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 impaired mobility, incontinence, CKD, and venous insufficiency developed a facility-acquired unstageable sacral PU that progressed from a blanchable red area to a worsening wound with slough, eschar, drainage, odor, pain, and infection. Staff notes showed the wound deteriorated over time, yet the resident was removed from provider rounds and did not receive a provider evaluation for 27 days while the ulcer enlarged and later merged with a new stage 2 area. The PA stated she expected staff to arrange provider review for a significant decline, and a nurse agreed the resident should have been seen sooner.
Dishwashers in the main kitchen and on the Edgewater unit failed to reach the required 160°F rinse temperature needed to sanitize dishware. Surveyors observed temperatures below standard using an irreversible registering thermometer and a color-indicator test strip, and facility staff confirmed the rinse cycle did not meet requirements.
A resident with ESRD on hemodialysis, CHF, DM, and depression experienced significant weight loss while the facility failed to document multiple post-dialysis weights, complete a comprehensive dietary assessment, or implement nutritional interventions. Staff confirmed the resident frequently refused meals after dialysis, and the EHR lacked several weights needed for nutritional monitoring despite a physician order to compare dry post-dialysis weights.
Failure to prevent repeated resident-to-resident physical abuse occurred when a resident with Alzheimer’s disease, dementia with agitation, depression, severe psychotic disorder with delusions, and wandering was involved in multiple altercations with peers. The resident’s care plan documented agitation, physical aggression, verbal aggression, wandering into peers’ rooms, and taking items, and progress notes showed incidents of grabbing, kicking, flicking, hitting, choking, and punching other residents, as well as being struck by peers during these events. Admin staff said behaviors were discussed daily, but the facility did not effectively manage the resident’s behaviors, resulting in repeated abuse episodes.
Emergency suction machines were not kept ready for use on 4 of 4 resident care units. Staff found machines boxed, unassembled, or difficult to locate in the clean utility room, and one nurse stated the last time she tried to use a suction machine, it did not work. An RN and other staff confirmed that unpacking or locating the equipment would delay response during an emergency.
Housekeeping and environmental cleanliness were not maintained consistently in resident rooms and common areas. Surveyors observed dust, food crumbs, debris, sticky and wet floors, odors, unemptied trash, and soiled briefs left on a wheelchair and scooter seat. Residents and a family member reported that bathrooms and trash were not being cleaned or emptied regularly, and an admin staff member stated staff were expected to clean rooms as needed and remove trash to the soiled utility room.
Failure to Ensure Timely Provider Evaluation of Worsening Sacral Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent the worsening of a facility-acquired sacral pressure ulcer for a resident with chronic kidney disease, venous insufficiency, a left heel pressure ulcer, and a sacral pressure ulcer. The resident was incontinent of bowel and bladder, dependent on staff for toileting hygiene, had impaired mobility, and preferred to lie on her back rather than on her side. The care plan identified a potential for impaired skin integrity related to incontinence and impaired mobility, and the resident had an unstageable sacral pressure ulcer with orders for cleansing, Santyl, Polymer Wic, and Mepilex dressings. Progress notes showed the sacral area initially as a large red blanchable area, then as peeling red skin with drainage, and later as a new unstageable pressure ulcer acquired in-house. The wound was documented as improving on 04/21/26, but by 04/28/26 it had deteriorated, increased in size, developed increased exudate, pain, erythema, fragility, excoriation, warmth, and induration. On 04/30/26, the wound committee assessed the wound as stable, but the nurse's assessment the same day documented deterioration with increased drainage, slough, eschar, and size. The wound continued to worsen, with later notes describing foul odor, copious drainage, necrotic tissue, and additional breakdown. The facility failed to ensure a provider evaluated the sacral ulcer between 04/15/26 and 05/13/26, a period of 27 days during which the wound worsened. Staff interviews indicated the resident was removed from provider rounds after antibiotics were started and was also removed from the PA's rounds schedule when routine physician rounds were planned. The PA stated she expected staff to schedule a provider appointment for a decline or significant change in a pressure ulcer, and a nurse agreed the resident should have been seen at the clinic for the documented decline at the end of April. During this period, the wound enlarged, developed infection, and later merged with a new right upper buttock stage 2 pressure ulcer before the resident was sent to the wound clinic and then transferred to the hospital after the wound was found to extend to bone.
Dishwashers Failed to Reach Required Sanitizing Temperature
Penalty
Summary
The facility failed to ensure sanitization of dishware used to serve residents, staff, and visitors because the mechanical dishwashing machines in the main kitchen and on the Edgewater unit did not maintain the required hot water temperature during the rinse cycle. During the recertification survey, the survey team determined a potential Immediate Jeopardy situation when the dishwasher rinse cycle failed to reach 160 degrees Fahrenheit at plate level. Survey observations showed the Edgewater dishwasher measured 158 degrees Fahrenheit with an irreversible registering temperature indicator. On the main kitchen dishwasher, temperatures measured 148 degrees Fahrenheit and 146 degrees Fahrenheit, and later 150.9 degrees Fahrenheit with a different thermometer; a facility color-indicator test strip also showed the dishwasher failed to reach the appropriate temperature. Facility staff members verified that the temperature and test strip results were below requirements, and a dietary administrative staff member confirmed the rinse temperature did not reach 160 degrees Fahrenheit.
Failure to Monitor Dialysis Weights and Address Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional status for Resident #81, who had end stage renal disease, CHF, DM, depression, and dependence on renal dialysis. The resident had a physician order to collect weight at dialysis for accuracy and compare the dry post-dialysis weight for nutritional determinations, and the care plan identified the resident as at risk for nutritional problems and weight loss. Facility policy required accurate nutritional assessment, identification of residents at nutritional risk, and monitoring of weight, but the record showed the facility did not complete a comprehensive dietary admission assessment and did not implement nutritional interventions for the resident's weight loss. Review of the record showed weights of 121.0 lbs on admission, 122.0 lbs one week later, then 117.9 lbs pre-dialysis and 112.8 lbs post-dialysis on one date, followed by 112.9 lbs and 108.4 lbs on later dates, with a dialysis communication document listing a post-dialysis weight of 103.8 lbs. The EHR did not contain the resident's weight from June 14 through June 22 and from June 26 through July 9, including eight post-dialysis weights. Staff confirmed the resident received dialysis three days a week, that weights including dry weights were entered into the EHR, and that the resident frequently refused to eat after returning from dialysis. The resident's calculated weight loss from June 4 to July 3 was 14.21%.
Failure to Prevent Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure residents remained free from abuse when Resident #1 was involved in repeated resident-to-resident physical altercations. The facility policy stated that resident-to-resident altercations should be reviewed as potential abuse and that physical abuse includes hitting, slapping, and punching. Resident #1’s record showed diagnoses of Alzheimer’s disease, dementia with agitation, depression, severe psychotic disorder with delusions, and wandering. Her care plan documented behaviors related to dementia, including elopement attempts, agitation, restlessness, physical aggression, verbal aggression, barricading, wandering into peers’ rooms, taking items, and refusing to let them go. The progress notes documented multiple incidents in which Resident #1 either initiated or was involved in physical contact with other residents, including grabbing another resident, kicking a resident in the leg, flicking a resident in the forehead, hitting another resident in the face, being hit by another resident after touching a toy, having a book hit her hand, hitting another resident after being struck, grabbing another resident’s shirt collar and choking that resident, being pushed against a wall after grabbing a male resident, and punching another resident in the back of the head while leaving the dining room. During interviews, administrative staff stated they discussed behaviors daily and described Resident #1 as trying to annoy other residents rather than intentionally hurt them, noting she could be nice one minute and act out the next and did not target any one person. The facility failed to effectively manage Resident #1’s behaviors, resulting in repeated episodes of resident-to-resident abuse.
Emergency Suction Machines Not Ready for Use
Penalty
Summary
Keep all essential equipment working safely was not maintained when the facility failed to ensure emergency suction machines remained in operating condition on 4 of 4 resident care units: Sunset, Edgewater, Grandview, and [NAME]. On the Edgewood unit, a nurse observed the emergency suction machine boxed and not assembled in the clean utility room, and the nurse stated that assembling it would slow response time during an emergency. On the Sunset unit, a staff member went to the clean utility room to find the suction machine, had to move boxes to locate it, and an unidentified nurse stated the last time she tried to use the suction machine, it did not work. On the [NAME] unit, a staff member went to the clean utility room but could not identify the box containing the emergency suction machine. On the Grandview unit, a staff member located the suction machine in the clean utility room, and the nurse confirmed that unpacking and setting it up would increase response time in an emergency. Two administrative staff members later confirmed that the location of the suction machines and/or the unassembled machines would not be helpful during an emergency.
Housekeeping and Environmental Cleanliness Lapses
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, homelike environment for residents on multiple days of survey. Review of the facility housekeeping policy stated that environmental cleaning is part of infection control and that standard or light cleaning should occur daily in occupied rooms, including emptying trash containers and sweeping and damp mopping hard surface flooring as needed. However, observations on 07/06/26 and 07/07/26 found dust on a fan in one resident room, no bedding on one resident’s bed while the resident was lying in bed watching TV, dust/debris and food crumbs on floors, sticky floors, water on the floor, food debris on an over-the-bed table, and an odor in another resident room. Similar findings were observed again on 07/09/26 in the unit kitchenette, where food debris, dust, a wet substance, and a sticky floor were present, and a dietary aide agreed the floor needed cleaning. Additional observations showed a garbage bag containing a soiled brief on a wheelchair seat in one resident room and on the seat of another resident’s electric scooter. A resident’s bathroom garbage was full of incontinence products, and the resident stated they had to ask for the trash to be emptied and had had a full trash bin since Friday. Another resident stated the bathroom had not been cleaned recently, and another stated the toilet was not cleaned regularly and that they sometimes cleaned it themselves. Other observations included a full garbage can, food crumbs and wrappers, a dried substance on the floor, and food particles and dust/debris on the floor and under a bed. A family member stated the kitchen floors were gross, and an administrative staff member stated the facility used a contracted cleaning company and expected staff to clean resident rooms as needed and take trash to the soiled utility room rather than leaving it in the room.
Find your facility
Search by name to see its inspection history, citations and penalties — and how to prepare for the next survey.
Get alerted when Immediate Jeopardy citations hit in North Dakota — free
You're all set
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
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.
