Cycle 1
Health 2024-09-11 · Fire 2024-09-11
3 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Jamestown, ND
Smp Health - Ave Maria
5-star overall rating with 4-star inspections with $6,788 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
501 19th St Ne, Jamestown, ND
(701) 252-5660
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
92
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Smp Health
Operator or chain grouping
Approved since
1978-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 5 overall / 4 health / 5 staffing / 2 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
0.99
Registered nurse staffing · state 0.93 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.50 · national 0.87
Aide hours / resident day
3.96
Nurse aide staffing · state 2.99 · national 2.35
Total nurse hours
5.42
All reported nurse hours · state 4.41 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.40
Weekend nurse staffing · state 3.75 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.59 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.09
CMS adjusted RN staffing hours
Adjusted total hours
5.97
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
26%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,610
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.27
Composite VBP score used to determine payment impact.
Payment multiplier
1.0103
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 16.89% · Performance 22.60% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.69
Baseline 5.51% · Performance 6.13% · Measure score 5.69 · Achievement 5.69 · Improvement 0
Total nurse turnover
8.05
Baseline 47.20% · Performance 30.77% · Measure score 8.05 · Achievement 8.05 · Improvement 6.85
Adjusted total nurse staffing
8.36
Baseline 5.23 hours · Performance 5.46 hours · Measure score 8.36 · Achievement 8.36 · Improvement 3.64
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.41% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 78 · Observed rate 3.85% · Lower 95% interval 6.21% |
| Discharge to community | 42.28% |
50.57%
8.3 pts worse
|
Worse than the National Rate · Eligible stays 72 · Observed rate 41.67% · Lower 95% interval 33.26% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.43% |
95.27%
1.2 pts better
|
Numerator 54 · Denominator 56 |
| Falls with major injury | 1.79% |
0.77%
1 pts worse
|
Numerator 1 · Denominator 56 |
| Discharge self-care score | 52.17% |
53.69%
1.5 pts worse
|
Numerator 24 · Denominator 46 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 23 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 1.79% |
2.29%
0.5 pts better
|
Numerator 1 · Denominator 56 · Adjusted rate 2.09% |
| Healthcare-associated infections requiring hospitalization | 6.13% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 0% · Lower 95% interval 2.99% |
| Staff COVID-19 vaccination coverage | 5.51% |
8.2%
2.7 pts worse
|
Numerator 15 · Denominator 272 |
| Staff flu vaccination coverage | 63.79% |
42%
21.8 pts better
|
Numerator 192 · Denominator 301 |
| Discharge function score | 60.87% |
56.45%
4.4 pts better
|
Numerator 28 · Denominator 46 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 31 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 53.13% |
25.2%
27.9 pts better
|
Numerator 17 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.4
0.2 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.9 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.9
0.7 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
98.3%
1.4 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.6% · 4Q avg 99.7% |
| 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 | 6.1% |
5.1%
1 pts worse
|
3.3%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 6.4% · Q3 5.1% · Q4 4.1% · 4Q avg 6.1% · 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 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 1.4% |
5.5%
4.1 pts better
|
5.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 1.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.9% |
17.4%
1.5 pts better
|
19.6%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 15.7% · Q3 18.1% · Q4 15.9% · 4Q avg 15.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.9% |
23.4%
0.5 pts better
|
16.7%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 22.4% · Q3 22.0% · Q4 26.7% · 4Q avg 22.9% · 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 | 21.2% |
19.0%
2.2 pts worse
|
16.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 14.6% · Q3 33.1% · Q4 9.4% · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.6% |
20.1%
1.5 pts better
|
14.9%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 26.2% · Q3 23.3% · Q4 15.3% · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.8%
1.1 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · 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 1.2% · Q2 1.4% · 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 | 32.2% |
25.2%
7 pts worse
|
19.8%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.7% · Q2 34.2% · Q3 28.7% · Q4 31.8% · 4Q avg 32.2% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
5.3%
1.2 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 4.3% · Q3 3.7% · Q4 6.8% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
93.6%
2.6 pts better
|
81.7%
14.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 98.0% · Q3 97.2% · Q4 92.0% · 4Q avg 96.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.6% |
10.7%
3.9 pts worse
|
12.0%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 12.7% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.9%
1 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.0% |
88.3%
10.7 pts better
|
79.7%
19.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.8% |
20.5%
8.3 pts worse
|
23.9%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.8% · Observed 23.8% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-12 · Fire 2023-10-12
3 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-09-29 · Fire 2022-09-29
1 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-09-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-19
F · Potential for more than minimal harm
2022-09-29
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-11-25
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-09-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-09-11
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 2024-10-16
D · Potential for more than minimal harm
2024-09-11
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 2024-10-16
G · Actual harm
2024-06-13
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 2024-06-11
D · Potential for more than minimal harm
2023-10-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-12
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-11-16
E · Potential for more than minimal harm
2022-09-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-03
Penalties and ownership
What sits behind the stars
$6,788
2024-06-13
Fine
Fine · fine $6,788
Fine
Ownership
Alton, Aaron
Corporate Officer · Individual
Carson, Paul
Corporate Director · Individual
Hansen, Becky
Corporate Director · Individual
Hansen, Becky
Corporate Officer · Individual
Houle, Sharon
Corporate Director · Individual
Lagodinski, Tonie
Operational/Managerial Control · Individual
Lagodinski, Tonie
W-2 Managing Employee · Individual
Montecuollo, David
Corporate Director · Individual
Redlin, Frank
Corporate Director · Individual
Schmitz, Lynette
Corporate Director · Individual
Sisters Of Mary Of The Presentation Long Term Care
Operational/Managerial Control · Organization
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#2
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#3
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