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
A newly admitted resident did not have a baseline care plan developed within 48 hours of admission, as required by facility policy. The resident's assessment indicated needs for assistance with transfers and toileting, but the baseline care plan lacked interventions for these areas. An administrative staff member confirmed the omission.
Staff failed to assess and utilize the correct sling sizes for two residents during full body mechanical lift transfers, resulting in the use of slings without proper size identification or the use of an incorrect size. Staff relied on a general sizing chart in the supply room rather than individualized assessments, and there was no documentation or education provided regarding appropriate sling selection.
Two residents experienced abuse, including yelling, intimidation, and threats by staff, as well as physical altercations between residents. Staff failed to use proper de-escalation techniques, did not maintain resident dignity, and did not report incidents or injuries promptly to supervisory staff, resulting in unaddressed physical and mental distress.
Staff failed to promptly report an incident where a resident with cognitive impairment and behavioral health diagnoses was subjected to yelling, distress, and improper handling by multiple CNAs during a transfer. The resident was left naked on the bathroom floor, found crying with unexplained scratches, and the full details were not communicated to the charge nurse or reported to authorities within the required timeframe.
A resident with chronic pain and dementia exhibiting agitation experienced multiple episodes of pain and aggressive behavior toward staff and other residents. Despite these documented incidents, the care plan was not updated to address pain management or behavioral interventions, and administrative staff confirmed the need for revisions. The facility also could not provide its care plan policy when requested.
A resident who required a Hoyer lift with two staff for transfers fell during a transfer when a sling loop disengaged from the lift bar after the resident shifted weight. Two CNAs and an LPN were present. The incident resulted in a head laceration requiring staples. Investigation found that the sling strap slid and detached due to the resident's movement and the configuration of the lift bar.
A resident with cognitive impairment and a history of behavioral issues physically pushed and grabbed another resident, causing a brief loss of balance and further physical contact, before a nurse intervened to separate them. The incident occurred despite the aggressive resident's care plan identifying risks for such behaviors.
A resident who had recently returned from hospitalization for pneumonia was left unattended in a wheelchair with foot pedals still attached, contrary to facility policy. The CNA responsible did not remove the pedals after being advised by an RN and left the area, during which time the resident attempted to stand and fell, striking their head on a chair. The resident's care plan required assistance with ambulation, which was not provided at the time of the incident.
A resident with a known risk for elopement, documented wandering behaviors, and a functioning wander guard was able to exit the facility unsupervised. Although the door alarm was triggered and sent to staff walkie-talkies, staff did not respond promptly, allowing the resident to remain outside for several minutes before being returned by an employee who found them in the parking lot.
Two residents with histories of behavioral issues physically assaulted other residents, one after a wheelchair collision and another during a meal, resulting in physical abuse of residents with cognitive impairments. Both incidents were witnessed by staff and involved residents with documented behavioral risks.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a newly admitted resident. Record review showed that the resident was admitted on 12/10/25, with a comprehensive assessment completed on 12/12/25 indicating the resident required assistance with transfers and toileting, but was independent with eating. However, the baseline care plan created on the admission date did not include interventions for the resident's specific needs related to transfers, eating, or toileting. An administrative staff member confirmed during interview that staff did not develop a baseline care plan for this resident as required by facility policy.
Failure to Assess and Use Correct Sling Size During Mechanical Lift Transfers
Penalty
Summary
The facility failed to utilize appropriate assistive devices necessary to prevent accidents and/or injury for two residents observed during mechanical lift transfers. Specifically, staff did not assess or use the correct sling sizes for residents requiring full body mechanical lift transfers. For one resident, the sling used during transfer did not have a size noted, and for another, staff could not locate the resident's usual sling and instead used a large-sized sling without confirming its appropriateness. Staff interviews revealed that sling size information was only available on a chart in the supply room, and there was no individualized assessment or documentation of correct sling size for each resident. Further review and interviews confirmed that the facility had not assessed residents who require full body mechanical lifts for the appropriate sling size, nor had they provided staff with adequate information or education regarding proper sling selection. The lack of assessment and failure to ensure the use of correct sling sizes during transfers placed residents at risk for falls and injuries, as observed during the survey.
Failure to Protect Residents from Abuse and Inadequate Response to Incidents
Penalty
Summary
The facility failed to protect two residents from abuse, including verbal, mental, and physical abuse by staff, as well as resident-to-resident altercations. One resident with anxiety, conduct disorder, depression, and moderate cognitive impairment was subjected to yelling, intimidation, and threats by multiple CNAs during an attempt to assist her with toileting. Staff were observed hollering at the resident, pointing in her face, and insisting she apologize while she was naked and distressed on the bathroom floor. The resident was found crying with fresh scratches on her arm, which staff could not adequately explain. Staff also threatened to withhold snacks as a form of punishment, and failed to report the incident and injuries to the charge nurse in a timely manner. Another resident with dementia and agitation exhibited behaviors that led to two separate resident-to-resident altercations. In one incident, the resident was found holding another resident's arm and struck the other resident in the face with a closed fist. In a separate event, the same resident hit another resident in the mouth during a verbal outburst in the activity room. Both incidents resulted in staff intervention to separate the residents and assess for injuries, though no significant injuries were noted at the time. The facility's policies on abuse, neglect, and exploitation were not followed, as evidenced by staff's failure to prevent and appropriately respond to abusive behaviors, both from staff to resident and resident to resident. Staff did not use appropriate de-escalation techniques, failed to maintain residents' dignity, and did not ensure timely and accurate reporting of abuse or injuries to supervisory staff.
Failure to Timely Report Resident Abuse Incident
Penalty
Summary
Facility staff failed to report an incident of abuse involving a resident with anxiety, conduct disorder, moderate cognitive impairment, and delusions within the required timeframe. The incident involved multiple certified nurse aides (CNAs) attempting to get the resident up for supper, during which the resident was distressed, yelling, refusing to cooperate, and ultimately ended up naked on the bathroom floor. A gait belt was applied directly to the resident's bare skin, and staff lifted her with it at least once. Several CNAs were reported to have yelled at the resident, pointed in her face, and insisted she apologize. Another CNA later found the resident crying on the floor with scratches on her left arm, which no staff could explain. The resident was then calmed, cleaned, dressed, and brought to supper. The charge nurse was only informed that the resident had a behavior and that a gait belt was used, but was not told about the yelling, the resident being on the floor naked, the number of staff involved, or any injuries. The full details of the incident were not reported to the charge nurse at the time. The facility reported the incident to the State Survey Agency (SSA) six days after the event, which was not within the required two-hour timeframe. An administrative nurse confirmed that the incident was not reported in a timely manner and acknowledged that it was unacceptable for staff to holler at or threaten residents.
Failure to Update Care Plan for Resident with Pain and Aggression
Penalty
Summary
The facility failed to review and revise the care plan for a resident with chronic pain and dementia with agitation, despite multiple documented incidents indicating changes in the resident's condition. The resident's medical record showed 21 instances of pain or requests for pain medication, two occasions of verbal or physical aggression with other residents, and 23 occasions of verbal or physical aggression with staff over a period of approximately two months. The current care plan did not include problems, goals, or interventions addressing the resident's pain or aggressive behaviors. During staff interviews, administrative staff confirmed that the care plan required updates and revisions to reflect the resident's current status. Additionally, the facility was unable to provide a copy of their care plan policy when requested.
Resident Fall Due to Improper Sling Attachment During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and proper use of assistive devices during a transfer with a mechanical lift. The resident, who was on hospice services and required the assistance of two staff members for transfers using a Hoyer lift, was being transferred by two CNAs with an LPN present. During the transfer, while the resident was elevated in the sling, she shifted her weight, resulting in a loud pop as a sling loop disengaged from the lift bar. This caused the lift bar to shift to a perpendicular position, and the resident fell from the sling to the floor, sustaining a laceration to the forehead that required staple closure. A thorough investigation, including reenactments and staff interviews, determined that the resident's movement during the transfer caused the right upper sling strap to slide along the moveable strap attachment bar, which then rotated perpendicular to the main crossbar. This configuration, combined with the resident's poor bodily control, led to the upper sling strap disengaging from the bar, resulting in the fall. Upon assessment, the resident was found on the floor with the upper right loop of the lift pad unattached to the bar, and was subsequently transported to the hospital for treatment.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when a resident with Lewy Body Dementia, who had a care plan noting potential for behaviors directed at others due to cognitive impairment and decreased impulse control, displayed physical aggression toward another resident. The incident occurred when the resident, while seated in a recliner, noticed another resident approaching and responded by gesturing in a 'shooing' manner, then rising and making physical contact by pushing and grabbing the other resident's arm and wrist, causing a momentary loss of balance. The aggressive resident continued to push the other resident, who eventually sat down nearby. When the second resident attempted to stand again, the first resident made a fist and raised it toward the other's face, though no strike occurred, and then shoved the resident in the stomach with both hands. A nurse observed the altercation and intervened to separate the two residents. Neither resident appeared to recall the event, and no injuries were noted. The care plan for the aggressive resident had identified risks for such behaviors, but the incident still occurred, indicating a failure to ensure residents remained free from abuse as required by facility policy.
Failure to Remove Wheelchair Foot Pedals and Provide Supervision Resulting in Resident Fall
Penalty
Summary
The facility failed to properly utilize assistive devices necessary to prevent accidents for a resident who sustained a fall. According to the facility's Standards of Care, wheelchair foot pedals are to be used during transport for extended distances and removed when the resident is stationary, unless otherwise care planned. The resident, who had recently returned from hospitalization for pneumonia, was brought to the dining room in a wheelchair by a CNA. The CNA left the resident at the table with the wheelchair pedals still attached and then left the area to dispose of garbage, stopping to speak with an RN along the way. Although the CNA had asked the RN about the foot pedals and was told they should be removed, the CNA did not return to remove them before leaving the resident unattended. While the CNA was away, the resident attempted to stand and subsequently fell, striking the back of his head on a dining room chair. The care plan for the resident indicated a need for assistance with ambulation using a gait belt and hand-held assist, but this was not followed at the time of the incident. The failure to remove the wheelchair foot pedals and provide adequate supervision contributed to the resident's fall.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident identified as being at risk for elopement was able to leave the facility unsupervised. The resident had a history of wandering, was disoriented to place, and had impaired safety awareness, as documented in quarterly elopement assessments and the care plan. The care plan included interventions such as the use of a wander guard, structured activities, and frequent checks, but these measures were not sufficient to prevent the resident from exiting the building. On the day of the incident, the resident was found outside in the facility's parking lot by an employee, fully dressed and sitting in a wheelchair, attempting to get into a parked car. The wander guard device was in place and appeared to be functioning, and the door alarm was triggered and sent to staff walkie-talkies. However, staff did not respond to the alarm in a timely manner, allowing the resident to remain outside for approximately five minutes before being returned to the building by a staff member who recognized the resident in the parking lot. Review of camera footage confirmed that the resident was able to hold the door to disarm the locking system and exit the facility. The incident lasted about ten minutes, with the resident outside for half of that time. Documentation and interviews confirmed that the alarm system was operational, but the lack of immediate staff response to the alarm resulted in the resident's unsupervised elopement.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in two separate incidents of resident-to-resident physical altercations. In the first incident, a resident with vascular dementia, psychotic and mood disturbances, and anxiety, who was noted to have behavioral symptoms and a history of being short-tempered, struck another resident in the face after a minor collision between their wheelchairs. The resident who was struck had diagnoses including anxiety and metabolic encephalopathy, which can cause confusion and memory loss. The altercation occurred after the aggressor yelled at the other resident to move away and then made physical contact when the request was not met quickly enough. In the second incident, a resident with a history of violent behavior and a care plan noting prior physical altercations slapped another resident on the upper arm while both were seated at a dining table. The resident who was slapped had severe cognitive impairment due to dementia and anxiety. The incident was witnessed by a dietary aide, and the aggressor was identified as having intact cognition. Both incidents demonstrate a failure to prevent resident-to-resident abuse, as required by facility policy.
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