Souris Valley Care Center: Abuse Response Failures - ND
The resident suffered a left hip fracture.
Federal inspectors found that staff at Souris Valley Care Center violated basic fall protocols on November 11, 2025, when they failed to have a licensed nurse perform a full-body examination before moving the fallen resident from the bathroom floor.
The facility's own policy was clear: "Do not move resident. Stay with the resident and summon the licensed nurse. A nurse must observe the resident and perform a full-body exam to determine if there may be suspected injury and direct whether to move the resident."
None of that happened.
Certified nurse aide #4 was bathing the resident when the fall occurred. The aide later told inspectors she had not secured the resident in the bath chair with the safety strap. "When I had finished her bath and was going to get her dried off and dressed she reached for the door on the tub and fell out of the tub chair," the aide said.
The aide called for help on her walkie-talkie. CNA #6 responded and found the resident "wet, crawling on all fours and trying to get back into the tub."
"I asked her if she was ok and she said, 'Get me off the floor I'm cold,'" CNA #6 told inspectors.
The aides waited for additional help. And waited.
"We waited for help for 10-15 minutes and then we used the hoyer lift to get [the resident] off the floor into the bath chair," CNA #6 said. "We waited for help to come and after no one came to help us we called again, and no one came."
A Hoyer lift is a mechanical device designed to transfer patients who cannot support their own weight. The aides used it to move the resident from the wet bathroom floor back into the bath chair.
Only then did a nurse arrive.
Nurse #5 entered the bathroom at 1:20 p.m. and found the resident sitting in the bath chair without the safety belt fastened. A Hoyer lift sheet was still underneath her. When the nurse pointed to the sheet and shrugged her shoulders, CNA #4 finally revealed what had happened: "Did they tell you she fell."
The nurse's assessment was cursory. "The resident said she had no pain and moved her legs and arms without any concerns and then I left the tub room," the nurse told inspectors.
No full-body examination. No systematic check for injuries. No evaluation of whether the resident should be moved at all.
After the nurse left, the aides faced another transfer challenge. They needed to move the resident from the bath chair to her wheelchair. This time, they used a sit-to-stand lift.
The resident's care plan specified she required "pivot x2 with gait belt" for transfers — meaning she needed assistance from two people using a gait belt for support. The sit-to-stand lift was not included in her care plan and had not been assessed as a safe transfer option.
The resident had a documented history that should have raised red flags. Her care plan noted an "ADL self-care performance deficit" related to "dementia, impaired balance, limited mobility and weakness." A physician's progress note from that same day referenced "multiple falls."
By the end of the day, the resident was experiencing left hip pain. A physician's examination revealed the extent of the damage: "Fracture of femoral neck, left."
The facility reported the incident to state survey agencies the next day, November 12. Federal inspectors arrived to investigate on November 20.
The inspection revealed a cascade of protocol failures. Staff had not followed the facility's fall prevention policy. They had moved a fallen resident without medical clearance. They had used transfer equipment not approved in the resident's care plan.
The resident required hospital admission for her hip fracture.
Hip fractures in elderly residents carry serious consequences. The injury typically requires surgical intervention and extensive rehabilitation. For residents with dementia and mobility issues, recovery can be particularly challenging.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm," but noted that the facility's failure to ensure proper post-fall assessment "may have resulted in further injury and/or pain to the resident."
The inspection found that few residents were affected by this specific deficiency, but the case illustrates broader concerns about staff training and protocol adherence at the 300 Main Street facility.
The resident's experience highlights what can happen when basic safety procedures break down. A routine bath became a medical emergency because staff did not secure a safety strap. A fall became a more serious injury because staff prioritized getting a resident off a cold floor over waiting for proper medical assessment.
The facility's policy existed for exactly this scenario — to prevent staff from moving residents who might have sustained fractures or other injuries that could be worsened by improper handling. But when the moment came, staff abandoned the protocol.
The resident who said "Get me off the floor I'm cold" while crawling on wet bathroom tiles received exactly what she asked for. What she needed was a nurse's careful assessment before anyone moved her at all.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Souris Valley Care Center from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
SOURIS VALLEY CARE CENTER in VELVA, ND was cited for abuse-related violations during a health inspection on November 20, 2025.
The resident suffered a left hip fracture.
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.