Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
113% worse than North Dakota average
North Dakota average: 3.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 19, 2025
Visit Reason
The inspection was conducted due to a facility reported incident involving alleged sexual abuse between residents.
Findings
The facility failed to ensure residents remained free from abuse when Resident #1 engaged in unwanted sexual contact with Resident #2. Corrective actions were implemented including investigation, monitoring, care plan updates, and staff education.
Complaint Details
The complaint involved substantiated sexual abuse by Resident #1 towards Resident #2. Resident #2 reported the incident and was interviewed by the social worker and charge nurse. Resident #1 has a diagnosis of dementia with behavioral disturbances and was placed under 72-hour monitoring with updated care plans.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect residents from sexual abuse, resulting in unwanted sexual contact between residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Monitoring duration: 72
Dates of corrective action education: Education provided to nursing staff on supervision and behavior interventions from 08/19/25 through 09/02/25
Inspection Report
Annual Inspection
Deficiencies: 3
Jun 19, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, accident prevention, and infection control at Valley Senior Living on Columbia.
Findings
The facility was found deficient in accurately coding resident assessments (MDS), ensuring proper use of assistive devices to prevent falls, and following infection prevention and control standards during resident care and wound management.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Level of Harm - Actual harm: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 35 sampled residents, affecting the accuracy of resident assessments and care planning. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly utilize assistive devices (gait belt) during staff-assisted transfer, resulting in a resident fall and fracture. | Level of Harm - Actual harm |
| Failed to follow infection control standards related to enhanced barrier precautions, catheter care, dressing changes, and hand hygiene for 3 of 12 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled for MDS accuracy: 35
Residents sampled for infection control: 12
Residents affected by gait belt deficiency: 1
Residents affected by MDS coding deficiency: 1
Residents affected by infection control deficiencies: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse (#1) | Confirmed failure to accurately code MDS and expected staff to follow infection control policies | |
| Certified Nursing Assistant (#3) | Failed to use gait belt properly during resident transfer; suspended and terminated after investigation | |
| Licensed Baccalaureate Social Worker (#4) | Witnessed resident fall during transfer | |
| Certified Nurse Aides (#6 and #7) | Observed failing to follow infection control standards during resident care | |
| Nurses (#2 and #5) | Observed failing to follow infection control standards during dressing changes |
Inspection Report
Annual Inspection
Deficiencies: 3
Jun 19, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements in areas including resident assessments, accident prevention, and infection control.
Findings
The facility was found deficient in accurately coding resident assessments (MDS), ensuring proper use of assistive devices to prevent falls, and following infection prevention and control standards during resident care and wound management.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Level of Harm - Actual harm: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 35 sampled residents, affecting comprehensive care planning. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly utilize assistive devices (gait belt) during staff-assisted transfer, resulting in a resident fall and fracture. | Level of Harm - Actual harm |
| Failed to follow infection control standards related to enhanced barrier precautions, catheter care, dressing changes, and hand hygiene for 3 of 12 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 35
Residents sampled: 1
Residents sampled: 12
Residents affected: 3
Date of deficient practice: Feb 26, 2025
Date corrective action completed: Mar 3, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse (#1) | Confirmed failure to accurately code MDS and infection control expectations | |
| Certified Nursing Assistant (#3) | Failed to use gait belt properly during resident transfer; suspended and terminated | |
| Licensed Baccalaureate Social Worker (#4) | Witnessed resident fall during transfer | |
| Certified Nurse Aides (#6 and #7) | Observed failing to follow infection control procedures during resident care | |
| Nurses (#2 and #5) | Observed failing to follow infection control procedures during dressing changes |
Inspection Report
Annual Inspection
Deficiencies: 7
May 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, and hospice services at Valley Senior Living on Columbia.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for oxygen use, inadequate pressure ulcer prevention, insufficient supervision to prevent accidents, failure to follow fall prevention protocols resulting in a resident fracture, inadequate toileting assistance, missing hospice election documentation, and lapses in infection prevention and control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Level of Harm - Actual harm: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive care plan for oxygen use for 2 of 5 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate pressure ulcer care and prevent new ulcers for 1 of 8 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate supervision to prevent accidents for 1 of 1 sampled resident requiring one-to-one supervision with meals. | Level of Harm - Actual harm |
| Failed to follow fall prevention care plan resulting in a fall and compression fracture for 1 resident. | Level of Harm - Actual harm |
| Failed to provide appropriate toileting assistance for 1 of 29 sampled residents, resulting in risk for skin breakdown and other complications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure resident medical record contained hospice election form for 1 of 5 sampled residents receiving hospice services. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow infection control standards including hand hygiene and proper catheter bag emptying for 2 of 21 sampled residents and 1 supplemental resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Toileting assistance failures: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse (#1) | Confirmed staff expectations for care plans, toileting assistance, and infection control | |
| Certified Nurse Aide (#2) | Failed to perform hand hygiene before and after care for Resident #56 | |
| Certified Nurse Aide (#3) | Failed to follow proper catheter bag emptying procedures for Resident #154 | |
| Certified Nurse Aide (#6) | Removed wet brief without gloves and failed hand hygiene for Resident #49 | |
| Certified Nurse Aide (#7) | Left Resident #165 unattended with supplement shake, failing supervision | |
| Nurse (#5) | Confirmed expectation for CNA supervision during meals for Resident #165 |
Inspection Report
Routine
Deficiencies: 7
May 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, and hospice services at Valley Senior Living on Columbia.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for oxygen use, inadequate pressure ulcer prevention, insufficient supervision to prevent accidents, failure to follow fall prevention protocols resulting in a resident fracture, inadequate toileting assistance, missing hospice election documentation, and failure to follow infection prevention and control standards.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Level of Harm - Actual harm: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive care plan for residents on oxygen, limiting staff communication and continuity of care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate pressure ulcer care and prevent new ulcers by not applying pressure relief boots as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate supervision to prevent accidents for a resident requiring one-to-one supervision during meals, placing the resident at risk for choking. | Level of Harm - Actual harm |
| Failed to follow fall prevention care plan by not using a gait belt, resulting in a resident fall and compression fracture. | Level of Harm - Actual harm |
| Failed to provide appropriate toileting assistance to a resident, resulting in incontinence and risk for skin breakdown and infections. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents' records contained hospice election form, limiting coordination of care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow infection control standards including hand hygiene and proper catheter bag emptying procedures, risking spread of infection. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Toileting assistance failures: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse (#1) | Confirmed staff expectations for care plans, toileting assistance, and infection control | |
| Certified nurse aide (#2) | Failed to perform hand hygiene before and after care for Resident #56 | |
| Certified nurse aide (#3) | Failed to follow proper catheter bag emptying procedures for Resident #154 | |
| Certified nurse aide (#6) | Removed wet brief without gloves and failed hand hygiene for Resident #49 | |
| Certified nurse aide (#7) | Left Resident #165 unattended with supplement shake, failing supervision | |
| Nurse (#5) | Stated expectation for CNA to stay with Resident #165 during meals |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 8, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to follow a physician's order for removal of a Foley catheter for one resident.
Findings
The facility failed to follow physician orders for removal of a Foley catheter and to attempt voiding trials for Resident #147, increasing the risk of catheter-associated urinary tract infections and decreasing quality of life. The facility also failed to provide a copy of their policy addressing physician orders.
Complaint Details
The complaint was substantiated as the facility failed to follow physician orders for catheter removal and voiding trials as confirmed by an administrative staff member.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow a physician's order for removal of a Foley catheter and to attempt voiding trials for Resident #147. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents with catheter sampled: 7
Residents affected: 1
Date of physician order: Apr 27, 2023
Scheduled catheter change date: May 16, 2023
Inspection Report
Complaint Investigation
Deficiencies: 3
Jun 8, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to follow physician orders for catheter removal, inaccurate medication labeling, and improper storage of dietary supplements.
Findings
The facility failed to follow a physician's order for removal of a Foley catheter for one resident, failed to ensure accurate labeling of insulin medication for another resident, and failed to store dietary supplements under safe and sanitary conditions in medication carts. These failures posed risks of infection, medication errors, and contamination.
Complaint Details
The visit was complaint-related, focusing on failure to follow physician orders for catheter removal, medication labeling errors, and improper storage of dietary supplements. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to follow physician's order for removal of Foley catheter and to attempt voiding trials for 1 of 7 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate labeling of medications for 1 of 3 residents observed during insulin administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store dietary supplements under safe and sanitary conditions in 2 of 5 medication carts observed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents with catheter: 7
Residents observed for medication labeling: 3
Medication carts observed: 5
Residents affected: 1
Residents affected: 1
Medication carts affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Nurse who administered insulin and commented on labeling process | |
| Administrative nurse #2 | Confirmed expectation to notify pharmacy and apply order change sticker; confirmed failure to remove scoops from supplement containers | |
| Administrative staff member #3 | Confirmed physician orders for catheter removal were not followed |
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