Cycle 1
Health 2025-05-29 · Fire 2025-05-29
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Carrington, ND
Golden Acres Manor
3-star overall rating with 3-star inspections with 6 recent health deficiencies
1 E Main St, Carrington, ND
(701) 652-3117
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
64
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1978-05-01
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
1.09
Registered nurse staffing · state 0.93 · national 0.68
LPN hours / resident day
0.34
Licensed practical nurse staffing · state 0.50 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.99 · national 2.35
Total nurse hours
3.60
All reported nurse hours · state 4.41 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.02
Weekend nurse staffing · state 3.75 · national 3.43
Weekend RN hours
0.71
Weekend registered nurse coverage · state 0.59 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.25
CMS adjusted RN staffing hours
Adjusted total hours
4.14
CMS adjusted total nurse staffing hours
Case-mix index
1.19
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
6,378
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9875
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.77
Performance 20.61% · Measure score 1.77 · Achievement 1.77 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.29
Performance 6.55% · Measure score 4.29 · Achievement 4.29 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Performance 61.91% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
7.18
Baseline 4.37 hours · Performance 5.12 hours · Measure score 7.18 · Achievement 7.18 · Improvement 4.82
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.64% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 15.38% · Lower 95% interval 7.8% |
| Discharge to community | 39.96% |
50.57%
10.6 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 28.57% · Lower 95% interval 26.14% |
| Medicare spending per beneficiary | 0.61 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 97.56% |
95.27%
2.3 pts better
|
Numerator 40 · Denominator 41 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 41 |
| Discharge self-care score | 44.44% |
53.69%
9.2 pts worse
|
Numerator 12 · Denominator 27 |
| Discharge mobility score | 59.26% |
50.94%
8.3 pts better
|
Numerator 16 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 9.76% |
2.29%
7.5 pts worse
|
Numerator 4 · Denominator 41 · Adjusted rate 8.36% |
| Healthcare-associated infections requiring hospitalization | 6.55% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 3.03% · Lower 95% interval 3.33% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 63 |
| Staff flu vaccination coverage | 52.44% |
42%
10.4 pts better
|
Numerator 43 · Denominator 82 |
| Discharge function score | 59.26% |
56.45%
2.8 pts better
|
Numerator 16 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.4
0.3 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.9
0.4 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.3%
1.7 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% |
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 | 3.8% |
5.1%
1.3 pts better
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 4.5% · Q3 2.3% · Q4 0.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.5% |
4.4%
0.1 pts worse
|
11.4%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.3% · Q3 6.8% · Q4 5.9% · 4Q avg 4.5% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
5.5%
1.6 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.1% · Q3 14.6% · Q4 6.2% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.4% |
17.4%
1 pts worse
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 16.7% · Q3 18.6% · Q4 20.4% · 4Q avg 18.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.6% |
23.4%
2.2 pts worse
|
16.7%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 28.6% · Q3 28.6% · Q4 18.9% · 4Q avg 25.6% · 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 | 15.1% |
19.0%
3.9 pts better
|
16.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 19.4% · Q3 17.6% · Q4 6.2% · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
20.1%
6.5 pts better
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 16.2% · Q3 18.4% · Q4 8.7% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.8%
1.3 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.6% |
3.1%
2.5 pts worse
|
1.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 9.1% · Q3 2.4% · Q4 2.0% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.3% |
25.2%
1.1 pts worse
|
19.8%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 20.8% · Q3 38.7% · Q4 20.6% · 4Q avg 26.3% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
5.3%
2.9 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 2.6% · Q4 4.5% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
93.6%
5.7 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.6% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.8% |
10.7%
1.1 pts worse
|
12.0%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 10.7% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.9%
0.5 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.3% |
88.3%
6 pts better
|
79.7%
14.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.7% |
20.5%
4.8 pts better
|
23.9%
8.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 14.3% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-30 · Fire 2024-05-30
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-05-25 · Fire 2023-05-25
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-30
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 2024-06-24
F · Potential for more than minimal harm
2024-05-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-24
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-29
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 2025-06-27
E · Potential for more than minimal harm
2025-05-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-29
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-07-12
D · Potential for more than minimal harm
2025-05-29
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 2025-06-27
D · Potential for more than minimal harm
2025-05-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-29
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-06-27
E · Potential for more than minimal harm
2024-05-30
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 2024-07-04
D · Potential for more than minimal harm
2023-05-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-06-25
D · Potential for more than minimal harm
2023-05-25
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 2023-06-25
D · Potential for more than minimal harm
2023-05-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-25
Penalties and ownership
What sits behind the stars
Ownership
Alpha Inc
Operational/Managerial Control · Organization
Page, Mitchell
5% Or Greater Direct Ownership Interest · Individual
Page, Mitchell
Operational/Managerial Control · Individual
Page, Mitchell
Corporate Director · Individual
Page, Mitchell
5% Or Greater Mortgage Interest · Individual
Sabre LLC
5% Or Greater Direct Ownership Interest · Organization
Sabre LLC
5% Or Greater Mortgage Interest · Organization
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#3
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