Smp Health St Aloisius
A critical access hospital in Harvey, North Dakota 58341
325 E Brewster St, Harvey, North Dakota 58341. (701) 324-4651.
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The short answer
Record last released by CMS on Oct 20, 2026.
- 1of 5 CMS’s overall rating
- Not rated patient survey rating
- 4 deficiencies cited in the last three years
- 25 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- 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?
The last inspection on record was on Oct 16, 2024: a standard inspection.
4 deficiencies cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
4 deficiencies in 1 month of the last 36. Last cited Oct 2024. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | 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 | Nov |
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 Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Oct 16, 2024: standard inspection3 deficiencies
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Maintenance
The inspectors’ words, 202 words
“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 42397 Based on observation, policy review, record review and staff interview, the Critical Access Hospital (CAH) failed to ensure monitoring of the equipment commonly used in life-saving procedures for 1 of 4 defibrillators (Operating Room) observed. Failure to monitor equipment as required limited the CAH’s ability to ensure properly functioning equipment for life-saving patient treatment. Findings include: Review of the policy titled “Checking the Crash Cart” occurred on 10/16/24. This policy, revised March 2021, stated, “. . . WEEKLY AND AFTER EACH USE: 1. Check the . . . defibrillator for proper battery charge. . . . 2. Do a weekly check of the defibrillator at 30 joules, the pacer and the recorder. . . .” On 10/15/24 at 11:00 a.m. during observation of operating room (OR), an administrative nurse (#1) stated the OR staff check the defibrillator each procedure day or at least weekly. Reviewed on 10/15/24, the 2023 and 2024 maintenance records for the OR defibrillator failed to include documentation of at least weekly monitoring.”
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Patient Care Services
The inspectors’ words, 350 words
“PATIENT CARE SERVICES CFR(s): [The doctor of medicine or osteopathy-] (iv) Periodically reviews and signs the records of all inpatients cared for by nurse practitioners, clinical nurse specialists, or physician assistants. (v) Periodically reviews and signs a sample of outpatient records of patients cared for by nurse practitioners, clinical nurse specialists, certified nurse midwives, or physician assistants only to the extent required under State law where State law requires record reviews or co signatures, or both, by a collaborating physician. This Standard is not met as evidenced by: 42397 Based on record review, review of the facility’s medical staff rules and regulations, and staff interview, the Critical Access Hospital (CAH) failed to ensure a doctor of medicine or osteopathy periodically reviewed and signed the records of all inpatients cared for by Allied Health Professionals (AHP) (nurse practitioners, clinical nurse specialists, certified nurse midwives, or physician assistants) for 2 of 10 closed records (Patient #2 and #20) reviewed who were admitted and cared for by a nurse practitioner or physician assistant. Failure to ensure a physician periodically reviewed and signed records of inpatients cared for by the AHP limited the CAH’s ability to ensure the quality and appropriateness of patient care provided. Findings include: Review of the CAH’s current “Medical Staff Rules and Regulations” occurred on 10/16/24. The regulations, dated August 2024, stated, “. . . A physician must review and sign all inpatient records developed by Allied Health Professionals for patients seen by such Allied Health Professionals. . . .” On the afternoon of 10/14/24, the CAH provided a list of inpatient admissions from April 1 - October 14, 2024. Review of the medical records occurred on all days of survey. The records identified a nurse practitioner or physician assistant admitted the following patients to the CAH, but lacked evidence a physician reviewed and signed the records: * Patient #2 admitted on 09/08/24. * Patient #20 admitted on 06/29/24. During an interview on 10/16/24 at 12:15 p.m., an administrative staff member (#2) confirmed she was unable to locate evidence a physician reviewed and signed Patient #2 and #20’s inpatient records.”
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Pa, Np, & Clinical Spec Responsibilities
The inspectors’ words, 308 words
“PA, NP, & CLINICAL SPEC RESPONSIBILITIES CFR(s): Whenever a patient is admitted to the CAH by a nurse practitioner, physician assistant, or clinical nurse specialist, a doctor of medicine or osteopathy on the staff of the CAH is notified of the admission. This Standard is not met as evidenced by: 42397 Based on record review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff notified a medical doctor (MD) or doctor of osteopathy (DO) of a patient’s admission to the CAH by a nurse practitioner (NP) or physician assistant (PA) for 3 of 20 records (Patient #2, #3 and #20) reviewed who were admitted by an NP or PA. Failure of staff to notify the MD/DO of patients admitted by an NP or PA limited the MD/DO’s ability to ensure the appropriateness of the admission and to monitor the care provided to the patients by the NP or PA. Findings include: Review of the policy titled “Physician Review of Allied Health Care Professional Patient Records and Allied Health Care Professional Physician Notification of Admission” occurred on 10/16/24. This policy, dated May 2018, stated, “. . . The Allied Health Professional . . . will notify an on-staff physician of a patient’s admission to Acute Care/Inpatient . . . and provide documentation in the patient’s record of the notification. . . . “ Review of patient medical records occurred on all days of survey. The following records of patients admitted by an NP or PA lacked evidence the CAH staff notified an MD of the admissions: * Patient #2 admitted on 09/08/24. * Patient #3 admitted on 10/14/24. * Patient #20 admitted on 06/29/24. During interview on 10/16/24 at 12:15 p.m., an administrative staff member (#2) confirmed mid-level practitioners (nurse practitioners and physician’s assistants) are required to notify the MD/DO of a patient’s admission.”
Oct 15, 2024: standard inspection1 deficiency
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Initial Comments - Not A Deficiency Citation
The inspectors’ words, 152 words
“This survey used the 2012 edition of NFPA 101, Life Safety Code, Chapter 19-Existing Health Care Occupancies and the 2012 edition of NFPA 99, Health Care Facilities Code in compliance with 42 CFR 485.623(d)(e). The facility was located in a two-story building of Type II (222) construction with a full basement. The facility was protected with an automatic sprinkler system designed to meet the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems. A two-hour fire rated occupancy separation wall was constructed between the hospital and the attached nursing facility to the east and a clinic to the west. The basement storage areas were separated from the main floor by two-hour fire resistive construction and were not included in this survey. Note: Observation and records review determined the facility to be in compliance with the minimum requirements of the 2012 Life Safety Code and NFPA 99, Health Care Facilities Code.”
All 2 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Oct 16, 2024 | Standard inspection | 3 deficiencies cited |
| Oct 15, 2024 | Standard inspection | 1 deficiency cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 1 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 3; readmission, 0 better and 2 worse of 4.
- CMS gives no CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “The number of cases/patients is too few to report a star rating.”
- In CMS’s patient survey (Oct 1, 2024 to Sep 30, 2025): 64% rated it 9 or 10 out of 10, and 76% would definitely recommend it.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart failure 12.9%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): pneumonia 17.2%. CMS gives no comparison with the national rate for them in this release.
- Emergency department patients spent a median of 76 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 0% left before being seen.
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 1 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | Not rated |
Is it certified, and in good standing?
- Medicare-certified critical access hospital since Feb 1, 2002.
- Ownership: voluntary non-profit - private.
- It is not accredited by a private organisation, so the state carries out its routine inspections for Medicare.
- 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 on record in the last three years.
- Voluntary non-profit - Private.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- CMS’s HAC Reduction Program file has no result for it: the program covers general acute care hospitals Medicare pays under its inpatient prospective payment system.
- None of the deficiencies cited in the last three years came from an inspection that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- 45% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Sisters of Mary of the Presentation Health System runs it.
- 10 owners or officers are people: Kathy Muscha (corporate director); Ryan L Mickelsen (managing employee (under contract)); Ryan L Mickelsen (corporate officer); Nicole Anderson (corporate officer); Gordon Schmidt (corporate director); Doug Heil (corporate director); Anne G Picard (corporate director); Mary Hager (corporate director); Steven C Kourajian (corporate director); Debra Berry (corporate director).
- CMS’s Provider of Services file records no change of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
How does it compare nearby?
- No other hospital CMS lists is in Wells County.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. 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 Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital 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 hospital”, and paying will never change a finding, a rating or the order of results.