Citations in North Dakota
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in North Dakota.
Statistics for North Dakota (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in North Dakota
A resident with mild vascular dementia, agitation, and a documented history of socially inappropriate and physically aggressive behaviors punched another cognitively impaired resident with traumatic brain injury and dementia in a common area. Staff heard yelling and then observed the aggressor standing over the injured resident with a raised fist after the punch. The aggressor admitted he intended to cause pain and expressed no remorse. The injured resident reported facial and headache pain, with redness noted on the left side of the face, and was evaluated in the ED before returning with mild residual redness and reduced pain.
Surveyors found that both the North and South Kitchens were not maintained in a clean and sanitary condition, with burnt and baked-on food debris in ovens, scattered food and debris on floors, dried food on cabinet surfaces, and mineral buildup and food debris under a handwashing sink. Debris, dust, and mineralization were also observed on top of the mechanical warewashing machine, and these conditions persisted across multiple observations, with additional debris created during oven cleaning. Two dietary staff members did not perform hand hygiene and handled the rims of beverage cups with bare hands while removing covers and arranging them on resident meal plates, contrary to FDA Food Code standards for preventing contamination of cleaned and sanitized utensils and lip-contact surfaces.
Surveyors found that staff failed to follow the facility’s hand hygiene and glove use policy during personal care and wound care for two residents. A CNA removed a wet brief, changed briefs, and performed perineal care without appropriate glove use or performing hand hygiene before, between glove changes, or after care. In a separate incident, a nurse provided wound care to a resident on enhanced barrier precautions for a chronic ulcer and suspected MRSA carrier status, entering and exiting the room without hand hygiene and performing the entire dressing change with the same soiled gloves, including handling clean dressings and supplies. An administrative nurse reported that staff were expected to perform hand hygiene with ABHR after resident care, between glove changes, and during dressing changes.
Surveyors identified that a resident’s insulin pen label indicated a 10‑unit Lantus Solostar dose while nursing staff prepared and administered 12 units based on the eMAR, and an administrative nurse confirmed the label did not match the physician’s order. Facility policy stated that pharmacy should provide updated labels or a “see MAR for orders” label after dose changes, and that staff should follow the electronic order if pharmacy has not yet updated the label. In addition, a medication cart was observed unlocked and unattended on multiple occasions, despite facility policy requiring carts to remain locked when unattended, and an administrative nurse acknowledged the expectation that staff keep the cart locked.
The facility failed to protect residents from abuse when multiple resident-to-resident altercations occurred despite an existing Abuse Prevention Plan. In one case, a resident in a wheelchair was kicked and punched in the jaw by a roommate with known agitation and a history of physical altercation. In other cases, a cognitively impaired resident was slapped during an activity and later pushed, kicked, and slapped in her room by other residents with moderate cognitive impairment, after another resident told her to stop singing and to shut up. Although assessments found no significant physical injuries or expressed distress, the involved residents’ care plans contained identical, non-individualized interventions and a vague problem statement about being vulnerable adults, without clear, specific strategies for managing violent or physically aggressive behavior, contributing to repeated incidents of abuse.
Surveyors found that two residents sharing a bathroom were exposed to persistent fecal soiling in the toilet bowl and on the toilet seat, along with an unlined trash can containing soiled wipes, despite a facility policy requiring regular cleaning of toilet surfaces and lined trash containers. Over repeated observations on multiple days, bowel movement residue remained present even after staff completed toileting care, and a resident reported that housekeeping had not cleaned the room or bathroom. Housekeeping staff reported being on-site daily, and administration stated that staff are expected to notify housekeeping or use sanitizing wipes after care, yet the bathroom remained unclean, failing to provide a safe, clean, and homelike environment.
A resident who required hands-on assistance with ambulation was injured when staff failed to provide adequate supervision and support while the resident walked to the bathroom. According to the facility’s fall prevention policy, residents are to receive care based on their individualized fall risk, and the resident reported that CNAs usually held onto them when walking. On the day of the incident, a CNA applied a gait belt and opened the bathroom door but, per the resident’s repeated statements to multiple staff, did not accompany the resident into the bathroom and remained in the bedroom. The resident walked alone, lost balance, and struck their head on the countertop, sustaining a quarter-sized open flap wound to the posterior head with active bleeding. An RN documented the injury and the resident’s condition, and an administrative staff member confirmed the expectation that staff follow the care plan and provide adequate assistance.
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.
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.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse when one resident with a known history of socially inappropriate and physically aggressive behaviors punched another resident in the face. The facility’s Abuse Prevention Plan policy required identification, correction, and intervention in situations where abuse occurs, assessment of residents whose behaviors might lead to conflict, and development of an individual abuse prevention plan that includes the resident’s risk of abusing others and specific measures to minimize that risk. Despite this policy, a resident with documented behaviors such as threatening harm to other residents, being verbally aggressive, and a history of becoming physically abusive toward other residents was able to physically assault another resident. The assaulted resident had diagnoses of traumatic brain injury and dementia with behaviors, with a Brief Interview for Mental Status (BIMS) score indicating moderately impaired cognition. On the day of the incident, staff heard hollering from the commons area and then observed the aggressive resident standing over the other resident with a raised fist after having already punched him in the face. The aggressive resident admitted to punching the other resident because he was upset about a comment made to his female companion and stated that he intended to cause pain and did not care about the consequences. Following the punch, the injured resident complained of pain in the left temporomandibular area, with redness noted and an increasing headache rated 7–8/10 and facial pain rated 2/10. The resident was sent to the emergency department for further evaluation. Later documentation indicated the resident returned with mild redness on the left side of the face, no bruising developing, and reported facial pain of 1/10 with denial of headache. The surveyor determined that this incident constituted verified abuse under the facility’s definitions and that the facility failed to ensure residents remained free from abuse as required by policy and regulation.
Unsanitary Kitchen Conditions and Improper Handling of Tableware
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain clean and sanitary conditions in both the North and South Kitchens, as required by the 2022 FDA Food Code. In the North Kitchen, observations showed burnt loose and baked-on debris in two ovens located under a stove, as well as scattered food and debris on the floors throughout the kitchen and in the mechanical warewashing room. On a subsequent observation, loose debris, dust, and mineralization were found accumulated on top of the mechanical warewashing machine, and the scattered food and debris remained on the floors in the kitchen and warewashing room. In the South Kitchen, surveyors observed burnt loose and baked-on debris in the double ovens, an approximately 14-inch linear area of dried food on the side of a silver lower cabinet, scattered food and debris on the floors throughout the kitchen, and mineral buildup and food debris under the handwashing sink. On later observations, the dried food on the cabinet and scattered food and debris on the floors and under the handwashing sink remained, with new debris present on the floor from cleaning the double ovens. Additionally, two unidentified dietary staff members failed to perform hand hygiene and touched the rims of water, juice, milk, and coffee cups with their bare hands when removing covers and arranging them onto resident meal plates, contrary to FDA Food Code requirements for preventing contamination of cleaned and sanitized utensils and lip-contact surfaces.
Failure to Follow Hand Hygiene and Glove Use Standards During Personal and Wound Care
Penalty
Summary
Surveyors identified a failure to follow the facility’s hand hygiene policy and infection prevention standards during personal care for one resident. Observation showed a CNA transferring a resident to the toilet using a stand lift and removing the resident’s wet brief without wearing gloves. The CNA then applied gloves without performing hand hygiene, placed a clean brief on the resident, removed the gloves, and wiped her hands on her pants. Without completing hand hygiene, the CNA applied new gloves, performed perineal care, removed the gloves, assisted the resident back to bed, and exited the room without performing hand hygiene. The facility’s hand hygiene policy required hand hygiene before and after direct resident contact, when assisting with personal care and toileting, and after removing gloves. Surveyors also identified infection control failures during wound care for another resident who required enhanced barrier precautions due to a chronic right thigh ulcer, colostomy, and suspected MRSA carrier status. Observation showed a nurse donning a gown and gloves and entering the resident’s room without performing hand hygiene. The nurse obtained supplies from a dresser, placed them on the bedside table, removed the existing dressing from the right hip wound, and cleaned drainage from the wound. Without removing the soiled gloves, the nurse opened clean dressings, cleansed the wound with normal saline, patted it dry with gauze, and applied and taped a new dressing. The nurse then removed the gown and soiled gloves and exited the room without performing hand hygiene before entering or after exiting the room, and without changing gloves and performing hand hygiene between the soiled and clean portions of the dressing change. An administrative nurse stated she expected staff to perform hand hygiene with alcohol-based hand sanitizer after resident care, between glove changes, and during dressing changes.
Medication Labeling Inconsistencies and Unsecured Medication Cart
Penalty
Summary
The deficiency involves failure to ensure accurate medication labeling and secure storage of medications. Surveyors observed that an insulin pen for Resident #3 was labeled for Lantus Solostar at 10 units in the morning, while a nurse prepared and administered 12 units, stating the provider had changed the order and that the correct 12‑unit dose was reflected in the electronic medication administration record (eMAR). Review of the eMAR confirmed a 12‑unit Lantus Solostar order with a start date of 11/17/2025. An administrative nurse later confirmed that the insulin pen label did not match the physician’s order in the eMAR and stated that insulin pen labels typically indicate “See MAR for dose,” and she expects staff to follow the eMAR. Facility policy on labeling of medications indicated that when a dose change occurs, pharmacy either sends a “see MAR for orders” label or a new label, and if pharmacy has not yet complied, nursing staff are to continue to administer the correct dose per the physician’s orders in the electronic record. The deficiency also includes failure to keep a medication cart locked when unattended. Surveyors observed a medication cart identified as #700 unlocked and unattended while a staff nurse was down the hallway. On another observation, the same medication cart was again found unlocked and unattended, and it remained so for eight minutes until an administrative nurse walked by and locked it. Review of the facility’s medication administration policy showed that the medication cart is required to be locked at all times when unattended. During interview, an administrative nurse stated she expects staff to lock the medication cart when it is not being attended.
Failure to Prevent and Individualize Care for Repeated Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, specifically resident-to-resident physical altercations, and to ensure adequate supervision, oversight, and effective, individualized care plan interventions. The facility’s Abuse Prevention Plan defines resident-to-resident altercations as incidents where a resident willfully inflicts injury upon another resident and includes physical acts such as hitting and slapping as abuse. Despite this policy, multiple incidents occurred in which residents physically struck other residents, indicating that processes to prevent such abuse were not effectively implemented. In one incident, a resident propelling himself in a wheelchair down the hall was kicked in the back of his wheelchair by his roommate, who then struck him in the jaw with a closed fist. Staff intervened and separated the residents, and nursing assessed the victim with no injuries noted and no reported pain. The aggressor’s care plan documented a diagnosis of restlessness and agitation, use of an antipsychotic medication, and a history of a physical altercation with the same roommate due to agitation, indicating known behavioral risks that required targeted interventions. In separate incidents, a resident with severe cognitive impairment was physically struck on two occasions by other residents with moderate cognitive impairment. During an activity, after one resident knocked clothing items from a table, another resident became visibly distressed, moved her wheelchair next to her, verbally admonished her, and slapped her on the cheek, resulting in mild redness but no reported pain or psychosocial distress. On another occasion, after one resident told the cognitively impaired resident to stop singing and to shut up, staff briefly redirected and then left to assist another resident; upon return, a different resident was found in the cognitively impaired resident’s room, pushing her chair, kicking her leg, and slapping at her hand, after which the cognitively impaired resident slapped back. Assessments again noted no physical injuries or expressed distress. The care plans for the involved residents all contained identical, non-individualized interventions related to altercations and a generic problem statement about being vulnerable adults needing assistance to remain safe, without specifying what interventions staff should implement if residents became violent or physically aggressive. These omissions contributed to repeated resident-to-resident abuse and the facility’s failure to protect residents from abuse.
Failure to Maintain Clean and Homelike Shared Bathroom Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, sanitary, and homelike bathroom environment for two residents who shared a bathroom. The facility’s environmental services policy, dated 2020, required that the community be maintained in a clean and hygienic condition and that surfaces such as toilet seats be cleaned according to a schedule established by the environmental services supervisor, with community trash containers lined. Despite this policy, surveyors observed bowel movement (BM) splattered throughout the inside of the toilet bowl and smeared on the back and top of the toilet seat, as well as a trash can without a liner containing several soiled wipes next to the toilet. One of the residents reported that housekeeping had not cleaned the bathroom yet that day. Subsequent observations on multiple occasions over two days showed that BM remained in the toilet bowl and on the toilet seat, even after staff had reportedly completed toileting care for one of the residents in that same bathroom. The resident continued to report that housekeeping had not been in to clean the room or bathroom on either day. A housekeeping staff member stated that housekeeping staff are present seven days a week, and an administrative staff member stated she expects staff to notify housekeeping to address bathroom cleanliness or to clean areas with sanitizing wipes after care is provided. Nonetheless, the bathroom remained soiled over repeated observations, demonstrating a failure to ensure a clean and homelike environment as required by facility policy.
Failure to Provide Hands-On Assistance With Ambulation Resulting in Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and hands-on assistance with ambulation to prevent accidents for a resident identified as being at risk for falls. The facility’s Fall Prevention Policy stated that each resident would be assessed for fall risk and receive care and services according to their individualized level of risk to minimize the likelihood of falls. For this resident, the facility-reported incident (FRI) documented that a CNA called an RN to the bathroom, where the RN found the resident on the floor with a quarter-sized open flap wound to the right posterior head and active bleeding. The RN’s note indicated the CNA stated she was walking the resident to the toilet when the resident’s right ankle twisted, causing her to fall and hit her head on the countertop. In contrast, the resident consistently reported to multiple staff, including a social worker, that the CNA had applied a gait belt and opened the bathroom door but did not walk into the bathroom with her, remaining instead in the bedroom by the recliner. The resident stated she walked to the bathroom alone, attempted to catch her balance, but was unable to do so and struck her head on the countertop, describing that she “really cracked it.” She also reported that other CNAs typically “hold onto” her when she walks to the bathroom. Nursing progress notes documented the head injury, the resident’s alert status, orientation to what happened, and pain at the wound site without headache. An administrative staff member stated an expectation that staff ensure residents receive adequate assistance and that staff follow the resident’s care plan, underscoring that the resident did not receive the hands-on assistance with ambulation that was required at the time of the fall.
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 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.
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