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)
Some of the Latest Corrective Actions taken by Facilities in North Dakota
Latest Citations in North Dakota
A resident eloped from the facility, and the incident was not reported to the State Agency until more than two months later. Facility staff could not determine how or when the resident left, and administrative staff confirmed the delay in reporting the event.
A resident who was confused and had a code alert applied for safety eloped from the facility and was found by a community member in a nearby gym. The facility was unable to determine when the resident left, had inconsistent documentation, and did not thoroughly investigate the incident to identify causes or implement interventions.
A resident with diabetes and malnutrition experienced significant weight loss due to staff failing to accurately monitor and document food and supplement intake, provide necessary encouragement and assistance during meals, and update the care plan to reflect the need for 1:1 meal support. Observations showed discrepancies between actual intake and recorded documentation, with supplements and meals often left unassisted and no alternative menu items offered when food was refused.
Surveyors observed that the kitchen was not maintained in a clean and sanitary condition, with dust and debris found on the warewashing machine, uncovered bowls, a dishware cart, and the floor in the dishwashing area. A dietary staff member confirmed that cleanliness standards were not met.
Staff failed to follow infection control standards during high-contact care activities, including not wearing required gowns for enhanced barrier precautions, improper glove use, and inadequate hand hygiene after perineal care and dressing changes. In several cases, staff did not retract the foreskin during male perineal care, and continued with other tasks without proper hand hygiene, increasing the risk of infection spread among residents.
Multiple residents dependent on staff for ADLs were observed with untrimmed, dirty nails, inconsistent oral care, and inadequate assistance during meals. Staff failed to provide regular hygiene support and proper meal setup, resulting in residents struggling to maintain personal cleanliness and access food, despite care plans indicating the need for such assistance.
A resident with impaired skin integrity and incontinence did not receive timely skin assessments or regular incontinence care as required by their care plan and physician's orders. Staff failed to document or treat multiple wounds on the resident's feet, and incontinence care was often provided only once or twice daily, leading to prolonged periods of wetness and increased risk for further skin breakdown.
Staff did not honor a resident's request to have a bladder scan before toileting cares and proceeded with care tasks against the resident's wishes. During the process, a CNA made an unprofessional comment, which the resident found inappropriate. Facility policy requires staff to treat residents with dignity and respect at all times, and the actions observed did not meet these standards.
A resident with quadriplegia was repeatedly left without access to a call bell that could be independently activated, despite a care plan specifying the need for specialized call bell placement. Staff were observed leaving the call bell out of reach after providing care, and the resident reported this occurred frequently. Facility policy and staff interviews confirmed the expectation that call bells should be accessible and usable by the resident.
Surveyors found that three residents' MDS assessments were inaccurately coded: one resident with serious mental illness was not coded as such, another with a suprapubic catheter was incorrectly coded for both indwelling and external catheters, and a third with Parkinson's Disease did not have this active diagnosis reflected in their MDS. These errors were confirmed by administrative and corporate staff.
Failure to Timely Report Resident Elopement to State Agency
Penalty
Summary
The facility failed to ensure that an alleged violation involving neglect was reported to the State Agency in a timely manner. Specifically, a resident eloped from the facility, and the incident was not reported to the State Agency until over two months later. The facility was unable to determine how or when the resident left the building. Interviews with the resident's family and administrative staff confirmed the delay in reporting the elopement and the lack of clarity regarding the circumstances of the resident's departure and return.
Failure to Investigate Resident Elopement
Penalty
Summary
The facility failed to thoroughly investigate an elopement incident involving a resident who was found by a community member in a nearby town gym and returned to the facility. The facility was unable to determine the exact time the resident left the building, with conflicting dates noted between the facility report and the medical record. Nursing documentation indicated the resident was confused and a code alert was applied for safety, but there was over an hour gap in staff charting during the time of the incident. The facility did not identify the causative factors of the elopement, limiting their ability to implement appropriate interventions.
Failure to Monitor and Assist with Nutrition Leading to Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with a history of diabetes and malnutrition, resulting in significant weight loss. The resident experienced a 20% weight loss since admission, with documented weights showing a rapid decline over several months. Physician orders included a regular, easy-to-chew diet and scheduled nutritional supplements (Boost) three times daily and as needed for malnutrition. The care plan identified impaired physical functioning, the need for supervision at meals, and interventions such as encouraging food and fluid intake, recording meal percentages, and consulting a dietitian for caloric and nutritional needs. Despite these interventions, staff did not accurately monitor or document the resident's food and supplement intake. Multiple observations revealed discrepancies between actual consumption and what was recorded in the medical record and medication administration record (MAR). Staff frequently left supplements and meals unassisted, failed to provide encouragement, and did not offer alternative menu items when the resident refused food. The resident was often left alone during meals, and staff did not consistently provide the 1:1 assistance indicated by the interdisciplinary team (IDT). The MAR also showed that the resident did not receive any as-needed supplements during the survey period. The facility's records lacked a current dietitian evaluation addressing the significant weight loss and did not update the care plan to reflect the need for 1:1 meal assistance. Staff interviews confirmed expectations for accurate documentation and observation of intake were not met. The combination of inadequate monitoring, lack of assistance, and failure to implement care plan changes contributed to the resident's continued weight loss.
Unsanitary Kitchen Conditions and Improper Dishware Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment as required by professional standards. Observations in the main kitchen revealed loose debris and dust on top of the mechanical warewashing machine, visible dry particles and debris on a tray of uncovered bowls located in a high traffic area, dry food and debris on the bottom of a cart used to store clean dishware, and an accumulation of food and dirt debris on the floor between the table legs of a stainless-steel counter and the wall in the dishwashing room. A dietary staff member confirmed that the kitchen environment and floors should remain clean.
Failure to Follow Infection Control Standards During High-Contact Care Activities
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices for several residents requiring enhanced barrier precautions (EBP) due to indwelling medical devices or wounds. In several instances, nursing staff performed high-contact care activities such as flushing Foley catheters and changing wound dressings without donning required gowns, despite clear facility policies and visible indicators (red dot stickers and PPE supplies) at resident rooms. Additionally, staff failed to follow proper glove use and hand hygiene protocols, such as not removing gloves or performing hand hygiene after handling soiled dressings or before obtaining clean supplies, and not changing gloves or performing hand hygiene between different care tasks. Certified nurse aides (CNAs) were observed providing perineal care and assisting with transfers without adhering to hand hygiene requirements. For example, after removing gloves post-perineal care, CNAs did not perform hand hygiene before proceeding to other tasks like adjusting clothing, handling personal items, or bagging linens. In one case, a CNA used soiled gloves to retrieve and apply barrier cream from a resident's nightstand, then continued with other tasks without proper glove change or hand hygiene. These lapses occurred despite the facility's policies and professional standards requiring hand hygiene after glove removal and between resident care activities. Further deficiencies were noted in the technique of perineal care for male residents. Staff failed to retract the foreskin during cleaning, as required to remove smegma and reduce bacterial growth, which was later observed by a nurse during catheterization preparation. Interviews with administrative nursing staff confirmed that the observed practices did not meet the facility's expectations for infection control during high-contact care activities, including the use of appropriate PPE and adherence to hand hygiene protocols.
Failure to Provide Adequate Assistance with Personal Hygiene and Dining
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), including personal hygiene and dining, for six residents who were dependent on staff support. Observations and record reviews revealed that multiple residents had untrimmed, dirty fingernails and toenails, and some had not received regular oral care. For example, one resident with paraplegia had long, thick, yellow toenails and stated that it had been a while since they were last trimmed. Another resident, dependent on staff for personal hygiene, had toenails approximately one-fourth inch in length and reported that staff only occasionally clipped them. Additional residents were observed with dirty fingernails, debris under their nails, and incomplete or irregular nail care, despite care plans indicating the need for staff assistance. Residents also experienced lapses in oral hygiene and assistance with meals. One resident with hemiplegia and hemiparesis was observed multiple times unable to reach or open items on their meal tray due to physical limitations, with staff failing to provide necessary setup or positioning assistance. This resident also reported inconsistent help with oral care, and was observed with visible debris on their face and mouth. Another resident was found with yellow-brown substance on their teeth and white crust at the corners of their mouth, and staff were observed using an unlabeled or incorrect toothbrush and basin, failing to ensure proper identification and hygiene supplies. Interviews with staff confirmed that CNAs were responsible for providing personal care, including nail and oral hygiene, but observations indicated that these tasks were not consistently performed as required by facility policy and individual care plans. The deficiencies were identified through direct observation, record review, and staff and resident interviews, demonstrating a pattern of inadequate assistance with ADLs for residents dependent on staff support.
Failure to Provide Timely Skin and Incontinence Care
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident with impaired skin integrity and incontinence. Despite a care plan and physician's orders indicating the need for weekly skin assessments and regular check and change assistance for incontinence, staff did not identify or document multiple areas of skin breakdown on the resident's toes and feet. Observations confirmed the presence of purple and red abrasion-type wounds with open areas on both feet, which were not recorded in the weekly skin assessments, treatment administration record, or physician's orders. The facility's policy required full assessment and documentation of skin breakdown, but this was not followed for the resident in question. Additionally, the facility did not provide a policy on the process or frequency of incontinence care for residents requiring check and change. Documentation showed that the resident often received incontinence care only once or twice in a 24-hour period, with only one day where care was provided four times. The resident reported long intervals between changes, sometimes remaining wet for extended periods, which required full bed changes. The lack of routine incontinence care and failure to monitor and treat skin issues in a timely manner contributed to the deficiency.
Failure to Honor Resident Dignity and Respect During Cares
Penalty
Summary
Facility staff failed to provide care in a manner that maintained and respected the dignity and individuality of a resident with intact cognition. During an observed care event, two CNAs and a nurse transferred the resident from a wheelchair to bed in preparation for a bladder scan and toileting. Despite the resident's explicit request to have the bladder scan performed before toileting cares, staff did not honor this request and proceeded with rolling the resident and changing the brief before conducting the scan. Additionally, during the care process, one CNA made an unprofessional and inappropriate comment referencing her own body while rolling the resident. The resident later confirmed hearing the comment and expressed that it was not professional. Facility policy requires staff to treat residents with dignity and respect at all times, and an administrative nurse confirmed that both the failure to honor the resident's request and the CNA's comment were unacceptable.
Failure to Ensure Call Bell Accessibility for Resident with Quadriplegia
Penalty
Summary
Staff failed to ensure that a resident with quadriplegia consistently had access to a call bell that could be activated independently. The resident's care plan specified the use of an easy call universal quadriplegic call bell, which could be activated by turning the head, or a soft touch call bell placed in the resident's hand while in bed. Despite this, multiple observations showed that after staff exited the resident's room, the call bell was left out of reach, either in the seat of the wheelchair or clipped to the pillowcase in a way that the resident could not activate it. The resident, who was cognitively intact, reported that staff often failed to leave the call bell within reach or accessible for activation. Interviews with staff confirmed that the expectation was for the call bell to be placed within the resident's reach and to ensure the resident could activate it. The failure to follow these procedures resulted in the resident being unable to call for assistance as needed.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, as identified through record review, reference to the RAI User's Manual, and staff interviews. For one resident with diagnoses including psychosis, schizotypal disorder, and bipolar disorder, the facility did not code the presence of a serious mental illness in Section A1510 of the MDS, despite documentation supporting the diagnosis. Another resident with a suprapubic catheter had their MDS coded for both an indwelling and an external catheter in Section H0100, contrary to the manual's instructions to code only as an indwelling catheter. Additionally, a resident with a documented diagnosis of Parkinson's Disease and a new medication order for carbidopa-levodopa did not have this active diagnosis reflected in Section I of their quarterly MDS. These inaccuracies were confirmed by administrative and corporate staff during interviews, who acknowledged the failures in proper MDS coding. The deficiencies were identified through review of medical records, physician orders, and provider notes, which demonstrated discrepancies between the residents' documented conditions and the information entered into the MDS assessments.
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