Average — CMS composite of the measures below.
The next survey window likely opens 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 Smp Health - Ave Maria during CMS and state inspections, most recent first.
A facility failed to protect two residents from physical abuse by each other after a roommate conflict over food escalated into an unwitnessed altercation involving hair pulling, hitting, and biting. One resident with intact cognition and another with dementia and impaired cognition became physically aggressive, and the incident involved bodily fluids that required bloodborne pathogen testing.
A resident repeatedly directed verbal abuse toward his roommate, including name-calling, yelling, and statements about putting a pillow over the roommate’s face so he would die. The roommate’s record and care plan did not address these behaviors, and staff interviews showed the comments were not consistently reported to nursing leadership or social services. The facility did not identify the conduct as abuse or ensure the roommate was protected from the repeated verbal aggression.
A facility failed to report resident-to-resident verbal abuse to the SSA after one resident made vulgar name-calling and threatening statements toward a roommate, including comments telling staff to "knock him out" and to put a pillow over the roommate's face so he dies. The record lacked evidence of an abuse report, and an admin staff member confirmed the incidents were not reported.
Failure to investigate resident-to-resident verbal abuse. A resident’s roommate made vulgar comments and told staff to knock him out and put a pillow over his face so he dies. Although staff documented the behavior and discussed it in a stand-up meeting, leadership stated the DON, administrator, and social work designee were not notified, so the incident was not investigated as abuse or reported to the SSA.
Failure to notify the provider of out-of-range BG readings for a resident with DM. The resident’s orders required BG checks QID and MD notification for BG >300 or <70, but the MAR showed multiple high and low readings without documentation that staff notified the MD. An administrative nurse confirmed the record lacked documentation of provider notification.
The facility failed to follow infection control practices, including hand hygiene, enhanced barrier precautions, and glucometer cleaning, affecting four residents. A CNA did not perform hand hygiene after glove removal, and a nurse did not disinfect a glucose meter before storage. Additionally, CNAs did not wear gowns during high-contact care for a resident under enhanced barrier precautions.
A resident with a wound vacuum was observed sitting in the hallway with the wound vacuum collection container visible, compromising their dignity. Despite a hand towel partially covering the canister during a second observation, the contents were still visible. An administrative nurse acknowledged that wound vacuum containers should be covered when residents are outside their rooms.
A facility failed to ensure accurate labeling of medications for a resident receiving insulin from an injector pen. A nurse prepared the insulin pen, which lacked a legible label with the resident's name or identifying information. This was confirmed by an administrative nurse, despite the facility's policy requiring proper labeling by the pharmacy or with resident identification if received from mail order pharmacies.
A resident with dementia and anxiety disorder was subjected to abuse by a CNA who placed a rag in her mouth to silence her. The resident, who exhibited behaviors such as moaning and nonsensical speech, was dependent and cognitively impaired. The CNA's actions were reported by other staff, revealing a failure to adhere to the facility's abuse policy and provide necessary services to avoid mental anguish.
Failure to Protect Residents From Physical Abuse
Penalty
Summary
The facility failed to protect two sampled residents from physical abuse by each other. One resident with intact cognition and a care plan noting irritability when he felt others were taking something from him was involved in an unwitnessed altercation with his roommate, who had dementia and moderately impaired cognition. According to the incident documentation, the roommate went to the other resident’s side of the room and tried to take popcorn from his nightstand, after which the two residents became physically aggressive with each other. The altercation involved hair pulling, hitting, and biting. One resident reported that his roommate hit him on the top of the head, pulled out a clump of his hair, and tried to hit him in the face, and he responded by biting the roommate’s hand. The incident required staff intervention to separate the residents and was serious enough that bloodborne pathogen testing was performed because saliva and blood were involved.
Failure to Protect Roommate from Verbal Abuse
Penalty
Summary
The facility failed to ensure one supplemental resident was free from resident-to-resident verbal abuse. Resident #35 shared a room with Resident #4 after the room change on 10/22/25. The facility policies reviewed stated that residents have the right to be free from verbal abuse and that behavior monitoring, assessment, documentation, communication, and care plan revision are required when new or worsening behaviors occur. Resident #4’s record showed repeated verbal behaviors directed toward his roommate, including calling him names, yelling at him when he snored or used the television, and making statements such as telling staff to "knock him out" and saying to put a pillow over his face so he dies. Additional notes documented that Resident #4 called his roommate vulgar names, made comments about his weight, and repeatedly yelled at him during the night and when the roommate was snoring. The care plan for Resident #4 addressed anxiety, depression, and psychotropic/anti-anxiety medications, but did not include interventions for these verbal behaviors toward Resident #35. Interviews showed staff were not consistently informed about the behaviors. A nurse stated she was not notified of the comments and that the administrator or social worker were also not notified. Another nurse stated the nurse manager should have been called to ensure Resident #35’s safety when there is a threat like that because this is abuse. An administrative staff member stated a CNA reported the behavior and was told to complete a behavior observation form, which was later brought to the office and discussed at a management stand-up meeting. A social services staff member stated she first heard about the behavior the day before the interview. The facility did not identify the behaviors as verbal abuse, protect Resident #35 from abuse, update the care plan, or assess and monitor the behaviors for patterns or causes.
Failure to Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to report suspected resident-to-resident abuse to the State Survey Agency for one supplemental resident who experienced verbal abuse. The facility policy stated that each resident has the right to be free of verbal abuse and that any alleged incident must be reported to the North Dakota Health Department immediately, within 24 hours or less. Review of the medical record showed that one resident was moved into the same room as another resident, and the roommate later made vulgar name-calling statements and threatening remarks, including telling staff to "knock him out" and saying to put a pillow over the roommate's face so he dies. The record lacked evidence that the facility reported these incidents to the SSA as possible abuse, and an administrative staff member confirmed the incidents were not reported. The facility failed to recognize the name calling and threatening behaviors as abuse and report them to the SSA.
Failure to Investigate Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving a resident who experienced verbal abuse from a roommate. The facility policy titled, Abuse, stated that each resident has the right to be free of verbal abuse and that all alleged abuse would be investigated by the DON. Review of the record showed one resident was admitted on 10/10/25 and another resident was moved into the same room on 10/22/25. Progress notes and a behavior observation form documented that the roommate called the other resident vulgar names and told staff to "knock him out," and later said to put a pillow over the resident's face so he dies. The behavior observation form also recorded that the resident was napping and snoring when the statement was made, and the roommate responded, "I don't care" when told the comment was not nice and rude. During interviews, an administrative staff member stated a CNA reported the behavior, the issue was discussed at a stand-up meeting, and the social service member stated she first heard about it the day before the interview. Another administrative staff member stated that neither she, the administrator, nor the social worker designee were notified, so the behaviors were not investigated as abuse and were not reported to the SSA.
Failure to Notify Provider of Out-of-Range Blood Glucose Readings
Penalty
Summary
The facility failed to ensure staff provided necessary care and services for a resident with diabetes mellitus and polyneuropathy. The resident’s care plan stated the resident would be free from signs and symptoms of hyperglycemia and hypoglycemia, would have no complications related to diabetes through the review date, and would receive diabetes medication as ordered by the doctor with monitoring and documentation for side effects and effectiveness. A physician’s order directed staff to check blood glucose four times daily and as needed, and to notify the MD if glucose was greater than 300 or less than 70. Review of the resident’s medication administration records from November 1, 2025 through December 9, 2025 showed 16 blood glucose readings above 300 mg/dL, ranging from 301 mg/dL to 460 mg/dL, and 4 readings below 70 mg/dL, ranging from 58 mg/dL to 69 mg/dL. The medical record lacked documentation that staff notified the provider of these out-of-range readings, and an administrative nurse confirmed the lack of documentation during interview.
Infection Control Deficiencies in Hand Hygiene and Equipment Cleaning
Penalty
Summary
The facility failed to adhere to infection control standards for hand hygiene, enhanced barrier precautions, and cleaning of a glucometer, affecting four residents. During observations, a CNA did not perform hand hygiene after removing gloves while assisting a resident with perineal care and other tasks. Similarly, a nurse failed to perform hand hygiene after removing soiled gloves and before donning clean gloves during a dressing change for another resident. These actions were contrary to the facility's hand hygiene policy, which mandates hand hygiene before applying and after removing gloves. Additionally, the facility did not comply with its enhanced barrier precautions policy. Two CNAs assisted a resident under enhanced barrier precautions without wearing the required gowns during high-contact care activities, such as changing briefs and transferring the resident. Furthermore, a nurse did not disinfect a glucose meter with an Oxivir wipe before placing it back in a Ziploc bag, as required by the facility's policy. These lapses in infection control practices were confirmed by an administrative nurse during interviews.
Failure to Maintain Resident Dignity with Wound Vacuum
Penalty
Summary
The facility failed to maintain the dignity of a resident with a wound vacuum by not adequately covering the wound vacuum collection container. Observations on two occasions showed the resident sitting in the hallway with the wound vacuum and its contents visible, which does not preserve the resident's personal dignity. On the second observation, a hand towel was partially covering the canister, but the contents remained visible. An administrative nurse confirmed that wound vacuum containers should be covered when residents are out of their rooms.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure accurate labeling of medications for a resident who was observed receiving medication from an injector pen. During an observation, a nurse prepared a Novolog insulin pen for administration to the resident, but the pen lacked a legible label with the resident's name or other identifying information. This was confirmed during an interview with an administrative nurse, who acknowledged the absence of a legible label on the insulin pen. The facility's policy on medication storage and labeling, revised in July 2024, requires that medications be labeled by the pharmacy or, if received from mail order pharmacies without individual labels, be labeled with resident identification information.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from mental and physical abuse, as evidenced by an incident involving a certified nurse aide (CNA) who placed a rag in the resident's mouth to silence her. The resident, who had diagnoses of dementia with agitation and anxiety disorder, exhibited behaviors such as moaning, groaning, and making nonsensical sounds, which were interpreted as signs of internal distress or confusion. Despite the resident's severe cognitive impairment and dependency, the CNA resorted to inappropriate and abusive actions to manage the resident's behavior, which was witnessed and reported by other staff members. The facility's policy on abuse clearly defines physical and mental abuse, yet the staff failed to adhere to these guidelines by not providing the necessary services to avoid mental anguish and emotional distress for the resident. The CNA's actions were reported by other CNAs, who described the abusive behavior and the CNA's admission of using a rag to silence the resident. This incident highlights a significant lapse in the facility's duty to ensure a safe and respectful environment for its residents, as the staff did not utilize appropriate interventions for managing the resident's behaviors.
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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 Jamestown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eventide Jamestown | 1.4 mi | ★★★★★ | 2 | 0 |
| Smp Health - St Raphael | 33 mi | ★★★★★ | 2 | 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.