F609 in North Dakota. Pick another state for the same tag.
Against expectation — 2025
North Dakota cites F609 more often than its own record predicts
Versus expected share1.81×
1.81 times the share F609 takes of citations nationally.
Share of North Dakota citations4.42%
Of every deficiency written in North Dakota in 2025, this is the portion that was F609.
North Dakota4.42%
National2.45%
Share of all citations that were F609.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Dakota surveyors wrote
F609 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.
K · Immediate jeopardy, patternOctober 15, 2024
Based on review of the facility reported incident (FRI) investigation, review of facility policy, and staff interviews, the facility failed to report potential sexual abuse to law enforcement for 1 of 1 sampled resident (Resident #1) with cognitive impairment. Failure to report potential sexual abuse placed Resident #1 and all other residents at risk for possible abuse and/or injury.
During the on-site survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 10/07/24. The IJ was identified during an interview with three administrative staff members (#1, #2, and #5) and a staff nurse (#4) on 10/07/24 at approximately 9:55 p.m. …
D · No harm, potential for more than minimal, isolatedJuly 30, 2026
Based on record review, review of facility policy and staff interview, the facility failed to report incidents of abuse to the State Survey Agency (SSA) within the required time frames for 3 of 16 sampled residents (Resident #47, #56 and #57) reviewed for resident-to-resident abuse. Failure to ensure incidents of potential abuse are reported to the SA immediately, but no later than 2 hours after the allegation is made, may result in continued abuse, fear, anxiety, and psychosocial harm.
Findings include:
Review of the facility policy titled Resident to Resident Altercation occurred on 07/29/26 and 07/30/26. This revised policy, dated 05/25/26, stated, . 4. If a Resident-to-Resident Altercation is suspected or alleged, the facility will take the following actions: . e. …
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