VELVA, ND — Federal health inspectors issued an immediate jeopardy citation against Souris Valley Care Center following a complaint investigation completed on November 20, 2025, finding the facility failed to keep its environment free from accident hazards and did not provide adequate supervision to prevent resident accidents. The facility has not submitted a plan of correction.
Highest-Level Federal Deficiency Issued
The Centers for Medicare & Medicaid Services (CMS) uses a grid system to classify nursing home deficiencies by both scope and severity. The citation issued to Souris Valley Care Center — Scope/Severity Level J — represents an isolated incident that posed immediate jeopardy to resident health or safety. This is one of the most serious ratings a nursing home can receive during a federal inspection.
Immediate jeopardy citations are reserved for situations where a facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. According to CMS guidelines, fewer than 2% of all nursing home deficiencies nationwide reach the immediate jeopardy threshold, making this citation a significant indicator of care failure at the Velva facility.
The specific deficiency was cited under regulatory tag F0689, which falls under the federal requirement that nursing homes must ensure their environment is free from accident hazards and that each resident receives adequate supervision and assistive devices to prevent accidents. This regulation is one of the cornerstones of federal nursing home safety standards, codified under 42 CFR §483.25(d).
What F0689 Requires of Nursing Facilities
The F0689 regulation addresses a fundamental obligation of every skilled nursing facility: accident prevention and environmental safety. Under federal law, nursing homes must take a proactive, systematic approach to identifying and eliminating hazards that could lead to resident injuries.
This includes but is not limited to:
- Conducting individualized risk assessments for each resident upon admission and at regular intervals - Implementing fall prevention programs tailored to each resident's mobility level, cognitive status, and medical conditions - Ensuring that physical plant hazards such as wet floors, broken equipment, poor lighting, unsecured furniture, and obstructed pathways are identified and corrected promptly - Providing adequate staffing levels so that residents who require close monitoring or one-on-one assistance receive it consistently - Documenting all accidents and near-misses, analyzing their root causes, and implementing corrective measures to prevent recurrence
When a facility receives an F0689 citation at the immediate jeopardy level, it indicates that inspectors determined the failure was not merely a documentation gap or minor oversight. Rather, the conditions observed presented a direct and serious threat to at least one resident's physical safety.
Medical Implications of Supervision and Hazard Failures
Accident hazards in nursing home environments carry especially high medical stakes because of the population these facilities serve. The typical nursing home resident is elderly, often medically fragile, and may have multiple conditions that increase vulnerability to injury.
Falls remain the leading cause of injury-related death among adults aged 65 and older in the United States. For nursing home residents, the consequences of a single fall can be catastrophic. Hip fractures, which occur in a significant percentage of nursing home falls, carry a one-year mortality rate of approximately 20-30% among elderly patients. Even when a hip fracture does not prove fatal, it frequently leads to a permanent decline in mobility, increased dependence on care, and a substantially reduced quality of life.
Beyond falls, environmental hazards in care facilities can lead to burns, lacerations, choking incidents, and entrapment injuries. Residents with cognitive impairments such as dementia are at particularly elevated risk because they may not recognize dangers in their environment or may wander into unsafe areas without staff awareness.
Inadequate supervision compounds these risks. A resident who is assessed as a high fall risk but left unmonitored during transfers, toileting, or ambulation faces a dramatically increased likelihood of injury. Similarly, residents who require assistance with eating may be at risk of aspiration or choking if staff members are not available to provide timely help during meals.
The medical evidence is clear: proper supervision and hazard-free environments are not optional amenities — they are essential components of safe care that directly affect resident survival and wellbeing.
Three Deficiencies Cited in Single Investigation
The immediate jeopardy citation was not the only finding from the November 2025 complaint investigation. Inspectors identified a total of three deficiencies during their review of Souris Valley Care Center. While the F0689 citation drew the highest severity level, the presence of multiple deficiencies during a single investigation can suggest broader systemic issues within a facility's care delivery and management structure.
Complaint investigations differ from standard annual surveys in an important way: they are triggered by specific allegations of harm or noncompliance, typically filed by residents, family members, staff, or other concerned parties. The fact that inspectors confirmed deficiencies during such an investigation means the original complaint was substantiated by evidence gathered on-site.
The category assigned to the primary deficiency — Quality of Life and Care Deficiencies — further underscores the nature of the findings. This classification encompasses failures that directly affect the day-to-day experience and physical welfare of residents, rather than administrative or procedural shortcomings alone.
No Plan of Correction Filed
Perhaps the most concerning aspect of the inspection outcome is the facility's current correction status: "Deficient, Provider has no plan of correction."
Under federal regulations, when a nursing home receives a deficiency citation, it is required to submit a plan of correction (POC) to the state survey agency. This plan must outline the specific steps the facility will take to remedy the deficiency, prevent its recurrence, and protect residents from further harm. The POC must include timelines, responsible parties, and monitoring mechanisms.
The absence of a plan of correction can carry serious consequences. CMS and state agencies have the authority to impose a range of enforcement remedies against facilities that fail to achieve compliance, including:
- Civil monetary penalties ranging from hundreds to thousands of dollars per day - Denial of payment for new Medicare and Medicaid admissions - Directed plans of correction imposed by the regulatory agency - State monitoring requiring on-site oversight by an independent party - In the most serious cases, termination from the Medicare and Medicaid programs, effectively closing the facility to federally funded residents
For an immediate jeopardy citation specifically, CMS policy requires that the facility remove the jeopardy situation within 23 calendar days, or face mandatory termination from federal healthcare programs. The clock on this enforcement timeline begins on the date the facility is notified of the immediate jeopardy finding.
Souris Valley Care Center: Facility Background
Souris Valley Care Center is located in Velva, North Dakota, a small community in McHenry County with a population of approximately 1,000 residents. In rural communities like Velva, the local nursing home often serves as the primary or only option for long-term care within a reasonable distance, making the quality of care delivered at these facilities especially critical for area families.
Rural nursing homes across the United States face well-documented challenges including staffing shortages, recruitment difficulties, and limited access to specialized medical services. However, federal care standards apply equally to all certified nursing facilities regardless of size or location. Every resident is entitled to the same level of protection from hazards and the same standard of supervision, whether the facility is located in a major metropolitan area or a rural community.
What Families Should Know
For families with loved ones currently residing at Souris Valley Care Center — or those considering placement at the facility — this inspection outcome warrants careful attention and follow-up. Steps that families can take include:
- Reviewing the full inspection report on the CMS Care Compare website (medicare.gov/care-compare), where all deficiency citations, scope/severity levels, and facility responses are publicly available - Contacting the facility's administrator directly to ask what actions have been taken to address the immediate jeopardy finding and when a plan of correction will be submitted - Reaching out to the North Dakota Long Term Care Ombudsman Program, which advocates for the rights and welfare of nursing home residents and can assist with concerns or complaints - Monitoring the facility's compliance status in the weeks ahead, as CMS enforcement actions related to immediate jeopardy findings typically unfold on a compressed timeline
The inspection findings are part of the public record and available for review by any interested party. Transparency in nursing home oversight exists specifically so that residents, families, and communities can make informed decisions about care.
Looking Ahead
The immediate jeopardy citation at Souris Valley Care Center represents a serious regulatory finding that demands prompt corrective action. Federal and state regulators will be monitoring the facility's response closely, and the timeline for resolving an immediate jeopardy situation is measured in days, not months.
Whether the facility can demonstrate meaningful, sustained improvement will determine both its regulatory standing and, more importantly, the safety of the residents who depend on it for daily care. The full inspection report, including all three deficiency citations from the November 2025 investigation, is available for public review through CMS and provides additional detail beyond the scope of this article.
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.
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