Warroad Care Center
1401 Lake Street Northwest, Warroad, MN 56763 · Roseau County · 49 certified beds · avg 46 residents/day · certified since Aug 1, 1986
Abuse citation flag (CMS)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
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 · Nov 6, 2024 · F-0600
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 (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: Dec 20, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Nov 6, 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 (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: Dec 20, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jun 13, 2024 · F-0803 · triggered by a complaint
The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
Why it matters: When menus aren't planned and followed properly, residents may not get the nutrition their health depends on.
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: Jul 11, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Sep 8, 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 (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: Oct 20, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 22, 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: Dec 15, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (48)
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 |
|---|---|---|
| Dec 18, 2025 | F · Potential for harm, facility-wide | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Dec 18, 2025 | F · Potential for harm, facility-wide | 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. |
| Dec 18, 2025 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Dec 18, 2025 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Dec 18, 2025 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Dec 4, 2025 | D · Potential for 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 |
| Dec 4, 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. · from a complaint |
| Mar 27, 2025 | D · Potential for harm, one-off | 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 |
| Nov 6, 2024 | ▲ J · Immediate jeopardy, 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. |
| Nov 6, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Nov 6, 2024 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Nov 6, 2024 | F · Potential for harm, facility-wide | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. |
| Nov 6, 2024 | F · Potential for harm, facility-wide | The facility did not designate a physician to serve as medical director — the doctor responsible for overseeing resident care policies and coordinating medical care across the facility. |
| Nov 6, 2024 | F · Potential for harm, facility-wide | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
| Nov 6, 2024 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Nov 6, 2024 | F · Potential for harm, facility-wide | 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. |
| Nov 6, 2024 | F · Potential for harm, facility-wide | The facility did not develop, carry out, or maintain an effective training program for all new and existing staff members. |
| Nov 6, 2024 | F · Potential for harm, facility-wide | The facility did not develop or maintain an effective training program for its direct care staff, including training on how to communicate effectively with residents. |
| Nov 6, 2024 | F · Potential for harm, facility-wide | The facility did not educate its staff on residents' rights and the facility's responsibilities toward residents. Staff can only respect rights they've been taught about. |
| Nov 6, 2024 | F · Potential for harm, facility-wide | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. · from a complaint |
| Nov 6, 2024 | F · Potential for harm, facility-wide | The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. |
| Nov 6, 2024 | F · Potential for harm, facility-wide | The facility did not include required infection control training — with written standards, policies, and procedures — as part of its infection prevention program. |
| Nov 6, 2024 | F · Potential for harm, facility-wide | The facility did not provide its staff with training in compliance and ethics — teaching employees the laws and ethical standards that govern how residents must be treated. |
| Nov 6, 2024 | F · Potential for harm, facility-wide | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Nov 6, 2024 | F · Potential for harm, facility-wide | The facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. · from a complaint |
| Nov 6, 2024 | E · Potential for harm, repeated | 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. |
| Nov 6, 2024 | D · Potential for harm, one-off | 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. |
| Nov 6, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Nov 6, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Nov 6, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Nov 6, 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. |
| Nov 6, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Nov 6, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Nov 6, 2024 | C · Minimal risk, facility-wide | The facility did not bring in qualified outside professionals to provide a required service when it didn't have a qualified professional on staff. |
| Nov 6, 2024 | C · Minimal risk, facility-wide | The facility did not have an agreement with at least one Medicare- or Medicaid-certified hospital to ensure residents can be transferred quickly when they need hospital care. |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jul 17, 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 |
| Jun 13, 2024 | ▲ J · Immediate jeopardy, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint |
| Dec 6, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Dec 6, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Dec 6, 2023 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · from a complaint |
| Nov 29, 2023 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Nov 29, 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. |
| Nov 29, 2023 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Nov 29, 2023 | 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 22, 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 |
| Nov 22, 2023 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint |
| Sep 8, 2023 | ▲ J · Immediate jeopardy, 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 (27 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 10 | 2 | J ▲ |
| 2024 | 30 | 3 | J ▲ |
| 2025 | 8 | 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)
7 fines totaling $280,774, plus 4 Medicare payment denial periods.
| Date | Type | Amount / length |
|---|---|---|
| Nov 6, 2024 | Fine | $145,889 |
| Nov 6, 2024 | Payment Denial | 15 days from Dec 5, 2024 |
| Jun 13, 2024 | Fine | $16,187 |
| Jun 13, 2024 | Payment Denial | 5 days from Jul 6, 2024 |
| Jan 2, 2024 | Fine | $3,529 |
| Dec 11, 2023 | Fine | $8,469 |
| Nov 22, 2023 | Fine | $11,180 |
| Nov 22, 2023 | Payment Denial | 1 days from Dec 21, 2023 |
| Nov 6, 2023 | Fine | $5,293 |
| Sep 8, 2023 | Fine | $90,227 |
| Sep 8, 2023 | Payment Denial | 15 days from Oct 5, 2023 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Minnesota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 6.01 | 4.83 | 3.95 | top 12% in Minnesota; top 4% in the U.S. |
| Registered Nurse hours | 1.01 | 1.22 | 0.69 | bottom 36% in Minnesota; top 15% in the U.S. |
| Weekend total nurse staffing | 5.24 | 4.27 | 3.50 | top 10% in Minnesota; top 5% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.59 | 0.69 | 0.48 | top 50% in Minnesota; top 24% in the U.S. |
| Total nursing staff turnover (%) | 0.0 | 42.2 | 45.8 | — |
| RN turnover (%) | 0.0 | 38.6 | 42.9 | — |
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 5.00, RN 0.84, weekend 4.36. 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: 2/5 · long-stay residents: 2/5 · short-stay residents: —/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bertilrud, Mark | Individual | W-2 Managing Employee | NOT APPLICABLE | 05/09/2016 |
| Bertilrud, Mark | Individual | Corporate Director | NOT APPLICABLE | 05/09/2016 |
| Casperson, Tom | Individual | Corporate Officer | NOT APPLICABLE | 06/01/2022 |
| Doyle, Ronda | Individual | Corporate Officer | NOT APPLICABLE | 10/27/2004 |
| Erickson, Deborah | Individual | Corporate Officer | NOT APPLICABLE | 01/07/2010 |
| Evans, Robert | Individual | Corporate Officer | NOT APPLICABLE | 06/24/2009 |
| Griffin, Miki | Individual | Corporate Officer | NOT APPLICABLE | 06/01/2022 |
| Marvin, Maureen | Individual | Corporate Officer | NOT APPLICABLE | 06/01/2022 |
| Musgrove, Donnie | Individual | Corporate Officer | NOT APPLICABLE | 06/01/2022 |
| Schaible, Brian | Individual | Corporate Officer | NOT APPLICABLE | 04/12/2006 |
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 reviews your menus, and can I see this week's menu and join my family member for a meal?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What percentage of your residents and staff are vaccinated against flu and pneumonia, and how do you offer the vaccines?"
- "Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
- "How do you handle COVID-19 vaccination for residents and staff, and what happens during an outbreak?"
- "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 |
|---|---|---|---|---|---|
| Lifeceare Roseau Manor | 19.7 mi | Roseau, MN | ★★★★☆ | 4/5 |
Compare this facility with the 1 closest →
Facility data as of CMS processing date 2026-08-01. CCN 245329.