Souris Valley Care Center: Immediate Jeopardy - ND
The resident suffered a fractured left hip.
Federal inspectors found that staff at Souris Valley Care Center violated basic fall protocols on November 11, moving the injured resident multiple times without proper evaluation and using transfer equipment not approved in her care plan.
The resident, who has dementia and requires assistance from two people to transfer between surfaces, fell when she reached for the bathroom door while a nursing assistant was drying her off after a shower. The aide had failed to secure the resident in the bath chair with the required 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 nursing assistant told investigators. She immediately called for help on her walkie-talkie.
A second aide arrived to find the resident "wet, crawling on all fours and trying to get back into the tub." The resident told staff: "Get me off the floor I'm cold."
Both aides waited for additional help. Nobody came.
"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," the second aide said. When asked if the resident had pain, she said no.
The facility's own fall prevention policy, dated October 14, explicitly prohibits what happened next. The policy states that after any fall, staff must "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."
Instead, nursing assistants moved the resident twice without any licensed nurse evaluation.
A licensed nurse finally arrived in the bathroom at 1:20 p.m., but only because she noticed the light was on and went to perform a routine skin check. She found the resident sitting in the bath chair without the safety belt, with a mechanical lift sheet underneath her.
The aide pointed to the lift sheet. The nurse "shrugged her shoulders," according to her own account to investigators.
Only then did the nursing assistant mention the fall. "Did they tell you she fell," the aide asked.
The nurse asked the resident about pain. The resident said she had none and moved her arms and legs without apparent difficulty. The nurse left.
But the evaluation was incomplete and came too late. Staff had already violated protocol by moving the resident from the floor to the bath chair, then from the bath chair to her wheelchair using a sit-to-stand lift.
The sit-to-stand lift was never included in the resident's care plan. Her plan specified she required a "pivot" transfer with assistance from two people using a gait belt, not mechanical assistance.
A physician's note from November 11 documented the consequences: the resident "fell when she had gotten out of the shower earlier today" and "initially started having left hip pain." The diagnosis was "fracture of femoral neck, left."
The resident was admitted to the hospital.
Federal inspectors determined that staff failures "may have resulted in further injury and/or pain to the resident." The facility received a citation for failing to provide treatment and care according to professional standards.
The inspection found that nursing assistants made multiple critical errors: failing to use the required safety strap during bathing, moving a fallen resident without nurse assessment, waiting 15 minutes to provide assistance, and using unauthorized transfer equipment.
The resident's care plan identified her specific vulnerabilities: dementia, impaired balance, limited mobility and weakness. She had a history of multiple falls. Yet staff ignored basic safety protocols designed to protect residents with exactly these risk factors.
The nursing assistant who failed to secure the safety strap told investigators she simply forgot. The second aide who helped with the mechanical lift said they called for additional help twice but nobody responded.
The licensed nurse who eventually responded said she only discovered the fall by accident when she noticed the bathroom light was on during her rounds.
Federal regulations require nursing homes to ensure residents receive treatment and care according to professional standards to maintain their highest level of functioning. The inspection found Souris Valley Care Center failed this basic requirement.
The facility submitted an incident report to state authorities on November 12, one day after the fall and hip fracture occurred.
Investigators classified the violation as causing "minimal harm or potential for actual harm," despite the resident's hospitalization for a fractured hip. The citation affects how Medicare rates the facility's quality of care.
The resident's case illustrates how quickly routine care can turn dangerous when staff ignore safety protocols. A simple bath became a medical emergency because a nursing assistant forgot to use a safety strap and supervisors failed to respond when help was needed.
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 immediate jeopardy violations during a health inspection on November 20, 2025.
The resident suffered a fractured left hip.
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.