Souris Valley Care Center
Inspection Findings
F-Tag F0610
F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
dated, 11/17/25, occurred on 11/18/25 and stated, . INVESTIGATION SUMMARY: The resident [Resident #1's] care planned as assist of 1 with bathing and assist of 1 with pivot transfers. On 11/11/2025, at approximately 1300 [1:00 p.m.], CNA . finished the resident's bath, pivot transferred into the bath chair. Prior to securing the lap belt to the bath chair, the resident grabbed onto the open door to the whirlpool and fell forward. CONCLUSION: At the conclusion of the investigation, the facility determined there was no willful intent to neglect as the resident . spontaneous movement of grabbing the open tub door prior to securing
the bath chair belt, resulted in the fall.Upon request, the facility provided staff interviews related to the incident. The interviews identified the following:* On 11/13/2025, DNS [director of nursing services] interviewed [CNA (#4)] on what had transpired the day of the fall. [CNA (#4)] stated that she transferred the resident [Resident #1] in the bath chair, collected v/s [vital signs], and put the resident in the whirlpool.
When [CNA (#4)] was finished, she tated (sic) she opened the whirlpool tub door, and [CNA (#4)] expressed that the resident [Resident #1] was reaching and attempting to grab onto things and that [CNA (#4)] was guiding her hands back to the bath chair bars to hold on to. [CNA (#4)] stated that when she was moving the resident out of the whirlpool tub, is when the resident [Resident #1] started reaching for the open tub door and was attempting to grab onto it. [CNA (#4)] stated that she was reaching too far and ended up on the floor. * On 11/13/2025, DNS interviewed [(CNA (#6)] in regards to the incident on 11/11/2025. [(CNA (#6)] stated that the resident [Resident #1] was on the floor and that the resident stated, 'get me off the floor. [CNA (#6)] stated she went and got a sling and a hoyer and her and [CNA (#4)] assisted the resident off the floor. DNS immediately educated [(CNA (#6)] on fall management and to never move the resident without a nurse assessing the resident first. * On 11/13/2025, DNS spoke with [nurse (#5)] in regards to the incident. DNS asked for a run through of what happened. [Nurse (#5)] asked what happened and [CNA (#4)] told her that the resident had fallen out of the bath chair and that they [CNA (#4) and CNA (#6)] picked her up using the sling and hoyer.The facility's investigation failed to include specific details discovered during staff interviews that would raise concerns of staff negligence resulting in Resident #1's fall and subsequent fracture.
Event ID:
Facility ID:
If continuation sheet
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
11/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Souris Valley Care Center
300 Main St S Velva, ND 58790
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-Tag F0684
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
Based on record review, review of facility policy, review of the facility reported incident (FRI) and investigation, and staff interviews, the staff failed to provide treatment and care in accordance with professional standards of practice to maintain residents' highest level of functioning for 1 of 1 sampled resident (Resident #1) who experienced a fall from the bath chair. Failure to ensure a licensed nurse performed a full-body assessment after a fall may have resulted in further injury and/or pain to the resident.Findings includeReview of the facility policy titled Fall Prevention and Management occurred on 11/18/25. This policy, dated 10/14/25, stated, . For Fallen Resident . Procedure 1. Do not move resident.
Stay with the resident and summon the licensed nurse . A nurse 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. Do not attempt to move the resident if . hip fracture is suspected.Review of the FRI, submitted to the state survey agency (SSA) on 11/12/25, identified Resident #1 fell from the bath chair and sustained a left femoral neck (hip) fracture on 11/11/25. Review of Resident #1's medical record occurred on all days of survey. The current care plan stated, . I have an ADL [activities of daily living] self-care performance deficit R/T [related to] . Dementia, Impaired balance, Limited mobility and weakness. TRANSFER: Transfer Between Surfaces: pivot x2 [assist of two] with gait belt.A physician's progress note, dated 11/11/25, stated, . fell when she had gotten out of the shower earlier today. Initially started having left hip pain. Impression and plan multiple falls . Fracture of femoral neck, left . admitting .During an interview on 11/18/25 at 11:12 a.m., a certified nurse aide (CNA) (#4) stated, during Resident #1's bath on 11/11/25 she did not have the resident secured in the bath chair with the safety strap, and When I had finished her bath and was going to get her dried off and dressed she [Resident #1] reached for the door on the tub and fell out of the tub chair.
I called for help on my walkie and [CNA (#6)] came to help me. She got the hoyer [mechanical lift] and we transferred her [Resident #1] from the floor back to the bath chair. Then the nurse came in and checked [Resident #1] and did vitals and left the room. After that I called for help to transfer [Resident #1] from the tub chair to her wheelchair. When asked how the resident was transferred from the bath chair to the wheelchair the CNA (#4) stated, With the sit-to-stand lift.During an interview on 11/18/25 at 12:10 p.m., a CNA (#6) stated, [CNA (#4)] called for help on the walkie. I went in right away and [Resident #1] was wet, crawling on all fours and trying to get back into the tub. I asked her if she was ok and she said, 'Get me off
the floor I'm cold.' We waited for help to come and after no one came to help us we called again, and no one came. 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. I asked her if she had any pain and she said 'No.' [CNA (#4)] put the lap belt on her and I left to get the nurse. During an interview on 11/18/25 at 12:25 p.m., a nurse (#5) stated, At 1:20 p.m. I saw the tub room light on, and I went in there to do a skin check. [Resident #1] was in the bath chair without
the belt on and I noticed a hoyer lift sheet underneath her, I pointed to it and shrugged my shoulders and then [CNA (#4)] said, 'Did they tell you she fell.' [Resident #1] said she had no pain and moved her legs and arms without any concerns and then I left the tub room. 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. Following bathing, staff utilized a sit-to-stand lift that was neither included in the resident's care plan nor assessed as a safe transfer option for Resident #1. These lapses may have contributed to additional injury and pain for the resident.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
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
11/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Souris Valley Care Center
300 Main St S Velva, ND 58790
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-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
at 12:25 p.m., a staff nurse (#5) stated, At 1:20 p.m., I saw the tub room light on and I went in there to do a skin check. [Resident #1] was in the bath chair without the belt on. This interview conflicts with the CNA (#4's) statement that she applied the belt before leaving to get a nurse. Review of nursing progress notes identified the following:* 11/11/25 at 4:11 p.m., . resident had a fall from the bath chair at 1305 [1:05 p.m.], resident was able to move all extremities . * 11/11/25 at 6:43 p.m. [daughter's name] phones stating 'resident left hip is broken .* 11/17/25 at 4:53 p.m. Resident arrived today via [by] Nursing home van .
Resident did have a fall and fx [fracture] (sic) her left hip. - Review of Resident #2's medical record occurred
on all days of survey. A quarterly Minimum Data Set (MDS), dated [DATE REDACTED], identified dependent on staff for assistance with bathing and substantial/maximum assistance with transferring in and out of the shower/tub.
Observation on 11/18/25 at 1:38 p.m. showed Resident #2 seated in the whirlpool tub filled with water, bath chair safety strap behind the bath chair and not secured. When asked about the bath chair safety strap not being secured, the CNA (#3) stated, He [Resident #2] was sliding down in the chair so I took it off. I just remembered I had not put it back on. Facility staff failed to utilize the safety belt with whirlpool bathing for Residents #1 and #2 and failed to perform a nursing assessment prior to Resident #1 being moved/assisted off the floor following the fall. During an interview on 11/18/25 at 2:00 p.m., an administrative staff member (#1) stated she expected staff to secure the safety belt for all residents in the bath chair and staff should never remove the safety belt during a bath for any reason .
Event ID:
Facility ID:
If continuation sheet
SOURIS VALLEY CARE CENTER in VELVA, ND inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in VELVA, ND, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SOURIS VALLEY CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.