Cycle 1
Health 2025-06-25 · Fire 2025-06-25
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Moorhead, MN
Eventide Lutheran Home
2-star overall rating with 2-star inspections with $59,005 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1405 7th Street South, Moorhead, MN
(218) 233-7508
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
145
Certified beds
Average residents
111
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1987-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.60
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
3.16
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.42
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.06
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
4.88
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
484
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
69.07
Composite VBP score used to determine payment impact.
Payment multiplier
1.0219
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.54
Baseline 16.17% · Performance 18.86% · Measure score 5.54 · Achievement 5.54 · Improvement 0
Healthcare-associated infections
8.34
Baseline 4.90% · Performance 5.34% · Measure score 8.34 · Achievement 8.34 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
6.84
Baseline 5.04 hours · Performance 5.02 hours · Measure score 6.84 · Achievement 6.84 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.46% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 194 · Observed rate 7.73% · Lower 95% interval 6.92% |
| Discharge to community | 33.26% |
50.57%
17.3 pts worse
|
Worse than the National Rate · Eligible stays 173 · Observed rate 28.32% · Lower 95% interval 27.4% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.67% |
95.27%
1.4 pts better
|
Numerator 116 · Denominator 120 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 120 |
| Discharge self-care score | 58.24% |
53.69%
4.6 pts better
|
Numerator 53 · Denominator 91 |
| Discharge mobility score | 62.64% |
50.94%
11.7 pts better
|
Numerator 57 · Denominator 91 |
| Pressure ulcers or injuries, new or worsened | 3.33% |
2.29%
1 pts worse
|
Numerator 4 · Denominator 120 · Adjusted rate 3.31% |
| Healthcare-associated infections requiring hospitalization | 5.34% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 1.87% · Lower 95% interval 3.04% |
| Staff COVID-19 vaccination coverage | 16.17% |
8.2%
8 pts better
|
Numerator 43 · Denominator 266 |
| Staff flu vaccination coverage | 89.64% |
42%
47.6 pts better
|
Numerator 320 · Denominator 357 |
| Discharge function score | 68.13% |
56.45%
11.7 pts better
|
Numerator 62 · Denominator 91 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 50 · Denominator 50 |
| Resident COVID-19 vaccinations up to date | 63.33% |
25.2%
38.1 pts better
|
Numerator 38 · Denominator 60 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.6 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.0
0.7 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.3%
2.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 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 | 2.4% |
3.9%
1.5 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.7% · Q3 2.0% · Q4 2.2% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
4.3%
3.2 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.2% · Q4 2.6% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 8.7% |
4.1%
4.6 pts worse
|
5.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 9.3% · Q3 5.9% · Q4 10.0% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.5% |
12.4%
4.1 pts worse
|
19.6%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 17.3% · Q3 14.6% · Q4 18.8% · 4Q avg 16.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.0% |
17.5%
0.5 pts better
|
16.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 18.7% · Q3 14.5% · Q4 13.6% · 4Q avg 17.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 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 | 27.4% |
22.5%
4.9 pts worse
|
16.3%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 22.8% · Q3 31.5% · Q4 28.6% · 4Q avg 27.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.1% |
18.6%
5.5 pts worse
|
14.9%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 19.6% · Q3 31.6% · Q4 25.7% · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
2.3%
1.2 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.9% · Q4 2.6% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.6%
0.4 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.9% · Q3 1.0% · Q4 5.4% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.2% |
24.8%
5.4 pts worse
|
19.8%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 43.4% · Q3 18.7% · Q4 31.3% · 4Q avg 30.2% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
5.4%
1 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 7.3% · Q3 6.3% · Q4 6.8% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
88.6%
9.9 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 100.0% · Q3 98.0% · Q4 97.3% · 4Q avg 98.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
14.0%
5.7 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 8.2% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.9%
0.4 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 1.6% · Q3 1.5% · Q4 1.4% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
82.7%
17.3 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 | 25.1% |
23.1%
2 pts worse
|
23.9%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.1% · Observed 24.5% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-10 · Fire 2024-04-10
4 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-08-16 · Fire 2023-08-16
11 health deficiencies
Top issue: Resident Rights (3 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-06-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-24
E · Potential for more than minimal harm
2024-04-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-04-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-04-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-04-10
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2024-05-31
F · Potential for more than minimal harm
2023-08-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-18
F · Potential for more than minimal harm
2023-08-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-18
F · Potential for more than minimal harm
2023-08-16
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-09-18
F · Potential for more than minimal harm
2023-08-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-18
C · Minimal harm
2023-08-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-09-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-06-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-25
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-25
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-25
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-18
J · Immediate jeopardy
2025-04-30
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 2025-04-22
D · Potential for more than minimal harm
2025-04-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-24
G · Actual harm
2025-03-12
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 2025-02-20
G · Actual harm
2024-12-10
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 2024-12-01
F · Potential for more than minimal harm
2024-04-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-04-10
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-06
G · Actual harm
2023-09-15
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 2023-10-04
E · Potential for more than minimal harm
2023-08-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-18
E · Potential for more than minimal harm
2023-08-16
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-16
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-08-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-09-18
C · Minimal harm
2023-08-16
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2023-09-18
C · Minimal harm
2023-08-16
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-09-18
C · Minimal harm
2023-08-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-05-03
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 2023-05-29
C · Minimal harm
2023-05-03
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-03-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-24
Penalties and ownership
What sits behind the stars
$15,940
2025-04-30
Fine
Fine · fine $15,940
Fine
$14,800
2025-03-12
Fine
Fine · fine $14,800
Fine
$15,265
2023-08-16
Fine
Fine · fine $15,265
Fine
$13,000
2023-03-28
Fine
Fine · fine $13,000
Fine
Ownership
Anderson, Kelsey
Operational/Managerial Control · Individual
Berg, Brittni
Operational/Managerial Control · Individual
Blue Stone Therapy Inc
Operational/Managerial Control · Organization
Bock, Jodee
Corporate Director · Individual
Brandt, Terry
Corporate Director · Individual
Bye, Robert
Corporate Director · Individual
Bye, Robert
Corporate Officer · Individual
Fischbach, Tyler
Corporate Director · Individual
Gulbranson, Patrick
Corporate Director · Individual
Hager, Jim
Operational/Managerial Control · Individual
Halvorson, Joseph
Corporate Director · Individual
Harms, Kaley
Operational/Managerial Control · Individual
Hvidston, Luke
Corporate Director · Individual
Hvidston, Luke
Corporate Officer · Individual
Johnson, Vikki
Corporate Director · Individual
Johnson, Vikki
Corporate Officer · Individual
Kelly, Kayla
Operational/Managerial Control · Individual
Kollar, Emily
Operational/Managerial Control · Individual
Larson-Casselton, Cindy
Corporate Director · Individual
Lee, Judith
Corporate Director · Individual
Lunak, Brandon
Corporate Director · Individual
Nemer, Sara
Operational/Managerial Control · Individual
Oakes, Kara
Operational/Managerial Control · Individual
Ohe, Darin
Operational/Managerial Control · Individual
Riewer, Jon
Corporate Officer · Individual
Sand, Michael
Operational/Managerial Control · Individual
Schafer, Eric
Corporate Director · Individual
Seljevold, Peter
Corporate Director · Individual
Swenson, Karla
Corporate Director · Individual
Nearby options
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#2
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5-star overall rating with 5-star inspections with 2 recent health deficiencies
#3
Bethany On University
Fargo, ND
5-star overall rating with 4-star inspections with 2 recent health deficiencies
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