Cycle 1
Health 2025-06-04 · Fire 2025-06-04
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cavalier, ND
Wedgewood Manor
2-star overall rating with 1-star inspections with $54,925 in total fines with 3 recent health deficiencies
804 Main St W, Cavalier, ND
(701) 265-8453
Overall
2 / 5
CMS overall stars
Health inspections
1 / 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
33
Certified beds
Average residents
32
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1980-03-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.97
Registered nurse staffing · state 0.93 · national 0.68
LPN hours / resident day
0.31
Licensed practical nurse staffing · state 0.50 · national 0.87
Aide hours / resident day
2.79
Nurse aide staffing · state 2.99 · national 2.35
Total nurse hours
4.07
All reported nurse hours · state 4.41 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.53
Weekend nurse staffing · state 3.75 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.59 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.10
CMS adjusted RN staffing hours
Adjusted total hours
4.65
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 38% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 49% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.81% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 19.23% · Lower 95% interval 7.86% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.65 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 16 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 7.84% |
8.2%
0.4 pts worse
|
Numerator 4 · Denominator 51 |
| Staff flu vaccination coverage | 41.18% |
42%
0.8 pts worse
|
Numerator 35 · Denominator 85 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.8 |
1.4
2.4 pts worse
|
1.9
1.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 3.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.1 |
1.9
2.2 pts worse
|
1.8
2.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.1 · Observed 3.4 · Expected 1.4 · 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 | 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 | 1.7% |
5.1%
3.4 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 6.5% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.6% |
4.4%
0.8 pts better
|
11.4%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 3.6% · Q4 6.9% · 4Q avg 3.6% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
5.5%
1.8 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 3.7% · Q4 6.9% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.4% |
17.4%
About the same
|
19.6%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 21.4% · Q3 14.3% · Q4 10.3% · 4Q avg 17.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.5% |
23.4%
9.9 pts better
|
16.7%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 14.3% · Q3 15.4% · Q4 16.7% · 4Q avg 13.5% · 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 | 27.6% |
19.0%
8.6 pts worse
|
16.3%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.7% |
20.1%
7.6 pts worse
|
14.9%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 33.3% · Q3 28.6% · Q4 32.1% · 4Q avg 27.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.0% |
3.1%
4.9 pts worse
|
1.7%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 12.5% · Q3 11.1% · Q4 6.5% · 4Q avg 8.0% · 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 13.7% · Q2 18.8% · Q3 26.1% · Q4 30.2% · 4Q avg 22.0% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
5.3%
0.2 pts better
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 5.1% · Q3 4.4% · Q4 7.0% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
10.7%
10.7 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 46.8% |
20.5%
26.3 pts worse
|
23.9%
22.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 46.8% · Observed 34.6% · Expected 17.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-16 · Fire 2024-05-16
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-04-12 · Fire 2023-04-12
3 health deficiencies
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-05-16
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-05-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-12
F · Potential for more than minimal harm
2023-04-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-08
F · Potential for more than minimal harm
2023-04-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-06-08
E · Potential for more than minimal harm
2023-04-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-08
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-06-04
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 2025-07-09
D · Potential for more than minimal harm
2025-06-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-06-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-09
K · Immediate jeopardy
2024-10-15
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 2024-11-11
K · Immediate jeopardy
2024-10-15
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 2024-11-11
K · Immediate jeopardy
2024-10-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-11
E · Potential for more than minimal harm
2024-05-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-05-16
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 2024-06-20
D · Potential for more than minimal harm
2024-05-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-20
E · Potential for more than minimal harm
2023-04-12
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-05-16
D · Potential for more than minimal harm
2023-04-12
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 2023-05-16
D · Potential for more than minimal harm
2023-04-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-16
Penalties and ownership
What sits behind the stars
$54,925
2024-10-15
Fine
Fine · fine $54,925
Fine
Ownership
Beard, Maggie
Corporate Director · Individual
Deraas, Duane
Corporate Director · Individual
Gauthier, Melissa
Corporate Director · Individual
Hansen, Joyce
Operational/Managerial Control · Individual
Horgan, Larae
Corporate Director · Individual
Johnson, Patti
Operational/Managerial Control · Individual
Johnson, Patti
Corporate Officer · Individual
Letexier, Lisa
Operational/Managerial Control · Individual
Letexier, Lisa
Corporate Officer · Individual
Mcdonald, Katie
Operational/Managerial Control · Individual
Mcdonald, Katie
Corporate Officer · Individual
Olafson, Drew
Corporate Director · Individual
Otto, Darin
Corporate Director · Individual
Pembina County Memorial Hospital Association
Operational/Managerial Control · Organization
Safranski, Nicole
Corporate Director · Individual
Stone, Jeremy
Corporate Director · Individual
Sumra, Kulvinder
Corporate Director · Individual
Sumra, Kulvinder
Corporate Officer · Individual
Thompson, Susan
Corporate Director · Individual
Wright, George
Corporate Director · Individual
Nearby options
Other facilities in reach
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Pembilier Nursing Center
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5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
#2
Lutheran Sunset Home
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4-star overall rating with 3-star inspections with $11,057 in total fines with 7 recent health deficiencies
#3
Good Samaritan Society - Park River
Park River, ND
2-star overall rating with 2-star inspections with $26,685 in total fines with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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