Cycle 1
Health 2025-04-09 · Fire 2025-04-09
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fargo, ND
The Meadows On University
2-star overall rating with 2-star inspections with $41,041 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1315 S University Dr, Fargo, ND
(701) 237-3030
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
95
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eduro Healthcare
Operator or chain grouping
Approved since
1967-03-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
36 facilities
Chain averages 2 overall / 3 health / 2 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
0.79
Registered nurse staffing · state 0.93 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.50 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.99 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 4.41 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.75 · national 3.43
Weekend RN hours
0.53
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
0.72
CMS adjusted RN staffing hours
Adjusted total hours
3.37
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,205
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.11
Baseline 19.08% · Performance 20.45% · Measure score 2.11 · Achievement 2.11 · Improvement 0
Healthcare-associated infections
1.34
Baseline 7.40% · Performance 7.43% · Measure score 1.34 · Achievement 1.34 · Improvement 0
Total nurse turnover
2.88
Baseline 68.22% · Performance 53.57% · Measure score 2.88 · Achievement 2.47 · Improvement 2.88
Adjusted total nurse staffing
3.45
Baseline 4.15 hours · Performance 4.06 hours · Measure score 3.45 · Achievement 3.45 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.01% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 8.89% · Lower 95% interval 6.24% |
| Discharge to community | 56.27% |
50.57%
5.7 pts better
|
No Different than the National Rate · Eligible stays 34 · Observed rate 47.06% · Lower 95% interval 39.27% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 61 · Denominator 61 |
| Falls with major injury | 1.64% |
0.77%
0.9 pts worse
|
Numerator 1 · Denominator 61 |
| Discharge self-care score | 39.02% |
53.69%
14.7 pts worse
|
Numerator 16 · Denominator 41 |
| Discharge mobility score | 31.71% |
50.94%
19.2 pts worse
|
Numerator 13 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 8.2% |
2.29%
5.9 pts worse
|
Numerator 5 · Denominator 61 · Adjusted rate 6.97% |
| Healthcare-associated infections requiring hospitalization | 7.43% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 9.76% · Lower 95% interval 3.96% |
| Staff COVID-19 vaccination coverage | 2.94% |
8.2%
5.3 pts worse
|
Numerator 3 · Denominator 102 |
| Staff flu vaccination coverage | 46.76% |
42%
4.8 pts better
|
Numerator 65 · Denominator 139 |
| Discharge function score | 56.1% |
56.45%
0.4 pts worse
|
Numerator 23 · Denominator 41 |
| 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 | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 5 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
1.4
1.3 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 3.6 · Expected 2.6 · 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 1.5 · Expected 2.0 · 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 | 89.1% |
98.8%
9.7 pts worse
|
95.5%
6.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
5.1%
4.5 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.8% |
4.4%
0.4 pts worse
|
11.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 5.3% · Q3 2.7% · Q4 0.0% · 4Q avg 4.8% |
| Percentage of long-stay residents who lose too much weight | 7.7% |
5.5%
2.2 pts worse
|
5.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 2.7% · Q3 11.4% · Q4 6.1% · 4Q avg 7.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.1% |
17.4%
17.7 pts worse
|
19.6%
15.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 40.5% · Q3 25.0% · Q4 20.6% · 4Q avg 35.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.1% |
23.4%
17.3 pts better
|
16.7%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 7.7% · Q3 8.3% · Q4 0.0% · 4Q avg 6.1% · 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 | 15.9% |
19.0%
3.1 pts better
|
16.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.2% |
20.1%
9.9 pts better
|
14.9%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 7.7% · Q3 19.4% · Q4 13.3% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
1.8%
0.4 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.9% |
3.1%
0.8 pts worse
|
1.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.1% · Q3 4.9% · Q4 2.7% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.0% |
25.2%
3.2 pts better
|
19.8%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 23.5% · Q3 12.3% · Q4 28.0% · 4Q avg 22.0% |
| Percentage of long-stay residents with pressure ulcers | 9.7% |
5.3%
4.4 pts worse
|
5.1%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 6.4% · Q3 8.5% · Q4 11.1% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.8% |
93.6%
1.2 pts better
|
81.7%
13.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 97.2% · Q3 90.2% · Q4 94.7% · 4Q avg 94.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.6% |
10.7%
1.9 pts worse
|
12.0%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 14.9% · Expected 13.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.9%
0.3 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.2% · Q3 2.4% · Q4 2.3% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.5% |
88.3%
8.8 pts worse
|
79.7%
0.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.8% |
20.5%
1.7 pts better
|
23.9%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 19.1% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-08 · Fire 2024-02-08
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-08-09 · Fire 2023-08-09
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-29
D · Potential for more than minimal harm
2024-02-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-08
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-03-05
F · Potential for more than minimal harm
2023-08-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-15
F · Potential for more than minimal harm
2023-08-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-08-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-08-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-09
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-30
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-12-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-09
G · Actual harm
2025-04-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-04-09
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 2025-05-20
E · Potential for more than minimal harm
2025-04-09
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 2025-05-20
E · Potential for more than minimal harm
2025-04-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-09
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 2025-05-20
D · Potential for more than minimal harm
2025-04-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-01-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-01-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-17
D · Potential for more than minimal harm
2024-02-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-08
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 2024-03-01
D · Potential for more than minimal harm
2024-02-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-08
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 2024-03-01
E · Potential for more than minimal harm
2023-08-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-09
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 2023-09-08
Penalties and ownership
What sits behind the stars
$41,041
2025-04-09
Fine
Fine · fine $41,041
Fine
Ownership
Eduro Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Bewsey, Michael
5% Or Greater Indirect Ownership Interest · Individual
Ramos, Brian
5% Or Greater Indirect Ownership Interest · Individual
Eduro Healthcare LLC
Operational/Managerial Control · Organization
Thompson, Christopher
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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5-star overall rating with 5-star inspections with 2 recent health deficiencies
#2
Bethany On University
Fargo, ND
5-star overall rating with 4-star inspections with 2 recent health deficiencies
#3
Eventide Lutheran Home
Moorhead, MN
2-star overall rating with 2-star inspections with $59,005 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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