Sanford Hillsboro Care Center
12 3rd St SE, Hillsboro, ND 58045 · Traill County · 34 certified beds · avg 33 residents/day · certified since Jun 1, 1978
Part of chain: SANFORD HEALTH (4 facilities, chain avg rating 2.8★)
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, repeated · Jun 5, 2024 · 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: Jun 28, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 2, 2023 · 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: Nov 7, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (10)
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 |
|---|---|---|
| Jun 26, 2025 | 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. |
| Jun 26, 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. |
| Jun 26, 2025 | 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. |
| Jun 5, 2024 | ▲ 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. |
| Jun 5, 2024 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Jun 5, 2024 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Jun 5, 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. |
| Jun 5, 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. |
| Jun 5, 2024 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Nov 2, 2023 | ▲ 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 |
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 |
|---|---|---|---|
| 2023 | 1 | 1 | G ▲ |
| 2024 | 6 | 1 | K ▲ |
| 2025 | 3 | 0 | D |
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 $42,488.
| Date | Type | Amount / length |
|---|---|---|
| Jun 5, 2024 | Fine | $35,045 |
| Nov 2, 2023 | Fine | $7,443 |
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) | 5.79 | 5.15 | 3.95 | top 21% in North Dakota; top 5% in the U.S. |
| Registered Nurse hours | 0.98 | 1.09 | 0.69 | bottom 40% in North Dakota; top 17% in the U.S. |
| Weekend total nurse staffing | 4.81 | 4.43 | 3.50 | top 27% in North Dakota; top 8% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.47 | 0.59 | 0.48 | bottom 33% in North Dakota; top 37% in the U.S. |
| Total nursing staff turnover (%) | 38.6 | 48.8 | 45.8 | top 28% in North Dakota; top 33% in the U.S. |
| RN turnover (%) | 66.7 | 40.3 | 42.9 | bottom 17% in North Dakota; bottom 15% 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 4.52, RN 0.76, 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: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Sanford | Organization | 5% or Greater Indirect Ownership Interest | 100% | 07/20/2010 |
| Sanford North | Organization | 5% or Greater Direct Ownership Interest | 100% | 03/01/2011 |
| Cain, James | Individual | Corporate Director | NOT APPLICABLE | 11/19/2015 |
| Dulski, Karin | Individual | W-2 Managing Employee | NOT APPLICABLE | 11/19/2012 |
| Engbrecht, Wesley | Individual | Corporate Director | NOT APPLICABLE | 01/01/2021 |
| Gassen, William | Individual | W-2 Managing Employee | NOT APPLICABLE | 11/24/2020 |
| Gassen, William | Individual | Corporate Director | NOT APPLICABLE | 11/24/2020 |
| Gassen, William | Individual | Corporate Officer | NOT APPLICABLE | 11/24/2020 |
| Gulsvig, Neil | Individual | Corporate Director | NOT APPLICABLE | 03/28/2019 |
| Jacobs, Donald | Individual | Corporate Director | NOT APPLICABLE | 12/04/2014 |
| Lundeen, Mark | Individual | Corporate Director | NOT APPLICABLE | 12/04/2014 |
| Marlette, William | Individual | W-2 Managing Employee | NOT APPLICABLE | 06/16/2023 |
| Marlette, William | Individual | Corporate Officer | NOT APPLICABLE | 06/16/2023 |
| Molbert, Lauris | Individual | Corporate Director | NOT APPLICABLE | 01/01/2021 |
| Morrison, Tony | Individual | W-2 Managing Employee | NOT APPLICABLE | 02/01/1991 |
| Morrison, Tony | Individual | Corporate Officer | NOT APPLICABLE | 02/01/1991 |
| Munson, Jolyn | Individual | W-2 Managing Employee | NOT APPLICABLE | 02/25/2013 |
| North, Andrew | Individual | Corporate Director | NOT APPLICABLE | 12/01/2016 |
| Swenson, Stephanie | Individual | W-2 Managing Employee | NOT APPLICABLE | 11/01/2019 |
| Teiken, Brent | Individual | Corporate Director | NOT APPLICABLE | 01/01/2013 |
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?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "If you ever planned to discharge or transfer my family member, how much written notice would we receive and how could we appeal?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Where do you post your daily staffing numbers, and can I see today's?"
- "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 |
|---|---|---|---|---|---|
| Halstad Living Center | 11.6 mi | Halstad, MN | ★★★★☆ | 4/5 | |
| Luther Memorial Home | 13.8 mi | Mayville, ND | ★★★★☆ | 3/5 |
Compare this facility with the 2 closest →
Facility data as of CMS processing date 2026-08-01. CCN 355061.