Souris Valley Care Center

Location & what’s nearby

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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

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.

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

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

31.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 44.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 25 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.14 therapist hours per resident per day in 2026Q1 — more than 11% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% 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.

Staffing

How full it usually is: this home is certified for 46 beds and averages 40.3 residents a day — about 88% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.42 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.59 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 2.97 hrs/resident/day on weekends vs 3.60 on weekdays — 17% thinner on weekends. RN hours go from 0.53 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 63% is well above 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.

28 citations, most serious first. The 15 most serious are shown; the remaining 13 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-11-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of facility policy, review of the facility reported incident (FRI) and investigation, and staff interviews, the staff failed to provide appropriate supervision and use of assistive devices for 2 of 2 sampled residents (Resident #1 and #2) who required staff assistance while bathing. Failure to utilize the bath chair safety strap during bathing resulted in a fall with a fracture for Resident #1 and placed all residents at risk of accidents, falls, and/or injuries. During the on-site FRI investigation, the survey team determined noncompliance with regulatory requirements existed on 11/11/25 when facility staff failed to utilize the bath chair safety strap resulting in a fall/fracture.*On 11/18/25 at 2:03 p.m. the survey team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 11/11/25. *On 11/18/25 at 3:00 p.m., The survey team notified the administrator and the director of nursing (DON) of the IJ situation,…

  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
• Immediate jeopardy · Jcited before2025-04-24 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 1 of 1 sampled resident (Resident #18) with Multi-Resistant Staph Aureus (MRSA) (a type of contagious infection resistant to antibiotics) in a wound. Failure to follow infection control practices related to location of a dressing change and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. During the on-site recertification survey, the team determined an Immediate Jeopardy (IJ) situation existed on 04/21/25 at 3:55 p.m. The IJ was identified when a staff nurse performed a dressing change in the medication room and failed to wear Personal Protective Equipment (PPE) (a gown). This finding placed all residents, staff, and visitors at risk for infection and/or spread of infection. *04/22/25 at 10:00 a.m., the survey team notified the administrator and director of nursing (DON) of the IJ situation, provided the IJ template, and requested a plan for removal of the IJ. *04/22/25 at 1:45 p.m., the survey team…

  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
• Immediate jeopardy · Jcited before2024-04-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide appropriate and sufficient supervision and/or assistive devices for 1 of 5 sampled residents (Resident #35) who required staff assistance and a gait belt with transfers. Failure to provide adequate assistance and/or use the assistive devices appropriately during transfers placed the residents at risk for accidents, falls, and/or injuries. During the standard survey, the team determined an Immediate Jeopardy (IJ) situation existed on 04/16/24 at 5:15 p.m. The IJ resulted from staff failure to provide sufficient supervision and use the assistive device (gait belt) in a manner to avoid a fall and/or potential injury. * 04/16/24 at 5:29 p.m., The survey team contacted the State Survey Agency (SSA) to report the findings and discuss potential immediate jeopardy (IJ). * 04/16/24 at 6:30 p.m., The survey team notified the administrator and the director of nursing (DON), of the IJ situation, provided them…

  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
• Actual harm · Gcited before2024-08-27 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility reported incident investigation, and staff interview, the facility failed to ensure residents remained free from significant medication errors for 1 of 1 closed record (Resident #1) receiving insulin. Failure to administer insulin according to a physician's order may have contributed to Resident #1's hospitalization. This citation is considered past noncompliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 08/16/24. The facility implemented corrective action on 08/19/24 and completed staff education and began audits on 08/19/24. The final facility reported incident, dated 08/19/24 stated, . it was determined there was a transcription error on admission for the long-acting insulin dose. Instead of having an 8 PM scheduled long-acting insulin dose it was entered as an 8 AM dose. Review of Resident #1's medical record occurred on 08/27/24…

  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 · Past Non-Compliance
• Actual harm · G2024-04-17 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and resident and staff interviews, the facility failed to provide care and services to control pain for 1 of 1 sampled resident (Resident #31) reviewed for pain management. Failure to administer as needed (prn) pain medications and inform the physician of increased use of prn pain medication resulted in Resident #31 experiencing anxiety and mental anguish and may have contributed to the resident experiencing increased and/or unresolved pain. Findings include: Review of the facility policy titled Pain Management occurred on 04/17/24. This policy, dated February 2024, stated, . PURPOSE To provide residents assistance in pain management. To promote well-being by ensuring that residents are as comfortable as possible. Individualized approaches will be developed to address the resident's pain management in a holistic manner. Review of Resident #31's medical record occurred on all days of survey. A Minimum Data Set (MDS), dated [DATE], identified intact cognition and frequent…

  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 before2026-06-11 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, review of the facility reported incident (FRI), review of facility policy, and resident and staff interview, the facility failed to ensure residents remained free from abuse for 1 of 1 supplemental resident (Resident #27) who displayed physical behaviors towards another resident. Failure to protect Resident #31 from physical abuse may have resulted in pain or injury and placed all residents at risk for physical harm, pain, mental anguish, and emotional distress. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident.Findings include:Review of the facility policy titled Abuse and Neglect occurred on 06/11/26. This policy, dated 04/07/25, stated, . The resident/client has the right to be free from abuse . Residents/clients must not be subjected to abuse by anyone, including . other residents/clients . Procedure: . If it is an allegation of resident/client to resident/client abuse, the residents/clients will be separated immediately and both ensured a safe…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · Dcited before2026-06-11 · 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 observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and resident and staff interviews, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 12 sampled residents (Residents #3, #24, and #33). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: -Observation on all days of survey showed a pressure reducing mattress on Resident #3's bed. Review of Resident #3's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], failed to identify a pressure reducing device for the bed. During an interview on 06/11/26 at 9:16 a.m., an administrative nurse (#1) confirmed staff coded the quarterly MDS incorrectly, and resident does have a pressure reducing device for the bed. SECTION P: RESTRAINTS…

  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 before2026-06-11 · 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 record review, review of facility policy, and resident and staff interviews, the facility failed to review and revise care plans to reflect the residents' current status for 2 of 12 sampled residents (Resident #2 and #34). Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care.Findings include: Review of the facility policy titled Care Plan occurred on 06/10/26. This policy, revised 12/01/25, stated, . This plan of care will be modified to reflect the care currently required/provided for the resident . Review of the facility policy titled Trauma Informed Care occurred on 06/10/26. This policy, revised 12/31/25, stated, . PROCEDURE. Individualize Care Plan interventions to avoid re-traumatization . -Review of Resident #2's medical record occurred on all days of survey. Diagnoses included chronic embolism and thrombosis of deep veins of right lower extremity. Current physician's orders included Apixaban (an anticoagulant). Progress notes identified a hospitalization in April of 2026 for an upper GI (gastrointestinal) bleed.…

  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 · D2026-06-11 · tag F0757 — failed to avoid unnecessary drugs — isolated
  Ensure each resident’s drug regimen must be free from unnecessary drugs.
  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 adequate monitoring for 2 of 5 residents (Resident #2 and #32) reviewed for psychotropic medications. Failure to complete a baseline assessment before starting an antipsychotic and periodically while on the medication may result in undetected side effects and adverse consequences related to the antipsychotic medication.Findings include:Review of the facility policy titled Psychotropic Medications occurred on 06/10/26. This policy, revised 12/09/25, stated, . If the physician prescribes an antipsychotic for the resident . If a resident is admitted on psychotropic medications or returns from hospitalization on new psychotropic medications . a registered nurse must complete the Abnormal Involuntary Movement Scale [AIMS]. Throughout the administration of psychotropic medication, the following must be completed. the Abnormal Involuntary Movement Scale [AIMS]. every six months.-Review of Resident #2's medical record occurred on all days of survey and identified an admission date 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-11 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, review of facility policy, review of professional standards, and staff interview, the facility failed to ensure residents remained free of significant medication errors for 1 of 1 sampled resident (Resident #32) with a significant medication error. Failure to administer medication and monitor lab results according to physician's orders may inhibit the effectiveness of the medications and cause subtherapeutic levels.Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, pages 838-851, stated, . Obtain the appropriate medication. Compare the label of the medication container or unit-dose package against the order on the MAR [medication administration record] or computer printout. Rationale: This is a safety check to ensure that the right medication is given. If these are not identical, recheck the prescriber's written order in the client's chart. Prepare the medication. While preparing the medication, recheck each prepared drug and container with the MAR again.…

  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 before2026-04-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on review of the facility reported incident (FRI) investigation, record review, review of facility policy, and resident and staff interviews, the facility failed to ensure residents remain free from abuse for 1 of 5 sampled residents (Resident #2) who was subjected to physical abuse by another resident. Failure to ensure the facility had processes in place to meet the needs of residents resulted in a bruise to Resident #2's face and placed all residents at risk for physical harm, pain, mental anguish, and emotional distress.Findings include:Review of the facility policy titled Abuse and Neglect occurred on 04/08/26. This policy, dated 04/07/25, stated, . The resident/client has the right to be free from abuse, neglect . Residents/clients must not be subjected to abuse by anyone, including, but not limited to . other resident/clients. Review of the facility's initial FRI investigation, dated 03/20/26, stated, . Male resident became upset with female resident's vocalizations. Male resident told female resident to shut up and female resident told male resident to shut up. Male…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-07 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, review of facility policy, and staff interview, the facility failed to notify the resident's physician for 1 of 1 sampled resident (Resident #3) reviewed for falls. Failure to notify the resident's physician of changes in condition promptly may prevent the physician from altering treatment/care.Findings include:Review of the facility policy titled Fall Prevention and Management occurred on 12/17/25. This policy, revised 10/14/25, stated, . For residents with suspected head injury, physicians should be notified by phone and not fax.Review of Resident #3's medical record occurred on 12/17/25. Diagnoses included Alzheimer's disease, dementia, and repeated falls. A care plan review, dated 09/29/25, identified falls, and gait/balance problems.Review of Resident #3's progress notes identified the following:* 12/06/25 at 6:40 a.m., Safety Event. Resident came up to the nursing station and stated, 'I fell in my room and hit my head and I have another knot on the back of my head.' She stated that 'He' helped her back to bed. Upon writer's assessment, resident 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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-07 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 1 of 9 sampled residents (Resident #2). Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care. Findings include:Review of the facility policy titled Care Plan occurred on 12/17/25. This policy, dated December 1, 2025, stated, . Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, . needs.The interdisciplinary team will review care plans at least quarterly. Care plans also will be reviewed, evaluated and updated when there is a significant change in the resident's condition.Review of Resident #2's care plan, revised 11/01/24, identified assistance of one staff member required for bed mobility, positioning up…

  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 · D2025-11-20 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on information received from the facility reported incident (FRI), record review, and staff interviews, the facility failed to thoroughly investigate and document an alleged violation of neglect for 1 of 1 sampled resident (Resident #1) who fell from a bath chair. Failure to thoroughly investigate an incident of potential neglect may result in future neglect and or harm to other residents. Findings include:Review of the FRI, submitted to the state survey agency (SSA) on 11/12/25, identified Resident #1 fell from the bath chair and sustained a left femoral neck (hip) fracture on 11/11/25.A physician's progress note, dated 11/11/25, stated, . fell when she had gotten out of the shower earlier today. Initially started having left hip pain. Impression and plan multiple falls .Fracture of femoral neck, left . admitting .During an interview on 11/18/25 at 11:12 a.m., the certified nurse aide (CNA) (#4) stated during Resident #1's bath on 11/11/25, she did not have the resident secured in the bath chair with the safety strap, and, When I had finished her bath and was going to get her…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-20 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, review of facility policy, review of the facility reported incident (FRI) and investigation, and staff interviews, the staff failed to provide treatment and care in accordance with professional standards of practice to maintain residents' highest level of functioning for 1 of 1 sampled resident (Resident #1) who experienced a fall from the bath chair. Failure to ensure a licensed nurse performed a full-body assessment after a fall may have resulted in further injury and/or pain to the resident.Findings includeReview of the facility policy titled Fall Prevention and Management occurred on 11/18/25. This policy, dated 10/14/25, stated, . For Fallen Resident . Procedure 1. Do not move resident. Stay with the resident and summon the licensed nurse . A nurse must observe the resident and perform a full-body exam to determine if there may be suspected injury and direct whether to move the resident. Do not attempt to move the resident if . hip fracture is suspected.Review of the FRI, submitted to the state survey agency (SSA) on 11/12/25, identified Resident #1 fell…

  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

“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.

Fines & penalties

$175,053 in federal fines across 4 penalties.

• $107,150 — penalty dated 2025-11-20
• $26,761 — penalty dated 2025-04-24
• $8,824 — penalty dated 2024-08-27
• $32,318 — penalty dated 2024-04-17

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

Part of a chain

This home belongs to GOOD SAMARITAN SOCIETY — 92 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 9 rows in the source record cover these 8 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.

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