State surveyors inspected 65 of North Dakota's 72 nursing homes in the 12 months from August 2025 through July 2026 and cited 353 health deficiencies, according to CMS's nursing home health citation file, processed September 1, 2026. The most cited was F880, which CMS words as “provide and implement an infection prevention and control program”, at 39 of those buildings (60%). 8 of the citations were immediate jeopardy, the most serious level CMS has.
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North Dakota, the 12 months from August 2025 through July 2026, from CMS's nursing home health citation file.
August 2025 through July 2026. Source: CMS's nursing home health citation file, processed September 1, 2026.
| Rank | Tag | Citations | Buildings cited |
|---|---|---|---|
| 1 | F880Provide and implement an infection prevention and control program | 44 | 39 (60%) |
| 2 | F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents | 33 | 25 (38%) |
| 3 | F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody | 26 | 22 (34%) |
| 4 | F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards | 19 | 19 (29%) |
| 5 | F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs | 17 | 17 (26%) |
| 6 | F684Provide appropriate treatment and care according to orders, resident’s preferences and goals | 16 | 16 (25%) |
| 7 | F641Ensure each resident receives an accurate assessment | 15 | 15 (23%) |
| 8 | F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals | 14 | 13 (20%) |
| 9 | F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities | 11 | 11 (17%) |
| 10 | F658Ensure services provided by the nursing facility meet professional standards of quality | 11 | 11 (17%) |
| 11 | F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident | 9 | 8 (12%) |
| 12 | F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely | 9 | 8 (12%) |
| 13 | F610Respond appropriately to all alleged violations | 8 | 8 (12%) |
| 14 | F686Provide appropriate pressure ulcer care and prevent new ulcers from developing | 7 | 7 (11%) |
| 15 | F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections | 6 | 6 (9%) |
| 16 | F759Ensure medication error rates are not 5 percent or greater | 6 | 6 (9%) |
| 17 | F583Keep residents' personal and medical records private and confidential | 5 | 5 (8%) |
| 18 | F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies | 5 | 5 (8%) |
| 19 | F695Provide safe and appropriate respiratory care for a resident when needed | 5 | 5 (8%) |
| 20 | F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive | 4 | 4 (6%) |
| 21 | F677Provide care and assistance to perform activities of daily living for any resident who is unable | 4 | 4 (6%) |
| 22 | F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift | 4 | 4 (6%) |
| 23 | F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services | 4 | 4 (6%) |
| 24 | F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights | 3 | 3 (5%) |
| 25 | F552Ensure that residents are fully informed and understand their health status, care and treatments | 3 | 3 (5%) |
| Rank | Tag | Citations | Buildings cited |
|---|---|---|---|
| 26 | F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function | 3 | 3 (5%) |
| 27 | F698Provide safe, appropriate dialysis care/services for a resident who requires such services | 3 | 3 (5%) |
| 28 | F732Post nurse staffing information every day | 3 | 3 (5%) |
| 29 | F757Ensure each resident’s drug regimen must be free from unnecessary drugs | 3 | 3 (5%) |
| 30 | F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician | 3 | 3 (5%) |
| 31 | F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | 3 | 3 (5%) |
| 32 | F558Reasonably accommodate the needs and preferences of each resident | 2 | 2 (3%) |
| 33 | F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered | 2 | 2 (3%) |
| 34 | F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge | 2 | 2 (3%) |
| 35 | F637Assess the resident when there is a significant change in condition | 2 | 2 (3%) |
| 36 | F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed | 2 | 2 (3%) |
| 37 | F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason | 2 | 2 (3%) |
| 38 | F692Provide enough food/fluids to maintain a resident's health | 2 | 2 (3%) |
| 39 | F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature | 2 | 2 (3%) |
| 40 | F883Develop and implement policies and procedures for flu and pneumonia vaccinations | 2 | 2 (3%) |
| 41 | F908Keep all essential equipment working safely | 2 | 2 (3%) |
| 42 | F553Allow resident to participate in the development and implementation of his or her person-centered plan of care | 1 | 1 (2%) |
| 43 | F554Allow residents to self-administer drugs if determined clinically appropriate | 1 | 1 (2%) |
| 44 | F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions | 1 | 1 (2%) |
| 45 | F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment | 1 | 1 (2%) |
| 46 | F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment | 1 | 1 (2%) |
| 47 | F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | 1 | 1 (2%) |
| 48 | F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured | 1 | 1 (2%) |
| 49 | F687Provide appropriate foot care | 1 | 1 (2%) |
| 50 | F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube | 1 | 1 (2%) |
| 51 | F697Provide safe, appropriate pain management for a resident who requires such services | 1 | 1 (2%) |
| 52 | F712Ensure that the resident and his/her doctor meet face-to-face at all required visits | 1 | 1 (2%) |
| 53 | F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia | 1 | 1 (2%) |
| 54 | F745Provide medically-related social services to help each resident achieve the highest possible quality of life | 1 | 1 (2%) |
| 55 | F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist | 1 | 1 (2%) |
| 56 | F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures | 1 | 1 (2%) |
| 57 | F760Ensure that residents are free from significant medication errors | 1 | 1 (2%) |
| 58 | F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service | 1 | 1 (2%) |
| 59 | F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident | 1 | 1 (2%) |
| 60 | F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs | 1 | 1 (2%) |
| 61 | F808Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law | 1 | 1 (2%) |
| 62 | F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility | 1 | 1 (2%) |
| 63 | F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies | 1 | 1 (2%) |
| 64 | F865Have a plan that describes the process for conducting QAPI and QAA activities | 1 | 1 (2%) |
| 65 | F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action | 1 | 1 (2%) |
| 66 | F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public | 1 | 1 (2%) |
| 67 | F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention | 1 | 1 (2%) |
| 68 | F949Provide behavior health training consistent with the requirements and as determined by a facility assessment | 1 | 1 (2%) |
A tag is ranked by how many times it was cited. “Buildings cited” counts the inspected buildings that drew the tag at least once, and its percentage is of every building inspected; we print a percentage only where 20 or more buildings were inspected. “Rank a year earlier” is the same ranking over August 2024 through July 2025. CMS publishes citations months after the survey, so the newest months are still filling in: compare ranks across the two years, not counts. Immediate jeopardy is CMS severity J, K or L; actual harm is G, H or I. No building is named on this page: open a building for its own inspections.
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