Deficiencies (last 3 years)
Deficiencies (over 3 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
182% worse than North Dakota average
North Dakota average: 3.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Deficiencies: 1
Dec 30, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements for newly admitted residents.
Findings
The facility failed to develop a baseline care plan reflecting the needs of one sampled new admission resident, which may result in inconsistent and unsafe care. The baseline care plan was not developed within 48 hours as required by facility policy.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop a baseline care plan for Resident #1 within 48 hours of admission. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 1
Inspection Report
Deficiencies: 1
Dec 4, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control standards, specifically related to contact precautions for a resident diagnosed with Clostridioides difficile infection.
Findings
The facility failed to follow infection control standards for one sampled resident on contact precautions, including failure of staff to wear gowns and perform hand hygiene as required, which could potentially spread infection throughout the facility.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow standards of infection control and prevention related to contact precautions and hand hygiene for Resident #1 with C. difficile infection. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| administrative nurse | Stated expectation for staff to follow contact-based precautions and perform hand hygiene as specified in facility policies. |
Inspection Report
Annual Inspection
Deficiencies: 8
Apr 9, 2025
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements and evaluate the quality of care and services provided to residents at The Meadows on University nursing home.
Findings
The facility was found deficient in multiple areas including failure to honor resident dignity and preferences, inaccurate resident assessments, inadequate assistance with activities of daily living, insufficient skin care and incontinence management, poor nutritional monitoring and assistance, unsanitary kitchen conditions, and lapses in infection prevention and control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Level of Harm - Actual harm: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to reasonably accommodate the needs and preferences of residents regarding call lights. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure accurate coding of the Minimum Data Set (MDS) for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide care and assistance to perform activities of daily living for residents unable to do so independently. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, including skin integrity and incontinence care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide enough food/fluids to maintain a resident's health, resulting in significant weight loss. | Level of Harm - Actual harm |
| Failure to procure food from approved sources and maintain a clean and sanitary kitchen environment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an infection prevention and control program, including lapses in enhanced barrier precautions, hand hygiene, and perineal care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 15
Residents affected: 6
Weight loss percentage: 20
Weight loss percentage: 11
Weight loss percentage: 10
Weight loss percentage: 7
Check and change frequency: 1
Check and change frequency: 2
Check and change frequency: 3
Check and change frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Administrative Nurse | Interviewed regarding expectations for staff honoring resident requests, call bell placement, accurate MDS coding, infection control practices, and documentation of meal intakes. |
| CNA #20 | Certified Nurse Aide | Named in findings for failing to honor resident's bladder scan request and making inappropriate comments during care. |
| Nurse #11 | Nurse | Observed failing to wear gown during catheter care and dressing changes. |
| Nurse #13 | Nurse | Observed failing to perform hand hygiene and PPE use during wound care. |
| CNA #10 | Certified Nurse Aide | Observed failing to change gloves and perform hand hygiene between tasks during personal care. |
| CNA #8 | Certified Nurse Aide | Observed failing to perform hand hygiene after perineal care. |
| Nurse #16 | Administrative Nurse | Confirmed wounds on resident's feet and discussed skin assessments. |
Inspection Report
Routine
Deficiencies: 8
Apr 9, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, facility policies, and infection control at The Meadows on University nursing home.
Findings
The facility was found deficient in multiple areas including failure to honor resident dignity and preferences, inaccurate resident assessments, inadequate assistance with activities of daily living, insufficient skin care and incontinence management, poor nutritional monitoring and assistance, unsanitary kitchen conditions, and lapses in infection prevention and control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Level of Harm - Actual harm: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to reasonably accommodate the needs and preferences of each resident regarding call lights. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure accurate coding of the Minimum Data Set (MDS) for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide care and assistance to perform activities of daily living for residents unable to do so independently. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and care for residents with impaired skin integrity and concerns of incontinence care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide enough food/fluids to maintain a resident's health, resulting in significant weight loss. | Level of Harm - Actual harm |
| Failure to procure food from approved sources and maintain a clean and sanitary kitchen environment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an infection prevention and control program, including proper use of enhanced barrier precautions, hand hygiene, and perineal care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 15
Residents affected: 6
Weight loss percentage: 20
Weight loss percentage: 11
Weight loss percentage: 10
Weight loss percentage: 7
Check and change frequency: 13
Check and change frequency: 11
Check and change frequency: 4
Check and change frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Administrative Nurse | Expected staff to honor resident requests, place call bells within reach, and follow infection control practices. |
| CNA #20 | Certified Nurse Aide | Made inappropriate comment during resident care and failed to place call bell within reach. |
| Nurse #11 | Nurse | Failed to wear gown during catheter care and dressing changes. |
| Nurse #13 | Nurse | Failed to perform hand hygiene and wear gown during wound care. |
| CNA #10 | Certified Nurse Aide | Failed to change gloves and perform hand hygiene between tasks. |
| CNA #8 | Certified Nurse Aide | Failed to perform hand hygiene after perineal care. |
| Nurse #16 | Administrative Nurse | Confirmed wounds and stated expectations for weekly skin assessments and infection control. |
Inspection Report
Routine
Deficiencies: 5
Jan 13, 2025
Visit Reason
The inspection was conducted to evaluate the nursing facility's compliance with professional standards of quality, medication administration, resident care, infection prevention, and food service standards.
Findings
The facility was found deficient in multiple areas including failure to administer rapid-acting insulin within the prescribed timeframe, failure to provide scheduled medications, inadequate toileting assistance, serving food at unacceptable temperatures, and failure to follow infection control protocols.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to administer rapid-acting insulin within the time frame specified by the manufacturer for 1 of 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to obtain routine, regularly scheduled medication for 1 of 1 resident, resulting in missed medication dose. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate toileting/check and change assistance for 1 of 1 resident, risking skin breakdown and infections. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to serve foods at palatable and safe temperatures for 2 of 2 residents, potentially impacting nutrition. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to follow infection control standards including hand hygiene and mask use for residents with influenza and catheter care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Insulin dose: 10
Missed medication dose: 1
Temperature reading: 120.5
Days without toileting assistance: 4
Days toileting checked once: 6
Days toileting checked twice: 15
Days toileting checked thrice: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse (#1) | Interviewed regarding insulin administration timing, missed medication, toileting expectations, and infection control practices | |
| Nurse (#2) | Observed administering insulin to Resident #1 | |
| Certified Nurses Aide (#3) | Observed delivering meal tray to Resident #1 | |
| Nurse (#5) | Observed changing catheter bag and serving meal to Resident #3 without proper hand hygiene | |
| Staff member (#4) | Observed entering Resident #7's room without mask |
Inspection Report
Routine
Deficiencies: 4
Feb 8, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in medication administration, medication regimen reviews, medication error rates, and drug labeling practices at The Meadows on University nursing facility.
Findings
The facility failed to follow professional standards in blood glucose testing and insulin administration, failed to ensure PRN psychotropic medication orders included duration, had a medication error rate exceeding 5% due to improper medication administration, and failed to ensure proper labeling of medications for residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to clarify orders regarding timing of blood glucose testing and sliding scale insulin administration for Resident #13. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure PRN psychotropic medication order for Resident #11 included a stop date for continued use. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate of 11% due to errors in administration for Residents #23 and #294. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure appropriate labeling of medications for Residents #13 and #37, including missing instructions on insulin pen and inconsistent medication label times. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 11
Medication administration observations: 27
Residents observed with medication errors: 2
Units of insulin administered: 10
PRN Ativan dosage: 0.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff nurse (#3) | Observed administering insulin and preparing medication for Resident #13. | |
| Administrative nurse (#1) | Interviewed regarding facility protocols, medication orders, and labeling practices. | |
| Administrative nurse (#2) | Interviewed regarding medication errors and facility protocols. | |
| Medication aide (#4) | Observed administering medication patches and involved in medication error. | |
| Staff nurse (#5) | Observed placing Lidocaine patches on Resident #294. |
Inspection Report
Deficiencies: 2
Aug 9, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident safety, cleanliness, and accurate resident assessments at The Meadows on University nursing home.
Findings
The facility failed to ensure a safe, clean, and homelike environment by not cleaning personal fans and oxygen concentrator filters for two residents on oxygen. Additionally, the facility failed to accurately code the Minimum Data Set (MDS) assessments for several residents, affecting care planning and restraint use documentation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to clean personal fans and oxygen concentrator filters for residents on oxygen, risking illness. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure accurate coding of the Minimum Data Set (MDS) for several residents, including incorrect prognosis of terminal illness and restraint use. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 5
Residents sampled: 13
Residents affected: 2
Residents affected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| administrative nurse (#1) | Confirmed failures related to cleaning oxygen concentrator filters and personal fans, and inaccurate MDS coding |
Inspection Report
Deficiencies: 4
Aug 9, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident safety, cleanliness, and accurate resident assessments at The Meadows on University nursing home.
Findings
The facility failed to ensure a safe, clean, and homelike environment for residents on oxygen due to unclean personal fans and oxygen concentrator filters. Additionally, the facility failed to accurately code the Minimum Data Set (MDS) assessments for several residents, affecting care planning and restraint use documentation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to clean personal fans and oxygen concentrator filters for residents on oxygen, risking illness. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide a policy/procedure for cleaning personal fans and oxygen concentrator filters. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 13 sampled residents and one supplemental resident, affecting care planning. | Level of Harm - Minimal harm or potential for actual harm |
| Incorrect coding of physical restraint use for residents, including bed rail use. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 13
Residents affected: 2
Residents affected: 3
Supplemental residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| administrative nurse (#1) | Confirmed failure to clean oxygen concentrator filters and personal fans; confirmed inaccurate MDS coding and restraint use coding |
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