Overall Score
CMS Five-Star Quality RatingNot ratedCMS Five-Star overall rating
- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
CMS has not published a rating for this facility, so there is no peer position to show.
How the rating is built
- Health inspectionsStarting point—
- StaffingCan add or remove a star—
- Quality measuresCan add or remove a star—
CMS withholds a rating when a facility is new, has too little inspection history, or is under review.
- Special Focus FacilityCMS has placed this facility in the Special Focus Facility program for a history of serious quality problems. It is inspected twice as often and can lose Medicare certification if it does not improve.
- Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles—No dataND 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 turnover—No dataND 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 assessments—No dataND 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 staff3.45hrsAbove only 8% 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 only0.95hrsAbove 56% 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 better66%Above only 10% of peersND avg49%RN turnover50%
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$132,380Above only 4% of peersND avg$27,396Fines · denials3 · 1
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 cycles46citations
9inspection dates
2actual harm (G–I)
4immediate jeopardy (J–L)
Sep 11, 2025most recent
Citations by monthMay 2023 – Sep 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Click to filter the findings below
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Sep 11, 2025Cycle 1worst E · no actual harm
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Oct 10, 2025
- 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 Oct 10, 2025
- 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 Oct 10, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Oct 10, 2025
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalD · isolatedCorrected Oct 10, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Oct 10, 2025
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationD · isolatedCorrected Oct 10, 2025
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Oct 10, 2025
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Oct 10, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 10, 2025
- F637Assess the resident when there is a significant change in conditionResident Assessment and Care PlanningD · isolatedCorrected Oct 10, 2025
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Oct 10, 2025
Jul 16, 2025Cycle 1worst J · immediate jeopardy
- 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 ExploitationJ · isolatedCorrected Aug 13, 2025
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 13, 2025
May 13, 2025Cycle 1worst G · actual harm
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareG · isolatedCorrected Jun 4, 2025
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Jun 4, 2025
Mar 20, 2025Cycle 2worst E · no actual harm$96,272, payment denial
- Encode each residentâs assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningD · isolatedCorrected Apr 24, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Apr 24, 2025
Jan 22, 2025Cycle 2worst D · no actual harm
- 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 Jan 14, 2025
Sep 18, 2024Cycle 3worst D · no actual harm
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Oct 23, 2024
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Oct 23, 2024
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Oct 23, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Oct 23, 2024
Jul 16, 2024Cycle 2worst G · actual harm$13,975
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Jul 26, 2024
Oct 5, 2023Cycle 3worst E · no actual harm
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Oct 27, 2023
- Encode each residentâs assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningD · isolatedCorrected Oct 27, 2023
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Oct 27, 2023
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Oct 27, 2023
- F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Nursing and Physician ServicesD · isolatedCorrected Oct 27, 2023
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Oct 27, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Oct 27, 2023
May 24, 2023Cycle 3worst K · immediate jeopardy$22,133
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 22, 2023
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Jun 22, 2023
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jul 24, 2023
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jun 22, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareK · patternCorrected Jun 22, 2023
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesE · patternCorrected Jul 24, 2023
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesF · widespreadCorrected Jun 22, 2023
- F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Nursing and Physician ServicesE · patternCorrected Jun 22, 2023
- F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareD · isolatedCorrected Jun 22, 2023
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected Jun 22, 2023
- 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 Jul 24, 2023
- 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 ExploitationK · patternCorrected Jun 22, 2023
- F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsE · patternCorrected Jun 22, 2023
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsK · patternCorrected Jun 22, 2023
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsD · isolatedCorrected Jun 22, 2023
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.45hrs
- Registered nursesRN hours only0.95hrs
- Licensed practical nursesLPN hours0.25hrs
- Nurse aidesCNA hours2.24hrs
- Weekend nursingAll staff on Saturdays and Sundays2.50hrs
- North Dakota average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better66%Above only 10% of peersND avg 49%
- RN turnoverRegistered nurses only50%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy52 certified beds · ~43 residents a day83%Above only 15% of peersND avg 90%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $132,380In fines
- 3Fines
- 1Payment denial
- $27,396ND avg in fines
Above only 4% of peersFewer fines than 4% of rated homes in North Dakota
Actions on record
- Mar 20, 2025Civil money penalty$96,272
- Mar 20, 2025Denial of payment for new admissionsfrom Aug 9, 2025
- Jul 16, 2024Civil money penalty$13,975
- May 24, 2023Civil money penalty$22,133
Ownership
As filed with CMSStructure
- Ownership type
- Non profit - Corporation
- Chain
- Good Samaritan Society90 facilities in the chain3.0★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Rural
- Ownership change
- None in the last 12 months
People and entities on file
Indirect owners (5%+)
- Sanford
Operational or managerial control
- The Evangelical Lutheran Good Samaritan Society
Corporate directors
- James Cain
- Dana Dykhouse
- Wesley Engbrecht
- William Gassen
- Neil Gulsvig
- Stephanie Herseth Sandlin
- Mark Lundeen
- Lauris Molbert
- +4 more
Corporate officers
- Joel Fluit
- William Gassen
- Aimee Middleton
- Nicholas Olson
- Michael Rogers
- Nathan Schema
Contracted managers
- Jessica Skjolden
Managing employees
- Theresa Brandenburg
- Tony Morrison
Person Organization
Sources & notes
Public data, updated quarterlyData 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 355093 · 725 E 10TH ST, BOTTINEAU, ND, 58318.
- Percentiles compare this facility with every rated nursing home in North Dakota and Bottineau 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.
