Missouri Slope
4916 N Washington St, Bismarck, ND 58503 · Burleigh County · 192 certified beds · avg 185 residents/day · certified since Nov 22, 2021
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
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)
▲ Actual harm, one-off · Oct 15, 2024 · 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: Nov 1, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 12, 2024 · F-0689 · triggered by a complaint
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: Jun 11, 2024 (Past Non-Compliance)
All citations in the current public record (20)
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 |
|---|---|---|
| May 14, 2026 | E · Potential for harm, repeated | 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. |
| May 14, 2026 | 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. |
| May 14, 2026 | 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. |
| Mar 27, 2025 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Mar 27, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Mar 27, 2025 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · from a complaint |
| Mar 27, 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. · from a complaint |
| Mar 27, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint |
| Mar 27, 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. · from a complaint |
| Oct 15, 2024 | ▲ 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 |
| Jun 12, 2024 | ▲ 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. · from a complaint |
| Feb 15, 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 |
| Feb 15, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 15, 2024 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Feb 15, 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 |
| Feb 15, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Feb 15, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Feb 15, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint |
| Feb 15, 2024 | D · Potential for harm, one-off | The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. · from a complaint |
| Feb 15, 2024 | 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. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (6 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 11 | 2 | G ▲ |
| 2025 | 6 | 0 | E |
| 2026 | 3 | 0 | E |
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)
2 fines totaling $39,404.
| Date | Type | Amount / length |
|---|---|---|
| Oct 15, 2024 | Fine | $30,580 |
| Jun 12, 2024 | Fine | $8,824 |
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) | 5.82 | 5.15 | 3.95 | top 17% in North Dakota; top 5% in the U.S. |
| Registered Nurse hours | 0.96 | 1.09 | 0.69 | bottom 37% in North Dakota; top 17% in the U.S. |
| Weekend total nurse staffing | 4.91 | 4.43 | 3.50 | top 21% in North Dakota; top 7% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.46 | 0.59 | 0.48 | bottom 30% in North Dakota; top 39% in the U.S. |
| Total nursing staff turnover (%) | 52.2 | 48.8 | 45.8 | bottom 42% in North Dakota; bottom 31% in the U.S. |
| RN turnover (%) | 28.6 | 40.3 | 42.9 | top 28% in North Dakota; top 26% 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 5.45, RN 0.90, weekend 4.60. 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: 2/5 · short-stay residents: 4/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Missouri Slope Lutheran Care Center, INC. | Organization | 5% or Greater Direct Ownership Interest | 100% | 11/06/2019 |
| Andrist, Steve | Individual | Corporate Director | NOT APPLICABLE | 11/06/2019 |
| Hebert, Brian | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/23/2025 |
| Hebert, Brian | Individual | ADP of the SNF | NOT APPLICABLE | 04/23/2025 |
| Missouri Slope Lutheran Care Center, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 11/06/2019 |
| Missouri Slope Lutheran Care Center, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 02/13/2025 |
| Nitschke, Darrell | Individual | Corporate Director | NOT APPLICABLE | 09/26/2022 |
| Saude, Jerry | Individual | Corporate Director | NOT APPLICABLE | 11/06/2019 |
| Thompson, Reier | Individual | Corporate Officer | NOT APPLICABLE | 11/06/2019 |
| Thompson, Reier | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/06/2019 |
| Thompson, Reier | Individual | ADP of the SNF | NOT APPLICABLE | 11/06/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "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 |
|---|---|---|---|---|---|
| Good Samaritan Society Augusta Place a Prospera Co | 0.7 mi | Bismarck, ND | ★★★★★ | 4/5 | |
| St Gabriel's Community | 0.9 mi | Bismarck, ND | ★★★★★ | 4/5 | |
| Baptist Health & Rehab | 2.2 mi | Bismarck, ND | ★★★★☆ | 4/5 | |
| St Vincent's - a Prospera Community | 3.6 mi | Bismarck, ND | ★☆☆☆☆ | 1/5 | abuseSFF |
| Good Samaritan Society Miller Pointe a Prospera Co | 4.7 mi | Mandan, ND | ★★★☆☆ | 2/5 | |
| Dakota Alpha | 5.7 mi | Mandan, ND | ★★★★★ | 5/5 | |
| Sunset Drive - a Prospera Community | 5.8 mi | Mandan, ND | ★☆☆☆☆ | 1/5 | abuseSFF |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 355128.