No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Maple Manor Care Center

1116 9th Ave, Langdon, ND 58249 · Non profit - Corporation · 45 certified beds · (701) 256-2987 Medicare & Medicaid certified

Call the home — (701) 256-2987 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation$31,694 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $31,694 in federal fines (most recent 2025-09-09)
  • its independent health-inspection rating is low (2/5)
  • it did not file the payroll staffing data CMS requires — its 1 of 5 staffing rating is the rating CMS assigns for not reporting, not a measure of how many nurses are on the floor
  • 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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
301 5th St · (701) 549-2711 · Call to confirm hours
Pharmacy
Grocery
124 9th Ave E · (701) 256-2600 · Call to confirm hours
Park
1316 7th St · (701) 256-2155 · Typically dawn to dusk
Place of worship

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased28.9%19.8%15.4%worse
Long-stay residents who lose too much weight3.8%5.8%5.4%better
Long-stay residents with a catheter left in their bladder5.8%1.6%0.9%worse
Long-stay residents with a urinary tract infection1.4%2.6%2.0%better
Long-stay residents with depressive symptoms3.1%4.4%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury7.7%5.1%3.3%worse
Long-stay residents whose ability to walk worsened16.0%17.6%16.1%typical
Long-stay residents on antianxiety or hypnotic medication12.1%17.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.8%95.3%typical
Long-stay residents with pressure ulcers5.7%4.9%4.7%worse
Long-stay residents with worsening bladder/bowel control22.2%24.9%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table35.2%22.7%17.1%worse
Long-stay hospitalizations per 1,000 resident days0.471.491.67better
Long-stay outpatient ER visits per 1,000 resident days2.511.861.80worse

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.

10.7%U.S. median 10.7%
Went back to hospital

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot 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 SNF10.7%CMS range 6.4–16.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot 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 dischargenot 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 dischargenot 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 identifiednot 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 settingnot 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 dischargenot 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 staynot 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 worsenednot 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 hospitalization8.1%CMS range 3.5–13.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.531.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.

Inspection trend

9
deficiencies at the latest standard inspection (2025-09-10)
6
at the previous standard inspection (2024-07-10)

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.

ABCDEFGHIJKL

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

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · G2025-09-10 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of professional reference, and resident and staff interview, the facility failed to develop and provide an effective pain management regimen to meet resident needs for 2 of 14 sampled residents (Resident #4 and #5) reviewed for pain management. Failure to develop, implement, and provide an effective pain management plan resulted in unresolved pain and discomfort and decreased quality of life. Findings include:Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, pages 625-626, stated, . pain is a physical and emotional experience . Pain interferes with functional abilities and quality of life. Severe and persistent pain affects all body systems, causing potentially serious health problems while increasing the risk of complications and delays in healing. Pain management is the alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the client. Page 631 stated, .…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-09-10 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of a facility job description and staff interview, the facility failed to ensure 1 of 1 dietary manager (#11) obtained the proper qualifications to serve as the dietary manager. Failure to ensure staff have the qualifications to carry out the functions of a manager in the dietary department has the potential to result in foodborne illness to residents, staff, and visitors.Findings include: Review of the facility job description titled Dietary Manager occurred on 09/10/25. This undated job description stated, . Minimum requirements include one of the following . Certification as a dietary manager . Certification as a food service manager . Has similar national certification for food service management and safety from a national certifying body . Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, but no later than October 1, 2023 . During an interview on 09/08/25 at 3:00 p.m., the dietary manager (#11) confirmed she had 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-09-10 · tag F0868 — widespread
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility Quality Assurance and Performance Improvement (QAPI) program, review of the facility policy, and staff interview, the facility failed to ensure the Medical Director (physician) actively participated on the Quality Assurance (QA) committee for 3 of 4 quarters (July-September 2024, October-December 2024, and April-June 2025). Failure to ensure the medical director participates in the facility's QA activities deprived the committee of the physician's unique contribution for analyzing and correcting problems with identified resident care areas.Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership occurred on 09/10/25. This policy, revised January 2025, stated, . The following individuals serve on the committee . Medical director . The committee meets at least quarterly (or more often as necessary). Committee members are reminded of meeting day, time and location via e-mail at least two business days prior to the meeting. Review of the QA committee attendance records…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-09-10 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and review of facility policy, the facility failed to serve food in accordance with professional standards for food safety in 1 of 2 dining rooms (north dining room). Failure to ensure no bare-hand contact with ready-to-eat food has the potential to result in a food borne illness. Findings include: Review of the facility policy titled Kitchen and Service Kitchen Safe Practice Guidelines occurred on 09/10/25. This policy, dated 07/14/25, stated, . When handling clean dishes care will be taken to minimize hand contact with food surfaces. plates [will be touched] on the outside rim . Review of the facility policy titled Serving Meals occurred on 09/10/25. This policy, dated 07/13/25, stated, . Staff will serve meal without touching prepared food. Review of the facility policy titled Dietary Infection Control and Glove Usage occurred on 09/10/25. This policy, dated 07/14/25, stated, . Change Gloves after . touching hair or face with gloved hands. -Observations of food service showed the following:*On 09/09/25 at 7:45 a.m., a dietary staff member (#13) placed 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-09-10 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of professional reference, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 14 sampled residents (Residents #4 and #5) observed during personal cares. Failure to practice infection control standards during medication administration and resident cares has the potential to spread infection throughout the facility. Findings include:Review of the Centers for Disease Control (CDC) Frequently Asked Questions (FAQS) about Enhanced Barrier Precautions in Nursing Homes at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html, dated 06/28/24, stated, 1 . Enhanced Barrier Precautions [EBP] involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [multidrug-resistant organism] as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). 9 . Adherence to other recommended infection prevention practices including performing hand hygiene, cleaning and…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-10 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 3 of 14 sampled residents (Resident #3, #11, and #32). Failure to review and revise the care plan as the needs change for the resident 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, Comprehensive Person-Centered occurred on 09/10/25. The revised policy, dated March 2025, stated, . Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. -Observation on the afternoon of 09/08/25 showed facility staff changed Resident #32's brief and left his/her pants down and around the ankles and covered with a blanket. On 09/09/25 at 3:39 p.m., observation showed the resident lying in bed without pants and covered with a blanket. Review of Resident #32's medical record occurred on all days of survey. The current…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-10 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 2 of 3 sampled residents (Residents #3 and #5) observed during medication pass. Failure to disinfect the rubber seal of insulin pens increases the risk of infection to residents and failure to follow manufacturer instructions for eye drop administration may impede the effectiveness of the eye drops. Findings include: Review of the facility policy titled Insulin Administration occurred on 09/10/25. This policy, dated May 2025, stated, . Pull off the pen cap. Wipe the rubber seal with an alcohol swab. Information found at https://www.drugs.com/pro/pataday-once-daily-relief.html, revised 08/14/25, stated, . Pataday (treatment for dry eyes) . Package Insert/Prescribing Info [information] . if using other ophthalmic products while using this product, wait at least 5 minutes between each product . -Observation on 09/09/25 at 9:14 a.m. showed a nurse (#4) administered Pataday eye drops to both of Resident #5's eyes. At…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-10 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and staff interviews, the facility failed to ensure 1 of 1 sampled resident (Resident #29) with contractures received the necessary devices. Failure to consistently provide a rolled washcloth to the resident's right hand may result in worsening of the contracture, pain, and further skin breakdown. Findings include:Review of Resident #29's medical record occurred on all days of survey. Diagnosis included hemiplegia and hemiparesis [weakness or paralysis] following cerebral infraction [stroke] affecting the right side. The care plan stated, I require assist for all ADL's [Activity of Daily Living] . Please ensure that a rolled-up washcloth to [sic] placed to her right hand while at night and when she is in bed during the day. Observation occurred on all days of survey and showed Resident #29's right hand contracted in a gripped position. On the afternoon of 09/09/25 and 09/10/25, observation showed Resident #29 in bed without a rolled-up wash cloth in her right hand.During an interview on the afternoon of 09/10/2025, a CNA (#5) stated staff are…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to properly utilize assistive devices for 1 of 4 sampled residents (Resident #16) reviewed for falls. Failure to properly use a bed and chair alarm placed the resident at risk for falls. Findings include:Review of Resident #16's medical record occurred on all days of survey. Diagnosis included dementia and anxiety. The current care plan stated, . I am at risk for falls . Silent fall alarms on chair and bed. A Quarterly Minimum Data Set (MDS) dated [DATE] identified a bed and chair alarm used daily. A Fall Risk Evaluation, completed 08/23/24 identified a Fall Risk Score of 18 (High Risk of falls). Observations on all days of survey showed Resident #16's chair and bed alarm unplugged and not functioning. During an interview on 09/10/2025 at 8:44 a.m., an administrative nurse (#1) confirmed Resident #16's bed and chair alarm were unplugged, was not aware if the resident was able to unplug the alarms, and expected staff to ensure 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-10 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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, review of facility policy, and resident and staff interviews, the facility failed to serve foods at palatable temperatures on 2 of 3 days of survey (July 8-9, 2024). Failure to serve foods at a temperature acceptable to residents may result in decreased intake, weight loss, and inadequate nutrition. Findings include: Review of the facility policy titled Food Temperatures occurred on 07/10/24. This policy, dated 07/13/23, stated, . Foods will be served at the appropriate temperatures to ensure good flavor and to prevent food borne illnesses. All hot food items will be served to the resident at the temperature of at least 140 degrees. During an interview on 07/08/24, Resident A stated, The food is always cold. Observation of the noon meal occurred on 07/08/24 at 12:25 p.m. in dining room [ROOM NUMBER]-3 and showed a cook (#5) dished the final resident tray. A temperature of the three-bean vegetable showed a reading of 72.5 degrees Fahrenheit (F). Observation of the evening meal occurred 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-10 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of facility policy, and staff interview, the facility failed to store food in a sanitary manner in 1 of 1 main kitchen. Failure to apply an identifying label to food and add an open date has the potential to affect food quality/preparation and may result in the spread of foodborne illness to residents, staff, and visitors. Findings include: Review of the facility policy titled Storage and Cooking of Food occurred on 07/10/24. This policy, dated July 2023, stated, . Food Storage . Foods which have been opened or prepared will be placed in an enclosed container, dated and labeled. If food is ever found undated these will be thrown without exception. Observation of the main kitchen occurred on 07/08/24 at 11:20 a.m. with a dietary manager (#6) and showed the following: Walk-in Refrigerator: *Four individually dished containers identified as taco sauce by a dietary staff member with no identifying label or prepared date. *One brick of a white substance identified as cream cheese but not sure, by a dietary staff member with an unidentifiable date and no…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2024-07-10 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of facility policy, confidential interview, and staff interview, the facility failed to provide resident care for 2 of 11 sampled residents (Resident #8 and #14) requiring assistance with activities of daily living in a manner that promotes, maintains, or enhances their quality of life. Failure to cover a urinary catheter leg bag (Resident #8) and failure to clean and shave resident's face and change the soiled shirt (Resident #14) has the potential to affect the resident's psychosocial well being and personal dignity. Findings include: Review of the facility policy titled Dignity occurred on 07/10/24. This policy, revised February 2024, stated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. Staff are expected to promote dignity and assist residents: for example: helping the resident to keep urinary catheter bags covered. Review of the facility policy titled Activities of Daily Living (ADLs), Supporting…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-10 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    1. Based on record review, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 sampled residents (Resident #15) reviewed with orders for specific parameters for blood glucose levels. Failure to notify the physician of high blood glucose levels as ordered placed the resident at risk for delayed treatment and adverse health events. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, Nurses are expected to analyze procedures and medications ordered by the physician or primary care provider. Review of the facility policy titled Physician, Physician Assistant, Nurse Practitioner or Clincal Nurse Specialist Lab Notification occurred on 07/10/24. This policy, revised 03/11/24, stated, . The physician . will determine parameters for 'immediate' and 'non-immediate' lab results. Notification parameters for 'immediate' lab results will be included in lab order. Immediate…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of professional reference, and staff interviews, the facility failed to provide supervision to prevent accidents for 1 of 2 sampled residents (Resident #33) observed during a gait belt transfer. Failure to provide supervision of certified nurse aides (CNAs) by a licensed nurse regarding resident transfer assistance may result in unnecessary pain, falls and/or injury for residents. Findings included: Review of the North Dakota Administration Code (NDAC) online at www.ndlegis.gov/information/acdata/pdf/33-43-01.pdf stated, . 33-43-01-12. Supervision and delegation of nursing interventions. An individual on the department's nurse aide registry [CNA] may perform nursing interventions which have been delegated by a licensed nurse. An individual on the departments nurse aide registry as delegated and supervised by a licensed nurse . Review of Resident #33's medical record occurred on all days of survey and included diagnoses of weakness and dementia. The current care plan stated, . TRANSFER: Resident is transfer of 1-2 depending on pt [patient]…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of a professional reference, and staff interview, the facility failed to provide appropriate toileting for 1 of 6 sampled residents (Resident #33) who required staff assistance with toileting. Failure to provide toileting may result in a loss of dignity and placed the resident at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and risk for fall and/or injuries. Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 892, stated, Fecal and Urinary Incontinence: Moisture from incontinence promotes skin maceration [tissue softened by prolonged wetting or soaking] and makes the epidermis [skin] more easily eroded and susceptible to injury. Digestive enzymes in feces, urea in urine . also contribute to skin excoriation [area of loss of the superficial layers of the skin] . Any accumulation of secretions . is irritating to the skin, harbors microorganisms, and makes an individual prone to skin…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-09 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of Medicare Part A letters/notices, Centers for Medicare and Medicaid Services instructions, and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) form and Notice of Medicare Non-coverage (NOMNC) form two days in advance of discharge for 2 of 3 residents (Resident #23 and #38) discharged from Medicare Part A services. Failure to provide Medicare Part A letters/notices within the required time frame has the potential to limit the residents' right to an expedited review of service termination (NOMNC) and/or to exercise their rights to Medicare Part A services (SNFABN). Findings include: Review of [Medicare Advantage/Health Plan] Expedited Determination Notices (MA) webpage on 08/09/23, at https://www.cms.gov/medicare/medicare-general-information/bni/downloads/instructions-for-notice-of-medicare-non-coverage-nomnc.pdf, stated, . The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-09 · tag F0623 — isolated
    Provide 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, review of facility policy, and staff interview, the facility failed to provide the resident or their representative and/or the State Long Term Care Ombudsman written notice of transfer for 1 of 4 residents (Resident #30) with a recent 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 or inform the Ombudsman of the transfer. Findings include: Review of the facility policy titled Transfer or Discharge Notice occurred on 08/09/23. This policy, revised March 2021, stated, . Under the following circumstances, the notice is given as soon as it is practicable but before the transfer . the resident and representative are notified in writing . A copy is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Review of Resident #30's medical record occurred on all days of survey and identified a hospital transfer on 07/23/23. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-09 · tag F0641 — isolated
    Ensure 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 1.17.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 15 sampled residents (Resident #8 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 H: BLADDER AND BOWEL The Long-Term Care Facility RAI User's Manual, revised October 2019, page H-2 states, . Suprapubic catheters and nephrostomy tubes should be coded as an indwelling catheter (H0100A) only and not as an ostomy (H0100C) . Review of Resident #8's medical record occurred on all days of survey. A physician's order, dated 05/18/23, identified the resident as having a suprapubic catheter. The annual MDS, dated [DATE], identified the resident as having an ostomy. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-09 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of the North Dakota Provider Manual for Preadmission Screening and Resident Review (PASARR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 1 of 1 sampled resident (Resident #28) with a newly diagnosed mental illness. Failure to complete a change in status assessment may result in the delivery of care and services that are inconsistent with residents' needs. Findings include: The North Dakota PASARR Provider Manual, revised 12/29/20, page 13 states, . Change in Status Process . Whenever the following events occur, nursing facility staff must contact Maximus to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC (mental illness, intellectual disability, and conditions related to intellectual disability [referred to in regulatory language as related conditions or RC]) was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-09 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the current status for 3 of 15 sampled residents (Resident #8, #17, and #35). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered occurred on 08/09/23. This policy, revised March 2022, stated, . care plans are revised as information about the resident and the resident's condition change. -Review of Resident #8's medical record occurred on all days of survey. A progress note, dated 07/13/23, stated, . does have positioning wedges, but continually rolls himself to different position . Observations on 08/08/23 and 08/09/23 showed the resident utilized positioning devices (positioning wedges and leg spacer). The current care plan lacked information related to Resident #8's use of positioning devices. During an interview on 08/09/23 at 2:38 p.m., an administrative…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-09 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, the facility failed to ensure the consultant pharmacist reported drug regimen irregularities for 2 of 5 sampled residents (Resident #18 and #25) selected for drug regimen review. Failure to report drug regimen irregularities and act upon recommendations may result in residents receiving unnecessary medications and experiencing adverse consequences related to their use. Findings include: - Review of Resident #18's medical record occurred on all days of survey. Diagnoses included impulse disorder, major depressive disorder, anxiety disorder, and avoidant personality disorder. A Fax Communication to Physician, dated 03/12/23, noted the resident has been on Abilify (antipsychotic medication) since 01/19/22. The medical record lacked evidence to show the consultant pharmacist communicated the need for a gradual dose reduction (GDR) to the resident's physician at any time from January 2022 to March 2023. - Review of Resident #25's medical record occurred on 08/09/23. A Fax Communication to Physician, dated 04/12/23, noted the resident has been…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, review of facility policy, and staff interview, the facility failed to ensure a medication regimen free from unnecessary medications for 2 of 5 sampled residents (Resident #18 and #25) selected for medication regimen review. Failure to attempt a gradual dose reduction (GDR) or identify contraindications for a GDR may result in residents receiving unnecessary medications and experiencing adverse consequences related to their use. Findings include: Review of the facility policy titled Tapering Medication and Gradual Dose Reduction occurred on 08/09/23. This undated policy stated, . Residents who use psychotropic medications shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs. Within the first year after a resident is admitted on a psychotropic medication or after the resident has been started on a psychotropic medication, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between attempts), unless clinically contraindicated. After the first…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-09 · tag F0868 — isolated
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — the official record, unedited, may be distressing

    Based on review of Quality Assurance and Performance Improvement (QAPI) meeting minutes, facility policy, and staff interview, the facility failed to ensure participation by the medical director for 1 of 3 quarterly meetings (May 9, 2023) reviewed. Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement occurred on 08/09/23. This policy, revised 01/20/23, stated, . The QAPI Committee shall be interdisciplinary and shall: a. Consist at a minimum of: . The Medical Director or his/her designee . Meet at least quarterly . Review of QAPI meeting minutes occurred on 08/09/23. The May 9, 2023 QAPI meeting minutes failed to identify the medical director attended the meeting or reviewed meeting minutes. During an interview on 08/09/23 at 1:48 p.m., an administrative staff member (#1) stated she could not find evidence the medical director attended the meeting or reviewed the minutes.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    HAND HYGIENE 1. Based on observation, review of professional reference, and staff interview, the facility failed to follow standards of infection control for 1 of 4 sampled residents (Resident #24) observed while receiving toileting assistance. Failure to follow infection control practices regarding hand hygiene during cares has the potential for transmission of communicable diseases and infections to residents, staff, and visitors. Findings include: Review of the Centers for Disease Control (CDC) document titled When and How to Wash Your Hands, page 1, reviewed November 15, 2022, found at https://www.cdc.gov/handwashing/when-how-handwashing.html, stated, . Washing hands can . prevent the spread of respiratory and diarrheal infections. Germs can spread from person to person or from surfaces to people when you: Touch your eyes, nose, and mouth with unwashed hands . eat food and drinks with unwashed hands. Touch surfaces or objects that have germs on them . Key Times to Wash Hands . before . eating food . After using the toilet . Observation on 08/08/23 at 11:07 a.m. showed 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$31,694 in federal fines across 1 penalty.

  • $31,694 — penalty dated 2025-09-09

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

Who owns this facility

Owner / managerTypeRoleSince
BRAATEN, JOHNIndividualW-2 MANAGING EMPLOYEEsince 07/01/2021
HAKANSON, MEGANIndividualW-2 MANAGING EMPLOYEEsince 07/01/2022
BROOKS, WILLIAMIndividualCORPORATE OFFICERsince 01/01/2014
BUNN, DAWNIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2021
JORDAN, CHARLESIndividualCORPORATE OFFICERsince 01/01/2014

CMS files one row per role, so the 6 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$4.7M
Net patient revenuemost recent cost report
-26.7%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 42%Medicare 3%Other / private 54%

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 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$440per resident / day
operating cost
$13,381per month
≈ monthly operating cost
$347per day
avg. revenue, all payers

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

What families pay in ND

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 355050. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-10, 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.

What to do next