Citations in North Dakota
Statistics, citations 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 dementia, cleft palate, and dysphagia was ordered an IDDSI Level 6 soft and bite-sized diet, but marshmallows were left in the room and later eaten, leading to a choking episode with cyanosis, pulselessness, apnea, and hospitalization. Staff also served a meal tray with a whole Salisbury steak patty and other foods not prepared into bite-sized pieces, and interviews showed staff were not consistently educated on the resident’s diet restrictions or IDDSI requirements.
Medication Labeling and Preparation Errors: A nurse prepared a resident’s Humalog insulin pen without an open and discard date, and in a separate observation, pre-dished oral meds for several residents and left them on the med cart before administration. Facility policy required insulin pens to be labeled with open and discard dates and medications to be administered as soon as possible after preparation.
A facility's QAPI committee did not develop a PIP to address a choking incident involving a resident with dysphagia on a Level 6 soft and bite-sized diet. Staff confirmed the resident ate regular-sized marshmallows kept in the room, and the resident was later found on the floor with marshmallow-like material removed during suctioning. The facility's QAPI process had monitored food temperatures but not diet accuracy, and the dietary QAPI process did not include diet accuracy.
Failure to maintain a clean, comfortable, and homelike environment was cited after surveyors observed multiple resident rooms and bathrooms with dirt, dust, food debris, residue, sticky floors, scuff marks, a soiled toilet, and fecal matter on a bathroom floor. Residents and a family member reported poor housekeeping, urine odors, garbage buildup, and rooms not being consistently cleaned, and an environmental staff member confirmed the housekeeping dept was short staffed.
Failure to notify a resident’s guardian of an unplanned discharge. The resident left the facility AMA and did not return, but staff did not immediately inform the guardian as required by facility policy. Record review showed the resident had a guardian over the person, finances, and property, and the guardian later confirmed she was not called when the resident left.
Failure to investigate a reported lift fall and spinal injury: A resident with intact cognition and transfer assistance needs said she was dropped from a mechanical lift and later had a T8 compression fracture. The family reported the fall and pain to staff, but staff denied the incident, did not believe it occurred, and no investigation was conducted.
Choking Episode After Inappropriate Foods Were Left and Served to a Resident on a Soft and Bite-Sized Diet
Penalty
Summary
The facility failed to provide appropriate supervision for a resident with an ordered mechanically altered diet when snack items not consistent with that diet were left in the resident’s room. The resident had diagnoses including dementia, cleft palate, and dysphagia, and speech therapy had recommended an IDDSI Level 6 soft and bite-sized diet. The care plan identified the resident as being at risk for aspiration and choking and specified mechanically altered consistency, Level 6 soft and bite-sized. On the day of the incident, staff found the resident after a loud thump and observed him face down on the floor with blood present and his color purple from the head to the upper limbs. A nurse documented that marshmallows were coming out of the resident’s mouth and nose and that suctioning was performed. The resident’s record and hospital documentation stated he had been eating marshmallows when he became pulseless, apneic, and cyanotic, and he was admitted after a choking-related event with aspiration pneumonia and oxygen needs. The facility investigation stated the resident had been snacking on a bag of marshmallows that had been brought in by his sister and left on his over-the-bed table. The investigation and interviews showed staff did not ensure foods served or available to the resident matched the ordered diet. Administrative nurses stated the marshmallows were not bite-sized and that staff were not really educated on mechanically altered diets and IDDSI levels. The CNA involved stated the nurse was in charge of knowing what the resident could or could not have. During a later meal observation, a CNA delivered a tray to the resident that included a whole Salisbury steak patty and baked apples cut into approximately 1-inch pieces, and the CNA left without cutting the meat into bite-sized pieces. The dietary supervisor stated kitchen staff did not cut food into bite-sized pieces before meals left the kitchen, and the dietician and speech language pathologist confirmed that marshmallows were not appropriate and that meat patties should be cut into bite-sized pieces for this diet.
Medication Labeling and Preparation Errors
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications for 2 of 9 observations of medication preparation and administration. During observation, a staff nurse prepared Resident #25’s Humalog insulin pen for administration and obtained the pen from a plastic bag labeled with the resident’s name, but the pen did not have an open and discard date. Facility policy stated that insulins are to be labeled with open and discard dates and disposed of 28 days after opening unless otherwise specified by the manufacturer. In a separate observation, three medication cups containing oral medications, each labeled with resident first names, were left on top of the medication cart while a nurse prepared a fourth cup. When asked about the practice, the nurse stated she had prepared supper medications for a few residents so she could help feed residents in the dining room and would administer the medications to those four residents at that time. Facility policy stated that drugs are to be administered as soon as possible after doses are prepared and that medications should not be pre-dished for future medication passes. An administrative nurse later confirmed staff should label insulin pens with an open and discard date and should not pre-dish medications.
QAPI Failed to Address Diet Accuracy After Choking Incident
Penalty
Summary
The facility's QAPI committee failed to develop a Performance Improvement Project to decrease or prevent adverse events and ensure compliance with federal requirements related to a resident choking incident. The facility's QAPI plan stated that PIPs are used to examine and improve care or services in specifically identified areas, but during interviews an administrative nurse stated that QAPI had previously monitored food temperatures and not the accuracy of diets served to residents, and a dietary supervisor confirmed the dietary QAPI process did not include diet accuracy. The choking incident involved a resident with dysphagia who was on a mechanically altered diet, Level 6 soft and bite-sized, and was at risk for aspiration and choking. The facility investigation stated the resident had been eating lunch and had a bag of marshmallows on the over-bed table, which he had been snacking on before lunch. Staff later heard a loud crash and found him prone on the floor next to his wheelchair; suctioning was performed and small white pieces of material that looked like marshmallow were removed. Surveyor review and staff interview confirmed the resident ate regular-sized marshmallows, and the State Survey Agency determined the incident resulted in an Immediate Jeopardy when staff failed to remove snack items not consistent with the resident's diet order from the room.
Failure to Maintain Clean Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for 4 of 14 sampled residents and 9 supplemental residents observed during survey. Review of the facility’s Environmental Cleaning Principles policy stated that environmental cleaning is an important part of infection control and emphasized frequent cleaning and disinfection of high-touch areas. During observations, multiple resident rooms and bathrooms were found with visible dirt, dust, food debris, residue, scuff marks, sticky flooring, and soiled surfaces, including a bathroom floor smeared with fecal matter, a soiled toilet, and a fall mat with dried liquid residue. Several residents and a family member reported that housekeeping services were not consistently provided or were inadequate. One resident reported a strong urine smell in the bathroom and said housekeeping had not cleaned the floor well, while another said the bathroom was not cleaned well and garbage piled up. A resident stated housekeeping had not cleaned much lately, and another reported the room and facility were not consistently maintained in a clean condition, with a family member cleaning the room on multiple occasions. A family member also stated the room was always dirty and the bed was not made until after 1:00 p.m. An environmental staff member confirmed the housekeeping department was short staffed.
Failure to Notify Guardian of Resident Discharge
Penalty
Summary
The facility failed to immediately notify Resident #19’s representative of the resident’s discharge after the resident left the facility and did not return. Review of the facility policy titled Notification of Change- R/S, LTC showed that the facility must immediately inform the resident representative when there is a decision to transfer or discharge the resident. Resident #19’s record identified family member #B as the resident’s guardian over the person, financial, and property effective 03/19/26. Progress notes documented that on 03/28/26 the resident left against medical advice and was not in her room when staff checked later that evening; staff called family member C, who stated, “My mom wants me to take care of her in our house,” and then ended the call. The note also stated the resident left AMA without notifying staff and without signing the sign-out sheet. During interview, family member B confirmed the facility did not call her when the resident left and did not return, and stated the administrative staff member and an unknown nurse had received the guardianship paperwork on 03/26/26.
Failure to Investigate Reported Lift Fall and T8 Compression Fracture
Penalty
Summary
The facility failed to thoroughly investigate a reported fall and injury for one resident who stated she had been dropped from a mechanical lift. The resident had intact cognition on the quarterly MDS and a care plan noting weakness, need for assistance with transfers, and transfer assistance with one person. The facility policy on Fall Prevention And Management required staff to notify the physician and resident representative and, if the resident was stable, begin an investigation after a fall. The FRI submitted to the state survey agency identified a moderate injury with compression to the T8 vertebrae and stated the resident reported being dropped from a mechanical lift, while staff denied the incident and no one was notified. Nursing notes documented that the family called the facility about the resident’s report of a fall from the sling of the lift and later reported severe pain all over, and the provider was informed that the resident said she had fallen and had no record of a fall or pain, prompting x-rays. During interview, a family member stated staff told her there were no reported falls and that the resident could not have fallen, and an administrative nurse stated the facility did not conduct an investigation because the fall did not seem real.
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Compliance trends in North Dakota
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
No tags meet the emerging criteria for this period — nothing rare is spiking right now.
Trusted data from CMS and state health departments
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