Missouri Slope: Whirlpool Bath Fall Causes Actual Harm - ND
The finding, classified under F689, the federal tag covering free from accident hazards, placed the deficiency in the past non-compliance category, meaning the facility had already begun responding before the inspector arrived on June 12. That timing did not change what happened to the resident.
The inspection report is spare on detail about the resident's injuries. It says only that actual harm occurred, and that the fall happened during a whirlpool bath. What caused it was straightforward: the CNA responsible for the bath did not use the seat belt built into the whirlpool chair for exactly this purpose.
Whirlpool chairs are mechanical lifts that lower residents into a therapeutic bath. The seat belt is the primary restraint keeping a resident secured during that process. Not using it is not a judgment call or a close procedural question. The strap is there, and it was not fastened.
The facility's own investigation reached the same conclusion. Managers determined the CNA had failed to ensure adequate supervision of the resident during the bath, and that the failure was the direct cause of the fall.
What followed was a round of corrective action that the facility says it began on June 11, one day before the inspector's arrival. Bath aides were educated and re-educated on the requirement to use the whirlpool chair seat belt during every resident bath. A Whirlpool Safety Checklist was added to the lead CNA's job duties. A Whirlpool Safety Performance Tracker was introduced as an ongoing quality assurance measure.
The inspector confirmed the deficiency existed. The corrective actions were also noted.
But the sequence raises a question the inspection report does not fully answer. The facility says it started re-educating bath aides on June 11. The complaint that triggered the inspection almost certainly predates that. Someone, at some point before the inspector walked in, notified authorities that something had gone wrong during a bath. The facility's response began the day before the visit. The resident had already been harmed.
Inspectors classified the number of residents affected as few, the lower end of the scale, which suggests the problem was not systemic across the bathing program. The corrective record the facility submitted describes a targeted response to a specific failure by a specific staff member.
That framing, a single CNA who did not use a seat belt, is accurate as far as it goes. But a seat belt on a whirlpool chair does not require training to understand. It requires someone to reach down and fasten it before the lift begins moving. The re-education the facility now requires for all bath aides, the new checklist, the new performance tracker, all of that infrastructure exists because something that basic did not happen.
Missouri Slope is a long-term care facility in Bismarck. The inspection was complaint-driven, not a routine survey, which means someone with knowledge of the incident chose to report it. The resident who fell is not named in the report. Their condition before the fall, the nature of the injuries, and their status after are not described.
What the record contains is a seat belt that was not used, a resident who fell, and a facility that was still working through staff re-education when the inspector arrived.
The checklist is now part of the lead CNA's duties. The tracker is now a quality assurance measure. The resident who fell in the whirlpool chair is not mentioned again.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Missouri Slope from 2024-06-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 8, 2026 · Our methodology
MISSOURI SLOPE in BISMARCK, ND was cited for violations during a health inspection on June 12, 2024.
That timing did not change what happened to the resident.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.