Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 - St Catherine North during CMS and state inspections, most recent first.
Staff failed to follow physician orders for three residents. One resident’s ordered knee-high compression socks were not applied and were not identified in the care plan, a resident with Alzheimer’s disease and dysphagia was initially offered whole pills despite an order to crush meds in puree, and another resident’s ordered ace wrap for lymphedema was not observed on the right arm during multiple checks.
Staff failed to follow infection control practices during resident care and shared equipment use. A med aide brought an electronic vitals machine into a resident’s COVID isolation room and did not disinfect the entire machine afterward. During toileting, wound care, and incontinence care for multiple residents, CNAs and an RN failed to perform hand hygiene after glove removal, before touching other items, and before applying clean gloves. An admin nurse confirmed staff were expected to perform hand hygiene after glove removal and before touching other items or applying new gloves.
Failure to document GDR attempts or contraindications for psychotropic meds affected two residents. One resident with schizoaffective disorder, psychosis, and depression received an antipsychotic, and another resident with Parkinson's disease, dementia, and depression received an antidepressant; both records lacked evidence of a GDR or a documented clinical reason it was contraindicated, and an administrative nurse confirmed the missing documentation.
Failure to complete a PASARR status change assessment for a resident with new mental health diagnoses and a new antipsychotic order. The resident had prior PASARR findings for depression, anxiety, and panic disorder, then later had paranoia and delusional disorder documented with Seroquel ordered for bedtime. The record lacked evidence of a new Level I screen, and a social services staff member confirmed the change-in-status screen was not completed.
Two residents experienced medication administration errors, resulting in a seven percent error rate. A medication aide dispensed an incorrect dose of Meclizine, and a nurse improperly crushed Depakote Sprinkle capsules, contrary to manufacturer instructions.
A resident experienced a significant medication error when a nurse crushed Depakote Sprinkle Capsules, contrary to manufacturer instructions. The capsules were meant to be opened and mixed with soft food, not crushed. This error was confirmed by an administrative staff member, highlighting a failure to follow the facility's medication administration policy.
The facility failed to properly label and store food items in two unit kitchenettes. An undated opened container of thickened juice was found in the Three South kitchenette, contrary to the manufacturer's instructions to use within 10 days of opening. Additionally, ice packs were not stored separately from food items in both the Three South and Three North kitchenettes. Staff acknowledged the expectation for proper storage and labeling practices.
A resident fell out of a Hoyer sling during a transfer due to inadequate supervision and assistance, resulting in injuries and an ER visit. The facility's investigation found that a CNA did not follow proper procedures, such as ensuring the sling was securely hooked and maintaining hands-on support. The resident exhibited signs of injury, including bruising and a hematoma, and experienced a seizure, necessitating further medical evaluation.
Failure to Follow Physician Orders for Compression Socks, Crushed Medications, and Ace Wrap
Penalty
Summary
The facility failed to follow physician orders for three sampled residents. Resident #71 had an order for beige knee-high compression socks to be worn in the morning and removed at bedtime for edema, but observations on 02/09/26 and 02/10/26 showed staff did not apply the compression socks. The resident’s current care plan also did not identify the use of the compression socks. An administrative nurse confirmed that staff failed to apply the socks and update the care plan. Resident #107, who had Alzheimer’s disease and dysphagia, had a physician order to crush medications in pureed food. During observation, a medication aide brought whole pills into the resident’s room, then exited with the pills after the resident refused them. A nurse later readministered the morning medications crushed in pudding and stated the medications were being readministered because the medication aide had attempted to give them whole. Resident #124 had an order for an ace wrap to the right upper extremity for lymphedema, to be applied in the morning and removed at bedtime, and the EMAR reflected that schedule. However, observations on multiple occasions showed no ace wrap on the resident’s right arm.
Infection Control Lapses During Resident Care and Equipment Use
Penalty
Summary
The facility failed to follow infection prevention and control standards for shared equipment use, glove removal, and hand hygiene during care for multiple residents. Review of facility policies showed that hand hygiene is required before and after direct resident contact, after removing gloves, and before touching non-contaminated items or surfaces. The policies also directed staff to remove gloves promptly after use, perform hand hygiene after glove removal, and disinfect common equipment before using it on another resident. During survey review, staff were observed not following these practices in several resident care situations. Resident #107 had a care plan noting a positive COVID-19 test on 2/3/2026 and droplet isolation precautions. On 2/10/26, a medication aide entered the room with an electronic vitals machine. After exiting, the aide wiped down the BP cuff, cord, and top of the machine but did not wipe down the entire machine. An administration nurse later stated the vitals machine should not have been taken into the COVID transmission-based room and, if used there, would need to be sanitized top to bottom. Another nurse later confirmed designated equipment was in the room and stated the machine used earlier had been disinfected top to bottom. During toileting and wound care observations, staff repeatedly failed to remove gloves and perform hand hygiene at required points. For Resident #11, two CNAs assisted with toileting; one CNA disinfected the toilet seat and grab bars, removed a glove, and then touched items in the shower room without hand hygiene, while both CNAs failed to perform hand hygiene before assisting with toileting. For Resident #57, a nurse removed soiled dressing and gloves during a dressing change, then applied clean gloves without hand hygiene and continued wound care while also touching the resident’s clothing, pillows, blanket, and light without removing gloves. For Resident #81, a CNA and a nurse provided incontinence care and repositioning; the CNA applied a clean brief and adjusted clothing and blanket without removing soiled gloves or performing hand hygiene, and the nurse also failed to perform hand hygiene after removing gloves and before exiting the room. An administrative nurse confirmed staff were expected to perform hand hygiene after glove removal and before touching other items or applying new gloves.
Failure to Document Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a medication regimen free from unnecessary medications for 2 of 5 sampled residents reviewed for medication use. A facility policy titled Drug Regimen Review stated that the consultant pharmacist would review antipsychotic and antidepressant medications for dose, duration, continued need, and adverse side effects, and that medication tapering should be attempted when the resident's clinical condition had improved or stabilized or the underlying cause of symptoms had resolved. Resident #6 had diagnoses of schizoaffective disorder, psychosis, and depression, and was receiving Lurasidone, an antipsychotic, daily since 7/17/2024. The medical record lacked documentation that a gradual dose reduction was attempted or that there were reasons a gradual dose reduction was contraindicated from 2024 through February 2026. Resident #11 had diagnoses of Parkinson's Disease, dementia, and depression, and was receiving Sertraline, an antidepressant, daily since 11/14/2024. The medical record also lacked documentation that a gradual dose reduction was attempted or that there were reasons a gradual dose reduction was contraindicated from November 2024 through February 2026. During an interview on 2/11/26 at 5:45 pm, an administrative nurse confirmed both residents' records lacked a gradual dose reduction.
Failure to Complete PASARR Status Change Assessment
Penalty
Summary
The facility failed to complete a status change assessment for one of three sampled residents reviewed for PASARR. The North Dakota PASARR Provider Manual stated that when certain events occur, nursing facility staff must contact the contracted agency to update the Level I screen to determine whether a first time or updated Level II evaluation is needed, including when a mental illness was not identified at the Level I screen and later emerged or was discovered. Resident #13’s record showed a PASARR dated 07/17/25 with diagnoses of major depression, generalized anxiety, and panic disorder, and mental health medication included Mirtazapine. A progress note dated 11/28/25 documented Seroquel 25 mg at bedtime for paranoia with a diagnosis of delusional disorder and target behaviors of paranoia, delusions, and anxiety. The record lacked evidence that the facility completed a PASARR related to the new diagnoses of paranoia and delusional disorder and the new order for Seroquel. During interview, a social services staff member confirmed the facility failed to complete a change in status Level I screen for the resident.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during medication administration for two of seven residents observed. Specifically, a medication aide incorrectly administered a dose of Meclizine to a resident with vertigo. The aide dispensed only one 12.5 mg tablet instead of the prescribed 25 mg dose, failing to provide the correct dosage as per the physician's order. This error was identified when the aide was asked to confirm the dosage and realized the mistake upon reviewing the medication administration record and the pill bottle. Another error involved a nurse improperly administering Depakote Sprinkle capsules to a resident. The nurse crushed the delayed-release capsules and mixed them with applesauce, contrary to the manufacturer's instructions, which specify that the capsules should not be crushed. This error was confirmed during an interview with an administrative staff member, who acknowledged that the Depakote Sprinkles should not have been crushed. These errors contributed to a medication error rate of seven percent, exceeding the acceptable threshold.
Significant Medication Error: Improper Administration of Depakote
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of Depakote Sprinkle Capsules. According to the physician's order, the resident was to receive Depakote Sprinkle Capsules, which could be opened and mixed with soft food but should not be crushed. However, during an observation, a staff nurse was seen crushing the Depakote Sprinkle Capsules along with other medications and administering them to the resident mixed in applesauce. This action was contrary to the manufacturer's prescribing instructions, which explicitly state that the capsules should not be crushed. The deficiency was confirmed during an interview with an administrative staff member, who acknowledged that the Depakote Sprinkles should not be crushed. The facility's policy on medication administration, which aligns with professional standards and manufacturer specifications, was not followed in this instance. This failure to adhere to the prescribed method of administration could potentially affect the medication's effectiveness and the resident's overall health.
Improper Food Storage and Labeling in Kitchenettes
Penalty
Summary
The facility failed to adhere to proper food storage and labeling protocols in two of its unit kitchenettes, specifically 3 South and 3 North. During an observation, it was noted that the refrigerator in the Three South kitchenette contained an opened container of thickened juice that was not dated, despite the manufacturer's label indicating it should be used within 10 days of opening. Additionally, the freezer compartment in the same kitchenette had an ice pack that was not separated from food items. Similarly, the Three North kitchenette freezer contained two ice packs that were not stored separately from food items. An administrative staff member acknowledged the expectation for ice packs to be stored in a plastic bag, and another staff member confirmed the undated juice should have been labeled with the date it was opened. These oversights in labeling and storage practices could potentially compromise the safety and quality of food items.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and assistance during a transfer using a full-body mechanical lift, resulting in an accident involving a resident. The resident, who required assistance from two staff members for transfers, fell out of the Hoyer sling during a transfer. This incident led to the resident sustaining injuries, including bruising and a hematoma on the back of the head, and necessitated an emergency room visit for further evaluation. The facility's investigation revealed that a certified nurse aide did not follow proper procedures for a safe transfer, such as ensuring the sling was securely hooked to the lift and maintaining hands-on guidance and support for the resident. The resident's medical records indicated that following the fall, the resident exhibited signs of discomfort and injury, including guarding the right hip, grimacing, and a large area of bruising on the head and neck. The resident also experienced a seizure and was sent back to the emergency room for further assessment. The facility's investigation confirmed that the staff member involved did not adhere to the established safe handling and transfer practices, which contributed to the resident's fall and subsequent injuries.
Removal Plan
- Completing an investigation with interviews of staff that determined the cause of the incident.
- Providing immediate staff education to staff via e-mail regarding proper transferring with Hoyer lifts.
- Completing competency validations of safe transfers for all nursing staff.
- Implemented weekly Hoyer transfer audits to ensure staff on all units are performing safe and appropriate transfers using mechanical lifts.
- Implemented weekly care plan audits to ensure Hoyer sling sizes are on each resident care plan.
- All mechanical lifts were inspected to ensure they were working properly.
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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 Fargo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany On 42nd | 1.5 mi | ★★★★★ | 0 | 0 |
| Bethany On University | 1.6 mi | ★★★★★ | 3 | 0 |
| The Meadows On University | 2.4 mi | ★★★★★ | 2 | 0 |
| Eventide Lutheran Home | 2.6 mi | ★★★★★ | 1 | 0 |
| Smp Health - St Catherine South | 3 mi | ★★★★★ | 0 | 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.