Cycle 1
Health 2025-08-28 · Fire 2025-08-28
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
New Rockford, ND
Lutheran Home Of The Good Shepherd
3-star overall rating with 2-star inspections with abuse icon flag with $31,829 in total fines with 4 recent health deficiencies
1226 1st Ave N, New Rockford, ND
(701) 947-2944
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
51
Certified beds
Average residents
47
Average occupied residents
Ownership
Non-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
0.87
Registered nurse staffing · state 0.93 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.50 · national 0.87
Aide hours / resident day
2.86
Nurse aide staffing · state 2.99 · national 2.35
Total nurse hours
4.35
All reported nurse hours · state 4.41 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.63
Weekend nurse staffing · state 3.75 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.59 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.05
CMS adjusted RN staffing hours
Adjusted total hours
5.26
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,212
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.95
Composite VBP score used to determine payment impact.
Payment multiplier
1.0052
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.92
Performance 51.72% · Measure score 2.92 · Achievement 2.92 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
7.26
Baseline 5.14 hours · Performance 5.14 hours · Measure score 7.26 · Achievement 7.26 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.94% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 10.26% · Lower 95% interval 6.66% |
| Discharge to community | 34.11% |
50.57%
16.5 pts worse
|
Worse than the National Rate · Eligible stays 29 · Observed rate 20.69% · Lower 95% interval 22.99% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 94.12% |
95.27%
1.1 pts worse
|
Numerator 32 · Denominator 34 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 34 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 16 · Denominator 28 |
| Discharge mobility score | 42.86% |
50.94%
8.1 pts worse
|
Numerator 12 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 34 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5.21% |
8.2%
3 pts worse
|
Numerator 5 · Denominator 96 |
| Staff flu vaccination coverage | 31.62% |
42%
10.4 pts worse
|
Numerator 37 · Denominator 117 |
| Discharge function score | 57.14% |
56.45%
0.7 pts better
|
Numerator 16 · Denominator 28 |
| 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 | 61.9% |
25.2%
36.7 pts better
|
Numerator 13 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.4
0.9 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.9
0.7 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
98.3%
0.5 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 95.5% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.7% |
98.8%
3.1 pts worse
|
95.5%
0.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
5.1%
3.9 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
4.4%
3.2 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
5.5%
1.2 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 2.5% · Q3 7.1% · Q4 0.0% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.2% |
17.4%
0.8 pts worse
|
19.6%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 14.6% · Q3 21.4% · Q4 19.0% · 4Q avg 18.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.0% |
23.4%
1.4 pts better
|
16.7%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 25.7% · Q3 16.2% · Q4 16.2% · 4Q avg 22.0% · 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 | 12.6% |
19.0%
6.4 pts better
|
16.3%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 13.6% · Q3 6.6% · Q4 9.3% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.2% |
20.1%
1.9 pts better
|
14.9%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 29.3% · Q3 14.3% · Q4 9.5% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.9% |
1.8%
1.1 pts worse
|
1.0%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.2% · Q3 1.9% · Q4 4.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.2% |
3.1%
1.1 pts worse
|
1.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 2.4% · Q3 0.0% · Q4 9.1% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.4% |
25.2%
0.2 pts worse
|
19.8%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 26.0% · Q3 26.2% · Q4 23.4% · 4Q avg 25.4% |
| 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 2.5% · Q2 5.6% · Q3 3.6% · Q4 2.5% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 48.0% |
88.3%
40.3 pts worse
|
79.7%
31.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 48.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-10 · Fire 2024-07-10
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-06-21 · Fire 2023-06-21
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-10
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 2024-08-23
F · Potential for more than minimal harm
2023-06-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-01
Inspection history
Recent health citations
G · Actual harm
2025-08-28
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 2025-09-22
D · Potential for more than minimal harm
2025-08-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-22
D · Potential for more than minimal harm
2025-08-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-22
G · Actual harm
2025-06-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-28
J · Immediate jeopardy
2024-07-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-10
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 2024-08-01
D · Potential for more than minimal harm
2024-07-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-07-10
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 2024-08-01
D · Potential for more than minimal harm
2024-07-10
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2024-08-01
Penalties and ownership
What sits behind the stars
$9,110
2025-08-28
Fine
Fine · fine $9,110
Fine
$9,110
2025-06-04
Fine
Fine · fine $9,110
Fine
$13,609
2024-07-10
Fine
Fine · fine $13,609
Fine
Ownership
Allmaras, Dianne
Corporate Director · Individual
Anderson, Karen
Corporate Director · Individual
Birkland, Karen
Corporate Director · Individual
Bollingberg, Nancy
Corporate Director · Individual
Guler, Josh
Corporate Director · Individual
Hegland, Amanda
Corporate Director · Individual
Jensrud, Kim
Operational/Managerial Control · Individual
Jensrud, Kim
Corporate Officer · Individual
Labrensz, Jeffrey
Corporate Director · Individual
Lutheran Home Of The Good Shepherd Inc
Operational/Managerial Control · Organization
Lutz, Lona
Corporate Director · Individual
O'connor, Kathleen
Corporate Officer · Individual
Parson, Lori
Corporate Director · Individual
Rau, Richard
Corporate Director · Individual
Schuster, Fern
Corporate Director · Individual
Swanson, Dennis
Corporate Officer · Individual
Wolkenhauer, Carol
Corporate Officer · Individual
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