Pembilier Nursing Center
500 Delano Ave, Walhalla, ND 58282 · Pembina County · 31 certified beds · avg 29 residents/day · certified since Jun 1, 1978
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · 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 · Jan 25, 2024 · F-0684
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: Feb 16, 2024 (Deficient, Provider has date of correction)
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 |
|---|---|---|
| Apr 29, 2026 | F · Potential for harm, facility-wide | 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. |
| Apr 29, 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. |
| Apr 29, 2026 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Apr 29, 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. |
| Jan 25, 2024 | ▲ 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. |
| Jan 25, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Jan 25, 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. |
| Jan 25, 2024 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| Jan 25, 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. |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 5 | 1 | G ▲ |
| 2026 | 4 | 0 | F |
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)
No fines or payment denials in the published 3-year window.
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) | 4.18 | 5.15 | 3.95 | bottom 16% in North Dakota; top 33% in the U.S. |
| Registered Nurse hours | 0.74 | 1.09 | 0.69 | bottom 14% in North Dakota; top 32% in the U.S. |
| Weekend total nurse staffing | 3.53 | 4.43 | 3.50 | bottom 13% in North Dakota; top 41% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.55 | 0.59 | 0.48 | top 50% in North Dakota; top 28% in the U.S. |
| Total nursing staff turnover (%) | 46.9 | 48.8 | 45.8 | top 39% in North Dakota; bottom 45% in the U.S. |
| RN turnover (%) | 33.3 | 40.3 | 42.9 | top 41% in North Dakota; top 33% 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 3.77, RN 0.67, weekend 3.19. Staffing rating: 4/5.
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: 3/5 · short-stay residents: —/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Carpenter, Kathleen | Individual | Corporate Director | NOT APPLICABLE | 11/01/2024 |
| Fraser, Debra | Individual | Corporate Officer | NOT APPLICABLE | 09/01/2016 |
| Fraser, Debra | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2016 |
| Fraser, Debra | Individual | ADP of the SNF | NOT APPLICABLE | 02/06/2025 |
| Gehrtz, Lacey | Individual | Corporate Officer | NOT APPLICABLE | 06/28/2023 |
| Jackson, Dean | Individual | Corporate Officer | NOT APPLICABLE | 03/05/2010 |
| Longtin, Phil | Individual | Corporate Officer | NOT APPLICABLE | 03/05/2010 |
| Moe, Linsey | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/19/2021 |
| Mostad, Manford | Individual | Corporate Officer | NOT APPLICABLE | 03/26/2015 |
| Schmidt, Barbara | Individual | Corporate Officer | NOT APPLICABLE | 10/01/2011 |
| Thompson, Susan | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Thompson, Susan | Individual | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "How do you coordinate hospice care, and can residents stay here while receiving it?"
- "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 |
|---|---|---|---|---|---|
| Wedgewood Manor | 15.8 mi | Cavalier, ND | ★☆☆☆☆ | 1/5 | SFF |
Compare this facility with the 1 closest →
Facility data as of CMS processing date 2026-08-01. CCN 355057.