Ellendale, ND

Prince Of Peace Care Center

4-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

201 8th St N, Ellendale, ND

(701) 349-3312

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

55

Certified beds

Average residents

51

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Benedictine Health System

Operator or chain grouping

Approved since

1978-06-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

22 facilities

Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars

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

0.89

Registered nurse staffing · state 0.93 · national 0.68

LPN hours / resident day

0.16

Licensed practical nurse staffing · state 0.50 · national 0.87

Aide hours / resident day

2.36

Nurse aide staffing · state 2.99 · national 2.35

Total nurse hours

3.40

All reported nurse hours · state 4.41 · national 3.89

Licensed hours

1.04

RN + LPN hours · state 1.42 · national 1.54

Weekend hours

3.09

Weekend nurse staffing · state 3.75 · national 3.43

Weekend RN hours

0.55

Weekend registered nurse coverage · state 0.59 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

1.04

CMS adjusted RN staffing hours

Adjusted total hours

4.00

CMS adjusted total nurse staffing hours

Case-mix index

1.16

Higher values indicate more complex resident acuity

RN turnover

36%

Annual RN turnover · state 38% · national 45%

Total nurse turnover

74%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,640

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

19.65

Composite VBP score used to determine payment impact.

Payment multiplier

0.9822

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

0

Baseline 67.27% · Performance 73.21% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

3.93

Baseline 4.54 hours · Performance 4.20 hours · Measure score 3.93 · Achievement 3.93 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	Not Available	1.02	Too few residents or stays to report publicly.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	10.91%	8.2% 2.7 pts better	Numerator 6 · Denominator 55
Staff flu vaccination coverage	70.67%	42% 28.7 pts better	Numerator 53 · Denominator 75
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 2 · 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 5 · 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	1.4	1.4 About the same	1.9 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 0.7 · Expected 1.0 · 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 0.9 · Expected 1.1 · 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	0.0%	5.1% 5.1 pts better	3.3% 3.3 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 who have depressive symptoms	0.7%	4.4% 3.7 pts better	11.4% 10.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.7%
Percentage of long-stay residents who lose too much weight	1.1%	5.5% 4.4 pts better	5.4% 4.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 2.1% · 4Q avg 1.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	36.9%	17.4% 19.5 pts worse	19.6% 17.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 38.1% · Q2 37.8% · Q3 36.4% · Q4 35.4% · 4Q avg 36.9%
Percentage of long-stay residents who received an antipsychotic medication	37.7%	23.4% 14.3 pts worse	16.7% 21 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 37.0% · Q2 41.7% · Q3 33.3% · Q4 39.3% · 4Q avg 37.7% · 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	15.8%	19.0% 3.2 pts better	16.3% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 21.7% · Q3 16.6% · Q4 12.8% · 4Q avg 15.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	22.0%	20.1% 1.9 pts worse	14.9% 7.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 34.1% · Q3 19.5% · Q4 7.1% · 4Q avg 22.0% · 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	0.5%	3.1% 2.6 pts better	1.7% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	17.5%	25.2% 7.7 pts better	19.8% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 16.8% · Q3 19.5% · Q4 16.4% · 4Q avg 17.5%
Percentage of long-stay residents with pressure ulcers	1.3%	5.3% 4 pts better	5.1% 3.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 2.5% · 4Q avg 1.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.4%	93.6% 3.8 pts better	81.7% 15.7 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 97.4%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-05 · Fire 2025-02-05

1 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 2 Health 2023-12-05 · Fire 2023-12-05

0 health deficiencies

No concentrated health issue counts in this cycle.

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2022-11-23 · Fire 2022-11-23

1 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-02-05

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2025-03-26

F · Potential for more than minimal harm 2023-12-05

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-12-16

D · Potential for more than minimal harm 2023-12-05

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-01-30

D · Potential for more than minimal harm 2023-12-05

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-12-20

F · Potential for more than minimal harm 2022-11-23

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-12-12

F · Potential for more than minimal harm 2022-11-23

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-12-12

Inspection history

Recent health citations

G · Actual harm 2025-12-22

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 2025-12-16

D · Potential for more than minimal harm 2022-11-23

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2022-12-06

Penalties and ownership

What sits behind the stars

Ownership

Benedictine Health System

5% Or Greater Indirect Ownership Interest · Organization

100% 25 facilities 1989-06-01

Benedictine Living Communities, Inc.

5% Or Greater Direct Ownership Interest · Organization

100% 6 facilities 1989-06-01

Benedictine Health System

Operational/Managerial Control · Organization

0% 25 facilities 1989-06-01

Benedictine Living Communities, Inc.

Operational/Managerial Control · Organization

0% 6 facilities 1989-06-01

Bergien, Tricia

Corporate Officer · Individual

0% 25 facilities 2016-11-17

Bowe, Tia