Lutheran Home of the Good Shepherd
1226 1st Ave N, New Rockford, ND 58356 · Eddy County · 51 certified beds · avg 47 residents/day · certified since May 1, 1978
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jul 10, 2024 · F-0880 · triggered by a complaint
The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Why it matters: Weak infection control lets illnesses like flu, COVID-19, and drug-resistant infections spread quickly among vulnerable residents.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Aug 1, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 28, 2025 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 22, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 4, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 28, 2025 (Past Non-Compliance)
All citations in the current public record (9)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Aug 28, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 28, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Aug 28, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 4, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jul 10, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jul 10, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Jul 10, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Jul 10, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jul 10, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (5 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 5 | 1 | J ▲ |
| 2025 | 4 | 2 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $31,829.
| Date | Type | Amount / length |
|---|---|---|
| Aug 28, 2025 | Fine | $9,110 |
| Jun 4, 2025 | Fine | $9,110 |
| Jul 10, 2024 | Fine | $13,609 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | North Dakota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.68 | 5.15 | 3.95 | top 26% in North Dakota; top 6% in the U.S. |
| Registered Nurse hours | 1.35 | 1.09 | 0.69 | top 17% in North Dakota; top 7% in the U.S. |
| Weekend total nurse staffing | 4.77 | 4.43 | 3.50 | top 31% in North Dakota; top 9% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.67 | 0.59 | 0.48 | top 30% in North Dakota; top 18% in the U.S. |
| Total nursing staff turnover (%) | 52.5 | 48.8 | 45.8 | bottom 40% in North Dakota; bottom 31% in the U.S. |
| RN turnover (%) | 41.7 | 40.3 | 42.9 | bottom 44% in North Dakota; top 50% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.47, RN 1.06, weekend 3.75. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 2/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Allmaras, Dianne | Individual | Corporate Director | NOT APPLICABLE | 11/01/2011 |
| Anderson, Karen | Individual | Corporate Director | NOT APPLICABLE | 01/01/2021 |
| Birkland, Karen | Individual | Corporate Director | NOT APPLICABLE | 10/01/2019 |
| Bollingberg, Nancy | Individual | Corporate Director | NOT APPLICABLE | 10/01/2019 |
| Guler, Josh | Individual | Corporate Director | NOT APPLICABLE | 10/01/2019 |
| Hegland, Amanda | Individual | Corporate Director | NOT APPLICABLE | 10/01/2019 |
| Jensrud, Kim | Individual | Corporate Officer | NOT APPLICABLE | 03/11/2013 |
| Jensrud, Kim | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/11/2013 |
| Labrensz, Jeffrey | Individual | Corporate Director | NOT APPLICABLE | 10/01/2019 |
| Lutheran Home of the Good Shepherd INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 10/28/2009 |
| Lutz, Lona | Individual | Corporate Director | NOT APPLICABLE | 10/01/2019 |
| O'Connor, Kathleen | Individual | Corporate Officer | NOT APPLICABLE | 10/01/2019 |
| Parson, Lori | Individual | Corporate Director | NOT APPLICABLE | 01/01/2021 |
| Rau, Richard | Individual | Corporate Director | NOT APPLICABLE | 10/01/2019 |
| Schuster, Fern | Individual | Corporate Director | NOT APPLICABLE | 01/01/2021 |
| Swanson, Dennis | Individual | Corporate Officer | NOT APPLICABLE | 10/01/2019 |
| Wolkenhauer, Carol | Individual | Corporate Officer | NOT APPLICABLE | 10/01/2019 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Golden Acres Manor | 19.3 mi | Carrington, ND | ★★★☆☆ | 3/5 |
Compare this facility with the 1 closest →
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Facility data as of CMS processing date 2026-08-01. CCN 355041.