Pembilier Nursing Center
500 Delano Ave, Walhalla, ND 58282 · Non profit - Corporation · 31 certified beds · (701) 549-3831 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has 1 actual-harm citation
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 | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 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 3 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 | 17.4% | 19.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.7% | 5.8% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.7% | 2.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 13.0% | 4.4% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.7% | 5.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 10.9% | 17.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.5% | 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 | 2.0% | 4.9% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 17.8% | 24.9% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.0% | 22.7% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.35 | 1.49 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.07 | 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 0.01 therapist hours per resident per day in 2026Q1 — more than 0% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 17% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 31 beds and averages 29.3 residents a day — about 95% occupied, or roughly 2 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 3.77 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.68 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 3.19 hrs/resident/day on weekends vs 4.01 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.72 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% 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.
9 citations, most serious first — scroll within the box to see all.
- Actual harm · G2024-01-25 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of professional reference, and review of facility policy, the facility failed to provide care and services to maintain the resident's highest level of well-being for 1 of 1 closed record (Resident #83) transferred to the emergency room (ER) for a change in health status. Failure to monitor and assess the resident's condition on a continuing basis resulted in a worsening of symptoms delay in hospitalization, and possible death. Findings include: Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 189, stated, . Nurses have responsibilities related to both medical and nursing diagnoses. Nursing diagnoses relate primarily to the nurse's independent functions, that is, the areas of healthcare that are unique to nursing and separate and distinct from medical management. However, the nurse is still responsible for identifying and responding to data that indicate real or potential medical problems.…
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 · F2026-04-29 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview, the facility failed to maintain a sanitary kitchen environment for 1 of 1 facility kitchen. Failure to ensure the sanitizer test strips used to test the concentration of sanitizing solution are not expired has the potential for inadequate sanitization and may result in foodborne illness.Findings include:Observation in the kitchen on 04/27/26 at 11:13 a.m. showed a dietary staff member (#4) tested the concentration of a premixed sanitizing solution with test strips that expired October 2025.During an interview on 04/27/26 at 11:25 a.m., a dietary staff member (#4) stated staff should not use expired test strips.
- Potential for harm · Ecited before2026-04-29 · tag F0880 — failed to prevent and control infections — patternProvide 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 4 of 12 sampled residents (Residents #3, #4, #18, and #20) and 1 supplemental resident (Resident #8) observed during cares. Failure to follow infection control standards for hand hygiene and glove use during cares and while performing procedures has the potential to transmit infections to residents, staff, and visitors. Findings include: Review of the facility policy titled Handwashing/Hand Hygiene occurred on 04/29/26. This undated policy stated, . Staff will perform hand hygiene when indicated using proper technique and consistent with accepted standards of practice. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. After handling items potentially contaminated with blood, body fluids, secretions, or excretions . moving from a contaminated body site to a clean body site . Review of the facility policy titled Clean Dressing Change…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-29 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of facility policy, and staff interview, the facility failed to promote privacy and confidentiality of the electronic medication administration record (eMAR) on 1 of 1 medication cart. Failure to promote resident privacy and lock computer screens may result in unauthorized viewing of the residents' private health information records by other residents, visitors, or unlicensed staff. Findings include: Review of the facility policy titled Safeguarding of Resident Identifiable Information occurred on 04/29/26. This undated policy stated, . Facility's policy to implement reasonable and appropriate measures to protect and maintain the safety and confidentiality of the resident's identifiable information . Computer screens showing clinical record information may not be left unattended and readily observable or accessible by other residents or visitors. Observation on 04/28/26 at 11:41 a.m. showed a nurse (#3) at the medication cart. The nurse left the medication cart with prepared insulin and removed Resident #8 from the dining room to administer medication in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-29 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, review of manufacturer's guidelines, and staff interview, the facility failed to ensure accurate labeling and storage for 1 of 1 resident (Resident #15) observed for eye drop administration. Failure to properly label and dispose of medications may result in residents receiving an incorrect dose of medication, reduced medication efficacy, and has the potential to cause an eye infection.Findings include: Review of prescribing information for Systane Ultra Preservative-Free [PF] single-use vials (eye drops), found at https://systane.myalcon.com/products/systane-complete-preservative-free/, occurred on 04/29/26, and stated . Systane Ultra Preservative-Free [PF] single-use vials. must be discarded after each use . After opening the vial of our Preservative-Free product, the risk of product contamination increases .Observation on 04/29/26 at 8:53 a.m. showed a nurse (#5) administered Systane Ultra PF single-use eye drops, one drop in each eye, to Resident #15. After administration, the nurse (#5) capped the single-use vial, placed it in the medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-25 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on information from the facility reported incident, record review, review of facility policy, and staff interview, the facility failed to notify the resident's physician and resident's authorized representative of a change in condition for 1 of 1 closed record (Resident #83) who had a positive COVID-19 test. Failure to notify the physician of this change may have prevented the physician from altering the treatment/care provided to the resident and the representative's ability to make informed decisions regarding medical care. Findings include: The survey team determined a deficient practice existed on 05/01/23. The facility implemented corrective action on 05/05/23 and completed nursing education on 05/11/23. Review of the facility policy titled Notification of Changes occurred on 01/23/24. This policy, dated, 10/12/22, stated, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority,…
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 before2024-01-25 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, review of facility policy, and staff interview, the facility failed to ensure safe and secure storage of controlled medications for 1 of 1 medication cart. Failure to store medications securely may result in unauthorized access to medications and/or medication errors. Findings include: Review of the facility policy titled Controlled Substance Administration and Accountability occurred on 01/24/24. This undated policy, stated, . Patient specific controlled substances (e.g. [such as] narcotic/epidural infusions, tablets etc.) are stored under double lock until administered to the patient. Observation of medication pass on 01/24/24 at 8:07 a.m. showed a staff nurse (#4) administered Resident #29's morning medications. The resident received two controlled medications, alprazolam (an antianxiety) and gabapentin (nerve pain medication). Observation showed staff failed to double lock these controlled medications. During an interview on the morning of 01/25/24 an administrative nurse (#1) confirmed staff failed to double lock the controlled medications.
- Potential for harm · D2024-01-25 · 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 and staff interview, the facility failed to ensure resident's records contained the certification of a terminal illness for 1 of 1 sampled resident (Resident #27) receiving hospice services. Failure to have these documents in the resident's records limits staff's ability to ensure coordination of care between the facility and hospice. Findings include: Review of Resident #27's medical record occurred on all days of survey. Resident #27 elected hospice services on 12/15/23. The medical record lacked the physician's certification of a terminal illness. During an interview on 01/24/24 at 4:23 p.m., an administrative nurse (#1) confirmed the medical record lacked the certification of terminal illness related to hospice.
- Potential for harm · Dcited before2024-01-25 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 2 of 8 sampled residents (Resident #9 and #14) observed during perineal cares. Failure to follow infection control standards during perineal cares has the potential to transmit infections to residents, staff, and visitors. Findings include: Review of the policy/procedure titled Handwashing/Hand Hygiene occurred on 01/25/24. This undated policy stated, Hand hygiene is indicated . After contact with blood, body fluids or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; . g. immediately after glove removal . - Observations for Resident #14 showed the following: * 01/23/24 at 9:45 a.m., showed two certified nurse aides (CNA) (#5 and #6) assisted Resident #14 onto the toilet using a mechanical lift. After toileting, the CNA (#6) performed perineal care, and without removing her gloves, applied a new brief, pulled up the resident's pants, and straightened the resident's clothes. The CNA (#6) pushed the lift…
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 | Since |
|---|---|---|---|
| CARPENTER, KATHLEEN | Individual | CORPORATE DIRECTOR | since 11/01/2024 |
| FRASER, DEBRA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/06/2025 |
| GEHRTZ, LACEY | Individual | CORPORATE OFFICER | since 06/28/2023 |
| JACKSON, DEAN | Individual | CORPORATE OFFICER | since 03/05/2010 |
| LONGTIN, PHIL | Individual | CORPORATE OFFICER | since 03/05/2010 |
| MOSTAD, MANFORD | Individual | CORPORATE OFFICER | since 03/26/2015 |
| SCHMIDT, BARBARA | Individual | CORPORATE OFFICER | since 10/01/2011 |
| MOE, LINSEY | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 04/19/2021 |
| THOMPSON, SUSAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
CMS files one row per role, so the 12 rows in the source record cover these 9 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.
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 355057. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-29, 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.