Elm Crest Manor
100 Elm Ave, #396, New Salem, ND 58563 · Non profit - Church related · 62 certified beds · (701) 843-7526 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
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 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 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 | 23.5% | 19.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 11.2% | 5.8% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.4% | 2.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 6.9% | 4.4% | 6.5% | typical |
| 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 | 4.5% | 5.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 9.9% | 17.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 27.8% | 17.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.8% | 4.9% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 30.3% | 24.9% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 25.5% | 22.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents rehospitalized after admission | 11.0% | 19.9% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.1% | 11.4% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.35 | 1.49 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.58 | 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 0.22 therapist hours per resident per day in 2026Q1 — more than 27% 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 | 10.1%CMS range 6.2–16.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 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 — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 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 number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.72 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 62 beds and averages 59.3 residents a day — about 96% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.35 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 3.93 hrs/resident/day on weekends vs 5.07 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.64 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
10 citations, most serious first — scroll within the box to see all.
- Potential for harm · D2026-01-22 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 15 sampled residents (Resident #16). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2025, pages A-30 through A-32, stated, .A1500: Preadmission Screening and Resident Review (PASRR) . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . Page M-5 of the RAI Manual, stated, . M0210: Unhealed Pressure Ulcers/Injuries . Coding Instructions: . Code 1, yes: if the resident had any pressure ulcer/injury . in the 7-day look-back period.Page M-24 stated, M0300F: . Enter the number…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, facility policy review, and staff interview, the facility failed to ensure appropriate care and services for 1 of 3 sampled residents (Resident #14) reviewed for edema (fluid retention). Failure to ensure consistent implementation of support stockings and document resident refusals, may result in worsening edema.Findings include:Review of policy, Compression Stockings occurred on 01/22/26. This policy, dated 11/05/19, stated, . Compression stockings are applied appropriately to aid circulation to lower extremities and to help prevent edema. applied by nursing personnel . Chart if resident refuses stockings.Review of Resident #14's medical record occurred on all days of survey. A physician's order, dated 06/27/24, stated, CIRCULATORY TREATMENT: TED Hose [support stockings to control edema] (knee high) ON AM OFF PM [sic] The current care plan stated, . Ineffective tissue perfusion . monitor for edema . Elevate feet/legs. Apply TED hose in am, off at hs [sic] (hour of sleep).- Observation on 01/20/26 at 11:40 a.m. showed Resident #14 seated 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 · D2026-01-22 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review, review of the hospice agreement, and staff interview, the facility failed to ensure resident records contained the hospice election form for 1 of 1 sampled resident (Resident #2) receiving hospice services. Failure to obtain the hospice election form limits staff's ability to ensure coordination of care between the facility and the hospice agency. Findings include: Review of the facility's Agreement for Hospice Care for Skilled Nursing Facility and Nursing Facility Residents occurred on 01/22/26. This agreement, dated 12/22/25, stated, . Hospice Provider will provide to the facility the following information . Hospice Provider Election Statement . Review of Resident #2's medical record occurred on all days of survey and identified the resident and/or representative chose hospice services on 12/22/25. The medical record lacked the hospice election statement. During an interview on 01/22/26 at 9:44 a.m., an administrative nurse (#1) confirmed Resident #2's medical record failed to include the hospice election statement.
- Potential for harm · Dcited before2025-04-14 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of the facility reported incident (FRI) and family and staff interviews, the facility failed to ensure alleged violations involving neglect were reported timely to the State Agency (SA) for 1 of 1 sampled resident (Resident #1). Failure to report an elopement in a timely manner placed all residents at risk for neglect and/or elopement. Findings include: Review of the FRI identified Resident #1 eloped from the facility on 01/27/25. The facility failed to report the elopement to the SA until 04/09/25. The facility could not identify how or when the resident left the building. During an interview on 04/14/25 at 5:00 p.m., Resident #1's family member stated the facility contacted her and stated a member of the community found the resident in the town gym about one block from the facility and returned her to the facility. During an interview on 04/14/25 at 5:30 p.m., two administrative staff members (#1 and #2) stated the elopement actually occurred on 02/01/25, and confirmed the facility failed to report the elopement to the SA in a timely manner.
- Potential for harm · D2025-04-14 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of the facility report incident (FRI), record review, and family and staff interview, the facility failed to thoroughly investigate an elopement for 1 of 1 sampled resident (Resident #1). Failure to thoroughly investigate an elopement to determine causative factors may limit the facility's ability to put appropriate interventions in place to prevent further elopement episodes. Findings include: Review of the FRI, received by the SA on 04/09/25, indicated Resident #1 eloped from the facility on 01/27/25. Review of Resident #'1's medical record occurred on 04/14/25. A nurses' note dated 02/01/25 at 2:55 p.m., stated the following: * Res. [resident] confusion regarding leaving elm crest and applying a code alert for her safety. Code alert applied to right ankle. The facility could not identify when the resident left the building but stated the elopement occurred on 02/01/25, not 01/27/25, but the medical record showed to staff charting charting between 1:40 p.m. and 2:44 p.m. (over 1 hour). During an interview on 04/14/25 at 5:00 p.m., Resident #1's family member 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.
- Potential for harm · F2025-01-08 · tag F0801 — widespreadEmploy 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 — the official record, unedited, may be distressing
Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#3) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services may result in foodborne illness to residents, staff, and visitors. Findings include: During an interview on 01/06/25 at 11: 55 a.m., the dietary supervisor (#3) stated she is enrolled in the Certified Dietary Manager (CDM) course, but has not competed the training. During an interview on 01/07/25 at 10:40 a.m., an administrative staff member (#2) confirmed the dietary supervisor (#3) lacked the required training for the position. The facility failed to ensure the dietary manager (#3) completed the education for a certified dietary manager, certified food service manager, or national certification for food service management and safety from a national certifying body.
- Potential for harm · Dcited before2025-01-08 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of facility policy, review of facility investigation report, and staff interview, the facility failed to report an incident of potential abuse/neglect to the State Survey Agency (SSA) for 1 of 1 sampled resident (Resident #7) who experienced a fall from the mechanical lift. Failure to report an event of potential abuse/neglect to the SSA places all residents at risk of potential abuse/neglect. Findings include: Review of the facility policy Abuse Policy occurred on 01/07/25. This policy, dated 06/10/20, stated, The resident has the right to be free from . negligence . Investigations must be documented and all findings including the initial report of allegation reported in writing to the administrator as soon as possible but no later than 24 hours following the incident. The Administrator or Designee will notify the State Department of Health of the reported incident. Review of Resident #7's medical record occurred on all days of survey. A fall report, dated 09/20/24, indicated Resident #7 fell from the mechanical lift. Review of the Final Abuse…
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 before2024-06-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and review of the facility reported incident investigation, the facility failed to provide food textures according to the resident's prescribed diet for 1 of 1 sampled resident (Resident #1) who had a choking incident. Failure to ensure Resident #1's diet is followed while serving snacks resulted in a hospital emergency room transfer and treatment for choking. This citation is considered past noncompliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: This surveyor determined a deficient practice existed on 06/14/24. The facility implemented corrective action and education on 06/14/24. Review of the facility policy titled Therapeutic Diet Order Policy occurred on 06/25/24. This policy, dated, 02/24/24, stated, . Therapeutic Diet is a diet ordered by a physician or delegated registered dietician, a part of treatment for a disease or clinical condition . dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form as prescribed . NDD1 Level 1 (National…
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 · E2023-11-21 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and facility policy, the facility failed to assure safe and secure storage of narcotic medications for 2 of 2 medication carts. Failure to store all medications securely may result in unauthorized access to medications and/or medication errors. Findings include: Review of the facility policy titled Controlled Drugs occurred on 11/21/23. This policy, dated 03/04/20, stated, . Strict control of narcotics is maintained always. Procedures: . All controlled medications are kept under double-lock and in a separate drawer (also known as the narcotic drawer) from other medications. Observation on 11/20/23 at 2:30 p.m. with two nurses (#2 and #3) showed schedule II-V narcotics/controlled medications ordered as needed (PRN) stored in the bottom drawer of two medication carts with non-controlled medications and not double locked.
- Potential for harm · D2023-11-21 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the residents' current status for 3 of 19 sampled residents (Resident #23, #28, and #33). 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 RESIDENT CARE PLANNING occurred on 11/21/23. This policy, dated 12/19/20, stated, . Each resident has a resident care plan (RCP) that is current, individualized, and consistent with the medical regimen. Implementation: Times and actions are stated so that caregivers new to the resident can carry out care with complete continuity. - Review of Resident #23's medical record occurred on all days of survey and identified the resident experienced a fall which resulted in a fracture on 08/01/23. Resident #23's care plan failed to identify a risk for falls and lacked specific interventions and measurable goals for falls. - Review of Resident #28's medical record occurred on all days of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PEACE CHURCH | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 03/01/1969 |
| DUSEK, ANITA | Individual | CORPORATE DIRECTOR | — | since 11/05/2025 |
| HEID, ALMA | Individual | CORPORATE DIRECTOR | — | since 03/01/2012 |
| KELLER, LINDA | Individual | CORPORATE DIRECTOR | — | since 03/25/2024 |
| LARSON, ROLLAND | Individual | CORPORATE DIRECTOR | — | since 02/24/1995 |
| LENNICK, KRISTEN | Individual | CORPORATE DIRECTOR | — | since 03/13/2023 |
| OLSON, JOEL | Individual | CORPORATE DIRECTOR | — | since 10/24/2001 |
| OLSON, LADONNA | Individual | CORPORATE DIRECTOR | — | since 02/21/2021 |
| TELLMAN, SHANE | Individual | CORPORATE DIRECTOR | — | since 05/27/2025 |
| SCHMITZ, DANIEL | Individual | CORPORATE OFFICER | — | since 04/28/2025 |
| ZAZESKI, CARRIE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/12/2024 |
| KOSIAK, DONALD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/18/2008 |
CMS files one row per role, so the 18 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
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
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
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 355110. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-22, 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.