Deficiencies (last 3 years)
Deficiencies (over 3 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
105% worse than North Dakota average
North Dakota average: 3.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 3
Date: May 1, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control standards, specifically focusing on hand hygiene and enhanced barrier precautions.
Findings
The facility failed to follow infection control standards for 3 of 9 sampled residents, including failure of certified nurse aides and a nurse to perform proper hand hygiene and apply required protective equipment during resident care, posing a potential risk for infection spread.
Deficiencies (3)
Failure to perform hand hygiene after removing gloves during perineal care for Resident #28.
Failure to perform hand hygiene after removing gloves and before exiting the room during perineal care for Resident #55.
Failure to follow enhanced barrier precautions by not applying a gown during high contact wound care for Resident #95.
Report Facts
Residents sampled: 9
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide | Two CNAs (#2 and #3) assisted Resident #28; CNA #2 failed hand hygiene | |
| Certified Nurse Aide | Two CNAs (#4 and #5) assisted Resident #55; CNA #4 failed hand hygiene | |
| Nurse | Nurse (#6) failed to apply gown during wound care for Resident #95 |
Inspection Report
Routine
Deficiencies: 3
Date: May 1, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with infection prevention and control standards.
Findings
The facility failed to follow infection control standards for 3 of 9 sampled residents, including failures in hand hygiene and enhanced barrier precautions during resident care, which could potentially spread infection throughout the facility.
Deficiencies (3)
Failure to perform hand hygiene after removing gloves during perineal care for Resident #28.
Failure to perform hand hygiene after removing gloves and before exiting the room during perineal care for Resident #55.
Failure to follow enhanced barrier precautions and apply a gown during high contact wound care for Resident #95.
Report Facts
Residents sampled: 9
Residents affected: 3
Inspection Report
Deficiencies: 2
Date: Mar 14, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to the submission and accuracy of Minimum Data Set (MDS) assessments for residents.
Findings
The facility failed to ensure timely electronic submission of required MDS assessments for two residents and failed to ensure accurate coding of MDS data for five residents, which may affect the accuracy of resident assessments and care planning.
Deficiencies (2)
Failure to ensure timely electronic data submission of required Minimum Data Sets (MDS) assessments for 1 supplemental resident and one closed record.
Failure to ensure accurate coding of the Minimum Data Set (MDS) for 3 sampled residents and 2 supplemental residents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| administrative nurse | Confirmed that MDS submissions were not accepted by CMS and that staff failed to code MDSs correctly. | |
| two administrative staff | Confirmed staff failed to code Resident #44's admission MDS correctly. |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Mar 30, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to provide dignified care, timely response to call lights, rough handling of residents, failure to report alleged misappropriation of resident property, inaccurate resident assessments, failure to provide restorative therapy services, medication errors related to dialysis days, serving food at improper temperatures, improper sanitizer concentrations in kitchens, and failure to follow infection control practices.
Complaint Details
The complaint investigation was substantiated with findings of failure to maintain resident dignity, failure to report misappropriation of property, inaccurate assessments, failure to provide restorative therapy, medication errors, improper food temperatures, unsafe sanitizer levels, and poor infection control practices.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and timely response to call lights, failure to report misappropriation of resident property, inaccurate Minimum Data Set assessments, failure to provide restorative therapy as ordered, significant medication errors for a resident on dialysis, serving food at unsafe temperatures, improper sanitizer concentrations in kitchen and kitchenettes, and failure to follow proper infection control practices during resident care.
Deficiencies (8)
Failure to provide care in a manner that maintains or enhances resident dignity, including delayed response to call lights and rough handling of residents.
Failure to timely report alleged misappropriation of resident property to the State Survey Agency and submit investigation results.
Failure to complete Minimum Data Set (MDS) assessments accurately reflecting residents' status and PASRR Level 2 screening results.
Failure to provide restorative therapy services as ordered for residents, resulting in decreased range of motion and functional abilities.
Failure to ensure a resident remained free from significant medication errors, including missed doses on dialysis days and lack of provider notification.
Failure to serve foods at palatable and safe temperatures, with multiple residents reporting cold food and observation of sausage at 93 degrees Fahrenheit.
Failure to prepare, store, and serve food under sanitary conditions due to high sanitizer concentrations (848 ppm) in main kitchen and kitchenettes, exceeding recommended range of 272-700 ppm.
Failure to follow infection control practices, including failure to perform hand hygiene after glove removal and before other tasks during personal care of residents.
Report Facts
Residents affected: 7
Missed medication doses: 32
Missed medication doses: 22
Missed medication doses: 10
Missed blood sugar checks: 11
Missed nutritional supplements: 7
Sanitizer concentration: 848
Call light wait times: 90
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Mar 30, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to provide dignified care, rough handling of residents, delayed response to call lights, failure to report alleged misappropriation of resident property, inaccurate resident assessments, failure to provide restorative therapy services, medication administration errors, serving food at improper temperatures, unsanitary food preparation conditions, and failure to follow infection control practices.
Complaint Details
The complaint investigation was substantiated with findings of failure to maintain resident dignity, failure to report alleged misappropriation of property, inaccurate resident assessments, failure to provide ordered restorative therapy, medication errors, unsafe food temperatures, unsanitary food preparation, and poor infection control practices.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity and timely response to call lights, failure to report alleged misappropriation of property, inaccurate Minimum Data Set assessments, failure to provide restorative therapy as ordered, significant medication administration errors especially related to dialysis days, serving food at unsafe temperatures, improper sanitizer concentrations in kitchens and kitchenettes, and failure to follow proper infection control hand hygiene practices during resident care.
Deficiencies (8)
Failure to provide care in a manner that maintains or enhances resident dignity, including delayed response to call lights and rough handling of residents.
Failure to timely report alleged misappropriation of resident property to the State Survey Agency.
Failure to complete Minimum Data Set assessments accurately reflecting residents' status and PASRR screening results.
Failure to provide restorative therapy services as ordered for residents, resulting in decreased range of motion and functional abilities.
Failure to ensure residents remain free from significant medication errors, including missed doses on dialysis days and lack of provider notification.
Failure to serve food at palatable and safe temperatures, with multiple residents reporting cold food and observation of sausage patties at 93°F.
Failure to prepare, store, and serve food under sanitary conditions due to high sanitizer concentrations (848 ppm) in main kitchen and kitchenettes, exceeding recommended range.
Failure to follow infection control practices, including inadequate hand hygiene after glove removal during personal care for multiple residents.
Report Facts
Residents affected: 7
Residents affected: 2
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 2
Sanitizer concentration ppm: 848
Missed medication doses: 32
Missed medication doses: 22
Missed medication doses: 10
Missed blood sugar checks: 11
Missed nutritional supplements: 7
Viewing
Loading inspection reports...
