Cycle 1
Health 2025-03-27 · Fire 2025-03-27
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Bismarck, ND
Missouri Slope
3-star overall rating with 2-star inspections with $39,404 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
4916 N Washington St, Bismarck, ND
(701) 223-9407
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
192
Certified beds
Average residents
178
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2021-11-22
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
0.81
Registered nurse staffing · state 0.93 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.50 · national 0.87
Aide hours / resident day
3.98
Nurse aide staffing · state 2.99 · national 2.35
Total nurse hours
5.40
All reported nurse hours · state 4.41 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.57
Weekend nurse staffing · state 3.75 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.59 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
5.84
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,226
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
58.68
Composite VBP score used to determine payment impact.
Payment multiplier
1.0139
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 20.47% · Performance 16.23% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
2.28
Baseline 4.67% · Performance 7.15% · Measure score 2.28 · Achievement 2.28 · Improvement 0
Total nurse turnover
2.75
Performance 52.46% · Measure score 2.75 · Achievement 2.75 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
8.44
Baseline 5.35 hours · Performance 5.48 hours · Measure score 8.44 · Achievement 8.44 · Improvement 2.59
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.03% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 343 · Observed rate 9.62% · Lower 95% interval 7.68% |
| Discharge to community | 53.43% |
50.57%
2.9 pts better
|
No Different than the National Rate · Eligible stays 317 · Observed rate 46.37% · Lower 95% interval 47.71% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 85.66% |
95.27%
9.6 pts worse
|
Numerator 209 · Denominator 244 |
| Falls with major injury | 1.23% |
0.77%
0.5 pts worse
|
Numerator 3 · Denominator 244 |
| Discharge self-care score | 52.63% |
53.69%
1.1 pts worse
|
Numerator 110 · Denominator 209 |
| Discharge mobility score | 42.11% |
50.94%
8.8 pts worse
|
Numerator 88 · Denominator 209 |
| Pressure ulcers or injuries, new or worsened | 3.69% |
2.29%
1.4 pts worse
|
Numerator 9 · Denominator 244 · Adjusted rate 3.9% |
| Healthcare-associated infections requiring hospitalization | 7.15% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 212 · Observed rate 6.13% · Lower 95% interval 4.52% |
| Staff COVID-19 vaccination coverage | 12.38% |
8.2%
4.2 pts better
|
Numerator 78 · Denominator 630 |
| Staff flu vaccination coverage | 97.96% |
42%
56 pts better
|
Numerator 624 · Denominator 637 |
| Discharge function score | 59.33% |
56.45%
2.9 pts better
|
Numerator 124 · Denominator 209 |
| Transfer of health information to provider | 85.29% |
95.95%
10.7 pts worse
|
Numerator 29 · Denominator 34 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 127 · Denominator 127 |
| Resident COVID-19 vaccinations up to date | 35.9% |
25.2%
10.7 pts better
|
Numerator 42 · Denominator 117 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.4
0.6 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.9
1.1 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
98.3%
1.5 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.4% · Q4 100.0% · 4Q avg 99.8% |
| 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 | 4.1% |
5.1%
1 pts better
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.2% · Q3 2.5% · Q4 3.8% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
4.4%
4.1 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 6.6% |
5.5%
1.1 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 7.3% · Q3 7.0% · Q4 5.8% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.7% |
17.4%
4.7 pts better
|
19.6%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 14.3% · Q3 13.0% · Q4 10.4% · 4Q avg 12.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.4% |
23.4%
4 pts better
|
16.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 19.1% · Q3 20.2% · Q4 21.0% · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.2% |
0.2%
About the same
|
0.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.6% · 4Q avg 0.2% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.4% |
19.0%
6.4 pts worse
|
16.3%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.0% · Q2 22.3% · Q3 22.2% · Q4 22.5% · 4Q avg 25.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.8% |
20.1%
3.7 pts worse
|
14.9%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 25.4% · Q3 25.2% · Q4 20.5% · 4Q avg 23.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
1.8%
1 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.4% · Q3 3.5% · Q4 3.2% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
3.1%
0.7 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.4% · Q3 5.1% · Q4 4.6% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.8% |
25.2%
5.6 pts worse
|
19.8%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.9% · Q2 34.0% · Q3 25.3% · Q4 30.8% · 4Q avg 30.8% |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
5.3%
2.1 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 7.5% · Q3 7.6% · Q4 5.1% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
93.6%
3.2 pts better
|
81.7%
15.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 96.4% · Q3 96.6% · Q4 97.8% · 4Q avg 96.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
10.7%
0.1 pts worse
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 10.5% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.9%
0.6 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.8% · Q3 1.0% · Q4 1.1% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.9% |
88.3%
7.6 pts better
|
79.7%
16.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
20.5%
0.3 pts worse
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 18.9% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-15 · Fire 2024-02-15
11 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2023-02-16 · Fire 2023-02-16
4 health deficiencies
Top issue: Nursing and Physician Services (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
2025-03-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-02
F · Potential for more than minimal harm
2024-02-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-27
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 2025-04-21
E · Potential for more than minimal harm
2025-03-27
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 2025-04-21
D · Potential for more than minimal harm
2025-03-27
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-21
G · Actual harm
2024-10-15
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 2024-11-01
G · Actual harm
2024-06-12
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 2024-06-11
D · Potential for more than minimal harm
2024-02-15
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 2024-03-20
D · Potential for more than minimal harm
2024-02-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-15
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-15
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 2024-03-20
D · Potential for more than minimal harm
2024-02-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-15
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-15
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-15
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-20
G · Actual harm
2023-02-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-11-25
E · Potential for more than minimal harm
2023-02-16
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-16
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-16
Penalties and ownership
What sits behind the stars
$30,580
2024-10-15
Fine
Fine · fine $30,580
Fine
$8,824
2024-06-12
Fine
Fine · fine $8,824
Fine
Ownership
Missouri Slope Lutheran Care Center, Inc.
5% Or Greater Direct Ownership Interest · Organization
Andrist, Steve
Corporate Director · Individual
Hebert, Brian
Operational/Managerial Control · Individual
Missouri Slope Lutheran Care Center, Inc.
Operational/Managerial Control · Organization
Nitschke, Darrell
Corporate Director · Individual
Saude, Jerry
Corporate Director · Individual
Thompson, Reier
Operational/Managerial Control · Individual
Thompson, Reier
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Good Samaritan Society Augusta Place A Prospera Co
Bismarck, ND
4-star overall rating with 4-star inspections with $16,036 in total fines with 2 fire-safety deficiencies in the latest cycle
#2
St Gabriel's Community
Bismarck, ND
5-star overall rating with 4-star inspections with 5 recent health deficiencies
#3
Baptist Health & Rehab
Bismarck, ND
3-star overall rating with 2-star inspections with $35,323 in total fines with 3 recent health deficiencies
Jump out