Woodside Village

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

facility implemented corrective actions for residents affected by the deficient practice as follows:Immediate Actions Taken:* Staff intervened and separated the two residents to prevent further escalation and assessed for injury. No injuries noted. * Other residents in vicinity redirected to ensure safety.* Incident reported to charge nurse and on-call administration. Report made to the North Dakota Department of Health and Human Services on 09/14/25. * Responsible parties of both residents and the Medical Doctor on-call notified of the incident on 09/14/25 by the charge nurse.* Both residents monitored the remainder of

the day. Follow-Up Actions: * Completed initial meeting and investigation of incident on 09/15/25* Documented 72-hour status monitoring of both residents in electronic medical record system.* Resident #4 and #7's care plans reviewed and revised on 09/15/25. * Psychiatric Nurse Practitioner continues to conduct health consultations/medication reviews for both residents. Provider saw both residents on scheduled provider rounds on 09/17/25. * Staff education provided on 09/19/25 to the dementia unit staff on de-escalation strategies for dementia behaviors and resident-to-resident altercations.* Registered Nurse Care Coordinator provided information concerning therapeutic response techniques at the neighborhood Quality of Care meeting on 09/25/25.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodside Village

4000 24th Ave S Grand Forks, ND 58201

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on record review, review of the facility reported incident (FRI) investigation, and review of facility standard of care policy, the facility failed to properly utilize assistive devices necessary to prevent accidents for 1 of 1 closed record resident (Resident #7) who sustained a fall. Failure to remove the wheelchair foot pedals may have contributed to Resident #7's fall. This citation is considered past non-compliance based

on review of the corrective actions the facility implemented immediately following the incident. Findings include:Review of the facility Standards of Care occurred on 12/22/25. This form, dated 10/06/25 stated, .

Foot pedals will be used for all residents being transported for extended distances and removed when stationary or unless Care Planned. Review of Resident #7s medical record occurred on 12/22/25. The care plan, dated 11/04/25, stated, Ambulation: I need assist of 1 with a gait belt, hand held assist. Review of the FRI investigation, dated 11/05/25, stated, At approximately 7:50 AM CNA [certified nurse aide] [CNA #1] brought [Resident #7] to the dining room table in a wheelchair. [CNA #1] left [Resident #7] at the table with wheelchair pedals in place and then returned to the residents room down the hall to retrieve a bag of garbage. On his way to throw the garbage he stopped to speak to the RN [registered nurse] [nurse name].

In [CNA #1] written report of the incident, he indicated that on the wheelchair pedals there was a sticker that stated pedals stay on at all times. [Nurse name] confirmed that [CNA #1] had asked her about this and

she clarified to [CNA #1] that the pedals should be removed. [CNA #1] did not return to [Resident #7] to remove the wheelchair pedals, instead walking to the utility room to discard the garbage. As [CNA #1] was returning toward the dining room, [Resident #7] stood up and fell, striking the back of his head on a dining room chair. [Resident #7] had been hospitalized for pneumonia and returned to our facility on 11/4/25. The wheelchair was left in his room as it was used to transport him back from the hospital. Based on the following information, non-compliance at F-F689 is considered past non-compliance. The facility implemented corrective actions for residents affected by the deficient practice as follows:*The nurse immediately assessed Resident #7.*Completed an investigation related to Resident #7's fall. *Resident #7's primary decision maker and physician notified. *Monitoring of Resident #7 for any signs of injury, distress or change

in condition. *Incident reported to the Department of Health and Human Services. *CNA (#1) terminated on 11/11/25. *Resident #7's care plan reviewed. *Staff education provided on 11/05/25 regarding foot pedals removed from wheelchair when resident is stationary.*Wheelchair positioning audits completed.

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