Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Souris Valley Care Center during CMS and state inspections, most recent first.
A resident with dementia, anxiety, and depressive disorder became upset with another resident who frequently called out for help, told her to “shut up,” and slapped her on the right cheek as he passed by. CNAs witnessed the exchange and separated the two residents. The resident who was struck, who had Alzheimer’s disease and anxiety, was later documented with a small, dime-sized bruise under her right eye aligned with her glasses, though she denied pain and did not recall the event. Despite a written abuse and neglect policy prohibiting abuse by anyone, including other residents, the incident showed the facility failed to ensure residents remained free from physical abuse.
A resident with Alzheimer’s disease, dementia, and a history of repeated falls reported a fall with head impact and a new “knot” on the back of the head, which was confirmed on assessment with bruising. Facility policy required that in cases of suspected head injury, the physician be notified by phone rather than by fax. Instead, staff sent a fax to the physician and later used email to communicate that neuro checks and VS were stable and to report multiple recent falls. An administrative staff member confirmed that the physician was not notified by phone about the head injury, resulting in a deficiency for failure to follow the facility’s fall management and physician notification policy.
A resident’s care plan was not updated to reflect improved physical mobility and ADL status, despite facility policy requiring quarterly review and revision with significant changes in condition. The care plan continued to document a need for one- and two-person assistance with bed mobility, positioning, turning, oral care, dressing, and transfers, while the resident’s MDS showed no upper or lower extremity impairment and independence with oral hygiene, dressing, bed mobility, sit-to-stand, toilet transfers, and wheelchair mobility. An administrative staff member confirmed that staff failed to revise the care plan to match the resident’s current functional ability, limiting staff communication of needs and continuity of care.
Staff did not use required safety straps on bath chairs for two residents needing assistance during bathing, resulting in a fall and hip fracture for one resident and leaving another unsecured in a whirlpool tub. The facility's policy required safety belts to be used at all times, but staff failed to follow this protocol and did not perform a nursing assessment after the fall.
A resident sustained a left hip fracture after falling from a bath chair when not secured with a safety strap during bathing. CNAs transferred the resident from the floor using a mechanical lift without prior nursing assessment, and the facility's investigation omitted key details from staff interviews regarding the incident and staff actions.
Staff did not follow established protocols after a resident with dementia and mobility deficits fell from a bath chair and sustained a hip fracture. CNAs moved the resident using a mechanical lift before a nurse performed a full-body assessment, and later used a sit-to-stand lift not included in the care plan. The nurse's assessment was limited to a skin check and basic observation, failing to meet policy requirements for post-fall evaluation.
A transcription error in a LTC facility led to a resident receiving long-acting insulin in the morning instead of the evening as prescribed. This resulted in elevated blood sugar levels and subsequent hospitalization for diabetic ketoacidosis, dehydration, and hyperglycemia. An administrative nurse confirmed the error in insulin administration.
The facility failed to provide appropriate supervision and use assistive devices for a resident with severely impaired cognition and a history of falls. Staff did not follow the care plan, leading to the resident attempting self-transfers and experiencing multiple falls, including one that resulted in a head laceration and skin tears.
A resident experienced unresolved pain and anxiety due to the facility's failure to administer PRN pain and anxiety medications as ordered. Despite physician orders and the resident's frequent pain, staff did not provide the medications as needed and failed to inform the physician about the increased use of PRN pain medication.
The facility failed to ensure accurate MDS coding for four residents, impacting their assessments and care plans. Errors included incorrect discharge status, unreported significant weight loss, misidentified pressure ulcers, and incorrect medication coding.
The facility failed to update the comprehensive care plans for five residents, resulting in outdated information regarding their medical conditions, medications, and care needs. This deficiency was confirmed through record reviews, facility policy reviews, and staff interviews.
The facility failed to maintain the dignity of two residents who required assistance with dressing. Both residents were observed wearing soiled clothing on multiple occasions, contrary to the facility's policy on resident dignity. An administrative nurse confirmed that staff are expected to change soiled clothing and ensure residents are fully dressed after care.
The facility failed to notify a resident's physician of significant weight loss, as required by policy. The resident, diagnosed with dementia and diabetes, experienced a 9.9% weight loss over 90 days, but the medical record lacked documentation of provider notification. An administrative nurse confirmed this oversight.
The facility failed to ensure staff followed standards of practice for administering intermediate-acting insulin. A nurse administered 18 units of Humalog Mix 75/25 insulin to a resident at 5:19 p.m., but the resident did not receive their supper meal until 5:44 p.m., 25 minutes later. The prescribing information requires it to be injected within 15 minutes before a meal. An administrative nurse confirmed that staff are expected to administer intermediate insulin within this timeframe.
The facility failed to ensure staff provided care and services for a resident with a CAM Boot and orders to keep the right foot elevated. Observations showed multiple instances where the resident's foot was not elevated, and documentation did not indicate who was responsible for the CAM Boot or foot elevation. An administrative staff member confirmed that nursing staff were expected to determine responsibility and document it, but this was not done.
The facility failed to maintain acceptable nutritional status for a resident who experienced a 27% weight loss over three weeks. Staff did not perform weekly weights as required, failed to re-weigh the resident, and did not document or address the significant weight loss.
The facility failed to limit the use of a PRN psychotropic medication, Lorazepam, to 14 days as required by their policy. The physician's order did not include a rationale for its extended use or a stop date. This oversight was confirmed by an administrative nurse during an interview.
The facility failed to follow infection control standards for three residents under enhanced barrier precautions (EBP). Staff did not adhere to policies on hand hygiene, glove use, and PPE, leading to improper handling of linens and resident care activities. These actions were confirmed during interviews with administrative nurses.
The facility failed to assess a resident's pneumococcal status and provide education on the benefits and potential side effects of the vaccination, as required by their policy. This deficiency was confirmed through record review and staff interviews.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Facial Bruising
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, despite having an abuse and neglect policy stating that residents must not be subjected to abuse by anyone, including other residents. According to the facility-reported incident and witness statements, a male resident with diagnoses including unspecified dementia, anxiety, and depressive disorder became upset with a female resident’s usual vocalizations of calling out for help. The male resident told the female resident to “shut up,” and she responded in kind; he then slapped her on the right cheek as he passed her. Certified nursing assistants observed the incident and separated the residents. Nursing progress notes documented that the male resident had impaired cognitive function and confusion, and that he required simple, direct communication, cues, reorientation, supervision, and redirection as needed. The female resident who was struck had diagnoses including Alzheimer’s disease and anxiety and was noted to frequently yell “help” as part of her usual behavior. Following the incident, nursing documentation identified a small, round bruise about the size of a dime under her right eye, aligned with the bottom of her glasses, with the resident denying pain. The facility’s initial investigation recorded that the female resident did not remember the incident and did not appear to be impacted by it, and an administrative staff member later stated that the incident occurred only once and that the bruise resolved. During a subsequent interview, the male resident denied any concerns with other residents and denied hitting or being hit by anyone. Despite the facility’s written policy prohibiting abuse by other residents, the occurrence of the slap and resulting facial bruise demonstrated that the facility failed to ensure the resident remained free from physical abuse.
Failure to Notify Physician by Phone After Resident Head Injury
Penalty
Summary
The facility failed to promptly notify a resident’s physician by phone of a head injury following a fall, as required by its own fall prevention and management policy. The policy, revised 10/14/25, stated that for residents with suspected head injury, physicians should be notified by phone and not fax. The resident involved had diagnoses including Alzheimer’s disease, dementia, and repeated falls, and a care plan identifying falls and gait/balance problems. On 12/06/25 at 6:40 a.m., progress notes documented that the resident came to the nursing station stating she had fallen in her room, hit her head, and had “another knot” on the back of her head; assessment found a knot with bruising to the right back of the head, and staff sent a fax to the physician. Later that day at 2:07 p.m., documentation showed the physician was notified by email with information that neurological checks and vital signs were stable, and on 12/09/25, the physician was informed the resident had eight falls since 10/07/25, six of them since 11/20/25. During interview, an administrative staff member confirmed the facility did not notify the physician by phone regarding the 12/06/25 head injury, contrary to facility policy. This sequence of events, including the resident’s documented fall history, the identified head injury with bruising, and the use of fax and email instead of a phone call, formed the basis for the deficiency related to failure to notify the physician as required.
Failure to Update Care Plan to Reflect Improved ADL and Mobility Status
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect the resident’s current functional status, as required by facility policy and federal regulations. The facility’s care plan policy, dated December 1, 2025, required each resident to have an individualized, person-centered, comprehensive plan of care with measurable goals and timetables, and directed that the interdisciplinary team review care plans at least quarterly and update them with any significant change in condition. Record review showed that one resident’s care plan, last revised on November 1, 2024, continued to document a need for assistance of one staff member for bed mobility, positioning, turning, oral care, dressing, and transfers between surfaces, and assistance of two staff members for moving between lying and sitting positions. However, the resident’s MDS assessment identified that the resident had no impairment of upper or lower extremities and was independent with oral hygiene, upper and lower body dressing, bed mobility, sit-to-stand, toilet transfers, and wheelchair mobility. The facility did not update the care plan to reflect this improvement in physical mobility and ADL status, and an administrative staff member confirmed that staff failed to revise the care plan to match the resident’s current functional ability. This failure limited staff’s ability to communicate needs and ensure continuity of care.
Failure to Use Bath Chair Safety Straps and Provide Adequate Supervision During Bathing
Penalty
Summary
Staff failed to provide appropriate supervision and use of assistive devices for two residents who required assistance during bathing. Specifically, staff did not utilize the bath chair safety strap as required by facility policy, which states that safety belts must be used for bathing units and lifts to reduce the risk of injury. One resident, who had impaired balance, limited mobility, and required staff assistance for bathing and transfers, was not secured with the safety strap during a bath. As a result, the resident fell from the bath chair and sustained a left femoral neck (hip) fracture. The incident was confirmed through staff interviews, medical record review, and facility-reported incident documentation. Another resident, who was dependent on staff for bathing and required substantial assistance with transfers, was observed seated in a whirlpool tub with the safety strap not secured. The staff member present stated that the strap had been removed because the resident was sliding down in the chair and admitted to forgetting to reapply it. These actions were in direct violation of the facility's bathing policy and the expectation that the safety belt should always be secured when residents are in the bath chair. Additionally, after the fall, staff failed to perform a nursing assessment prior to moving or assisting the resident off the floor. Interviews with staff revealed inconsistencies in the use of the safety belt and the process followed after the fall. The lack of adherence to safety protocols and failure to assess the resident post-fall contributed to the deficiency identified by surveyors.
Failure to Investigate and Document Alleged Neglect After Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate and document an alleged violation of neglect involving a resident who fell from a bath chair and sustained a left femoral neck (hip) fracture. The incident occurred when the resident was not secured in the bath chair with the safety strap during bathing. The certified nurse aide (CNA) responsible for the resident admitted to not using the safety strap, and the resident fell after reaching for the door on the tub. Following the fall, the CNAs used a mechanical lift to transfer the resident from the floor back to the bath chair without a nurse's assessment, and then later transferred the resident to her wheelchair using a sit-to-stand lift. Staff interviews revealed inconsistencies and omissions in the facility's investigation. The CNAs involved described the sequence of events, including the lack of use of the safety strap and the delay in obtaining additional help. The nurse who later entered the room was informed of the fall only after noticing a lift sheet under the resident and questioning the situation. Nursing progress notes documented the fall, the resident's subsequent pain, and the eventual transfer to the hospital for evaluation and treatment of the hip fracture. The facility's internal investigation did not include all relevant details discovered during staff interviews, such as the failure to secure the resident in the bath chair and the improper transfer of the resident post-fall without prior nursing assessment. The investigation summary concluded there was no willful intent to neglect, attributing the fall to the resident's spontaneous movement, but failed to address the staff actions and omissions that contributed to the incident.
Failure to Follow Post-Fall Assessment and Safe Transfer Protocols
Penalty
Summary
Staff failed to provide treatment and care in accordance with professional standards of practice for a resident who experienced a fall from a bath chair. The facility's policy required that after a fall, the resident should not be moved and a licensed nurse must perform a full-body assessment to determine injury before any transfer. However, after the resident fell from the bath chair and sustained a left femoral neck (hip) fracture, certified nurse aides (CNAs) moved the resident from the floor back to the bath chair using a mechanical lift without waiting for a nurse to assess the resident. The CNAs reported waiting for help for 10-15 minutes before transferring the resident themselves, and only after the transfer did a nurse arrive to perform a skin check and basic assessment. The resident involved had a history of dementia, impaired balance, limited mobility, and weakness, and required assistance of two with a gait belt for transfers. The care plan did not include the use of a sit-to-stand lift, which was used by staff following the incident. The nurse did not perform a full-body assessment prior to the transfer, as required by policy, and the transfer method used was not part of the resident's care plan or assessed for safety. These actions and inactions resulted in a failure to follow established protocols for post-fall assessment and safe transfer, potentially contributing to further injury and pain for the resident.
Insulin Administration Error Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident remained free from significant medication errors, specifically in the administration of insulin. A transcription error occurred during the admission process, resulting in the long-acting insulin dose being scheduled for 8 AM instead of the prescribed 8 PM. This error led to the resident not receiving the necessary insulin at the correct time, which may have contributed to the resident's hospitalization. The resident's medical record indicated that the physician's order was for 7 units of long-acting insulin to be administered every evening. However, the medication administration record showed that the insulin was given in the morning. As a result, the resident experienced elevated blood sugar levels, a low-grade fever, and vomiting, leading to a hospital visit where they were diagnosed with diabetic ketoacidosis, dehydration, and hyperglycemia. An administrative nurse confirmed the failure to administer the insulin as ordered.
Failure to Provide Adequate Supervision and Use Assistive Devices
Penalty
Summary
The facility failed to provide appropriate and sufficient supervision and assistive devices for a resident who required staff assistance and a gait belt during transfers. This deficiency was identified during a standard survey when it was observed that staff did not follow the care plan for a resident with severely impaired cognition and a history of falls. The resident was at risk for falls due to balance difficulty, weakness, and unsteadiness, and required extensive assistance of two staff members with transfers using a gait belt. However, staff were observed not using the gait belt appropriately and not providing the required level of assistance during transfers and toileting, leading to the resident attempting self-transfers and experiencing falls, including one that resulted in a head laceration and skin tears requiring emergency room treatment and sutures. The resident had multiple falls within a short period, indicating a failure to implement and follow the care plan effectively. Observations showed that staff either did not use the gait belt or did not provide the necessary assistance during transfers, which directly contributed to the resident's falls and injuries. Interviews with facility staff confirmed that the care plan was not followed as expected, leading to the identified deficiency.
Removal Plan
- Inservice and education on appropriate actions/interventions per care plan specific to toileting and transfers to meet residents needs and prevent injury with the staff member directly involved in the deficient practice, all nursing staff on duty, and on-coming staff.
- Review of Resident's transfer requirements as outlined in their individual care plans.
- Review of facility policies and resources for questions/concerns.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for Resident #31, who experienced frequent and severe pain. Despite having physician orders for Acetaminophen, Tramadol, and Lorazepam, the resident did not receive these medications as needed. On multiple occasions, the resident's requests for pain and anxiety medications were denied or delayed, causing significant distress and anxiety. For instance, on one day, the resident did not receive any PRN doses of Tramadol or Lorazepam, and on another day, the resident received only two doses of Tramadol despite requesting it three times. The facility's records and interviews revealed that the staff did not follow the physician's orders or the facility's pain management policy. The resident's medical records indicated frequent pain rated at 10 on a 0-10 scale, affecting sleep and daily activities. Despite this, the staff failed to administer the medications as prescribed and did not inform the physician about the increased use of PRN pain medication, as suggested by the pharmacy reviews. The resident's care plan aimed to prevent interruptions in normal activities due to pain, but this goal was not met. Interviews with the resident and staff confirmed the issues with medication administration. The resident expressed anxiety and distress over not receiving the medications, and an administrative nurse acknowledged that the medications could have been given as requested. The facility's failure to administer PRN pain and anxiety medications as ordered and to communicate effectively with the physician contributed to the resident's unresolved pain and anxiety.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for four residents, which impacted the accuracy of their assessments and potentially the development of their comprehensive care plans. For Resident #44, the discharge status was incorrectly coded as a discharge to a short-term general hospital instead of an assisted living facility, despite clear documentation in the medical record and physician's orders indicating the correct discharge location. This error was confirmed by a staff member during an interview. Resident #35 experienced a significant weight loss of 25% over 180 days, but this was not accurately reflected in the quarterly MDS. The dietary manager confirmed the incorrect coding during an interview. Accurate weight tracking is crucial for monitoring the resident's nutritional status and ensuring appropriate interventions. Resident #20 had two stage two pressure ulcers present on admission, but the quarterly MDS incorrectly indicated that these ulcers were not present on admission. This discrepancy was confirmed by an administrative nurse. Additionally, Resident #29's MDS failed to correctly identify the use of an antiplatelet medication, clopidogrel, and instead incorrectly identified the use of an anticoagulant. This error was also confirmed by an administrative nurse during an interview.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to review and revise the comprehensive care plans to reflect the current status of five residents. For Resident #17, the care plan did not include problems and interventions related to risk for malnutrition, actual weight loss, use of a diuretic, diabetes, and insulin use, despite a significant weight loss noted in the progress notes. Resident #27's care plan was not updated to reflect the discontinuation of IV Vancomycin, the addition of Doxycycline, and the care associated with the resident's cam boot. Resident #29's care plan still indicated continuous oxygen use, even though the oxygen was discontinued per physician's orders. Resident #35's care plan failed to identify nutrition risk, actual weight loss, use of a diuretic, diabetes, and use of oral hypoglycemic medications, despite significant weight loss and poor meal intakes documented in the progress notes. Resident #41's care plan did not reflect the nutrition risk and weight loss, use of diuretics, and the discontinuation of oxycodone and oxycontin, even though these changes were noted in the progress notes and physician's orders. An administrative nurse confirmed that care plans are expected to be updated with the resident's current orders, medication changes, and when new problems are identified. The failure to update the care plans limited the staff's ability to communicate care needs and ensure continuity of care for each resident. This deficiency was identified through record reviews, facility policy reviews, and staff interviews, highlighting a significant lapse in maintaining accurate and current care plans for the residents involved.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to promote care in a manner that maintained or enhanced residents' dignity for two residents who required assistance with dressing. Resident #14 was observed on multiple occasions wearing pants soiled with food debris, both in the dining room and in her room. Similarly, Resident #6 was observed wearing a shirt and pants soiled with food debris. The facility's policy on resident dignity, which aims to maintain the dignity and self-esteem of all residents, was not adhered to. An administrative nurse confirmed that staff are expected to change residents' clothing if soiled and ensure they are fully dressed after care.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the resident's physician of a significant change in condition for one of the sampled residents, specifically regarding weight loss. The facility's policy requires immediate notification to the physician for significant weight changes, defined as a 5% change in 30 days, 7.5% in 90 days, and 10% in 180 days. Resident #17, who had diagnoses including dementia and diabetes, experienced a weight loss that met these criteria. Despite this, the medical record lacked documentation of provider notification of the significant weight loss. The progress notes for Resident #17 indicated a series of weight measurements showing a decline from 176.5 pounds to 163 pounds over a period of 90 days, which constituted a 9.9% weight loss. The resident's Mini Nutritional Assessment (MNA) scores also declined, indicating a risk for malnutrition. An administrative nurse confirmed that the facility staff failed to notify the provider of the significant weight loss, which may have prevented the physician from altering the treatment or care provided to the resident.
Failure to Administer Insulin Within Prescribed Timeframe
Penalty
Summary
The facility failed to ensure staff followed standards of practice for administering intermediate-acting insulin to a resident. Specifically, a nurse administered 18 units of Humalog Mix 75/25 insulin to a resident at 5:19 p.m., but the resident did not receive their supper meal until 5:44 p.m., 25 minutes later. The prescribing information for Humalog Mix 75/25 insulin requires it to be injected within 15 minutes before a meal. An administrative nurse confirmed that staff are expected to administer intermediate insulin within this timeframe.
Failure to Follow Physician's Orders for CAM Boot and Foot Elevation
Penalty
Summary
The facility failed to ensure staff provided care and services for a resident with orders for a CAM Boot. The resident had a diagnosis of a nondisplaced trimalleolar fracture of the right lower leg and physician's orders to keep the right foot elevated every shift. However, observations throughout the survey showed multiple instances where the resident's right foot was not elevated while seated in a wheelchair or in bed. Additionally, the treatment administration record (TAR) and certified nurse aide (CNA) documentation did not indicate who was responsible for the application and removal of the CAM Boot or for elevating the right foot. During the survey, it was observed that CNAs and a nurse failed to elevate the resident's heels after transferring the resident to bed or performing wound care. An administrative staff member confirmed that nursing staff were expected to determine responsibility for following the order and to document it in the TAR or CNA Kardex. The facility did not provide care according to physician's orders, develop and follow the plan of care, or direct the staff responsible to document the removal/application of the orthopedic device.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for one resident with significant weight loss. The facility's policy required weekly weights for the first four weeks following admission and re-weighing if weight varied by more than three percent. However, the staff did not weigh the resident weekly from mid-November to early December, resulting in a 52-pound weight loss, which represents a 27% decrease. The medical record did not identify the significant weight loss or its possible causes, and the staff failed to re-weigh the resident and document the conversation about the weight discrepancies. During an interview, the dietary manager and dietician acknowledged the failure to identify and address the resident's significant weight loss. The dietary manager recalled a conversation with nursing staff about the inaccuracy of the initial weights but admitted that no re-weighing or documentation occurred. This lack of adherence to the facility's policy and failure to monitor and reassess the resident's weight led to a delay in identifying and addressing the significant weight loss.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident remained free from unnecessary psychotropic medications. Specifically, the facility did not limit the use of a PRN psychotropic medication, Lorazepam, to 14 days as required by their policy. The physician's order for Lorazepam, dated October 2, 2023, did not include a rationale for its extended use or a stop date. This oversight was confirmed by an administrative nurse during an interview. The deficiency was identified as a repeat issue from a previous survey completed on May 25, 2023.
Failure to Follow Infection Control Standards
Penalty
Summary
The facility failed to follow infection control standards for three residents under enhanced barrier precautions (EBP). For Resident #17, a laundry aide applied alcohol-based hand rub (ABHR) to a gloved hand, entered the resident's room with clean laundry, and exited without removing the glove or performing hand hygiene. Additionally, a CNA assisted the resident without wearing gloves, placed soiled linens directly on the floor, and then placed a soiled blanket back on the bed without performing hand hygiene or donning clean gloves. These actions were contrary to the facility's policies on hand hygiene, glove use, and linen handling. For Resident #35, who had an unstageable pressure ulcer, two CNAs assisted the resident in transferring from a wheelchair to a toilet without donning gowns as required by EBP. One CNA removed a soiled brief, cleaned urine off the floor, and donned new gloves without performing hand hygiene. These actions violated the facility's policies on PPE use and hand hygiene. For Resident #195, who had a Stage II pressure ulcer, a nurse and a CNA entered the resident's room to provide care and transfer the resident without donning gowns, as required by EBP. This failure to follow the facility's policy on PPE use was confirmed during interviews with administrative nurses, who stated that staff were expected to adhere to the policies for handling linens, using gloves, and performing hand hygiene.
Failure to Assess Pneumococcal Status and Provide Education
Penalty
Summary
The facility failed to assess each resident's pneumococcal status and provide education regarding the benefits and potential side effects of the vaccination. Specifically, for one resident reviewed (Resident #17), the facility did not follow its policy to assess the resident's pneumococcal immunization status upon admission and provide the necessary education to the resident or their legal representative. This deficiency was identified through record review, policy review, and staff interviews during the survey process. The facility's policy, dated 09/21/23, mandates that upon admission, each resident or their representative should receive Vaccination Information Statements (VIS) for influenza and pneumococcal vaccines, and that the facility should review current vaccinations and document education on the benefits and potential side effects. However, Resident #17's medical record, reviewed during the survey, lacked evidence of such an assessment and education. An administrative nurse confirmed the failure to follow the policy for pneumococcal vaccine administration for this resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 21 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Velva
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Minot Health And Rehab, Llc | 20.7 mi | ★★★★★ | 5 | 0 |
| Trinity Homes | 21.2 mi | ★★★★★ | 16 | 0 |
| Benedictine Living Center Of Garrison | 35.4 mi | ★★★★★ | 0 | 0 |
| Garrison Mem Hosp Nsg Fac | 35.7 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Souris Valley Care Center.
100% money-back within 48 hours.
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.