North Dakota Veterans Home

F-F684 is considered past non-compliance. The facility implemented corrective actions for other residents who may be affected by the deficient practice by:

* Completing an investigation into Resident #1's choking episode/death.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 3 355114 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 355114 B. Wing 03/13/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

North Dakota Veterans Home 1600 Veterans Drive Lisbon, ND 58054

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 0684 * Updating facility policies regarding modified diets on 03/12/25, menu cards on 03/12/25, and meal assistance on 03/13/25. Level of Harm - Actual harm * Educating staff regarding modified diets, menu cards, and meal assistance immediately and all staff that Residents Affected - Few have worked since.

* Completing audits on prescribed diets/meal service.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 3 355114