Based on observation, record review, review of facility policy, and staff interview, the facility failed to complete a self-administration of medication (SAM) assessment for 1 of 1 sampled resident (Resident #4) observed with medications at the bedside. Failure to determine a resident's capacity to safely self-administer medications may result in medication errors, adverse drug events, and/or harm to the resident. Findings include:Review of the facility policy titled Self-Administration of Medication's occurred on 01/14/26. This policy, dated February 2021, stated, . comprehensive assessment, interdisciplinary team (IDT) assesses each resident to determine whether self-administration of medications is safe and clinically appropriate for the resident. …
F554 citations in North Dakota
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
North Dakota cites F554 more often than its own record predicts
1.95 times the share F554 takes of citations nationally.
Of every deficiency written in North Dakota in 2025, this is the portion that was F554.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Dakota surveyors wrote
F554 findings written in North Dakota, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
The short window
Recent years
| Year | Share of North Dakota citations | vs expected |
|---|---|---|
| 2023 | 1.75% | 3.17× |
| 2024 | 0.25% | 0.45× |
| 2025 | 1.10% | 1.95× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Dakota surveyors cite →
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