Cycle 1
Health 2025-04-03 · Fire 2025-04-03
20 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Bismarck, ND
St Vincent's - A Prospera Community
1-star overall rating with 1-star inspections with abuse icon flag with $44,606 in total fines with 20 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1021 N 26th St, Bismarck, ND
(701) 323-1999
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
97
Certified beds
Average residents
94
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
1978-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
89 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
0.69
Registered nurse staffing · state 0.93 · national 0.68
LPN hours / resident day
0.40
Licensed practical nurse staffing · state 0.50 · national 0.87
Aide hours / resident day
3.09
Nurse aide staffing · state 2.99 · national 2.35
Total nurse hours
4.18
All reported nurse hours · state 4.41 · national 3.89
Licensed hours
1.09
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.59
Weekend nurse staffing · state 3.75 · national 3.43
Weekend RN hours
0.27
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
0.79
CMS adjusted RN staffing hours
Adjusted total hours
4.73
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,404
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.01
Composite VBP score used to determine payment impact.
Payment multiplier
0.9874
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.17
Baseline 18.72% · Performance 19.96% · Measure score 3.17 · Achievement 3.17 · Improvement 0
Healthcare-associated infections
1.71
Baseline 5.12% · Performance 7.32% · Measure score 1.71 · Achievement 1.71 · Improvement 0
Total nurse turnover
3.73
Baseline 52.58% · Performance 48.42% · Measure score 3.73 · Achievement 3.73 · Improvement 1
Adjusted total nurse staffing
4.60
Baseline 4.48 hours · Performance 4.39 hours · Measure score 4.60 · Achievement 4.60 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.86% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 4.55% · Lower 95% interval 6.82% |
| Discharge to community | 37.71% |
50.57%
12.9 pts worse
|
Worse than the National Rate · Eligible stays 88 · Observed rate 28.41% · Lower 95% interval 28.69% |
| Medicare spending per beneficiary | 0.66 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 78.57% |
95.27%
16.7 pts worse
|
Numerator 55 · Denominator 70 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 70 |
| Discharge self-care score | 37.93% |
53.69%
15.8 pts worse
|
Numerator 22 · Denominator 58 |
| Discharge mobility score | 34.48% |
50.94%
16.5 pts worse
|
Numerator 20 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 2.86% |
2.29%
0.6 pts worse
|
Numerator 2 · Denominator 70 · Adjusted rate 3.59% |
| Healthcare-associated infections requiring hospitalization | 7.32% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 62 · Observed rate 8.06% · Lower 95% interval 4.41% |
| Staff COVID-19 vaccination coverage | 0.56% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 178 |
| Staff flu vaccination coverage | 72.67% |
42%
30.7 pts better
|
Numerator 117 · Denominator 161 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 29 · Denominator 58 |
| 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 | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 45% |
25.2%
19.8 pts better
|
Numerator 18 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.4
0.3 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.3 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.9
1.6 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
98.3%
0.5 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 98.8% · Q3 98.8% · Q4 98.8% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
98.8%
0.1 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.4% |
5.1%
2.3 pts worse
|
3.3%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 8.8% · Q3 4.9% · Q4 6.0% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
4.4%
0.6 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.7% · Q3 2.6% · Q4 7.7% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 11.8% |
5.5%
6.3 pts worse
|
5.4%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 10.5% · Q3 11.7% · Q4 9.8% · 4Q avg 11.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.5% |
17.4%
2.9 pts better
|
19.6%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 15.4% · Q3 15.2% · Q4 13.4% · 4Q avg 14.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.5% |
23.4%
1.9 pts better
|
16.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 21.5% · Q3 22.1% · Q4 23.2% · 4Q avg 21.5% · 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 | 16.2% |
19.0%
2.8 pts better
|
16.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.3% · Q2 8.8% · Q3 8.3% · Q4 24.1% · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.7% |
20.1%
1.4 pts better
|
14.9%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 16.7% · Q3 15.3% · Q4 22.1% · 4Q avg 18.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
1.8%
0.1 pts better
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.4% · Q3 1.1% · Q4 3.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
3.1%
0.3 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 5.1% · Q3 6.2% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.2% |
25.2%
4 pts better
|
19.8%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 20.0% · Q3 18.8% · Q4 20.1% · 4Q avg 21.2% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
5.3%
1.5 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 5.4% · Q3 5.9% · Q4 9.0% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.4% |
93.6%
7.2 pts worse
|
81.7%
4.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.8% · Q2 82.6% · Q3 92.9% · Q4 90.2% · 4Q avg 86.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.7% |
10.7%
7 pts better
|
12.0%
8.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.7% · Observed 3.8% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.9%
0.2 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 3.1% · Q4 3.2% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.9% |
88.3%
1.6 pts better
|
79.7%
10.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 7.9% |
20.5%
12.6 pts better
|
23.9%
16 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 7.7% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-29 · Fire 2024-02-29
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-03-02 · Fire 2023-03-02
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-03
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2025-05-28
F · Potential for more than minimal harm
2024-02-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-18
E · Potential for more than minimal harm
2024-02-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-02-29
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2024-04-18
F · Potential for more than minimal harm
2023-03-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-22
F · Potential for more than minimal harm
2023-03-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-22
D · Potential for more than minimal harm
2023-03-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-22
Inspection history
Recent health citations
G · Actual harm
2025-04-03
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 2025-05-07
G · Actual harm
2025-04-03
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-05-10
F · Potential for more than minimal harm
2025-04-03
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-04-03
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 2025-05-07
F · Potential for more than minimal harm
2025-04-03
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-05-07
E · Potential for more than minimal harm
2025-04-03
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 2025-05-07
E · Potential for more than minimal harm
2025-04-03
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 2025-05-07
D · Potential for more than minimal harm
2025-04-03
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 2025-05-07
D · Potential for more than minimal harm
2025-04-03
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-03
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-03
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-04-03
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 2025-05-07
D · Potential for more than minimal harm
2025-04-03
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 2025-05-07
D · Potential for more than minimal harm
2025-04-03
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 2025-05-07
D · Potential for more than minimal harm
2025-04-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-07
C · Minimal harm
2025-04-03
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-05-07
G · Actual harm
2024-02-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-08
F · Potential for more than minimal harm
2024-02-29
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 2024-04-08
E · Potential for more than minimal harm
2024-02-29
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 2024-04-08
E · Potential for more than minimal harm
2024-02-29
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 2024-04-08
E · Potential for more than minimal harm
2024-02-29
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-04-08
E · Potential for more than minimal harm
2024-02-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-29
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 2024-04-08
D · Potential for more than minimal harm
2024-02-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-29
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-02-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-08
E · Potential for more than minimal harm
2023-03-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-03-25
E · Potential for more than minimal harm
2023-03-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-25
D · Potential for more than minimal harm
2023-03-02
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 2023-03-25
Penalties and ownership
What sits behind the stars
$23,920
2025-04-03
Fine
Fine · fine $23,920
Fine
$20,686
2024-02-29
Fine
Fine · fine $20,686
Fine
Ownership
Sanford
5% Or Greater Direct Ownership Interest · Organization
The Evangelical Lutheran Good Samaritan Society
5% Or Greater Indirect Ownership Interest · Organization
Al Rabadi, Issa
Operational/Managerial Control · Individual
Brown, George
Corporate Director · Individual
Dykhouse, Dana
Corporate Director · Individual
Engbrecht, Wesley
Corporate Director · Individual
Fluit, Joel
Corporate Officer · Individual
Gassen, William
Corporate Director · Individual
Gassen, William
Corporate Officer · Individual
Gulsvig, Neil
Corporate Director · Individual
Herseth Sandlin, Stephanie
Corporate Director · Individual
Kitelinger, Kaylene
Operational/Managerial Control · Individual
Lundeen, Mark
Corporate Director · Individual
Mccausland, Maureen
Corporate Director · Individual
Middleton, Aimee
Corporate Officer · Individual
Molbert, Lauris
Corporate Director · Individual
Morrison, Tony
Operational/Managerial Control · Individual
North, Andrew
Corporate Director · Individual
Olson, Nicholas
Corporate Officer · Individual
Sandgren, Deeandra
Operational/Managerial Control · Individual
Sanford
Operational/Managerial Control · Organization
Schema, Nathan
Corporate Officer · Individual
Schieffer, Kevin
Corporate Director · Individual
Shulkin, David
Corporate Director · Individual
Teiken, Brent
Corporate Director · Individual
The Evangelical Lutheran Good Samaritan Society
Operational/Managerial Control · Organization
Ventling-Herrmann, Marnie
Corporate Director · Individual
Wenzel, Thomas
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Baptist Health & Rehab
Bismarck, ND
3-star overall rating with 2-star inspections with $35,323 in total fines with 3 recent health deficiencies
#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
St Gabriel's Community
Bismarck, ND
5-star overall rating with 4-star inspections with 5 recent health deficiencies
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