Based on record review, review of facility policy, and staff interview, the facility failed to provide care and services for 1 of 1 closed record (Resident #1) with diabetes. Failure to ensure residents receive treatment and care according to professional standards of practice related to blood glucose monitoring increases the risk of serious harm, impairment, or death. During the complaint survey, the team determined an Immediate Jeopardy (IJ) situation existed on [DATE] at 5:22 p.m. The IJ resulted from staff failure to recheck a resident's glucose [sugar] or take additional interventions after a test result of 61 mg/dL (milligrams per deciliter) on [DATE]. …
F684 citations in North Dakota
Quality of care · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
North Dakota cites F684 less often than its own record predicts
0.58 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 F684.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Dakota surveyors wrote
F684 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 observation, record review, resident and staff interview, the facility failed to ensure that 1 of 1 sampled resident (Resident #1) with a non-pressure skin wound received treatment and care in accordance with professional standards of practice. Failure to perform regular wound monitoring and assessments and document the progression of a wound resulted in delayed healing and worsening of the wound. Findings include: Observation on 07/28/26 at 8:52 a.m. showed an open area on Resident #1's mid-back. Resident #1 stated, They think it [the open area] is from the sling [ceiling lift sling]. During an interview on 07/30/26 at 10:42 a.m., Resident #1 stated she has had the open area for about a month. Review of Resident #1's medical record occurred on all days of survey. …
Based on observation, record review, review of facility policy, and staff and resident interviews, the facility failed to provide the necessary care and services for 2 of 15 sampled residents (Resident #22 and #29). Failure to follow physician's orders for wound care (Resident #22) and an implanted vascular access port care (Resident #29), and to address and report low blood glucose levels to the physician (Resident #29) may result in adverse outcomes. Findings include: Review of the facility policy titled Physician/Practitioner Orders occurred on [DATE]. This policy, dated [DATE], stated, . wound care including product to be used . A licensed nurse must provide wound care. …
The short window
Recent years
| Year | Share of North Dakota citations | vs expected |
|---|---|---|
| 2023 | 2.46% | 0.68× |
| 2024 | 3.46% | 0.87× |
| 2025 | 2.49% | 0.58× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Dakota surveyors cite →
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