Based on record review, review of facility policy, and resident and staff interview, the facility failed to ensure residents remain free from abuse for 7 of 7 sampled residents (Resident #1, #2, #3, #4, #5, #6 and #7) who were subjected to physical/verbal abuse by other residents. Failure to prevent resident-to-resident physical abuse resulted in altercations involving hitting, slapping, and scratching and placed all residents at risk for serious injury, pain, mental anguish, and emotional distress. During the on-site facility reported incident investigation survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed beginning on 05/24/26 when documentation identified Resident #1 placed her hands around Resident #7's neck. …
F600 citations in North Dakota
Abuse and neglect · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
North Dakota cites F600 more often than its own record predicts
2.22 times the share F600 takes of citations nationally.
Of every deficiency written in North Dakota in 2025, this is the portion that was F600.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Dakota surveyors wrote
F600 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 the facility reported incident (FRI) investigation, review of facility policy, and staff interviews, the facility failed to ensure residents remained free from abuse for 3 of 16 sampled residents (Resident #47, #56, and #57) who exhibited and/or were subjected to physical/verbal abuse. Failure to prevent resident-to-resident physical/verbal abuse resulted in hitting, emotional distress (crying), and fear. These actions placed all residents at risk for serious injury, pain, and mental/emotional harm. Findings include: Review of the facility policy titled Abuse and Neglect Policy and Procedure occurred on 07/29/26. This undated policy stated, . each resident has the right to be free from abuse, . …
Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from abuse for 4 of 6 sampled residents (Resident #1, #5, #16, #30) reviewed for resident-to-resident altercations. Failure to protect residents from verbal and/or physical abuse placed all resident at risk for physical harm, pain, mental anguish, and emotional distress. Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation occurred on 07/23/26. This policy, dated December 2025, stated, . Provide protection for the health, and welfare and rights of each resident by . implementing . policy and procedures that prohibit and prevent abuse . 'Abuse' willful infliction of injury . intimidation . …
The short window
Recent years
| Year | Share of North Dakota citations | vs expected |
|---|---|---|
| 2024 | 3.70% | 1.57× |
| 2025 | 5.80% | 2.22× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Dakota surveyors cite →
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