Cycle 1
Health 2024-11-26 · Fire 2024-11-26
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Wahpeton, ND
St Catherines Living Center
1-star overall rating with 1-star inspections with abuse icon flag with $56,329 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1307 N 7th St, Wahpeton, ND
(701) 642-6667
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
49
Certified beds
Average residents
44
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Benedictine Health System
Operator or chain grouping
Approved since
1976-07-01
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
0.61
Registered nurse staffing · state 0.93 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.50 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.99 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 4.41 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.05
Weekend nurse staffing · state 3.75 · national 3.43
Weekend RN hours
0.43
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
0.69
CMS adjusted RN staffing hours
Adjusted total hours
4.08
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
37%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,856
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.40
Composite VBP score used to determine payment impact.
Payment multiplier
0.9953
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.99
Baseline 21.44% · Performance 18.66% · Measure score 5.99 · Achievement 5.99 · Improvement 5.81
Healthcare-associated infections
2.14
Baseline 6.13% · Performance 7.20% · Measure score 2.14 · Achievement 2.14 · Improvement 0
Total nurse turnover
6.13
Baseline 42.22% · Performance 38.64% · Measure score 6.13 · Achievement 6.13 · Improvement 1.56
Adjusted total nurse staffing
2.70
Baseline 3.68 hours · Performance 3.85 hours · Measure score 2.70 · Achievement 2.70 · Improvement 0.31
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.46% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 72 · Observed rate 12.5% · Lower 95% interval 7.7% |
| Discharge to community | 36.56% |
50.57%
14 pts worse
|
Worse than the National Rate · Eligible stays 56 · Observed rate 28.57% · Lower 95% interval 27.45% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 52 · Denominator 52 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 52 |
| Discharge self-care score | 32.43% |
53.69%
21.3 pts worse
|
Numerator 12 · Denominator 37 |
| Discharge mobility score | 37.84% |
50.94%
13.1 pts worse
|
Numerator 14 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 3.85% |
2.29%
1.6 pts worse
|
Numerator 2 · Denominator 52 · Adjusted rate 3.81% |
| Healthcare-associated infections requiring hospitalization | 7.2% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 6.52% · Lower 95% interval 4.39% |
| Staff COVID-19 vaccination coverage | 1.06% |
8.2%
7.1 pts worse
|
Numerator 1 · Denominator 94 |
| Staff flu vaccination coverage | 19.44% |
42%
22.6 pts worse
|
Numerator 28 · Denominator 144 |
| Discharge function score | 54.05% |
56.45%
2.4 pts worse
|
Numerator 20 · Denominator 37 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 44.44% |
25.2%
19.2 pts better
|
Numerator 12 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.4
0.1 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.3 |
1.9
1.4 pts worse
|
1.8
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
98.3%
0.4 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 94.6% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.5% |
98.8%
3.3 pts worse
|
95.5%
About the same
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.2% |
5.1%
3.1 pts worse
|
3.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 11.9% · Q3 7.3% · Q4 5.4% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
4.4%
2.5 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.4% · Q3 0.0% · Q4 2.7% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 3.8% |
5.5%
1.7 pts better
|
5.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 0.0% · Q3 2.9% · Q4 3.1% · 4Q avg 3.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.9% |
17.4%
6.5 pts worse
|
19.6%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 22.9% · Q3 22.2% · Q4 24.2% · 4Q avg 23.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.8% |
23.4%
12.6 pts better
|
16.7%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 7.7% · Q3 16.0% · Q4 12.0% · 4Q avg 10.8% · 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 | 24.6% |
19.0%
5.6 pts worse
|
16.3%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.6% |
20.1%
4.5 pts worse
|
14.9%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 31.4% · Q3 25.0% · Q4 21.2% · 4Q avg 24.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.8%
0.3 pts better
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 0.0% · Q4 1.6% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
3.1%
1.8 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 2.6% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.4% |
25.2%
2.2 pts worse
|
19.8%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 20.9% · Q3 37.8% · Q4 20.7% · 4Q avg 27.4% |
| Percentage of long-stay residents with pressure ulcers | 9.3% |
5.3%
4 pts worse
|
5.1%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 7.6% · Q3 14.2% · Q4 10.4% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
93.6%
2.5 pts better
|
81.7%
14.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 96.2% · Q3 93.8% · Q4 97.4% · 4Q avg 96.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.9% |
10.7%
10.2 pts worse
|
12.0%
8.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 18.2% · Expected 9.7% · 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 5.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.3%
11.7 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.0% |
20.5%
6.5 pts better
|
23.9%
9.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.0% · Observed 12.1% · Expected 20.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-31 · Fire 2023-10-31
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-10-12 · Fire 2022-10-12
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
B · Minimal harm
2024-11-26
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2024-12-10
F · Potential for more than minimal harm
2023-10-31
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-11-20
F · Potential for more than minimal harm
2023-10-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-20
B · Minimal harm
2023-10-31
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2023-11-20
F · Potential for more than minimal harm
2022-10-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-28
F · Potential for more than minimal harm
2022-10-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-28
E · Potential for more than minimal harm
2022-10-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-10-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-28
B · Minimal harm
2022-10-12
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2022-10-19
Inspection history
Recent health citations
G · Actual harm
2026-01-28
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.
Not marked corrected
E · Potential for more than minimal harm
2026-01-28
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-28
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Not marked corrected
D · Potential for more than minimal harm
2026-01-28
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Not marked corrected
G · Actual harm
2025-03-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-06
J · Immediate jeopardy
2024-11-26
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 2024-12-11
D · Potential for more than minimal harm
2022-10-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-11-10
Penalties and ownership
What sits behind the stars
$17,215
2026-01-26
Fine
Fine · fine $17,215
Fine
$15,548
2025-03-11
Fine
Fine · fine $15,548
Fine
$23,566
2024-11-26
Fine
Fine · fine $23,566
Fine
Ownership
Benedictine Health System
5% Or Greater Indirect Ownership Interest · Organization
Benedictine Living Communities, Inc.
5% Or Greater Direct Ownership Interest · Organization
Benedictine Health System
Operational/Managerial Control · Organization
Benedictine Living Communities, Inc.
Operational/Managerial Control · Organization
Bergien, Tricia
Corporate Officer · Individual
Bowe, Tia
Corporate Director · Individual
Carley, Gerald
Corporate Director · Individual
Carley, Gerald
Corporate Officer · Individual
Cornelius, James
Contracted Managing Employee · Individual
Dewitt, Betty
Corporate Director · Individual
Greff, Kevin
Corporate Director · Individual
Hendrickson, Jodi
Corporate Director · Individual
Kadrmas, Beverly
Corporate Director · Individual
Kaiser, Karen
Corporate Director · Individual
Narum, Daniel
Corporate Director · Individual
Rymanowski, Kevin
Corporate Officer · Individual
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#2
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#3
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