Jamestown Regional Medical Center Hospice
A hospice in Jamestown, North Dakota 58401
2422 20th St SW, Jamestown, North Dakota 58401. (701) 952-4847.
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The short answer
Record last released by CMS on Oct 23, 2026. We couldn’t read Centers for Medicare & Medicaid Services’ list since Oct 27, 2026: qcor.cms.gov now refuses our reader. This record is as of then.
- 12 deficiencies cited in the last three years
- Not rated family caregiver rating
- 10of 10 CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean2
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
12 deficiencies cited in the last three years
The middle of the 3 hospices serving ZIP code 58401 had 2.
The last inspection on record was on Jun 12, 2026: a reaccreditation inspection by The Joint Commission.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
When those deficiencies happened
12 deficiencies in 2 months of the last 36. Last cited Jun 2026. Most serious: Standard-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Jun 12, 2026: reaccreditation inspection by The Joint Commission11 deficiencies
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Content of comprehensive assessment (42 CFR 418.54(c)(5))
The inspectors’ words, 299 words
“Observed in Record Review. In 5 of 14 patient records reviewed, the organization did not assess the patient’s desired pain goal per their organization policy. An example was observed in HOSRRHV #1 on recertification the patient complained of pain 5/10 but the RN did not assess the patient’s pain goal per the agency Comprehensive Assessment policy. In HOSNHV #3 the patient’s pain goal was not assessed and this patient was on Norco 5-325 mg five times per day and their worst pain was 7/10. In HOSRRBRV #1, #2, and #3 the worst pain assessed was 7/10 and there was no pain goal assessed. This was reviewed and validated with the RN Hospice Coordinator. Observed in Record Review. In 6 of 14 patient records reviewed, where the patient had a wound the hospice surveyor observed the organization failed to assess and reassess the patients wound care measurements. In HOSRRHV #1 the patient had a wound to his left mid buttock and per the agency protocol the wounds should be measured weekly. In the months of March and April there were 15 days and 12 days in between measurements. In HOSRRHV #2 the patient had a wound to her left coccyx with wound care being provided there were no measurements of the wound for 2 months. In HOSRRNHV #1 no wound measurements were found for the left medial buttock wound for over 1 month. In HOSRRNHV #4 the patient had a wound to left foot, no wound measurements for one month. In HOSRRNHV #6 the patient had a wound to his right back and there were no wound measurements for 2 months. In HOSRRBRV #2 the patient wounds to head and neck and no wound measurements for 1 and 1/2 months. This was reviewed and validated with the Hospice RN Coordinator.”
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Content of comprehensive assessment (42 CFR 418.54(c)(8))
“Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to assess the patient’s need for volunteer services. In HOSRRHV #1, #2, #3, HOSRRNHV #1-#6, HOSRRDC #1-#2, and HOSRRBRV #1-#3, the organization did not complete a volunteer assessment. This was reviewed and validated with the Hospice RN Coordinator.”
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Content of plan of care (42 CFR 418.56(c))
The inspectors’ words, 305 words
“Observed in Record Review. In 6 of 14 patient records reviewed, the hospice nurse surveyor observed that the organization failed to plan the patient’s care. In HOSRRHV #2 the patient was on 3 different medications for pain and the plan of care did not include a goal on pain management. In HOSRRNHV #5 the patient had 3 falls with a hematoma and laceration and there was no fall prevention goal entered in the plan of care. This patient was also combative and yelling she was placed on 2 medications for anxiety and combativeness and there was no goal in the plan of care. In HOSRRNHV #6 documentation the patient was assessed to have issues with depression and was placed on a medication for this and there was no goal associated with depression in the plan of care. This patient also had a pain medication ordered for 3 times a day due to pain and there was no pain goal added to the plan of care. In HOSRRDC #2 the patient had difficulty swallowing and had lost 14 lbs. in 2 months, it was noted there was no goal in the care plan for the dysphagia or the weight loss. In HOSRRBRV #1 patient was assessed to be in severe pain and on a subcutaneous injection every 2 hours and on a pain patch and a pain goal had not been entered into the plan of care. This patient also had nausea and was started on 2 medications and a goal for nausea was not entered into the plan of care. In HOSRRBRV #2 the patient was assessed to have severe pain and was on 3 different medications for pain and there was no goal in the plan of care to address the issues surrounding pain. This was reviewed and validated with the RN Hospice Coordinator.”
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Content of plan of care (42 CFR 418.56(c)(4))
The inspectors’ words, 136 words
“Observed in Patient Home. In 2 of 14 patient records reviewed, where medication reconciliation was provided by the nurse the surveyor observed that there were pain medications that were ordered with no clear indication when to give one over the other. For example in HOSRRHV #1 the patient had orders for Tylenol 500 mg one tablet every 4 hours as needed for mild or moderate pain, and this patient also had an order for Hydrocodone Acetaminophen 5-325 mg one tablet every 4 hours as needed for moderate pain. It is not clear when the patient should get the Tylenol versus the Hydrocodone. In HOSRRNHV #6 the patient had orders for Tylenol 325 mg 2 by mouth every 4 hours as needed. There is no indication entered. This was reviewed and validated with the RN Hospice Coordinator.”
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Coordination of services (42 CFR 418.56(e)(2))
“Observed in Record Review. In 1 of 3 patient records reviewed, the organization failed to send out bereavement mailings at designated time frames. The hospice surveyor observed in HOSRRBRV #2 the spouse did not receive their, one, two and three month mailings/contact per the organization’s Bereavement Policy. This was reviewed and validated with the Hospice RN coordinator.”
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Program data (42 CFR 418.58(b)(2)(i))
“Observed in Tracer Activities. The organization failed to compile and analyze data. The hospice had collected data on multiple topics relevant to the effectiveness and safety related to services, but none of the data was used by the organization to determine if effectiveness or safety was achieved. This was reviewed and validated by the Director of Homecare.”
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Program data (42 CFR 418.58(b)(2)(ii))
“Observed in Tracer Activities. While the HCO collected a large amount of data, there was no data analysis performed over time to determine trends in performance. The organization failed to compile, trend or analyze data related to process improvement projects for 2025 and 2026. This was reviewed and validated with the RN Hospice Coordinator.”
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Performance improvement projects (42 CFR 418.58(d)(1))
“Observed in Tracer Activities. the hospice surveyor observed that the organization did not have specific performance improvement projects. There was no evidence of trending or analysis of the data for process improvement in 2025 and 2026. This was reviewed and validated with the Hospice RN Coordinator.”
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Performance improvement projects (42 CFR 418.58(d)(2))
“Observed in Tracer Activities. The surveyor noted the organization failed to document what performance improvement projects were being conducted, the reasons for conducting these projects, and the measurable progress achieved as evidenced by the HCO was not able to produce this documentation at the time of survey. this was reviewed and validated with the Director of Homecare.”
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Training (42 CFR 418.100(g)(3))
“Observed in Tracer Activities. The Medical Director and Alternate Medical Director have no ongoing competencies. This was reviewed and validated with the Director of Homecare. Observed in Tracer Activities. The Alternate Medical Director have no initial competencies. This was reviewed and validated with the Director of Homecare.”
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Content (42 CFR 418.104(a)(3))
The inspectors’ words, 108 words
“Observed in Patient Home. In 1 of 3 home visits conducted, the medication list was found to be inaccurate. In HOSRRHV #1 the medication list of the organization did not reconcile with the medications in the facility. The nurse surveyor observed that there was a medication order for Dextromethorphan Guaifenesin 10 ml by mouth every 4 hours as needed, this did not have an indication and it was also not found in the facility. The medication aide at the facility stated that she has never given this medication. The patient has been on service for over 1 year. This was reviewed and validated with the RN Hospice Coordinator.”
May 17, 2024: initial inspection by The Joint Commission1 deficiency
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Hospice aide assignments and duties (42 CFR 418.76(g)(1))
“Observed in Individual Tracer. In 3 of 4 patient records reviewed, During the record review the Hospice surveyor noted that in 3 of 4 records that the care plan for the aide did not specify tasks the aide would perform. For example in RRHN1, RRHV3, the plan of care indicated bed bath only and there were no indications of other tasks such as skin care, oral care, dressing or toileting included. This was validated in a discussion with and observation by the Hospice clinical manager.”
All 2 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Jun 12, 2026 | Reaccreditation inspection by The Joint Commission | 11 deficiencies cited |
| May 17, 2024 | Initial inspection by The Joint Commission | 1 deficiency cited |
Is it certified?
- Medicare-certified hospice since Jul 26, 1995.
- Ownership: other.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency or CMS’s most serious finding: the place’s failure to meet a rule caused, or was likely to cause, serious injury, harm, impairment or death to someone in its care. Source: CMS; 42 CFR 489.3. on record in the last three years.
CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Who does the caring?
- From Medicare claims (Jan 1, 2023 to Dec 31, 2024): 19 nurse care minutes per routine home care day, 12.6% of skilled nursing minutes at weekends and a visit near death for 97.8% of patients who died.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 24% at home, 13% in assisted living, 19% in a nursing facility, 42% in a skilled nursing facility, 1% in a hospital.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | This provider |
|---|---|
| Nurse care minutes per routine home care day | 19.0 min |
| Skilled nursing minutes at weekends | 12.6% |
| Visits near death | 97.8% of patients who died |
Who owns it?
- 18 owners or officers are people: Jeremy Robert Rham (corporate director); Casey Henderson (corporate director); Amanda Kelly Thrift (corporate director); Holly June Cherlynn Utke (corporate director); Michael J Delfs (corporate officer, 0%); Michael J Delfs (managing employee (on the payroll), 0%); Clemens Jack Hager (corporate officer); Tania Falk (corporate director, 0%); Timothy Burchill (corporate director); Derek J Schaff (corporate officer, 0%); Derek J Schaff (managing employee (on the payroll), 0%); Sean Jordan Rinkenberger (corporate officer); Bradly M Skari (corporate director); Briana Bohn (corporate director); Steven Timothy Ottmar (corporate director); Randall Lee Jaspers (corporate director); Trisha Jungels (corporate officer, 0%); Trisha Jungels (managing employee (on the payroll), 0%).
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Usda Department of Agriculture Rural Development | Holds 5% or more of the mortgage | 43% | Mar 24, 2010 |
| Compeer Financial | Holds 5% or more of the mortgage | 21% | Mar 24, 2018 |
What do families say?
- CMS gives no family caregiver survey rating: “The number of cases is too small to report Star Ratings.”
- In CMS’s survey of family caregivers (Oct 1, 2023 to Sep 30, 2025): 86% rated it 9 or 10 out of 10, and 87% would definitely recommend it.
- CMS’s Hospice Care Index: 10 of 10 (Jan 1, 2023 to Dec 31, 2024).
- 100% of patients were assessed on all seven of CMS’s measures at the start of care (Oct 1, 2024 to Sep 30, 2025); 80.8% had visits from a nurse or social worker on at least 2 of their last 3 days (Jan 1, 2023 to Dec 31, 2024).
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Family caregiver survey ratingCMS star rating from its survey of patients’ family caregivers, 1 to 5 | Not rated |
| Hospice Care IndexCMS’s Hospice Care Index, 0 to 10 (higher is better): a point for each of ten measures from Medicare claims on which the hospice meets CMS’s threshold | 10 of 10 |
How does it compare nearby?
- Of the 3 hospices CMS’s data show serving patients in ZIP code 58401, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 2; this one had 12.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
| Place | Deficiencies, 3 years |
|---|---|
| Jamestown Regional Medical Center Hospice This hospice | 12 |
| Hia Hospice | 0 |
| Chi Health at Home - Hospice | 2 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
- Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.
Sources
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Centers for Medicare & Medicaid Services, Hospice General Information (yc9t-dgbk).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Provider Data (252m-zfp9).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, CAHPS Hospice Survey (gxki-hrr8).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR hospice inspection reports (Hospice Survey Reports - Oct 2021 through Sep 2026.xlsx).
Released Oct 23, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice All Owners (e983965e-1603-4cb8-82b5-c40090e380d1).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Enrollments (25704213-e833-4b8b-9dbc-58dd17149209).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice ZIP Data (95rg-2usp).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 27, 2026.
From the hospice
The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.