Based on review of the facility reported incident (FRI) investigation, review of facility policy, and staff interviews, the facility failed to conduct a thorough investigation of potential sexual abuse for all residents after suspected sexual abuse for 1 of 1 sampled resident (Resident #1). Failure to investigate alleged violations of sexual abuse and ensure all residents were protected during the investigation, placed Resident #1 and all other residents at risk for possible abuse, mental and emotional distress, and/or physical 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. …
F610 citations in North Dakota
Investigating alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
North Dakota cites F610 more often than its own record predicts
1.46 times the share F610 takes of citations nationally.
Of every deficiency written in North Dakota in 2025, this is the portion that was F610.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Dakota surveyors wrote
F610 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 investigate incidents of verbal and physical abuse for 3 of 16 sampled residents (Resident #47, #56 and #57) reviewed for resident-to-resident abuse. Failure to investigate alleged violations of resident-to-resident abuse, ensure residents were protected during investigation, implement corrective actions, and evaluate the effectiveness of the actions, placed Resident #47, #56, and #57, and all residents at risk for possible mental/emotional distress and injury. Findings include: Review of the facility policy Abuse and Neglect Policy and Procedure occurred on 07/29/26 and 07/30/26. This undated policy stated, , . …
The short window
Recent years
| Year | Share of North Dakota citations | vs expected |
|---|---|---|
| 2023 | 0.35% | 0.27× |
| 2024 | 0.74% | 0.52× |
| 2025 | 2.21% | 1.46× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Dakota surveyors cite →
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