Cycle 1
Health 2024-12-19 · Fire 2024-12-19
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Grafton, ND
Lutheran Sunset Home
4-star overall rating with 3-star inspections with $11,057 in total fines with 7 recent health deficiencies
333 Eastern Ave, Grafton, ND
(701) 352-1901
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
87
Certified beds
Average residents
83
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1978-11-01
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
0.65
Registered nurse staffing · state 0.93 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.50 · national 0.87
Aide hours / resident day
2.99
Nurse aide staffing · state 2.99 · national 2.35
Total nurse hours
4.33
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
3.68
Weekend nurse staffing · state 3.75 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.59 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.84
CMS adjusted RN staffing hours
Adjusted total hours
5.56
CMS adjusted total nurse staffing hours
Case-mix index
1.06
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,421
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.87
Composite VBP score used to determine payment impact.
Payment multiplier
1.0039
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
2.57
Baseline 46.47% · Performance 53.19% · Measure score 2.57 · Achievement 2.57 · Improvement 0
Adjusted total nurse staffing
7.41
Baseline 4.8 hours · Performance 5.19 hours · Measure score 7.41 · Achievement 7.41 · Improvement 3.43
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.5% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 34 · Observed rate 2.94% · Lower 95% interval 5.87% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.4 |
1.02
0.6 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 22 · Denominator 22 |
| Falls with major injury | 4.55% |
0.77%
3.8 pts worse
|
Numerator 1 · Denominator 22 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 22 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 8.46% |
8.2%
0.3 pts better
|
Numerator 11 · Denominator 130 |
| Staff flu vaccination coverage | 46.15% |
42%
4.1 pts better
|
Numerator 66 · Denominator 143 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · 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 | 1.8 |
1.4
0.4 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.3 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.9
0.4 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.8 · Expected 1.3 · 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 | 98.8% |
98.8%
About the same
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
5.1%
About the same
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 3.8% · Q3 3.8% · Q4 3.8% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
4.4%
3.7 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
5.5%
2.9 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 6.0% · Q4 1.5% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.2% |
17.4%
5.8 pts worse
|
19.6%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 24.7% · Q3 21.1% · Q4 22.5% · 4Q avg 23.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.9% |
23.4%
0.5 pts worse
|
16.7%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 23.0% · Q3 24.2% · Q4 23.1% · 4Q avg 23.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.3% |
0.2%
1.1 pts worse
|
0.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.2% · Q3 1.3% · Q4 1.3% · 4Q avg 1.3% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.4% |
19.0%
6.6 pts better
|
16.3%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 10.6% · Q3 15.0% · Q4 8.0% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.7% |
20.1%
3.4 pts better
|
14.9%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 15.5% · Q3 17.9% · Q4 18.2% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.1% |
1.8%
1.3 pts worse
|
1.0%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 4.5% · Q3 5.2% · Q4 1.2% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
3.1%
1.1 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 2.7% · Q4 2.7% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.3% |
25.2%
1.9 pts better
|
19.8%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 28.0% · Q3 25.2% · Q4 17.4% · 4Q avg 23.3% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
5.3%
0.5 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 4.9% · Q3 4.7% · Q4 6.3% · 4Q avg 5.8% · 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% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.7% |
10.7%
8 pts worse
|
12.0%
6.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 15.0% · Expected 9.0% · Used in QM five-star |
| 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 | 59.1% |
88.3%
29.2 pts worse
|
79.7%
20.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.1% |
20.5%
3.4 pts better
|
23.9%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 15.0% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-02 · Fire 2023-11-02
5 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-09-14 · Fire 2022-09-14
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-12-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-12-19
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 2025-01-23
D · Potential for more than minimal harm
2024-12-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-23
D · Potential for more than minimal harm
2024-12-19
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 2025-01-23
D · Potential for more than minimal harm
2024-12-19
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 2025-01-23
C · Minimal harm
2024-12-19
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2025-01-23
G · Actual harm
2024-05-21
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 2024-06-17
D · Potential for more than minimal harm
2024-01-25
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 2024-02-29
E · Potential for more than minimal harm
2023-11-02
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 2023-11-21
D · Potential for more than minimal harm
2023-11-02
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-11-21
D · Potential for more than minimal harm
2023-11-02
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 2023-11-21
D · Potential for more than minimal harm
2023-11-02
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-11-21
E · Potential for more than minimal harm
2022-09-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-07
D · Potential for more than minimal harm
2022-09-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-07
D · Potential for more than minimal harm
2022-09-14
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-10-07
D · Potential for more than minimal harm
2022-09-14
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 2022-10-07
Penalties and ownership
What sits behind the stars
$11,057
2024-05-21
Fine
Fine · fine $11,057
Fine
Ownership
Corrick, Roberta
Corporate Director · Individual
Dusek, John
Corporate Director · Individual
Hanson, Michael
Corporate Director · Individual
Lee, Tammy
Corporate Director · Individual
Nilson, Brad
Corporate Director · Individual
Pastorek, Kari
Corporate Director · Individual
Tompkins, Trevor
Operational/Managerial Control · Individual
Tompkins, Trevor
Corporate Officer · Individual
Viscito, Matthew
Operational/Managerial Control · Individual
Wysocki, Andrew
Corporate Director · Individual
Nearby options
Other facilities in reach
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2-star overall rating with 2-star inspections with $26,685 in total fines with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Wedgewood Manor
Cavalier, ND
2-star overall rating with 1-star inspections with $54,925 in total fines with 3 recent health deficiencies
#3
Kittson Healthcare
Hallock, MN
3-star overall rating with 2-star inspections with $21,587 in total fines with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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