Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Dakota Veterans Home during CMS and state inspections, most recent first.
A resident with dysphagia and a physician-ordered mechanical soft, ground meat diet was served unmodified food that did not meet prescribed consistency requirements. Dietary staff failed to grind the meal as ordered, and a CNA did not intervene. The resident choked during the meal and died despite staff attempts to assist.
A facility failed to accurately code the MDS for a resident who returned from the hospital after a fall. The MDS was incorrectly marked as not the first assessment since reentry, and a fall prior to reentry was not documented. This error could impact the resident's care plan and needs assessment.
A nurse failed to follow infection control practices during a dressing change for a resident. After removing soiled gloves, the nurse did not perform hand hygiene before donning new gloves to apply a clean dressing. The nurse also exited the room without performing hand hygiene, contrary to facility policy.
Failure to Provide Prescribed Diet Results in Resident Choking Death
Penalty
Summary
The facility failed to ensure that a resident received food items consistent with their prescribed diet, resulting in a choking episode and subsequent death. The resident had a complex medical history, including adult failure to thrive, Alzheimer's disease, dementia, dysphagia, functional quadriplegia, and weakness. A speech therapy evaluation and physician's order specified a mechanical soft diet with ground meats and nectar thickened liquids due to the resident's swallowing difficulties and risk of aspiration. The resident's care plan also indicated the need for one-on-one assistance with feeding, and the menu card for the meal in question specified ground marinated sirloin steak with gravy. Despite these clear dietary requirements, the dietary staff member responsible for plating the meal did not grind the food as required. The staff member acknowledged noticing the need for the food to be chopped but did not follow through, and the plate left the kitchen unmodified. Another staff member, a CNA, indicated that the meal was fine and left the kitchen, but no further action was taken to ensure the meal met the prescribed consistency. As a result, the resident was served food that did not align with the mechanical soft, ground meat diet ordered by the physician and recommended by the speech therapist. During the meal, the resident began choking. Staff attempted the Heimlich maneuver and used a life vac device in an effort to dislodge the food, but were unsuccessful. The resident ultimately passed away as a result of the choking incident. The failure to follow the prescribed diet and ensure the correct meal consistency directly led to the resident receiving unsafe food, which resulted in the fatal choking episode.
Inaccurate MDS Coding for Resident Post-Hospitalization
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for a resident, which is crucial for reflecting the resident's current status and needs. Specifically, the facility did not correctly code the MDS for a resident who had been transferred to the hospital after a fall and then returned to the facility. The coding error involved the A0310E and J1700A sections of the MDS, where the facility incorrectly marked the assessment as not being the first since reentry and failed to document a fall that occurred in the month prior to the resident's reentry. The resident's medical record indicated a fall on a specific date, yet the MDS completed after the resident's return to the facility did not reflect this incident. This inaccuracy in the MDS could potentially affect the development of a comprehensive care plan and the care provided to the resident. The failure to accurately complete the MDS was identified during a review of the resident's medical records and the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual.
Infection Control Breach During Dressing Change
Penalty
Summary
The facility failed to adhere to infection control practices during a dressing change for a resident. A nurse performed hand hygiene and donned gloves before removing an old dressing from the resident's foot and cleansing the wound. However, after removing the soiled gloves, the nurse did not perform hand hygiene before donning new gloves to apply a clean dressing and wrap the resident's foot. Additionally, the nurse exited the resident's room without performing hand hygiene after removing the gloves. This action was contrary to the facility's policy, which requires hand hygiene after removing dirty gloves and before applying new ones.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lisbon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkside Lutheran Home | 2.6 mi | ★★★★★ | 10 | 0 |
| Smp Health - Maryhill | 14.9 mi | ★★★★★ | 3 | 0 |
| Four Seasons Health Care Inc | 21.5 mi | ★★★★★ | 12 | 0 |
| Good Samaritan Society - Oakes | 28.1 mi | ★★★★★ | 11 | 1 |
| St Rose Care Center | 30.8 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.