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
Two residents requiring modified diets and direct or 1:1 supervision during meals were observed eating without the required staff supervision and with access to straws, despite physician orders and care plans specifying otherwise. Staff confirmed these orders were not followed during the observed mealtimes.
Multiple residents and family members reported significant delays in call light response, with some waiting up to an hour for assistance and experiencing incontinence as a result. Call light logs and staff interviews confirmed frequent staffing shortages and prolonged response times, with administration aware of the ongoing issues. These deficiencies affected both resident care and dining assistance.
Surveyors found that kitchen and nutrition center areas were not maintained in a clean and sanitary manner, with accumulations of dirt, debris, sticky substances, food residue, and mold observed on various surfaces and equipment. Multiple open, unlabeled, and undated food items were found in freezers, and improper storage practices were noted, such as a gel ice pack stored next to ice cream. These findings were confirmed by dietary staff and were not in compliance with professional standards and facility policy.
The facility did not update care plans for two residents to reflect their current needs: one was transferred using a sit-to-stand lift despite the care plan specifying a pivot transfer with a gait belt, and another experienced significant weight loss without the care plan including specific interventions or goals. This failure limited staff communication and continuity of care.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed environmental risks and insufficient oversight, resulting in unsafe conditions for residents.
Multiple residents experienced significant delays in call light response, with some waiting from 25 minutes to over three hours for assistance. Observations, call light logs, and staff interviews confirmed that insufficient nursing staff led to unmet resident needs, including prolonged periods in soiled conditions and emotional distress, contrary to facility policy and expectations.
Two residents dependent on staff for oral care did not consistently receive scheduled oral hygiene assistance as required by their care plans and facility policy. Documentation showed multiple missed instances of AM and PM oral care over several months, and an administrative staff member confirmed that staff were expected to provide this care as planned.
Staff did not adhere to facility policy for insulin pen preparation and administration for three residents. Insulin pens were primed with the needle cap on, held horizontally, and in some cases, with an incorrect number of units, rather than following the required procedure of removing the cap, holding the pen upright, and dialing the correct dose.
Staff failed to consistently follow infection control protocols, including proper use of enhanced barrier precautions and hand hygiene, during high-contact care activities for three residents. Incidents included not wearing required PPE, not performing hand hygiene after glove removal, and not offering hand hygiene to residents during perineal and device care.
A resident with severe cognitive impairment and dementia experienced multiple incidents of mental and physical abuse from other cognitively impaired residents, including being punched, slapped, and tipped backward in a wheelchair, resulting in a head injury. Facility staff failed to supervise and intervene effectively to prevent these altercations, despite facility policy prohibiting abuse by anyone.
Failure to Follow Physician Dietary Orders and Supervision Requirements During Meals
Penalty
Summary
Facility staff failed to follow professional standards of practice and physician orders for two residents requiring specific dietary modifications and supervision during meals. For one resident, physician orders and care plans specified a soft and bite-sized texture diet, thin liquids with no straw, and direct supervision during meals. Observations showed the resident had access to beverages with straws and consumed meals without staff supervision, contrary to the prescribed orders. Supervisory staff confirmed these requirements were not met during the observed mealtime. For another resident, physician orders and care plans required a minced and moist texture diet, thin liquids with no straw, and 1:1 supervision during meals. The resident's meal ticket also indicated the need for 1:1 supervision. However, during observation, the resident was seen eating at a dining room table with no staff present to provide the required supervision. An administrative dietary staff member confirmed that staff presence was expected for this resident during meals, as per the dietary orders.
Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff and related services to meet the needs of residents, as evidenced by multiple reports of delayed call light responses and staff shortages. Review of the facility's call light policy indicated that staff are required to respond to call lights promptly, but interviews with residents and family members revealed that call lights often went unanswered for extended periods, sometimes up to an hour. Specific residents reported waiting 30 minutes or more for assistance, including while needing help in the bathroom, which resulted in at least one instance of urinary incontinence due to the delay. Family members also expressed concerns about the timeliness of staff response across various shifts. Review of call light logs confirmed these delays, showing multiple occasions where residents waited 25 minutes or longer for assistance, with the longest wait times exceeding 50 minutes. Staff interviews corroborated these findings, with several staff members stating that they worked short-staffed on most shifts and that administration was aware of the ongoing shortages. These staffing issues affected both resident care areas and the dining room, particularly with feeding assistance, and were confirmed by an administrative nurse who acknowledged the failure to answer call lights promptly.
Failure to Maintain Sanitary Food Storage and Preparation Areas
Penalty
Summary
Surveyors observed that the facility failed to maintain cleanliness and proper food storage in both the main kitchen and nutrition center. Specific findings included accumulations of dirt, debris, and sticky substances on the kitchen floor, under the three-compartment sink, on the oven hood, cabinet doors, and within utensil drawers. Food residue was noted on the backsplash and walls behind the food preparation areas, and dried food particles were found on pan covers. The reach-in refrigeration unit contained visible food debris and a sticky dark pink substance, while the freezer had a large unopened bag of onion rings with significant ice buildup. The walk-in refrigerator showed grey-green mold on the condenser unit and debris on shelving, and the walk-in freezer contained multiple open, unlabeled, and undated bags of food items. Additionally, a ceiling fan in the dishwashing area had an accumulation of dust and hanging debris. In the nutrition freezer, a large blue gel ice pack was stored next to ice cream cups. During an interview, a dietary staff member confirmed the expectation that all kitchen areas should be cleaned and food should be stored properly. These observations were made in the presence of dietary staff and were in direct violation of both the 2022 FDA Food Code and the facility's own food preparation and sanitation policies.
Failure to Update and Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to review and revise comprehensive care plans to accurately reflect the current status and needs of two residents. For one resident, staff were observed transferring the individual from a wheelchair to the bathroom using a sit-to-stand mechanical lift, while the care plan specified a pivot transfer with one staff assist using a gait belt. A staff nurse confirmed that the resident was being transferred with a sit-to-stand lift, indicating the care plan was not updated to match the resident's actual transfer method. For another resident who experienced a weight loss of more than 10% in one month, the care plan noted unplanned weight loss but did not specify the related factors, evidence, target weight range, or frequency of weighing, and lacked interventions and goals addressing the weight loss. These deficiencies limited staff communication and continuity of care for the affected residents.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents, and there was insufficient oversight to mitigate these hazards. The report specifically notes the lack of preventive measures and supervision necessary to maintain resident safety in the affected area.
Delayed Call Light Response Due to Insufficient Nursing Staff
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents who required staff assistance, as evidenced by multiple instances of delayed responses to call lights. Observations and call light logs showed that several residents waited between 25 minutes to over three hours for staff to respond after activating their call lights. For example, one resident's call light was activated at 7:52 p.m. and staff responded one hour and 30 minutes later, while another resident waited over three hours for assistance. These delays were confirmed by both direct observation and review of facility call light logs. A confidential staff member reported being consistently short-staffed, resulting in residents crying and remaining in soiled conditions due to the lack of timely assistance. An administrative staff member stated that the expectation was for call lights to be answered within 15-20 minutes, which was not met in these cases. The facility's own policy and assessment indicated that adequate staffing should be provided to ensure resident safety and well-being, but the documented delays and staff interviews demonstrated that this standard was not maintained for several residents.
Failure to Provide Scheduled Oral Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide necessary oral hygiene services to two residents who were dependent on staff for oral care. According to the facility's policy, residents unable to perform activities of daily living (ADLs), including oral hygiene, should receive assistance to maintain personal hygiene. Record review showed that one resident required assistance of one staff member for oral care every morning and at bedtime, with an increased frequency scheduled in July. Documentation revealed multiple instances where scheduled oral care was not completed, including missed AM and PM care over several days in May, June, and July, and no night or PRN oral care documented in July. A second resident, who required set-up assistance for oral care twice daily, also had missed AM and PM oral care on several days in July. During staff interviews, an administrative staff member confirmed the expectation that staff provide oral care as outlined in the care plans. The findings were based on review of facility policy, medical records, and staff interviews, demonstrating a failure to ensure that dependent residents received the necessary services to maintain oral hygiene.
Failure to Follow Insulin Pen Priming Protocols
Penalty
Summary
Staff failed to follow professional standards of practice for insulin pen preparation and administration for three residents. Facility policy required staff to prime the insulin pen by dialing 2 units, removing the needle cap, and holding the pen upright to ensure a drop of insulin appeared at the needle tip. However, observations revealed that a nurse primed insulin pens for two residents by dialing 3 units instead of 2, left the needle cap on, and held the pen horizontally rather than upright. Similarly, a medication aide primed an insulin pen for another resident by dialing the correct 2 units but also left the needle cap on and held the pen horizontally. These actions were directly observed during insulin administration for all three residents. During an interview, an administrative staff member confirmed that the expected practice was to prime the pen with the cap off and the needle pointed upward, as per facility policy. The failure to follow these procedures resulted in a deficiency related to not meeting professional standards of quality for medication administration.
Failure to Follow Infection Control Standards During Resident Care
Penalty
Summary
Surveyors identified failures in infection prevention and control practices for three residents during observed care activities. For one resident with a colostomy and catheter, a CNA donned appropriate PPE and performed hand hygiene after changing the colostomy bag, but a nurse who assisted with the procedure failed to apply a gown before providing care and did not perform hand hygiene prior to donning gloves. The facility's policy required enhanced barrier precautions, including gown and gloves, for high-contact care activities involving indwelling medical devices, which was not followed in this instance. Additional observations revealed that a CNA did not perform hand hygiene after removing soiled gloves and before applying a clean brief to another resident during perineal care. In a separate incident, a CNA assisted a resident with toileting, removed soiled gloves, and then applied clean gloves without performing hand hygiene, and also did not offer hand hygiene to the resident. These actions were inconsistent with the facility's infection control policies, which require hand hygiene after glove removal and between procedures.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to provide an environment free from mental and physical abuse for a resident with severe cognitive impairment, Alzheimer's disease, dementia, and anxiety disorder. This resident experienced multiple incidents of abuse from other residents, all of whom also had severe cognitive or behavioral impairments. On several occasions, altercations occurred in common areas, including one incident where a resident was punched multiple times, another where slapping occurred between two residents, and a third where a resident was tipped backward in a wheelchair and sustained a large hematoma to the head requiring emergency room care. These events were captured on facility video footage and confirmed by administrative staff interviews. The facility's own policy stated that residents must not be subject to abuse by anyone, including other residents. Despite this, staff failed to adequately supervise the residents and did not implement interventions to prevent repeated mental and physical abuse. The lack of effective supervision and intervention allowed for ongoing resident-to-resident altercations, resulting in fear, anxiety, and physical injury to the affected resident.
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