Sanford Hillsboro Care Center
12 3rd St SE, Hillsboro, ND 58045 · Non profit - Corporation · 34 certified beds · (701) 636-3235 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- the CMS record shows $42,488 in federal fines (most recent 2024-06-05)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection 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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its 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 | 4 of 5 |
| Long-stay residentspeople who live here | 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 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 | 10.9% | 5.8% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 5.5% | 1.6% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.8% | 2.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 7.6% | 4.4% | 6.5% | worse |
| 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 | 1.6% | 5.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 14.2% | 17.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 16.4% | 17.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.9% | 98.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.5% | 4.9% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 15.9% | 24.9% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 28.9% | 22.7% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.73 | 1.49 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.62 | 1.86 | 1.80 | better |
‡ 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.
Therapy staffing: this home’s payroll records show 0.05 therapist hours per resident per day in 2026Q1 — more than 2% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims 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 discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 34 beds and averages 32.8 residents a day — about 96% occupied, or roughly 1 bed 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 4.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.94 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 3.75 hrs/resident/day on weekends vs 4.83 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.89 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% 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 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.
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.
10 citations, most serious first — scroll within the box to see all.
- Immediate jeopardy · Kcited before2024-06-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure an environment free of accident hazards for 1 of 1 sampled resident (Resident #27) who experienced a burn related to hot coffee. Failure to ensure appropriate coffee/water temperatures resulted in Resident #27 sustaining a burn and placed all residents at risk for serious burns/injuries. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 05/28/24 at 6:20 p.m. The IJ resulted from temperature readings obtained from the coffee/hot water machine, a lack of temperature monitoring by staff, and an injury to a resident. This finding placed residents in immediate danger due to hot temperatures and the potential for serious burns. *05/28/24 at 6:50 p.m. The survey team notified the administrator and director of nursing of the IJ situation, provided the IJ template, and requested a plan for removal…
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.
- Actual harm · Gcited before2023-11-02 · 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 record review, review of facility policy, and staff and resident interview, the facility failed to provide necessary supervision to prevent accidents for 1 of 1 sampled resident (Resident #1) with a burn. Failure to ensure placement of a barrier between the resident's skin and the heating pack and monitor the resident resulted in a burn to Resident #1's shoulder. Findings include: Review of the facility policy titled Heat Applications occurred on 11/02/23. This policy, dated 11/29/22, stated, . Procedure: Microwave Heating Packs . Place pack in microwave and follow manufacturer's recommendations for setting and length of heating time. Cover pack with towel and place on treatment area of resident . Check area in one minute for any redness of skin . Check area again every five minutes for any redness of skin or discomfort . Review of Resident #1's medical record occurred on 11/02/23. A physician's order, dated 10/19/23 and discontinued 10/31/23, stated, Ice/heat pack 3x [times]/day. If pt [patient] doesn't have preference between ice or heat, can alternate each throughout day…
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 · D2025-06-26 · 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 — the official record, unedited, may be distressing
Based on record review, review of facility policy, and staff interview, the facility failed to review and revise the care plan to reflect the current status for 1 of 5 sampled residents (Resident #30) reviewed for unnecessary medications. Failure to revise the care plan limited the staff's ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care Plan occurred on 06/26/25. This policy, dated 12/02/24, stated, . The plan of care will be modified to reflect the care currently required/provided for the resident. Review of Resident #30's medical record occurred on all days of survey. Physician's orders identified Lasix (diuretic) 40 milligrams twice a day and Tramadol (opioid pain medication) 50 milligrams twice a day and as needed for pain. Resident #30's care plan failed to identify problems and interventions due to the use of diuretic and opioid pain medication. During an interview on 06/26/25 at 11:00 a.m., an administrative staff member (#1) confirmed staff failed to update Resident #30's care plan.
- Potential for harm · Dcited before2025-06-26 · 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
Based on observation, record review, review of facility policy, professional reference, and staff interview, the facility failed to follow professional standards of practice for medication administration for 1 of 1 supplemental resident (Resident #11). Failure to correctly administer and document medication administration may result in errors and/or 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 832, stated, Practice Guidelines . Administering Medications . Administer only medications personally prepared. Review of the facility policy titled Medication: Administration Including Scheduling and Medication Aides occurred on 06/26/25. This policy, dated April 2025, stated . Purpose: . To administer medications correctly and in a timely manner . Medications are administered to the resident according to the 'Six Rights.' . Administer only those medications that you prepared. Do not ask anyone else to administer medications that you prepared. Do not…
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 before2025-06-26 · 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 facility policy, and resident and staff interview, the facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury for 1 of 2 sampled residents (Resident #30) reviewed for falls. Failure to lock tub chair brakes placed residents at risk for falls and/or injury. Findings include: Review of the facility policy titled Fall Risk & Prevention: Standards of Care occurred on 06/26/25. This policy, dated February 2024, stated, . Procedure: Transfer/Locomotion: 2. Follow care-plan for level assistance required . 4. Lock brakes on wheelchair for pivot transfer. Review of the facility policy titled Falls Resource Packet occurred on 06/26/25. This policy, dated April 2025, stated, . Fall reduction efforts include . Safe and proper use of any assistive device (wheelchair, walker, etc.) and not to use moveable items, (furniture, etc.) for balance or transfers . During an interview on 06/23/25 at 5:30 p.m., Resident #30 stated he had fallen in the shower…
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 · D2024-06-05 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 all forms of communication related to code level status accurately reflected the resident ' s wishes for 1 of 14 sampled residents (Resident #23) reviewed for advance directives. Failure to ensure the medical record and other forms of communication accurately reflected the resident's code status limited the facility's ability to communicate to direct care staff and emergency personnel the resident's choice in the event of a medical emergency. Findings include: Review of the facility policy titled Advance Care Planning occurred on 05/30/24. This policy, dated 11/13/23, stated, . Residents . have the right to make decisions concerning medical care, including the right to accept or to refuse medical or surgical treatment. Review of Resident #23's medical record occurred on all days of survey. The Uniform Code Level Directives for Cardiopulmonary Resuscitation, signed by the resident on 01/04/22, indicated Code Level 1: All available reasonable technology is used in 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 · D2024-06-05 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview, and review of facility policy, the facility failed to provide the resident or the resident's representative a written notice of transfer for 1of 1 resident (Resident #9) reviewed for hospital transfer. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights. Findings include: A review of the facility policy titled Transfer to Hospital Guide occurred on 05/30/24. This policy, dated, 02/19/23, stated, . Notify the resident, family member or legal representative of the transfer in a timely manner. Document completion in the Medical Record. Review of Resident #9's medical record occurred on all days of survey and identified a hospital transfer on 11/07/23. The medical record lacked documentation the facility provided the resident and/or representative with a written transfer notice. During an interview on the afternoon of 05/29/24 an administrative staff member (#1) confirmed the facility failed to provide written notice of a transfer to…
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 before2024-06-05 · 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 — the official record, unedited, may be distressing
Based on observation and review of facility policy, the facility failed to follow professional standards of practice for 1 of 1 resident (#17) observed for insulin preparation and administrations. Failure to prime the insulin pens correctly may result in residents receiving an inaccurate dose. Findings include: Review of the policy Medication: Insulin Administration, Insulin Pens, Insulin Pumps occurred on 05/30/24. This policy, revised December 2023, stated . Insulin Pen . Turn the dosage knob to '2' units to prime the pen. Holding the pen with the needle pointing upwards, press the button until at least a drop in insulin appears. Observation on 05/29/24 at 11:30 a.m. showed a nurse (#3) prepared Resident #17's Humalog insulin pen for administration. The nurse (#3) dialed the insulin pen to the prescribed units without priming the insulin pen. The nurse (#3) failed to prime the insulin pen as per facility policy. During an interview on 05/29/24 at 4:52 p.m., an administrative staff member (#1) confirmed it is her expectation that staff prime insulin pens per policy.
- Potential for harm · D2024-06-05 · 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 facility policy, and staff interview, the facility failed to follow standards of infection control for 3 of 14 sampled resident's (#17, #21, and #27) observed during medication administration, resident cares, and wound cares. Failure to follow infection control standards related to hand hygiene and glove use has the potential to transmit infections to residents, staff, and visitors. Findings include: Review of the facility policy titled Hand Hygiene occurred on 05/30/24. This policy, dated 03/29/22, stated, . Policy: . All employees are responsible for maintaining adequate hand hygiene by adhering to specific infection control practices. All employees in patient care areas . will adhere to the '4 Moments of Hand Hygiene and 2 Zones of Hand Hygiene'. 1. Entering . After contact with a patient's non-intact skin, wounds . If gloves are used to perform a clean/aseptic procedure, hand hygiene must be completed before donning gloves . - Observation on 05/28/24 at 5:35 p.m. showed a certified nurse aide (CNA) (#4) donned gloves and assisted Resident #21 off…
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 · C2024-06-05 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of daily staffing information and staff interview, the facility failed to post daily staffing data for all shifts on 9 of 15 days reviewed (May 14-28, 2024). 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 daily staffing data from May 14-28, 2024 showed on nine of the days, staff failed to post the number of staff working on six day shifts, six evening shifts, and one night shift. During an interview on the afternoon of 05/29/24, an administrative staff member (#1) confirmed staff failed to post staffing data for each shift on some of the days.
“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
$42,488 in federal fines across 2 penalties.
- $35,045 — penalty dated 2024-06-05
- $7,443 — penalty dated 2023-11-02
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.
Part of a chain
This home belongs to SANFORD HEALTH — 4 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.8 | +0.2 vs chain |
| Health inspection | 2 of 5 | 2.5 | -0.5 vs chain |
| Staffing | 5 of 5 | 4.3 | +0.7 vs chain |
| Quality measures | 4 of 5 | 3.0 | +1.0 vs chain |
The other 3 homes this chain runs (chain average 2.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SANFORD NORTH | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/01/2011 |
| SANFORD | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 07/20/2010 |
| DULSKI, KARIN | Individual | W-2 MANAGING EMPLOYEE | — | since 11/19/2012 |
| GASSEN, WILLIAM | Individual | W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 11/24/2020 |
| MARLETTE, WILLIAM | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 06/16/2023 |
| MORRISON, TONY | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 02/01/1991 |
| MUNSON, JOLYN | Individual | W-2 MANAGING EMPLOYEE | — | since 02/25/2013 |
| SWENSON, STEPHANIE | Individual | W-2 MANAGING EMPLOYEE | — | since 11/01/2019 |
| CAIN, JAMES | Individual | CORPORATE DIRECTOR | — | since 11/19/2015 |
| ENGBRECHT, WESLEY | Individual | CORPORATE DIRECTOR | — | since 01/01/2021 |
| GULSVIG, NEIL | Individual | CORPORATE DIRECTOR | — | since 03/28/2019 |
| JACOBS, DONALD | Individual | CORPORATE DIRECTOR | — | since 12/04/2014 |
| LUNDEEN, MARK | Individual | CORPORATE DIRECTOR | — | since 12/04/2014 |
| MOLBERT, LAURIS | Individual | CORPORATE DIRECTOR | — | since 01/01/2021 |
| NORTH, ANDREW | Individual | CORPORATE DIRECTOR | — | since 12/01/2016 |
| TEIKEN, BRENT | Individual | CORPORATE DIRECTOR | — | since 01/01/2013 |
| VENTLING-HERRMANN, MARNIE | Individual | CORPORATE DIRECTOR | — | since 01/01/2022 |
CMS files one row per role, so the 21 rows in the source record cover these 17 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.
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 355061. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-26, 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.