North Dakota Veterans Home

In the surveyor’s words

From the most serious findings on record at North Dakota Veterans Home, in the surveyor’s own words.

• Immediate jeopardy, patternF689Aug 2, 2023

  Based on observation, record review, and staff interview, the facility failed to ensure an environment free of accident hazards for 4 of 4 coffee/hot water machines located in various areas within the facility (Town Hall, and Freedom Ridge, Honor Hill, and Peace Garden households). Failure to ensure appropriate coffee/water temperatures resulted in serving temperatures above the acceptable range and resulted in one resident acquiring burns to the left thigh, forearm, and hand, and may result in serious burns to other residents. During the standard survey, the team determined an Immediate Jeopardy (IJ) situation existed on 07/27/23 at 3:07 p.m. […]

• Actual harm, isolatedF684Mar 13, 2025

  Based on record review, review of facility policy, and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #1) received the care and services necessary to attain the highest degree of safety possible during mealtime. Failure to ensure staff served Resident #1 food items consistent with his prescribed diet resulted in his choking episode/death. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: Review of the facility policy titled Diets Available on Skilled Care Unit occurred on 03/13/25. This policy, revised 03/12/25, stated, . Consistency adjustments are determined based on swallow studies, physician orders, and speech therapy evaluations. […]

• No harm, potential for more than minimal, patternF657Aug 2, 2023

  Based on record review, review of facility policy, and staff interviews, the facility failed to review and revise comprehensive care plans to reflect the current status for 4 of 20 sampled residents (Residents #12, #15, #41, and #50). Failure to review and revise the care plan limited the staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled CARE PLAN, Baseline and Comprehensive occurred on 07/27/23. This policy, dated 04/30/18, stated, . Care plan will be updated with resident condition or per their choice. - Review of Resident #12's medical record occurred on all days of survey and identified a diagnosis of post traumatic stress disorder (PTSD). […]

• No harm, potential for more than minimal, patternF812Aug 2, 2023

  Based on observation, review of manufacture instructions, review of facility policy, review of facility sanitizer logs, and staff interview, the facility failed to prepare and serve food under sanitary conditions in 1 of 1 kitchen (main kitchen) and 2 of 2 kitchenettes (Courage/Freedom and Honor/Peace). Failure to monitor the concentration of the quaternary solution may result in unsafe preparation of food and foodborne illness. Findings include: Review of the manufacturer instructions for Smart Power Sink and Surface Cleaner Sanitizer posted above the kitchen dishwasher sinks occurred on 07/27/23 at 2:03 p.m., stated, EPA-registered cleaner sanitizer for pre-cleaned use on hard, non-porous food prep surfaces and wares, kills foodborne organisms . […]

• No harm, potential for more than minimal, isolatedF641Jun 27, 2024

  Based on record review and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 15 sampled residents (Resident #34). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2023, page A6, stated, . Coding Instructions for A0310E, Is This Assessment the First Assessment (OBRA, Scheduled PPS, or OBRA Discharge) since the Most Recent Admission/Entry or Reentry? . […]