #10) reviewed for hospital transfers. Failure to provide a written copy of the bed hold notice does not allow the resident and/or their representatives to make an informed decision regarding their care. Findings include: Review of the facility policy titled Bed-Hold occurred on 12/04/24. This policy, revised October 2021, stated, . Upon transfer/admission to the hospital, the Social Worker or designee will complete the following information with the resident/responsible party. * Review Notice of Transfer For Hospitalization (ND [North Dakota]) . and obtain signature. * Review Bed Hold form and obtain signature. * Provide a signed copy to the resident/responsible party. * Ensure that a copy of the notice(s) accompanies the resident to the hospital. * File the signed forms in the resident's electronic health record. Review of Resident #10's medical record occurred on all…
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.
- Potential for harm · Dcited before2024-12-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 record review, review of the facility reported incident and investigation documents, and review of facility policy, the facility failed to provide appropriate supervision and/or assistance to prevent an accident for 1 of 1 resident (Resident #1) who fell during a mechanical stand lift transfer. Failure to provide two-person assistance and failure to utilize the shin strap resulted in Resident #1's fall from the stand lift, injury, and placed all residents transferred via a stand lift at risk for falls and/or injury. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 09/17/24. The facility completed the corrective action on 09/23/24. The final facility reported incident report, dated 09/17/24, stated, . The charge nurse was outside of room and heard resident calling for help in a loud tone, nurse immediately went in to investigate.…
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.
- Potential for harm · D2024-12-04 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, facility incident report, and staff interview, the facility failed to ensure a complete and accurate medical record for 1 of 4 sampled residents (Resident #9) reviewed for resident-to-resident altercations. Failure to have a complete and accurate medical record limited staff's access to the most recent medical information regarding the residents. Findings include: Review of a facility incident report, dated 11/12/24, stated, Staff overheard elevated voices and went to intervene. When approached, both residents had their hands placed onto the walker attempting to take it away from one another. No physical contact was noted resident to resident during this situation. During an interview on 12/03/24 at 5:04 p.m., an administrative nurse (#2) confirmed the other resident involved in the incident, dated 11/12/24, was Resident #9. Review of Resident #9's medical record occurred on all days of survey and included a diagnosis of Alzheimer's Disease. The medical record lacked documentation related to the 11/12/24 incident between Residents #4 and #9. During an…
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.
- Potential for harm · D2024-04-18 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 02/15/23. Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure reasonable accommodation of needs regarding call lights for 1 of 3 sampled residents (Resident #227) with a soft touch call light. Failure to place Resident #227's call light within reach may result in an inability to call for help, discomfort, increased falls, and/or incontinence. Findings include: Review of the facility's policy titled Standard of Care occurred on 04/18/24. This policy, revised January 2024, stated, . The following standards of care will be followed in proving care to the residents . Call light will be accessible for residents in their rooms . Review of Resident #227's medical record occurred on all days of survey. Diagnoses included weakness and history of falls. The current care plan stated, . High risk for falls . Keep call light within reach at all times when in room (soft touch) . Resident not to be left in room alone in wheelchair without supervision . Resident is assist x…
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.
- Potential for harm · Dcited before2024-04-18 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 22 sampled residents (Resident #1). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI Manual, revised October 2023, page N-7, stated, . N0415: High-Risk Drug Classes: . N0415A 1. Antipsychotics: Check if an antipsychotic medication was taken by the resident at any time during the 7-day look-back period . Review of Resident #1's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], showed Section N0415A coded as the resident received an antipsychotic medication within the 7-day look back period. The residents medical record…
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.
- Potential for harm · Dcited before2024-04-18 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the resident's current status for 1 of 22 sampled residents (Resident #227). Failure to revise the care to reflect Resident #227's current status limited the staff's ability to communicate needs and ensure continuity of care for residents. Findings include: Review of the facility policy titled Care Plans occurred on 04/18/24. This policy, revised November 2021, stated, . Pertinent information to properly care for the resident will be added to the NAR/CNA [nurse aide record/certified nurse aide] care plan for continuity of care . Care plans will be updated and changes will be made as they occur to ensure the most current care plan for the resident . any changes made to the comprehensive care plan will also be updated in the NAR/CNA care plan for accuracy . Review of Resident #227's medical record occurred on all days of survey. Resident #227's care plan, dated 04/10/24, stated, . Transfers: transfer/mobility assist x [times] 2 with…
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.
- Potential for harm · Dcited before2024-04-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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
THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 04/20/23. 1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 1 of 4 sampled residents (Resident #227) observed during stand lift transfers. Failure to ensure staff utilized the correct lift during transfers caused Resident #227 discomfort/pain and placed him at risk for possible injury. Findings include: Review of the facility policy titled Falls-Resident occurred on 04/18/24. This policy, revised March 2022, stated, . Purpose: To prevent falls, reduce injury . initiate the care plan for high risk of injury related to potential of falls . update the care plan with updated interventions . Review of Resident #227's medical record occurred on all days of survey. Diagnoses included chronic pain, weakness, and history of falls with hip fracture. Resident #227's care plan, dated 04/10/24 stated, . Transfers: transfer/mobility assist x [times] 2 [staff] with pal [sit-to-stand] lift . On…
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.
- No harm found · C2025-04-30 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, review of facility policy, and staff interview, the facility failed to ensure posting of accurate and complete staffing information on 1 of 4 days of survey (April 27, 2025). Failure to post accurate staffing data does not allow residents and visitors to be aware of the number of licensed and unlicensed staff on duty each shift. Findings include: Review of the facility policy titled Staffing Levels occurred on 04/30/25. This policy, revised on February 2024, stated, . the Director of Nursing is responsible for ensuring that nursing hours are posted daily . determines the level of nursing hours for the facility . Observation on 04/27/25 at 12:02 p.m., showed a staffing report dated 04/25/25. The facility failed to update the number of licensed and unlicensed staff working the days of 04/26/25 and 04/27/25. During an interview on 04/30/25 at 12:22 p.m., an administrative staff member (#1) stated she expected the charge nurse to complete and post a daily census/staffing report.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| EVENTIDE | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/01/2014 |
| BRANDT, TERRY | Individual | CORPORATE DIRECTOR | — | since 03/01/2026 |
| BYE, ROBERT | Individual | CORPORATE DIRECTOR | — | since 01/01/2019 |
| GULBRANSON, PATRICK | Individual | CORPORATE DIRECTOR | — | since 08/03/2023 |
| JOHNSON, VIKKI | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 01/01/2024 |
| LUNAK, BRANDON | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/01/2026 |
| SELJEVOLD, PETER | Individual | CORPORATE DIRECTOR | — | since 08/03/2023 |
| OHE, DARIN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/07/2019 |
| RIEWER, JON | Individual | CORPORATE OFFICER | — | since 07/25/2014 |
| BLUE STONE THERAPY INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/17/2025 |
| CLOSE, MICHELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/11/2022 |
| ECKES, LINDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2020 |
| LEIGH DEGENSTEIN, HEATHER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/25/2022 |
| SAMSON, NICOLE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2026 |
| SANDVIK, DESTINEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/01/2022 |
| SCHNEIDER, TANYA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/04/2024 |
| STRONG, JEFF | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/28/2018 |
| TROTTIER, NATHAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/30/2021 |
| WASS, JERILYN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2019 |
CMS files one row per role, so the 33 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners 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.
This home reported $689K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. 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
Straight from this home’s Medicare cost report (CMS, FY2023). 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
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.
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 355069. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-20, 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.