Cycle 1
Health 2025-06-26 · Fire 2025-06-26
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Bismarck, ND
St Gabriel's Community
5-star overall rating with 4-star inspections with 5 recent health deficiencies
4580 Coleman Street, Suite 1, Bismarck, ND
(701) 751-4224
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
72
Certified beds
Average residents
70
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Benedictine Health System
Operator or chain grouping
Approved since
2010-06-30
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
1.11
Registered nurse staffing · state 0.93 · national 0.68
LPN hours / resident day
0.35
Licensed practical nurse staffing · state 0.50 · national 0.87
Aide hours / resident day
2.89
Nurse aide staffing · state 2.99 · national 2.35
Total nurse hours
4.35
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
3.81
Weekend nurse staffing · state 3.75 · national 3.43
Weekend RN hours
0.66
Weekend registered nurse coverage · state 0.59 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.12
CMS adjusted RN staffing hours
Adjusted total hours
4.39
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
28%
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
1,364
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.22
Composite VBP score used to determine payment impact.
Payment multiplier
1.0124
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.87
Baseline 18.14% · Performance 18.71% · Measure score 5.87 · Achievement 5.87 · Improvement 0
Healthcare-associated infections
5.42
Baseline 6.32% · Performance 6.21% · Measure score 5.42 · Achievement 5.42 · Improvement 0.27
Total nurse turnover
7.02
Baseline 32.07% · Performance 35.00% · Measure score 7.02 · Achievement 7.02 · Improvement 0
Adjusted total nurse staffing
4.58
Baseline 4.68 hours · Performance 4.38 hours · Measure score 4.58 · Achievement 4.58 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 7.93% |
10.72%
2.8 pts better
|
No Different than the National Rate · Eligible stays 124 · Observed rate 2.42% · Lower 95% interval 5.35% |
| Discharge to community | 33.06% |
50.57%
17.5 pts worse
|
Worse than the National Rate · Eligible stays 107 · Observed rate 27.1% · Lower 95% interval 26.1% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.11% |
95.27%
3.8 pts better
|
Numerator 111 · Denominator 112 |
| Falls with major injury | 1.79% |
0.77%
1 pts worse
|
Numerator 2 · Denominator 112 |
| Discharge self-care score | 48.86% |
53.69%
4.8 pts worse
|
Numerator 43 · Denominator 88 |
| Discharge mobility score | 61.36% |
50.94%
10.4 pts better
|
Numerator 54 · Denominator 88 |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 4 · Denominator 112 · Adjusted rate 3.73% |
| Healthcare-associated infections requiring hospitalization | 6.21% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 99 · Observed rate 4.04% · Lower 95% interval 3.68% |
| Staff COVID-19 vaccination coverage | 2.07% |
8.2%
6.1 pts worse
|
Numerator 3 · Denominator 145 |
| Staff flu vaccination coverage | 37.5% |
42%
4.5 pts worse
|
Numerator 72 · Denominator 192 |
| Discharge function score | 60.23% |
56.45%
3.8 pts better
|
Numerator 53 · Denominator 88 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 38 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 26.67% |
25.2%
1.5 pts better
|
Numerator 16 · Denominator 60 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.4
0.5 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.2 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.9
1 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
98.3%
1.3 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.4% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| 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 | 3.7% |
5.1%
1.4 pts better
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.2% · Q3 3.4% · Q4 3.3% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
4.4%
3.1 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 1.8% · Q4 1.7% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
5.5%
1.7 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 9.8% · Q3 6.5% · Q4 6.1% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.9% |
17.4%
0.5 pts worse
|
19.6%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 16.4% · Q3 20.4% · Q4 17.0% · 4Q avg 17.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.2% |
23.4%
7.2 pts better
|
16.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 14.6% · Q3 14.3% · Q4 19.6% · 4Q avg 16.2% · 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 | 25.5% |
19.0%
6.5 pts worse
|
16.3%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.2% · Q2 35.1% · Q3 24.1% · Q4 16.2% · 4Q avg 25.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.9% |
20.1%
8.8 pts worse
|
14.9%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.8% · Q2 28.6% · Q3 28.9% · Q4 19.1% · 4Q avg 28.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
1.8%
0.3 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 1.5% · Q4 4.8% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
3.1%
0.4 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.4% · Q3 1.8% · Q4 5.3% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.7% |
25.2%
6.5 pts better
|
19.8%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 17.5% · Q3 18.0% · Q4 20.6% · 4Q avg 18.7% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
5.3%
0.2 pts worse
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 10.8% · Q3 3.5% · Q4 3.1% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
93.6%
6 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
10.7%
5.3 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 5.4% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.3% |
1.9%
2.4 pts worse
|
1.6%
2.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.2% · Q3 4.7% · Q4 4.1% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.3% |
88.3%
10 pts better
|
79.7%
18.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.8% |
20.5%
2.7 pts better
|
23.9%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.8% · Observed 16.1% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-12 · Fire 2024-06-12
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-07-13 · Fire 2023-07-13
4 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-07-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-07-25
D · Potential for more than minimal harm
2023-07-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-06-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-06-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-06-26
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 2025-07-31
D · Potential for more than minimal harm
2025-06-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-31
E · Potential for more than minimal harm
2024-06-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-12
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-12
D · Potential for more than minimal harm
2023-07-13
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.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-07-13
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-07-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-07-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-04
Penalties and ownership
What sits behind the stars
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
Carley, Gerald
Corporate Director · Individual
Glynn, Jeffrey
Corporate Director · Individual
Graeber, Luanna
Corporate Director · Individual
Greff, Kevin
Corporate Director · Individual
Hack, Taylar
Corporate Director · Individual
Kadrmas, Beverly
Corporate Director · Individual
Lindemann, Gene
Corporate Director · Individual
Opp, Kurran
Operational/Managerial Control · Individual
Rymanowski, Kevin
Corporate Officer · Individual
Trupka, Jerry
Corporate Director · Individual
Willis, Karin
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Missouri Slope
Bismarck, ND
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
#2
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
#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
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