North Dakota Veterans Home

Name: North Dakota Veterans Home
Address: 1600 VETERANS DRIVE, Lisbon, ND, 58054, US
Telephone: 7016836500

1600 Veterans Drive, Lisbon, ND 58054 · Ransom County · 52 certified beds · avg 50 residents/day · certified since Dec 2, 1991

5/5

Health inspection rating (on-site)

Serious findings on record

$9,620

Fines, last 3 years

6.76

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★★5/5 · CMS overall rating: 5/5

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, repeated · Aug 2, 2023 · 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 (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.

Corrected: Oct 16, 2023 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Mar 13, 2025 · F-0684 · triggered by a complaint

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

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: Mar 10, 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
Mar 13, 2025	▲ G · Actual 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
Jun 27, 2024	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jun 27, 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.
Aug 2, 2023	▲ K · Immediate jeopardy, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Aug 2, 2023	E · Potential for harm, repeated	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.
Aug 2, 2023	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.
Aug 2, 2023	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.
Aug 2, 2023	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Aug 2, 2023	D · Potential for harm, one-off	The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD).

Inspection trend by year

Year	Citations	Serious (G–L)	Worst severity that year
2023	6	1	K ▲
2024	2	0	D
2025	1	1	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)

1 fine totaling $9,620.

Date	Type	Amount / length
Mar 13, 2025	Fine	$9,620

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)	6.76	5.15	3.95	top 6% in North Dakota; top 2% in the U.S.
Registered Nurse hours	2.02	1.09	0.69	top 3% in North Dakota; top 2% in the U.S.
Weekend total nurse staffing	6.05	4.43	3.50	top 4% in North Dakota; top 2% in the U.S.
Weekend RN hours (not acuity-adjusted)	1.07	0.59	0.48	top 3% in North Dakota; top 5% in the U.S.
Total nursing staff turnover (%)	32.9	48.8	45.8	top 14% in North Dakota; top 20% in the U.S.
RN turnover (%)	29.4	40.3	42.9	top 31% in North Dakota; top 28% 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 5.07, RN 1.52, weekend 4.54. 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: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5

Who owns this facility

Government - State

Owner / manager	Type	Role	Stake	Since
North Dakota Veterans Home	Organization	5% or Greater Direct Ownership Interest	—	12/02/1991
Johnson, Mark	Individual	W-2 Managing Employee	NOT APPLICABLE	02/26/2008
Lunneborg, Kristin	Individual	Corporate Director	NOT APPLICABLE	04/19/2004
Lunneborg, Kristin	Individual	Operational/Managerial Control	NOT APPLICABLE	06/01/2003

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"Who completes resident assessments here, and how do you check them for accuracy?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
"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?"
"What mental health services do you offer on-site, and how do you care for residents with depression, anxiety, or a history of trauma?"
"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
Parkside Lutheran Home	2.6 mi	Lisbon, ND	★☆☆☆☆	2/5
SMP Health - Maryhill	14.9 mi	Enderlin, ND	★★★★★	5/5

Compare this facility with the 2 closest →

All facilities in Lisbon →

Facility data as of CMS processing date 2026-08-01. CCN 355114.

The Care File

Visit checklist — North Dakota Veterans Home

1600 Veterans Drive, Lisbon, ND 58054 · 7016836500

Health inspection rating 5/5 · CMS overall 5/5· Fines (3y): $9,620

Most serious findings on record:

▲ Aug 2, 2023 (F-0689, Immediate jeopardy, repeated): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
▲ Mar 13, 2025 (F-0684, Actual 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.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "Who completes resident assessments here, and how do you check them for accuracy?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
☐ "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?"
☐ "What mental health services do you offer on-site, and how do you care for residents with depression, anxiety, or a history of trauma?"
☐ "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?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 355114 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)