Cycle 1
Health 2025-02-20 · Fire 2025-02-20
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fargo, ND
Fargo Elim Health Care Center
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3534 University Drive S, Fargo, ND
(701) 271-1862
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
88
Certified beds
Average residents
84
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Cassia
Operator or chain grouping
Approved since
2022-10-10
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.27
Registered nurse staffing · state 0.93 · national 0.68
LPN hours / resident day
0.46
Licensed practical nurse staffing · state 0.50 · national 0.87
Aide hours / resident day
3.41
Nurse aide staffing · state 2.99 · national 2.35
Total nurse hours
5.14
All reported nurse hours · state 4.41 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.56
Weekend nurse staffing · state 3.75 · national 3.43
Weekend RN hours
0.82
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
1.37
CMS adjusted RN staffing hours
Adjusted total hours
5.56
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,189
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.02
Composite VBP score used to determine payment impact.
Payment multiplier
1.0142
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.30
Performance 19.44% · Measure score 4.30 · Achievement 4.30 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.92
Performance 6.07% · Measure score 5.92 · Achievement 5.92 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
4.43
Performance 45.59% · Measure score 4.43 · Achievement 4.43 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
8.96
Performance 5.63 hours · Measure score 8.96 · Achievement 8.96 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.44% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 164 · Observed rate 12.8% · Lower 95% interval 9.15% |
| Discharge to community | 51.06% |
50.57%
0.5 pts better
|
No Different than the National Rate · Eligible stays 142 · Observed rate 48.59% · Lower 95% interval 43.77% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 158 · Denominator 158 |
| Falls with major injury | 1.27% |
0.77%
0.5 pts worse
|
Numerator 2 · Denominator 158 |
| Discharge self-care score | 56.78% |
53.69%
3.1 pts better
|
Numerator 67 · Denominator 118 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 59 · Denominator 118 |
| Pressure ulcers or injuries, new or worsened | 0.63% |
2.29%
1.7 pts better
|
Numerator 1 · Denominator 158 · Adjusted rate 0.67% |
| Healthcare-associated infections requiring hospitalization | 6.06% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 122 · Observed rate 3.28% · Lower 95% interval 3.36% |
| Staff COVID-19 vaccination coverage | 8.13% |
8.2%
0.1 pts worse
|
Numerator 17 · Denominator 209 |
| Staff flu vaccination coverage | 96% |
42%
54 pts better
|
Numerator 216 · Denominator 225 |
| Discharge function score | 55.93% |
56.45%
0.5 pts worse
|
Numerator 66 · Denominator 118 |
| Transfer of health information to provider | 95.24% |
95.95%
0.7 pts worse
|
Numerator 40 · Denominator 42 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 66 · Denominator 66 |
| Resident COVID-19 vaccinations up to date | 48.19% |
25.2%
23 pts better
|
Numerator 40 · Denominator 83 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.4
0.1 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.9
0.6 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
98.3%
1 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 98.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.3% |
98.8%
1.5 pts worse
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
5.1%
3.3 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.4% · Q3 1.4% · Q4 1.4% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.3% |
4.4%
1.1 pts better
|
11.4%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 5.8% · Q3 4.2% · Q4 0.0% · 4Q avg 3.3% |
| Percentage of long-stay residents who lose too much weight | 1.6% |
5.5%
3.9 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 1.5% · Q4 3.1% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
17.4%
1.4 pts better
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 16.7% · Q3 19.1% · Q4 14.9% · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.1% |
23.4%
10.3 pts better
|
16.7%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 9.4% · Q3 15.5% · Q4 13.0% · 4Q avg 13.1% · 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 | 13.5% |
19.0%
5.5 pts better
|
16.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 17.2% · Q3 12.1% · Q4 15.1% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.5% |
20.1%
5.6 pts better
|
14.9%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 18.8% · Q3 12.7% · Q4 10.9% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
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% · 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 4.5% · Q2 4.3% · Q3 2.7% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.3% |
25.2%
6.1 pts worse
|
19.8%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 38.1% · Q3 29.7% · Q4 27.7% · 4Q avg 31.3% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
5.3%
2.1 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.2% · Q3 2.2% · Q4 1.4% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
93.6%
4.6 pts better
|
81.7%
16.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 98.9% · Q3 98.6% · Q4 96.1% · 4Q avg 98.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.4% |
10.7%
1.7 pts worse
|
12.0%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.4% · Observed 11.2% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.9%
0.7 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.4% · Q3 2.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.3% |
88.3%
5 pts better
|
79.7%
13.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.9% |
20.5%
6.4 pts worse
|
23.9%
3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.9% · Observed 24.3% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-20 · Fire 2023-12-20
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-10-04 · Fire 2022-10-04
1 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-06
E · Potential for more than minimal harm
2022-10-04
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-10-10
E · Potential for more than minimal harm
2022-10-04
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-10-10
D · Potential for more than minimal harm
2022-10-04
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-10-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-20
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 2025-03-27
D · Potential for more than minimal harm
2025-02-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-27
D · Potential for more than minimal harm
2023-12-20
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-01-24
D · Potential for more than minimal harm
2023-12-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-12-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-12-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-24
E · Potential for more than minimal harm
2022-10-04
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-10-05
Penalties and ownership
What sits behind the stars
Ownership
Elim Care Inc
5% Or Greater Direct Ownership Interest · Organization
Anderson, Paul
Corporate Director · Individual
Cassia
Operational/Managerial Control · Organization
Dahl, Robert
Corporate Officer · Individual
Kern, Matthew
Corporate Officer · Individual
Leff, William
Corporate Director · Individual
Muhonen, Renee
Operational/Managerial Control · Individual
Nuss, Patrick
Corporate Director · Individual
Tangedahl, Guy
Corporate Director · Individual
Weber Daniels, Nicolette
Corporate Director · Individual
Youngquist, Kathryn
Corporate Officer · Individual
Nearby options
Other facilities in reach
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5-star overall rating with 5-star inspections with 2 recent health deficiencies
#2
The Meadows On University
Fargo, ND
2-star overall rating with 2-star inspections with $41,041 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Eventide Lutheran Home
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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
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