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 chronic fatigue syndrome, a prior R humerus fracture, OA, repeated falls, and substantial transfer assistance needs fell while ambulating with a walker. Staff found the resident on the floor in the tub room with severe pain, and the facility determined that a CNA had transferred the resident without using the required gait belt during the assisted transfer.
Failure to protect residents from inappropriate sexual contact occurred when a resident with dementia and a history of inappropriate touching placed a hand down another resident's shirt. The other resident also had dementia and severely impaired cognition. Staff reported the incident, separated the residents, and noted the first resident frequently touched staff and residents and required redirection.
Infection control standards were not followed during care for two residents on EBP with indwelling catheters. During one resident’s bed bath, a CNA used the same washcloth for peri-area, catheter tubing, legs, buttocks, and back care, did not cleanse the genital area last, and did not sanitize the bedside table after removing the basin. During another resident’s lift transfer, staff did not use the required gown and glove PPE.
A facility failed to provide enough nursing staff to meet resident needs and to answer call lights promptly. One resident waited 34 minutes for bathroom assistance after a call light was turned off, two roommates waited for help and one became incontinent before a CNA arrived, another resident reported call lights being turned off without help and waits as long as four hours, and a fourth resident said staffing delays kept her from getting up for lunch and that waits could be as long as 45 minutes.
The facility failed to review and revise care plans for two residents to match their current status and orders. One resident with a left hip fracture was observed being transferred with a full body mechanical lift even though the care plan called for a sit-to-stand lift, and another resident's care plan did not reflect physician orders for heel boots to be on at all times and heels to be offloaded for pressure ulcers.
Failure to reposition and use pressure relief devices appropriately led to pressure ulcer care deficiencies for two residents. One resident with buttock skin breakdown and incontinence was observed seated in a reclining wheelchair for hours without repositioning or a brief change, and another resident with spinal cord injury and diabetes was observed in bed with blankets draped directly over the feet instead of over the ordered foot cradle, while a new deep tissue injury was documented and the record lacked repositioning documentation.
Failure to Use Gait Belt During Assisted Ambulation
Penalty
Summary
The facility failed to provide appropriate supervision and/or assistance to prevent an accident for one discharged resident who fell while ambulating. The resident had diagnoses including chronic fatigue syndrome, a right humerus fracture, osteoarthritis of the right shoulder and both knees, and repeated falls. The quarterly MDS identified functional limitations in upper and lower extremity ROM, substantial assistance needed for transfers, use of a walker, and a major injury during a fall. During the incident, staff found the resident sitting on the floor in the tub room with her legs outstretched toward the entrance while a staff member supported her upper back. The resident stated that she fell and thought her walker handle came out or something. The resident reported pain rated 9 out of 10, and the nurse documented that the walker brakes/handles were in safe working condition. The facility later determined that the CNA transferred the resident without placing a gait belt around her waist, despite the facility policy stating that a gait belt will be used for all assisted transfers and ambulation.
Failure to Protect Residents from Inappropriate Sexual Contact
Penalty
Summary
The facility failed to ensure residents remained free from abuse when Resident #20 placed a hand down Resident #21's shirt. The report states Resident #20 had dementia and a documented behavior symptom of inappropriate touching, including attempts to inappropriately touch female residents. Resident #21 also had Alzheimer's disease and dementia, with a BIMS completed on 04/03/26 showing severely impaired cognition. The facility policy required residents to be free from abuse by anyone, including other residents, and stated that if resident-to-resident abuse was alleged, the residents would be separated immediately and both ensured a safe environment. On 05/30/26 at approximately 6:45 p.m., the incident occurred and was documented in the facility reported incident and nursing note. The nurse's note stated a CMA reported that Resident #20 had his hand placed in Resident #21's shirt, and the hand was quickly removed. The note also stated the residents were separated and monitored. During interviews, staff stated Resident #20 frequently reached out to touch both staff and residents and that staff were expected to redirect him. An administrative staff member stated staff intervened immediately and that Resident #20 was moved to an area of the facility with more supervision.
Infection Control Failures During Catheter Care and EBP Transfers
Penalty
Summary
The facility failed to follow infection control and prevention standards during personal care for two residents who had indwelling urinary catheters and were on enhanced barrier precautions (EBP). Facility policy stated that EBP includes gown and glove use during high-contact resident care activities such as transfers, and that catheter care requires cleansing the genital area last with soap and water using a clean washcloth and clean sections for each stroke. During observation of one resident’s bed bath, two CNAs performed hand hygiene, applied PPE, and entered the room, but one CNA used the same washcloth to cleanse the peri area and catheter tubing and then washed the resident’s legs with the same washcloth. The CNA also used the same washcloth to wash the resident’s buttocks and back, did not cleanse the genital area last, and did not sanitize the bedside table after removing the basin. During observation of another resident’s transfer from bed to wheelchair using a sit-to-stand mechanical lift, a CNA applied gloves but did not apply a gown, and the nurse assisting with the transfer did not apply gloves or a gown. An administrative staff member stated that staff were expected to wear a gown and gloves when transferring residents on EBP and confirmed that staff failed to use appropriate infection control practices during the resident’s morning and catheter cares.
Delayed Response to Call Lights and Insufficient Nursing Staff
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs and to answer call lights in a timely manner for four confidential residents who required assistance. Facility policy titled call lights stated that residents should always have a method of calling for assistance and that call lights should be answered promptly, with staff going to the resident’s room promptly when a call light is observed or heard. During observation, Resident A’s call light was on at 8:57 a.m. and was not answered until 9:31 a.m., when a CNA entered the room after first turning off the light and stating she would return to help. Resident A stated staff should be coming in to help her to the bathroom and that call light wait time was worse in the morning because staff were getting everyone up and were short-staffed. Resident A also stated there had been times she had been incontinent. Resident B’s call light was observed on at 12:57 p.m., and both Resident A and Resident B stated they needed to use the restroom. An administrative staff member entered the room, was told the residents needed help, and left to find someone, but a CNA did not enter until about 19 minutes later. Resident B stated it was too late and reported being incontinent. Resident C stated she sometimes had to wait a long time for help, with the longest wait being four hours, and that certain CNAs and staff members entered her room and turned off her call light without helping her. Resident D stated her CNA was delayed because another resident’s bath took longer than expected, so she chose to eat lunch in her room after waiting to get up, and said the longest wait for help was about forty-five minutes. An administrative staff member stated staff are expected to get residents up at the time requested, answer call lights timely, and that it is unacceptable for staff to turn off call lights to find someone else.
Care Plans Not Updated to Match Current Resident Needs
Penalty
Summary
The facility failed to review and revise care plans to reflect the current status of 2 of 6 sampled residents. Resident #1's record showed a left intertrochanter (hip) fracture, while the current care plan still included an intervention revised on 02/09/26 stating ambulation with 1 staff assist using a standing lift for all transfers, even though the resident did not ambulate. During an observation on 06/16/26 at 2:35 p.m., two CNAs transferred Resident #1 from a wheelchair to bed using a full body mechanical lift instead of the sit-to-stand lift listed in the care plan. Resident #6's record included physician orders for heel boots to be on at all times and heels offloaded every shift for pressure ulcers to the left great and 2nd toes, as well as Prevalon boots to both feet at all times related to a pressure ulcer of the left heel, but the current care plan only stated that Prevalon boots were to be worn to both feet while in bed and did not reflect the heel boots at all times order.
Failure to Reposition and Use Pressure Relief Devices for Residents With Pressure Ulcers
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing. The facility failed to provide care and services to prevent the development of pressure ulcers for 2 of 6 sampled residents with pressure ulcers. Facility policies stated that residents without pressure ulcers should not develop them unless unavoidable, and that residents with pressure ulcers should receive treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing. The positioning policy stated that residents unable to reposition independently should be positioned in a manner that maintains skin integrity. Resident #1 had physician orders for frequent repositioning related to buttock skin breakdown and a care plan noting bladder incontinence, existing pressure ulcers, and the need for staff assistance with repositioning. Observations showed the resident seated in a reclining wheelchair at 8:45 a.m., 11:31 a.m., and 12:35 p.m., and at 2:35 p.m. the resident's brief, pants, mechanical lift sling, and pressure-relieving pad were saturated with urine during a check and change. Staff stated residents are repositioned every two hours, but the resident was not repositioned or changed for almost three hours. Resident #6 had diagnoses including spinal cord injury and diabetes mellitus, with orders for an Assure Foot cradle, Assure Heel Boots, and Prevalon boots, and a care plan directing repositioning with each brief check and change and use of the foot cradle to keep blankets lifted off the feet. Observations showed the resident in bed on the left side with blankets draped directly over the feet rather than over the foot cradle or foot board. A nurse's progress note documented a 2 x 2 cm deep tissue injury to the back of the upper right leg, and staff confirmed the injury was discovered during a skin assessment. The resident records lacked documentation of repositioning every 2 hours.
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Compliance trends in North Dakota
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 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): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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 Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 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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