Map showing the location of KNIFE RIVER CARE CENTER in BEULAH, North Dakota
118 22ND ST NE, BEULAH, ND, 58523

Overall Score

CMS Five-Star Quality Rating
3/5AverageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • North DakotaAbove only 34% of peers72 rated homes · average 3.2★
  • United StatesAbove only 41% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.9 vs ND avg
  • StaffingCan add or remove a star5★+0.9 vs ND avg
  • Quality measuresCan add or remove a star3★+0.2 vs ND avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 15% of peersND avg2.9★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover5★Above 59% of peersND avg4.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 41% of peersND avg2.8★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff5.21hrsAbove 83% of peersND avg4.42Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only1.13hrsAbove 85% of peersND avg0.92Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better56%Above only 32% of peersND avg49%RN turnover28%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$35,890Above only 26% of peersND avg$27,396Fines · denials1 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
31citations
7inspection dates
1actual harm (G–I)
2immediate jeopardy (J–L)
Dec 10, 2025most recent

Citations by monthDec 2022 – Dec 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Dec 10, 20251 citationCycle 1worst D · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrection pending
Feb 26, 20252 citationsCycle 1worst D · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Apr 2, 2025
  2. F584Honor 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.Resident RightsD · isolatedCorrected Apr 2, 2025
Nov 26, 20242 citationsCycle 2worst D · no actual harm
  1. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Dec 31, 2024
  2. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 12, 2024
Aug 14, 20242 citationsCycle 2worst G · actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 13, 2024
  2. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Aug 13, 2024
Jul 10, 20241 citationCycle 2worst K · immediate jeopardy$35,890
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareK · patternCorrected Jul 31, 2024
Dec 21, 202314 citationsCycle 2worst E · no actual harm
  1. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareE · patternCorrected Jan 25, 2024
  2. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Jan 25, 2024
  3. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Jan 25, 2024
  4. F790Provide routine and 24-hour emergency dental care for each resident.Quality of Life and CareD · isolatedCorrected Jan 25, 2024
  5. F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Nutrition and DietaryE · patternCorrected Jan 25, 2024
  6. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jan 25, 2024
  7. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Jan 25, 2024
  8. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Jan 25, 2024
  9. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jan 25, 2024
  10. F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected Jan 25, 2024
  11. F584Honor 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.Resident RightsD · isolatedCorrected Jan 25, 2024
  12. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Jan 25, 2024
  13. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Jan 25, 2024
  14. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Jan 25, 2024
Dec 1, 20229 citationsCycle 3worst K · immediate jeopardy
  1. F880Provide and implement an infection prevention and control program.Infection ControlK · patternCorrected Dec 31, 2022
  2. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jan 5, 2023
  3. F637Assess the resident when there is a significant change in conditionResident Assessment and Care PlanningD · isolatedCorrected Jan 5, 2023
  4. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Jan 5, 2023
  5. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Jan 5, 2023
  6. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Jan 5, 2023
  7. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jan 5, 2023
  8. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Jan 5, 2023
  9. F888Ensure staff are vaccinated for COVID-19Infection ControlD · isolatedCorrected Jan 5, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined5.21hrsAbove 83% of peers+0.79 vs ND avg
  • Registered nursesRN hours only1.13hrsAbove 85% of peers+0.21 vs ND avg
  • Licensed practical nursesLPN hours0.13hrs
  • Nurse aidesCNA hours3.95hrs
  • Weekend nursingAll staff on Saturdays and Sundays4.25hrs
  • North Dakota average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better56%Above only 32% of peersND avg 49%
  • RN turnoverRegistered nurses only28%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy86 certified beds · ~81 residents a day94%Above 53% of peersND avg 90%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $35,890In fines
  • 1Fine
  • 0Payment denials
  • $27,396ND avg in fines
Above only 26% of peersFewer fines than 26% of rated homes in North Dakota

Actions on record

  1. Jul 10, 2024Civil money penalty$35,890

Ownership

As filed with CMS

Structure

Ownership type
Non profit - Corporation
Chain
Independent
Certification
Medicare and Medicaid
Location type
Rural
Ownership change
None in the last 12 months

People and entities on file

Operational or managerial control
  • Beulah Community Nursing Home
Corporate officers
  • Carla Borlaug
  • Linda Czywczynski
  • Keith Gendreau
  • Dena Kemmet
  • Frederick Stern
Managing employees
  • Linda Czywczynski
  • Keith Gendreau

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 355053 · 118 22ND ST NE, BEULAH, ND, 58523.
  • Percentiles compare this facility with every rated nursing home in North Dakota and Mercer County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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