Souris Valley Care Center: No Correction Plan Filed - ND
The November 11 incident at Souris Valley Care Center revealed multiple breakdowns in basic fall response procedures. Staff moved the resident from the floor using mechanical equipment without a licensed nurse performing the required full-body assessment to check for injuries.
Resident #1, who required assistance from two people for transfers according to her care plan, fell when she reached for the bathroom door while sitting unsecured in the bath chair. Certified nurse aide #4 admitted she had not fastened the safety strap during the bath.
"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 told investigators. She immediately called for help on her radio.
CNA #6 responded and found the resident "wet, crawling on all fours and trying to get back into the tub." The resident asked to be helped off the cold floor, but the two aides waited 10 to 15 minutes for additional help that never arrived.
"We waited for help for 10-15 minutes and then we used the hoyer lift to get [Resident #1] off the floor into the bath chair," CNA #6 said.
The facility's own fall policy, dated October 14, explicitly prohibited this action. The policy required staff to "not move resident" and "summon the licensed nurse" who "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."
Nobody followed these procedures.
When nurse #5 finally arrived at 1:20 p.m., she found the resident already moved and sitting in the bath chair without the safety belt. She noticed a hoyer lift sheet underneath the resident and asked about it.
"Did they tell you she fell," CNA #4 responded.
The nurse conducted what she described as a "skin check" rather than the comprehensive assessment required by facility policy. She asked about pain and observed the resident move her arms and legs, then left the room.
The problems compounded after the bath. Staff used a sit-to-stand lift to transfer the resident from the bath chair to her wheelchair, equipment that was not included in her care plan and had not been assessed as safe for her condition.
The resident's care plan specified she needed a "pivot x2 with gait belt" transfer method, meaning assistance from two people using a gait belt. The sit-to-stand lift represented a completely different transfer approach that had not been evaluated for her specific mobility limitations and dementia.
Federal inspectors determined these protocol violations "may have resulted in further injury and pain to the resident." The resident was diagnosed with a fracture of the left femoral neck and required hospitalization.
A physician's progress note from November 11 documented the resident "fell when she had gotten out of the shower earlier today" and "initially started having left hip pain." The diagnosis listed "multiple falls" and "fracture of femoral neck, left."
The inspection, completed November 20 following a complaint, found the facility failed to provide treatment and care according to professional standards for maintaining the resident's highest level of functioning.
The case highlighted how multiple small violations can cascade into serious harm. The unsecured safety strap led to the fall. The delayed nursing assessment meant potential injuries went undetected. The use of unauthorized transfer equipment may have worsened existing damage.
CNA #6 told investigators she asked the resident about pain after the fall, and the resident said "No." However, hip fractures in elderly residents, particularly those with dementia, may not always present with immediate obvious pain symptoms.
The facility's policy recognized the particular vulnerability of residents with suspected hip fractures, specifically directing staff to "not attempt to move the resident if hip fracture is suspected." Yet staff moved this resident twice using mechanical equipment without any medical evaluation.
The resident required assistance from two people for all transfers according to her care plan, reflecting "impaired balance, limited mobility and weakness" related to her dementia. These documented limitations made the decision to use different transfer methods without assessment particularly concerning.
The inspection found that facility staff "failed to complete a nursing assessment to evaluate potential injury or determine an appropriate transfer method prior to assisting the resident from the floor." This failure occurred despite clear written policies requiring exactly such assessments.
The November 20 inspection classified the violation as causing "minimal harm or potential for actual harm," though the resident sustained a hip fracture requiring hospitalization. The finding affected "few" residents but demonstrated systemic problems with fall response protocols.
Federal inspectors noted that staff violations "may have contributed to additional injury and pain for the resident" beyond what the original fall might have caused. The resident, who was already dealing with dementia and mobility challenges, spent additional time on a cold bathroom floor while staff failed to follow emergency procedures designed to protect her.
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 violations during a health inspection on November 20, 2025.
The November 11 incident at Souris Valley Care Center revealed multiple breakdowns in basic fall response procedures.
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.