Bismarck, ND

Baptist Health & Rehab

3-star overall rating with 2-star inspections with $35,323 in total fines with 3 recent health deficiencies

3400 Nebraska Drive, Bismarck, ND

(701) 223-3040

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

140

Certified beds

Average residents

134

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Cassia

Operator or chain grouping

Approved since

1978-07-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

16 facilities

Chain averages 5 overall / 4 health / 5 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.80

Registered nurse staffing · state 0.93 · national 0.68

LPN hours / resident day

0.53

Licensed practical nurse staffing · state 0.50 · national 0.87

Aide hours / resident day

3.65

Nurse aide staffing · state 2.99 · national 2.35

Total nurse hours

4.98

All reported nurse hours · state 4.41 · national 3.89

Licensed hours

1.33

RN + LPN hours · state 1.42 · national 1.54

Weekend hours

4.57

Weekend nurse staffing · state 3.75 · national 3.43

Weekend RN hours

0.51

Weekend registered nurse coverage · state 0.59 · national 0.47

Physical therapist

0.07

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

0.83

CMS adjusted RN staffing hours

Adjusted total hours

5.15

CMS adjusted total nurse staffing hours

Case-mix index

1.32

Higher values indicate more complex resident acuity

RN turnover

29%

Annual RN turnover · state 38% · national 45%

Total nurse turnover

52%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,325

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

50.20

Composite VBP score used to determine payment impact.

Payment multiplier

1.0043

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

6.03

Baseline 17.16% · Performance 18.64% · Measure score 6.03 · Achievement 6.03 · Improvement 0

Healthcare-associated infections

1.95

Baseline 7.98% · Performance 7.25% · Measure score 1.95 · Achievement 1.95 · Improvement 1.94

Total nurse turnover

5.16

Baseline 44.23% · Performance 42.57% · Measure score 5.16 · Achievement 5.16 · Improvement 0.36

Adjusted total nurse staffing

6.94

Baseline 4.59 hours · Performance 5.05 hours · Measure score 6.94 · Achievement 6.94 · Improvement 3.40

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.89%	10.72% 0.8 pts better	No Different than the National Rate · Eligible stays 158 · Observed rate 8.86% · Lower 95% interval 7.13%
Discharge to community	43.58%	50.57% 7 pts worse	No Different than the National Rate · Eligible stays 103 · Observed rate 37.86% · Lower 95% interval 34.16%
Medicare spending per beneficiary	1.05	1.02 About the same
Drug regimen review with follow-up	98.45%	95.27% 3.2 pts better	Numerator 127 · Denominator 129
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 129
Discharge self-care score	28.72%	53.69% 25 pts worse	Numerator 27 · Denominator 94
Discharge mobility score	34.04%	50.94% 16.9 pts worse	Numerator 32 · Denominator 94
Pressure ulcers or injuries, new or worsened	1.55%	2.29% 0.7 pts better	Numerator 2 · Denominator 129 · Adjusted rate 1.19%
Healthcare-associated infections requiring hospitalization	7.25%	7.12% 0.1 pts worse	No Different than the National Rate · Eligible stays 107 · Observed rate 7.48% · Lower 95% interval 4.38%
Staff COVID-19 vaccination coverage	2.18%	8.2% 6 pts worse	Numerator 7 · Denominator 321
Staff flu vaccination coverage	82.16%	42% 40.2 pts better	Numerator 327 · Denominator 398
Discharge function score	40.43%	56.45% 16 pts worse	Numerator 38 · Denominator 94
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 26 · Denominator 26
Transfer of health information to patient	92%	96.28% 4.3 pts worse	Numerator 23 · Denominator 25
Resident COVID-19 vaccinations up to date	38.81%	25.2% 13.6 pts better	Numerator 26 · Denominator 67

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.2	1.4 0.8 pts worse	1.9 0.3 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.1 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.1	1.9 0.8 pts better	1.8 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	98.3% 1.3 pts better	93.4% 6.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.2% · Q3 99.2% · Q4 100.0% · 4Q avg 99.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	98.8% 1.2 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	6.1%	5.1% 1 pts worse	3.3% 2.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 7.1% · Q3 6.3% · Q4 4.8% · 4Q avg 6.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	11.4%	4.4% 7 pts worse	11.4% About the same	Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 11.8% · Q3 10.4% · Q4 11.5% · 4Q avg 11.4%
Percentage of long-stay residents who lose too much weight	1.3%	5.5% 4.2 pts better	5.4% 4.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.8% · Q3 0.9% · Q4 0.0% · 4Q avg 1.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	28.2%	17.4% 10.8 pts worse	19.6% 8.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 31.6% · Q3 26.3% · Q4 25.5% · 4Q avg 28.2%
Percentage of long-stay residents who received an antipsychotic medication	15.8%	23.4% 7.6 pts better	16.7% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 18.5% · Q3 17.2% · Q4 15.4% · 4Q avg 15.8% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	12.7%	19.0% 6.3 pts better	16.3% 3.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 18.9% · Q3 7.6% · Q4 3.7% · 4Q avg 12.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	7.7%	20.1% 12.4 pts better	14.9% 7.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 12.5% · Q3 6.8% · Q4 3.0% · 4Q avg 7.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.7%	1.8% 1.1 pts better	1.0% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.9%	3.1% 0.2 pts better	1.7% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.5% · Q3 1.7% · Q4 5.0% · 4Q avg 2.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	23.0%	25.2% 2.2 pts better	19.8% 3.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 25.1% · Q3 18.6% · Q4 24.7% · 4Q avg 23.0%
Percentage of long-stay residents with pressure ulcers	3.5%	5.3% 1.8 pts better	5.1% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 4.0% · Q3 4.1% · Q4 2.5% · 4Q avg 3.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	93.6% 6 pts better	81.7% 17.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.6% · 4Q avg 99.6%
Percentage of short-stay residents who had an outpatient emergency department visit	10.1%	10.7% 0.6 pts better	12.0% 1.9 pts better	Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 10.9% · Expected 12.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.9%	1.9% 1 pts worse	1.6% 1.3 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 6.2% · Q3 3.2% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	88.3% 11.7 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	15.8%	20.5% 4.7 pts better	23.9% 8.1 pts better	Short Stay · 20240701-20250630 · Adjusted 15.8% · Observed 19.1% · Expected 28.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-16 · Fire 2025-04-16

3 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-03-07 · Fire 2024-03-07

10 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2023-03-23 · Fire 2023-03-23

3 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Inspection history

Recent health citations

J · Immediate jeopardy 2025-07-22

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-07-15

D · Potential for more than minimal harm 2025-04-16

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2025-05-21

D · Potential for more than minimal harm 2025-04-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-05-21

G · Actual harm 2025-01-23

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-02-14

D · Potential for more than minimal harm 2025-01-23

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-11-08

G · Actual harm 2025-01-02

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-12-20

D · Potential for more than minimal harm 2024-03-07

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2024-04-11

D · Potential for more than minimal harm 2024-03-07

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-04-11

D · Potential for more than minimal harm 2024-03-07

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-04-11

D · Potential for more than minimal harm 2024-03-07

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2024-04-11

D · Potential for more than minimal harm 2024-03-07

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-04-11

D · Potential for more than minimal harm 2024-03-07

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-04-11

D · Potential for more than minimal harm 2024-03-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-04-11

G · Actual harm 2024-01-31

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-10-06

D · Potential for more than minimal harm 2023-03-23

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-04-27

D · Potential for more than minimal harm 2023-03-23

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2023-04-27

Penalties and ownership

What sits behind the stars

$17,345 2025-07-22

Fine

Fine · fine $17,345

Fine

$11,190 2025-01-23

Fine

Fine · fine $11,190

Fine

$6,788 2025-01-02

Fine

Fine · fine $6,788

Fine

Ownership

Elim Care Inc

5% Or Greater Direct Ownership Interest · Organization

100% 11 facilities 2009-11-26

Berg, Deanna

W-2 Managing Employee · Individual

0% 1 facilities 2019-03-01

Cassia Services

Operational/Managerial Control · Organization

0% 1 facilities 2020-01-01

Dahl, Robert

Corporate Officer · Individual

0% 17 facilities 2009-11-26

Grosz, Gerald