Based on record review, policy review, and staff interview, the facility failed to notify the physician of a deterioration in skin condition for 1 of 3 sampled residents (Resident #5) with a pressure ulcer. Failure to notify the physician of a deterioration in skin condition resulted in complications to the resident and prevented the physician from evaluating the effectiveness of the current treatment plan. Findings include: Review of the facility policy titled Prevention and treatment of [REDACTED]. This policy, dated September 2018, stated, . 10. Weekly the licensed nurse will . and examine the wound bed and surrounding skin. If wound bed has deteriorated; notify provider. 11. Notify the attending provider, . …
F580 citations in North Dakota
Notifying of changes · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
North Dakota cites F580 less often than its own record predicts
0.19 times the national share — cited less often here than elsewhere.
Of every deficiency written in North Dakota in 2025, this is the portion that was F580.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Dakota surveyors wrote
F580 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.
Based on record review, review of facility policy, and staff interview, the facility failed to notify the physician and/or resident representative of a change in condition and falls for 1 of 5 sampled residents (Resident #5) reviewed for symptoms of hypoglycemia and falls. Failure to promptly notify the physician regarding low blood glucose readings and failure to notify the resident representative regarding the falls limited the physician's ability to alter treatment and limited the resident representative's ability to make informed decisions regarding Resident #5's care. Findings include: Review of the facility policy titled Notification of Change occurred on 07/30/26. This policy, dated 2017, stated, . …
The short window
Recent years
| Year | Share of North Dakota citations | vs expected |
|---|---|---|
| 2023 | 2.46% | 1.72× |
| 2024 | 2.72% | 1.79× |
| 2025 | 0.28% | 0.19× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Dakota surveyors cite →
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