Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% worse than North Dakota average
North Dakota average: 3.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 22, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to protect residents from abuse and failure to properly utilize assistive devices to prevent accidents.
Complaint Details
The complaint investigation found substantiated non-compliance related to resident-to-resident physical abuse and improper wheelchair safety leading to a fall. Corrective actions included staff education, care plan revisions, monitoring, and staff termination.
Findings
The facility was found non-compliant for failing to protect a resident from physical abuse by another resident and for failing to properly remove wheelchair foot pedals which contributed to a resident's fall. Both citations were considered past non-compliance with corrective actions implemented.
Deficiencies (2)
Failure to protect residents from physical abuse, resulting in minimal harm or potential for actual harm to a resident.
Failure to properly utilize assistive devices to prevent accidents, specifically failure to remove wheelchair foot pedals leading to a resident fall.
Report Facts
Residents affected: 1
Residents affected: 1
Dates of incidents: Sep 14, 2025
Dates of incidents: Nov 4, 2025
Dates of incidents: Nov 5, 2025
Staff termination date: Nov 11, 2025
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 8, 2025
Visit Reason
The inspection was conducted following a complaint investigation related to a fall incident involving Resident #87 and concerns about infection prevention and control practices observed during care of Residents #126 and #283.
Complaint Details
The complaint investigation was substantiated based on findings of improper wheelchair footrest use leading to a fall and injury to Resident #87, and failure to follow infection control protocols during care of Residents #126 and #283.
Findings
The facility failed to provide adequate supervision and proper use of wheelchair footrests, resulting in a fall and injuries to Resident #87. Additionally, infection control deficiencies were found related to improper glove use and hand hygiene during tracheostomy care and insulin administration for Residents #126 and #283.
Deficiencies (2)
Failure to ensure staff utilized footrests properly on the wheelchair causing facial injuries to Resident #87 and placing residents at risk for falls.
Failure to follow infection control standards related to glove use and hand hygiene during tracheostomy care for Resident #126 and insulin administration for Resident #283.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Units of Insulin Glargine: 12
Units of Novolog: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #8 | Named in wheelchair fall incident for improper footrest use and placed on administrative leave | |
| Nurse #5 | Observed failing to remove soiled gloves and perform hand hygiene during tracheostomy care | |
| Nurse #4 | Observed administering insulin without gloves | |
| Administrative nurses #6 and #7 | Interviewed regarding infection control expectations | |
| Administrative staff member #2 | Confirmed expectation for nurses to wear gloves during injections |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 8, 2025
Visit Reason
The inspection was conducted following a complaint investigation related to a fall incident involving Resident #87 and concerns about infection prevention and control practices observed during care of Residents #126 and #283.
Complaint Details
The complaint investigation was substantiated based on the fall incident on 09/07/24 involving Resident #87 due to improper wheelchair footrest use, and infection control breaches observed on 01/08/25 and 01/09/25 involving Residents #126 and #283.
Findings
The facility failed to provide adequate supervision and proper use of wheelchair footrests, resulting in a fall and injury to Resident #87. Additionally, the facility failed to follow infection control standards during tracheostomy care and insulin administration, risking infection spread.
Deficiencies (2)
Failure to ensure staff utilized footrests properly on the wheelchair causing facial injuries to Resident #87 and placing residents at risk for falls.
Failure to follow infection prevention and control standards during tracheostomy care and insulin administration, including improper glove use and hand hygiene.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Units of Insulin Glargine: 12
Units of Novolog: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #8 | Named in fall incident involving improper wheelchair footrest use | |
| Nurse #5 | Observed failing to follow infection control procedures during tracheostomy care | |
| Nurse #4 | Observed administering insulin without gloves | |
| Administrative nurses #6 and #7 | Interviewed regarding infection control expectations | |
| Administrative staff member #2 | Interviewed confirming glove use expectations during injections |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 23, 2024
Visit Reason
The inspection was conducted based on a complaint alleging the facility failed to notify the resident's representative of a fall experienced by Resident A.
Complaint Details
Based on information provided by the complainant, the facility failed to notify the resident representative for 1 of 1 confidential resident (Resident A) who experienced a fall. Staff interviews and record reviews confirmed the failure to notify.
Findings
The facility failed to notify the resident representative of Resident A's fall, limiting the representative's ability to make informed medical decisions. Documentation and staff interviews confirmed the lack of notification despite facility policy requiring such communication.
Deficiencies (1)
Failure to notify the resident representative of a fall experienced by Resident A.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| administrative staff member (#1) | Confirmed staff failed to notify the resident representative of Resident A's fall during interview on 01/23/24. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 30, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident assessments, accident prevention, food safety, infection control, and catheter care at Woodside Village nursing home.
Findings
The facility was found deficient in accurately coding resident assessments, ensuring adequate supervision during mechanical stand-lift transfers, maintaining sanitary food preparation areas, following infection prevention protocols during a Covid-19 outbreak, and properly managing urinary catheter care. All deficiencies were noted with minimal harm or potential for actual harm affecting a few residents.
Deficiencies (4)
Failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 26 sampled residents, missing a fall with major injury.
Failed to ensure adequate supervision and proper use of mechanical stand-lift for 1 of 12 residents, resulting in pain and risk of accidents.
Failed to maintain the food preparation and service area in a sanitary manner in 1 of 3 kitchenettes observed, with dust blowing toward food service area.
Failed to follow infection control standards for PPE use and catheter care during Covid-19 outbreak and for 1 sampled resident with catheter.
Report Facts
Residents sampled for MDS coding: 26
Residents sampled for stand-lift supervision: 12
Kitchenettes observed: 3
Neighborhoods observed for infection control: 4
Residents sampled with catheter: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Managerial nurse (#6) | Confirmed staff failed to code a fall with major injury on the MDS and confirmed staff should ensure residents can bear weight during stand-lift. | |
| Certified Nurse Aide (#7) | Observed toileting Resident #112 with improper stand-lift technique causing pain. | |
| Certified Nurse Aides (#8 and #10) | Observed toileting Resident #112 with improper stand-lift technique. | |
| Administrative dietary staff member (#9) | Confirmed no cleaning schedule for fans in food preparation area. | |
| Administrative nurse (#1) | Interviewed regarding infection control expectations for PPE and catheter care. | |
| Administrative nurse (#2) | Observed leaving Covid area without removing PPE. |
Inspection Report
Routine
Deficiencies: 6
Date: Nov 3, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication management, and food storage at Woodside Village nursing home.
Findings
The facility was found deficient in multiple areas including failure to complete significant change in status assessments, inadequate pressure ulcer prevention, improper use of gait belts during resident transfers, failure to provide adequate fluids to residents, failure to limit PRN psychotropic medication orders to 14 days, and unsanitary food storage practices.
Deficiencies (6)
Failed to complete a significant change in status assessment for a resident who experienced a decline.
Failed to implement pressure ulcer prevention measures including consistent use of pressure-relieving boots as ordered.
Failed to provide adequate supervision and use gait belts correctly during resident transfers, placing residents at risk for falls and injury.
Failed to provide or offer fluids to a resident requiring assistance, risking dehydration and related complications.
Failed to ensure PRN psychotropic medication orders were limited to 14 days and properly reviewed.
Failed to store food and beverages in a sanitary manner, including unlabeled/undated food and expired nutritional beverages.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Dining/kitchenette areas affected: 3
Throw by dates: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Care Coordinator (#4) | Confirmed failure to complete significant change in status assessment and failure to review PRN medication every 14 days | |
| Nurse (#1) | Verified no order change for pressure-relieving boots and expected gait belt use | |
| Certified Nursing Assistant (#2) | Observed failing to use gait belt correctly during resident transfer | |
| Certified Nursing Assistant (#3) | Observed failing to use gait belt during resident transfer | |
| Certified Nursing Assistants (#9, #10, #11, #12) | Observed failing to offer fluids to resident | |
| Administrative Nurse (#8) | Expected staff to offer fluids with every interaction | |
| Food Service Supervisor (#5) | Expected staff to dispose of unlabeled/undated food and expired nutritional beverages |
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