Based on observation, record review, review of facility policy, and staff interviews, the staff failed to provide appropriate supervision for 1 of 1 sampled resident (Resident #1) who wandered. Failure to provide adequate staff supervision resulted in Resident #1 accessing unsafe areas, hazardous items, and urinating/defecating in common areas and other residents' rooms and placed Resident #1 and all residents at risk of accidents, falls, and/or injuries. 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 05/02/26 when documentation showed the facility failed to provide adequate supervision for Resident #1 which resulted in access to unsafe areas… …
F689 citations in North Dakota
Accidents and supervision · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
North Dakota cites F689 more often than its own record predicts
1.75 times the share F689 takes of citations nationally.
Of every deficiency written in North Dakota in 2025, this is the portion that was F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Dakota surveyors wrote
F689 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, facility reported incident (FRI) review, and staff interview, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 sampled residents (Resident #15) who had a fall with major injury. Failure to provide adequate supervision during personal cares resulted in a fall with a head injury and hospitalization. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident.Findings include:The surveyor determined a deficient practice existed on 10/25/25. …
Based on observation, record review, review of facility policy, and resident and staff interview, the facility failed to ensure residents remain free from accident/hazards for 2 of 2 sampled residents (Resident #23, and #30) reviewed for smoking. Failure to safeguard fire starting devices from resident access placed all residents, staff, and visitors at risk for injury or fires. Findings include: Review of the facility policy titled Smoke Free Facility Policy occurred on 07/23/26. This policy, dated 04/06/23, stated, . applies to all residents . both smokers and non-smokers. Smoking is prohibited in all areas of the facility. to promote safety. - Review of Resident #23's medical record occurred on all days of survey. The care plan stated, . …
The short window
Recent years
| Year | Share of North Dakota citations | vs expected |
|---|---|---|
| 2023 | 8.77% | 1.77× |
| 2024 | 10.12% | 1.88× |
| 2025 | 9.67% | 1.75× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Dakota surveyors cite →
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