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 The Meadows On University during CMS and state inspections, most recent first.
A newly admitted resident did not have a baseline care plan developed within 48 hours of admission, as required by facility policy. The resident's assessment indicated needs for assistance with transfers and toileting, but the baseline care plan lacked interventions for these areas. An administrative staff member confirmed the omission.
A CNA did not follow infection control protocols for a resident with C. diff, failing to wear a gown, perform hand hygiene with soap and water, or assist the resident with hand hygiene after providing care. The CNA used hand sanitizer instead of washing hands as required by facility policy for contact precautions.
A resident with diabetes and malnutrition experienced significant weight loss due to staff failing to accurately monitor and document food and supplement intake, provide necessary encouragement and assistance during meals, and update the care plan to reflect the need for 1:1 meal support. Observations showed discrepancies between actual intake and recorded documentation, with supplements and meals often left unassisted and no alternative menu items offered when food was refused.
Multiple residents dependent on staff for ADLs were observed with untrimmed, dirty nails, inconsistent oral care, and inadequate assistance during meals. Staff failed to provide regular hygiene support and proper meal setup, resulting in residents struggling to maintain personal cleanliness and access food, despite care plans indicating the need for such assistance.
Surveyors observed that the kitchen was not maintained in a clean and sanitary condition, with dust and debris found on the warewashing machine, uncovered bowls, a dishware cart, and the floor in the dishwashing area. A dietary staff member confirmed that cleanliness standards were not met.
Staff failed to follow infection control standards during high-contact care activities, including not wearing required gowns for enhanced barrier precautions, improper glove use, and inadequate hand hygiene after perineal care and dressing changes. In several cases, staff did not retract the foreskin during male perineal care, and continued with other tasks without proper hand hygiene, increasing the risk of infection spread among residents.
Staff did not honor a resident's request to have a bladder scan before toileting cares and proceeded with care tasks against the resident's wishes. During the process, a CNA made an unprofessional comment, which the resident found inappropriate. Facility policy requires staff to treat residents with dignity and respect at all times, and the actions observed did not meet these standards.
A resident with quadriplegia was repeatedly left without access to a call bell that could be independently activated, despite a care plan specifying the need for specialized call bell placement. Staff were observed leaving the call bell out of reach after providing care, and the resident reported this occurred frequently. Facility policy and staff interviews confirmed the expectation that call bells should be accessible and usable by the resident.
Surveyors found that three residents' MDS assessments were inaccurately coded: one resident with serious mental illness was not coded as such, another with a suprapubic catheter was incorrectly coded for both indwelling and external catheters, and a third with Parkinson's Disease did not have this active diagnosis reflected in their MDS. These errors were confirmed by administrative and corporate staff.
A resident with impaired skin integrity and incontinence did not receive timely skin assessments or regular incontinence care as required by their care plan and physician's orders. Staff failed to document or treat multiple wounds on the resident's feet, and incontinence care was often provided only once or twice daily, leading to prolonged periods of wetness and increased risk for further skin breakdown.
A facility failed to administer rapid-acting insulin within the recommended timeframe for a resident, potentially risking a hypoglycemic reaction. Additionally, another resident with CHF did not receive their scheduled Lasix dose due to unavailability, which could exacerbate their condition.
A resident with limited mobility did not receive appropriate toileting and incontinence care, as evidenced by records showing infrequent check and change over a 29-day period. The resident reported long periods without changes, and an administrative staff member confirmed that the facility's expectation was for more frequent assistance.
The facility failed to serve meals at palatable temperatures to two residents. A CNA delivered a cold meal to a resident, who refused to eat it, and a nurse delayed serving a meal, resulting in a fish stick being served at 120.5°F. Another resident reported frequently receiving cold food. This failure may negatively impact residents' meal consumption.
The facility failed to follow infection control standards, as a staff member entered a resident's room without a mask despite influenza precautions, and a nurse did not perform hand hygiene after glove removal before assisting another resident with a meal.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a newly admitted resident. Record review showed that the resident was admitted on 12/10/25, with a comprehensive assessment completed on 12/12/25 indicating the resident required assistance with transfers and toileting, but was independent with eating. However, the baseline care plan created on the admission date did not include interventions for the resident's specific needs related to transfers, eating, or toileting. An administrative staff member confirmed during interview that staff did not develop a baseline care plan for this resident as required by facility policy.
Failure to Follow Contact Precautions and Hand Hygiene for C. diff Resident
Penalty
Summary
A certified nursing assistant (CNA) failed to follow established infection prevention and control protocols for a resident diagnosed with enterocolitis due to Clostridioides difficile (C. diff), who was on contact/enteric precautions. Facility policy required staff to wear gloves and a gown upon entering the resident's room, perform hand hygiene with soap and water before and after glove use, and encourage or assist the resident with hand hygiene. During observation, the CNA entered the resident's room, donned gloves but did not wear a gown, and assisted the resident with a pivot transfer and toileting. The CNA did not perform hand hygiene after glove removal, instead using hand sanitizer, and did not encourage or assist the resident with hand hygiene as required by policy. The resident, who was independently able to complete toileting cares, was assisted by the CNA in transferring and ambulating within the room. The CNA failed to adhere to the facility's infection control policies regarding the use of personal protective equipment (PPE) and proper hand hygiene, specifically in the context of C. diff precautions, which require handwashing with soap and water. These actions were confirmed through observation, record review, and staff interview, indicating a lapse in following infection control standards for residents on contact precautions.
Failure to Monitor and Assist with Nutrition Leading to Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with a history of diabetes and malnutrition, resulting in significant weight loss. The resident experienced a 20% weight loss since admission, with documented weights showing a rapid decline over several months. Physician orders included a regular, easy-to-chew diet and scheduled nutritional supplements (Boost) three times daily and as needed for malnutrition. The care plan identified impaired physical functioning, the need for supervision at meals, and interventions such as encouraging food and fluid intake, recording meal percentages, and consulting a dietitian for caloric and nutritional needs. Despite these interventions, staff did not accurately monitor or document the resident's food and supplement intake. Multiple observations revealed discrepancies between actual consumption and what was recorded in the medical record and medication administration record (MAR). Staff frequently left supplements and meals unassisted, failed to provide encouragement, and did not offer alternative menu items when the resident refused food. The resident was often left alone during meals, and staff did not consistently provide the 1:1 assistance indicated by the interdisciplinary team (IDT). The MAR also showed that the resident did not receive any as-needed supplements during the survey period. The facility's records lacked a current dietitian evaluation addressing the significant weight loss and did not update the care plan to reflect the need for 1:1 meal assistance. Staff interviews confirmed expectations for accurate documentation and observation of intake were not met. The combination of inadequate monitoring, lack of assistance, and failure to implement care plan changes contributed to the resident's continued weight loss.
Failure to Provide Adequate Assistance with Personal Hygiene and Dining
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), including personal hygiene and dining, for six residents who were dependent on staff support. Observations and record reviews revealed that multiple residents had untrimmed, dirty fingernails and toenails, and some had not received regular oral care. For example, one resident with paraplegia had long, thick, yellow toenails and stated that it had been a while since they were last trimmed. Another resident, dependent on staff for personal hygiene, had toenails approximately one-fourth inch in length and reported that staff only occasionally clipped them. Additional residents were observed with dirty fingernails, debris under their nails, and incomplete or irregular nail care, despite care plans indicating the need for staff assistance. Residents also experienced lapses in oral hygiene and assistance with meals. One resident with hemiplegia and hemiparesis was observed multiple times unable to reach or open items on their meal tray due to physical limitations, with staff failing to provide necessary setup or positioning assistance. This resident also reported inconsistent help with oral care, and was observed with visible debris on their face and mouth. Another resident was found with yellow-brown substance on their teeth and white crust at the corners of their mouth, and staff were observed using an unlabeled or incorrect toothbrush and basin, failing to ensure proper identification and hygiene supplies. Interviews with staff confirmed that CNAs were responsible for providing personal care, including nail and oral hygiene, but observations indicated that these tasks were not consistently performed as required by facility policy and individual care plans. The deficiencies were identified through direct observation, record review, and staff and resident interviews, demonstrating a pattern of inadequate assistance with ADLs for residents dependent on staff support.
Unsanitary Kitchen Conditions and Improper Dishware Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment as required by professional standards. Observations in the main kitchen revealed loose debris and dust on top of the mechanical warewashing machine, visible dry particles and debris on a tray of uncovered bowls located in a high traffic area, dry food and debris on the bottom of a cart used to store clean dishware, and an accumulation of food and dirt debris on the floor between the table legs of a stainless-steel counter and the wall in the dishwashing room. A dietary staff member confirmed that the kitchen environment and floors should remain clean.
Failure to Follow Infection Control Standards During High-Contact Care Activities
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices for several residents requiring enhanced barrier precautions (EBP) due to indwelling medical devices or wounds. In several instances, nursing staff performed high-contact care activities such as flushing Foley catheters and changing wound dressings without donning required gowns, despite clear facility policies and visible indicators (red dot stickers and PPE supplies) at resident rooms. Additionally, staff failed to follow proper glove use and hand hygiene protocols, such as not removing gloves or performing hand hygiene after handling soiled dressings or before obtaining clean supplies, and not changing gloves or performing hand hygiene between different care tasks. Certified nurse aides (CNAs) were observed providing perineal care and assisting with transfers without adhering to hand hygiene requirements. For example, after removing gloves post-perineal care, CNAs did not perform hand hygiene before proceeding to other tasks like adjusting clothing, handling personal items, or bagging linens. In one case, a CNA used soiled gloves to retrieve and apply barrier cream from a resident's nightstand, then continued with other tasks without proper glove change or hand hygiene. These lapses occurred despite the facility's policies and professional standards requiring hand hygiene after glove removal and between resident care activities. Further deficiencies were noted in the technique of perineal care for male residents. Staff failed to retract the foreskin during cleaning, as required to remove smegma and reduce bacterial growth, which was later observed by a nurse during catheterization preparation. Interviews with administrative nursing staff confirmed that the observed practices did not meet the facility's expectations for infection control during high-contact care activities, including the use of appropriate PPE and adherence to hand hygiene protocols.
Failure to Honor Resident Dignity and Respect During Cares
Penalty
Summary
Facility staff failed to provide care in a manner that maintained and respected the dignity and individuality of a resident with intact cognition. During an observed care event, two CNAs and a nurse transferred the resident from a wheelchair to bed in preparation for a bladder scan and toileting. Despite the resident's explicit request to have the bladder scan performed before toileting cares, staff did not honor this request and proceeded with rolling the resident and changing the brief before conducting the scan. Additionally, during the care process, one CNA made an unprofessional and inappropriate comment referencing her own body while rolling the resident. The resident later confirmed hearing the comment and expressed that it was not professional. Facility policy requires staff to treat residents with dignity and respect at all times, and an administrative nurse confirmed that both the failure to honor the resident's request and the CNA's comment were unacceptable.
Failure to Ensure Call Bell Accessibility for Resident with Quadriplegia
Penalty
Summary
Staff failed to ensure that a resident with quadriplegia consistently had access to a call bell that could be activated independently. The resident's care plan specified the use of an easy call universal quadriplegic call bell, which could be activated by turning the head, or a soft touch call bell placed in the resident's hand while in bed. Despite this, multiple observations showed that after staff exited the resident's room, the call bell was left out of reach, either in the seat of the wheelchair or clipped to the pillowcase in a way that the resident could not activate it. The resident, who was cognitively intact, reported that staff often failed to leave the call bell within reach or accessible for activation. Interviews with staff confirmed that the expectation was for the call bell to be placed within the resident's reach and to ensure the resident could activate it. The failure to follow these procedures resulted in the resident being unable to call for assistance as needed.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, as identified through record review, reference to the RAI User's Manual, and staff interviews. For one resident with diagnoses including psychosis, schizotypal disorder, and bipolar disorder, the facility did not code the presence of a serious mental illness in Section A1510 of the MDS, despite documentation supporting the diagnosis. Another resident with a suprapubic catheter had their MDS coded for both an indwelling and an external catheter in Section H0100, contrary to the manual's instructions to code only as an indwelling catheter. Additionally, a resident with a documented diagnosis of Parkinson's Disease and a new medication order for carbidopa-levodopa did not have this active diagnosis reflected in Section I of their quarterly MDS. These inaccuracies were confirmed by administrative and corporate staff during interviews, who acknowledged the failures in proper MDS coding. The deficiencies were identified through review of medical records, physician orders, and provider notes, which demonstrated discrepancies between the residents' documented conditions and the information entered into the MDS assessments.
Failure to Provide Timely Skin and Incontinence Care
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident with impaired skin integrity and incontinence. Despite a care plan and physician's orders indicating the need for weekly skin assessments and regular check and change assistance for incontinence, staff did not identify or document multiple areas of skin breakdown on the resident's toes and feet. Observations confirmed the presence of purple and red abrasion-type wounds with open areas on both feet, which were not recorded in the weekly skin assessments, treatment administration record, or physician's orders. The facility's policy required full assessment and documentation of skin breakdown, but this was not followed for the resident in question. Additionally, the facility did not provide a policy on the process or frequency of incontinence care for residents requiring check and change. Documentation showed that the resident often received incontinence care only once or twice in a 24-hour period, with only one day where care was provided four times. The resident reported long intervals between changes, sometimes remaining wet for extended periods, which required full bed changes. The lack of routine incontinence care and failure to monitor and treat skin issues in a timely manner contributed to the deficiency.
Failure to Administer Insulin Timely and Ensure Medication Availability
Penalty
Summary
The facility failed to adhere to professional standards of practice in administering rapid-acting insulin to a resident. The manufacturer's instructions for Humalog insulin specify that it should be administered within 15 minutes before or immediately after a meal. However, a nurse administered 10 units of Humalog to a resident at 11:57 a.m., but the resident did not receive their meal until 12:56 p.m., 53 minutes after the insulin was given. This delay in meal service after insulin administration could potentially lead to a hypoglycemic reaction. An administrative nurse confirmed that the expectation was for meals to be served within 15 minutes of administering rapid-acting insulin. Additionally, the facility failed to ensure the availability of routine, regularly scheduled medication for another resident diagnosed with congestive heart failure (CHF). The resident was prescribed Lasix, a diuretic, to be taken in the morning for CHF management. However, on one occasion, the medication was not available, and the resident did not receive their scheduled dose. The medication was resumed the following day. An administrative nurse verified that the resident did not receive the Lasix as scheduled, which could potentially exacerbate the resident's CHF condition.
Inadequate Toileting and Incontinence Care for a Resident
Penalty
Summary
The facility failed to provide appropriate toileting and incontinence care for Resident A, who required staff assistance with toileting and check and change. According to the resident's care plan, they had a physical functioning deficit related to limited mobility and required assistance with toileting. However, a review of Resident A's check and change record over a 29-day period revealed significant lapses in care. On four days, the resident was not checked and changed for 24 hours, on six days, they were checked and changed only once in 24 hours, on fifteen days, they were checked and changed twice, and on four days, they were checked and changed three times in 24 hours. During an interview, Resident A expressed that their incontinent product was not changed for long periods, which was corroborated by the check and change records. An administrative staff member stated that the expectation was for staff to assist residents with toileting and check and change every 2-3 hours and per resident request. The failure to adhere to these expectations resulted in a deficiency, as it placed the resident at risk for skin breakdown, poor hygiene, and other complications associated with inadequate incontinence care.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to serve foods at palatable temperatures for two sampled residents who received meal trays in their rooms. According to the facility's policy, ready-to-eat foods that require reheating should be cooked to at least 135 degrees Fahrenheit for hot service. However, observations revealed that a CNA delivered a noon meal to a resident, who spit out the fish and refused to eat, stating the food was cold and often received cold meals. The CNA replaced the tray with a new one. Another observation showed a nurse removed a meal tray from a conveyor cart and delayed serving it to a resident, resulting in the fish stick being served at 120.5 degrees Fahrenheit, which the resident described as barely warm. Additionally, a confidential resident reported frequently receiving cold food and needing to request reheating. This failure to serve foods at acceptable temperatures may negatively impact residents' meal consumption.
Infection Control Lapses in Influenza Precautions and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection prevention and control standards, specifically concerning influenza precautions and hand hygiene. One resident, who tested positive for influenza, was not properly isolated as a staff member entered the room without wearing a mask, despite the physician's orders for contact and droplet precautions. This oversight in following the facility's policy on transmission-based precautions could potentially lead to the spread of infection. Additionally, another resident with a Foley catheter was subject to improper hand hygiene practices by a nurse. After attempting to change the resident's catheter bag, the nurse removed her gown and gloves but did not perform hand hygiene before assisting the resident with their meal. This failure to follow the facility's hand hygiene policy after glove removal and before handling food further exemplifies the lapses in infection control practices within the facility.
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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 26 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fargo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Smp Health - St Catherine South | 0.6 mi | ★★★★★ | 0 | 0 |
| Bethany On University | 0.8 mi | ★★★★★ | 3 | 0 |
| Eventide Lutheran Home | 1.4 mi | ★★★★★ | 1 | 0 |
| Smp Health - St Catherine North | 2.4 mi | ★★★★★ | 4 | 0 |
| Fargo Elim Health Care Center | 2.4 mi | ★★★★★ | 8 | 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.