NDAC ch. 33-07-03.2

Nursing Facilities

This chapter establishes comprehensive licensing and operating standards for nursing facilities in North Dakota. Facility operators must obtain and maintain a state license, meet requirements for governing body structure, staffing (including nursing and medical services), physical environment, infection control, quality improvement, dietary services, resident assessment and care planning, and resident recordkeeping. The chapter also addresses paid feeding assistants, emergency planning, education programs, and department oversight including inspections, plans of correction, and abuse/neglect reporting and investigation.

CHAPTER 33-07-03.2
NURSING FACILITIES
Section
33-07-03.2-01 Definitions
33-07-03.2-02 Conflict With Federal Requirements
33-07-03.2-03 Application for and Issuance of License
33-07-03.2-04 Waiver Provision
33-07-03.2-05 Access and Surveillance by the Department
33-07-03.2-06 Plan of Correction
33-07-03.2-07 Governing Body
33-07-03.2-08 Physical Environment
33-07-03.2-09 Emergency Plan
33-07-03.2-10 Quality Improvement Program
33-07-03.2-11 Infection Control Program
33-07-03.2-12 Education Programs
33-07-03.2-13 Medical Services
33-07-03.2-14 Nursing Services
33-07-03.2-15 Resident Assessment and Care Plan
33-07-03.2-16 Dietary Services
33-07-03.2-16.1 Paid Feeding Assistants
33-07-03.2-17 Resident Record Services
33-07-03.2-18 Pharmaceutical Services
33-07-03.2-19 Social Services
33-07-03.2-20 Activity Services
33-07-03.2-21 Approved Activity Training Program
33-07-03.2-22 Specialized Rehabilitative Services
33-07-03.2-23 Diagnostic Services
33-07-03.2-24 Housekeeping, Maintenance, and Laundry Services
33-07-03.2-25 Adult Day Care Services
33-07-03.2-26 Secured Units
33-07-03.2-01. Definitions.
The following terms are defined for this chapter, chapter 33 -07-04.2, and North Dakota Century 
Code chapter 23-16:
1. "Abuse" for the purposes of this chapter is defined in section 33-07-06-01. 
2. "Adult day care" means the provision of facility services to meet the needs of individuals who 
do not remain in the facility overnight.
3. "Authentication" means identification of the individual who made the resident record entry by 
that individual in writing, and verification that the contents are what the individual intended.
4. "Bed capacity" means bed space designed for resident care.
5. "Department" means the department of health and human services.
6. "Discharge" means movement from a facility to a noninstitutional setting when the discharging 
facility ceases to be legally responsible for the care of the resident.
7. "Emanating services" means services which are provided from a facility to nonresidents. 
8. "Facility" means a nursing facility. 
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9. "Governing body" means the individual or group in whom legal responsibility is vested for 
conducting the affairs of a private or governmental facility. Governing body includes, where 
appropriate, a proprietor, the partners of any partnership including limited partnerships, the 
board of directors and the shareholders or members of any corporation including limited 
liability companies and nonprofit corporations, a city council or commission, a county 
commission or human service zone board, a governmental commission or administrative 
entity, and any other person or persons vested with management of the affairs of the facility 
irrespective of the name or names by which the person or group is designated.
10. "Licensed health care practitioner" means an individual who is licensed or certified to provide 
medical, medically related, or advanced registered nursing care to individuals in North Dakota.
11. "Licensee" means the legal entity responsible for the operation of a facility.
12. "Medical staff" means a formal organization of licensed health care practitioners with the 
delegated authority and responsibility to maintain proper standards of medical care. 
13. "Misappropriation of resident property" means the willful misplacement, exploitation, or 
wrongful temporary or permanent use of a resident's belongings or money without the 
resident's consent. Willful for the purpose of this definition means to do so intentionally, 
knowingly, or recklessly.
a. "Intentionally" means to do deliberately or purposely.
b. "Knowingly" means to be aware or cognizant of what one is doing, whether or not it is 
one's purpose to do so.
c. "Recklessly" means to consciously engage in an act without regard or thought to the 
consequences. 
14. "Neglect" for the purposes of this chapter is defined in section 33-07-06-01.
15. "Nursing facility" means an institution or a distinct part of an institution established to provide 
health care under the supervision of a licensed health care practitioner and continuous 
nursing care for twenty -four or more consecutive hours to two or more residents who are not 
related to the licensee by marriage, blood, or adoption; and who do not require care in a 
hospital setting.
16. "Paid feeding assistant" means an individual who has successfully completed a 
department-approved paid feeding assistant training course and is paid to feed or provide 
assistance with feeding residents of a nursing facility. 
17. "Secured unit" means a specific area of the facility that has a restricting device separating the 
residents in the unit from the residents in the remainder of the facility.
18. "Signature" means the name of the individual written by the individual or an otherwise 
approved identification mechanism used by the individual that may include the approved use 
of a rubber stamp or an electronic signature.
19. "Transfer" means movement from a facility to another institutional setting when the legal 
responsibility for the care of the resident changes from the transferring facility to the receiving 
institutional setting.
20. "Writing" means the use of any tangible medium for entries into the medical record, including 
ink or electronic or computer coding, unless otherwise specifically required.
History: Effective July 1, 1996; amended effective May 1, 2001; July 1, 2004; January 1, 2024.
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General Authority: NDCC 50-06-16
Law Implemented: NDCC 23-16-01
33-07-03.2-02. Conflict with federal requirements.
If any part of this chapter or chapter 33 -07-04.2 is found to conflict with federal requirements, the 
more stringent shall apply. Such a finding or determination shall be made by the department and shall 
not affect the remainder of this chapter or chapter 33-07-04.2.
History: Effective July 1, 1996.
General Authority: NDCC 23-01-03, 28-32-02
Law Implemented: NDCC 23-16-01, 28-32-02
33-07-03.2-03. Application for and issuance of license.
An entity meeting the definition of nursing facility in this chapter must obtain a license from the 
department to operate in North Dakota. No person or entity shall establish or operate a facility without 
first having obtained a license.
1. Any person or entity who owns or leases a facility and desires to maintain or operate it shall 
apply to the department for a license in the form prescribed and shall obtain an initial license 
before accepting residents for care or treatment.
a. The department shall not approve an application for an initial license unless:
(1) The application and all required attachments and statements submitted by the 
applicant meet the requirements of this chapter and chapter 33-07-04.2. 
(2) The department has conducted an inspection or investigation of the facility to 
determine compliance with this chapter and chapter 33-07-04.2.
(3) The department has completed an investigation into the fitness of the applicant and 
determined the applicant to be fit based on the following:
(a) Evidence provided by the applicant which identifies that financial resources 
and sources of revenue for the applicant's facility appear adequate to provide 
staff, services, and the physical environment sufficient to comply with North 
Dakota Century Code chapter 23-16, this chapter, and chapter 33-07-04.2; 
(b) The applicant has furnished the department with a signed and notarized 
statement describing and dating every proceeding, within five years of the date 
of the application, in which the applicant was involved that resulted in a 
limitation, suspension, revocation, or refusal to grant or renew a nursing facility 
license or resulted in a ban on Medicare or Medicaid admissions or a Medicare 
or Medicaid decertification action; and 
(c) The applicant shall furnish a signed and notarized statement to the department 
describing every criminal proceeding within five years of the date of the 
application in which the licensee or any of its shareholders owning interest of 
five percent or more, officers, directors, partners, or other controlling or 
managing persons, has been convicted or nolo contendere plea accepted, of a 
criminal offense related to the operation, management, or ownership of a 
nursing facility.
b. The initial license shall be valid for a period not to exceed one year and shall expire on 
December thirty-first of the year issued. 
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2. The department shall issue a renewal license when a facility is in substantial compliance with 
the provisions of these licensing requirements, as determined by periodic unannounced onsite 
surveys conducted by the department and other information submitted by the facility upon the 
request of the department. Renewal licenses shall expire on December thirty -first of each 
year. The application for renewal must be received by the department with sufficient time prior 
to the beginning of the licensure period to process.
3. The department may issue a provisional license, valid for a specific period of time not to 
exceed ninety days, when there are one or more serious deficiencies or a pattern of 
deficiencies related to compliance with these licensing requirements. 
a. A provisional license may be renewed at the discretion of the department, provided the 
licensee demonstrates to the department that it has made progress towards compliance 
and can effect compliance within the next ninety days. A provisional license may be 
renewed one time. 
b. When a facility operating under a provisional license notifies the department that it has 
corrected its deficiencies, the department will ascertain correction. Upon finding 
compliance, the department shall issue a renewal license.
4. In the case where two or more buildings operated under the same management are used in 
the care of residents, a separate license is required for each building. 
5. Each license is valid only in the hands of the entity to whom it is issued and is not subject to 
sale, assignment, or other transfer, voluntary or involuntary, nor is a license valid for any 
premises other than those for which originally issued. The license must be displayed in a 
conspicuous place within the facility.
6. The facility shall notify the department in writing thirty days in advance of any of the following 
changes:
a. Transfer or change of ownership.
b. Transfer of operating rights, including a lease of the facility where the lessor retains no 
control of the operation or management of the facility.
c. Change in bed capacity.
d. Change in the name of the facility.
7. The facility shall notify the department in writing within thirty days of a change in administrator 
or nurse executive.
8. The department will review all reported allegations of resident abuse, neglect, and 
misappropriation of resident property by an individual used in a nursing facility to provide 
resident services. If there is reason to believe, either through oral or written evidence, that an 
individual used by a nursing facility to provide services to residents could have abused or 
neglected or misappropriated a resident's property, the department will investigate the 
allegation or refer the allegation to the appropriate licensure authority for followup.
9. If the department makes a preliminary determination that an individual used by a nursing 
facility to provide services to residents abused or neglected or misappropriated resident 
property, the individual will be notified and provided the same appeal and review rights 
provided to nurse aides on the registry identified in sections 33-07-06-10 and 33-07-06-11.
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10. The department will maintain a registry of individuals used by the nursing facility to provide 
services to residents that the department has investigated and validated findings of resident 
abuse, neglect, or misappropriation of resident property.
History: Effective July 1, 1996; amended effective July 1, 2004.
General Authority: NDCC 23-01-03, 28-32-02
Law Implemented: NDCC 23-16-01, 28-32-02
33-07-03.2-04. Waiver provision.
Any provisions of this chapter or chapter 33 -07-04.2 may be waived by the department for a 
specified period in specific instances, provided such a waiver does not adversely affect the health and 
safety of the residents and would result in unreasonable hardship upon the facility. A waiver may be 
granted for a specific period of time not to exceed one year and shall expire on December thirty -first of 
the year issued.
History: Effective July 1, 1996.
General Authority: NDCC 23-01-03, 28-32-02
Law Implemented: NDCC 23-16-01, 28-32-02
33-07-03.2-05. Access and surveillance by the department.
The department may evaluate a facility's compliance with this chapter or chapter 33 -07-04.2 at any 
time through:
1. An announced or unannounced onsite review; or
2. A request for submission of written documentation verifying compliance.
History: Effective July 1, 1996.
General Authority: NDCC 23-01-03, 28-32-02
Law Implemented: NDCC 23-16-01, 28-32-02
33-07-03.2-06. Plan of correction.
1. A facility shall submit to the department a plan of correction addressing areas of 
noncompliance with the licensure requirements of this chapter and chapter 33-07-04.2.
2. A plan of correction must include:
a. How the corrective action will be accomplished;
b. How the facility will identify other residents or portions of the facility having the potential 
to be affected by the same deficient practice;
c. What measures will be put into place or systemic changes made to ensure that the 
deficient practice will not recur; and
d. How the facility will monitor its corrective actions to ensure that the deficient practice is 
being corrected and will not recur.
3. A plan of correction is required within ten calendar days of receipt of the deficiency statement 
and is subject to acceptance, acceptance with revisions, or rejection by the department.
4. Corrections must be completed within sixty days of the survey completion date, unless an 
alternative schedule of correction has been specified by the department.
History: Effective July 1, 1996.
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General Authority: NDCC 23-01-03, 28-32-02
Law Implemented: NDCC 23-16-01, 28-32-02
33-07-03.2-07. Governing body.
The governing body is legally responsible for the quality of resident care services; for resident 
safety and security; for the conduct, operation, and obligations of the facility; and for ensuring 
compliance with all federal, state, and local laws.
1. The governing body shall establish, cause to implement, maintain, and as necessary, revise 
its practices, policies, procedures, and bylaws for the ongoing evaluation of the services 
operated or delivered by the facility and for the identification, assessment, and resolution of 
problems that may develop in the conduct of the facility. These policies, procedures, and 
bylaws must be in writing, dated, and made available to all members of the governing body 
and facility staff.
2. The governing body shall appoint a qualified administrator who is responsible for the 
management of the facility.
a. The administrator shall hold a valid North Dakota nursing home administrator's license.
b. In the absence of the administrator, an employee must be designated in writing to act on 
behalf of the administrator.
3. The governing body must ensure sufficient trained and competent staff is employed to meet 
the residents' needs. The governing body shall approve and ensure implementation of written 
personnel policies and procedures including:
a. Written job descriptions for personnel positions in all service areas. Job descriptions must 
include definition of title, qualifications, duties, responsibilities, and to whom the position 
reports.
b. Provisions for checking state registries and licensing boards for current licensure or 
registry status and history of disciplinary actions prior to employment.
c. Procedures to ensure all personnel for whom licensure, certification, or registration is 
required have a valid and current license, certificate, or registration.
d. Prohibitions on resident abuse, neglect, and misappropriation of resident property, and 
procedures for investigation, reporting, and followup action.
4. The governing body shall ensure the development and implementation of written policies and 
procedures for all services provided by the facility, including emanating services. These 
policies and procedures must be current and shall be revised when changes in standards of 
practice occur.
5. The governing body shall ensure the development and implementation of written resident care 
policies, procedures, and practices including:
a. Admission or retention policies which ensure:
(1) Only those persons whose needs can be met within the accommodations and 
services provided by the facility are admitted and retained by the facility.
(2) Residents are admitted to the facility only by the order of a licensed health care 
practitioner.
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(3) Resident information, including current medical findings, diagnosis, and orders from 
the licensed health care practitioner for immediate care of the resident are available 
to the facility prior to or at the time of admission.
(4) Other pertinent information including family history and past medical history is 
received from the licensed health care practitioner within forty-eight hours of 
admission.
(5) A physical examination of the resident is performed by the licensed health care 
practitioner within five days prior to admission or within forty-eight hours after 
admission, unless the licensed health care practitioner documents the current 
examination remains accurate.
(6) Each resident in the facility is under the supervision of a licensed health care 
practitioner.
(a) Licensed health care practitioners shall visit residents as often as medically 
indicated, but no less frequently than annually.
(b) Orders must be signed by the licensed health care practitioner at the time of 
each visit.
(c) Progress notes must be written or dictated at the time of each visit and signed 
within a time frame as determined by the facility, not to exceed thirty days.
b. A procedure whereby an ongoing evaluation of resident status and need for facility care 
is conducted and made a part of the resident record.
c. Arrangements are made in the form of a written contract for specific resident care 
services to be provided by outside resources if the specific resident care services 
required are not available by facility staff. Outside resource shall apprise the appropriate 
facility staff of recommendations, plans for implementation, and continuing assessment 
through dated, and signed reports.
d. Provisions to ensure resident rights are met in compliance with North Dakota Century 
Code chapter 50-10.2.
e. Prohibition of resident abuse, neglect, or misappropriation of resident property.
f. Provisions to ensure residents are free from physical restraints imposed or psychoactive 
drugs administered for the purpose of discipline or convenience that are not required to 
treat the resident's medical symptoms.
6. The governing body is responsible for services furnished in the facility whether or not they are 
furnished directly by the facility or by outside resources. The governing body shall ensure that 
a contractor of services furnishes such services that permit the facility to comply with all 
applicable laws, codes, rules, and regulations. The governing body shall:
a. Ensure the services performed under contract are provided in a safe and effective 
manner.
b. Maintain a copy of current contracts for all contracted services. The contracts must 
identify the scope and nature of the services provided.
History: Effective July 1, 1996.
General Authority: NDCC 23-01-03, 28-32-02
Law Implemented: NDCC 23-16-01, 28-32-02
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33-07-03.2-08. Physical environment.
The facility must be constructed, arranged, and maintained to ensure the safety and well -being of 
the residents.
1. The physical plant must comply with the construction standards of chapter 33-07-04.2; and
2. The facility must provide an environment that is maintained, clean, comfortable, and 
appropriately responds to the physical, functional, and psychosocial needs of the residents. 
The facility must provide adequate space, lighting levels, ventilation, and safety measures 
consistent with the services being offered and the needs of the residents being served.
History: Effective July 1, 1996.
General Authority: NDCC 23-01-03
Law Implemented: NDCC 23-01-03, 23-16-01
33-07-03.2-09. Emergency plan.
The facility shall have a written procedure to be followed in case of emergencies. The emergency 
plan must specify persons to be notified, locations of alarm signals and fire extinguishers, evacuation 
routes, procedures for evacuating residents, and assignment of specific tasks, and responsibilities to 
the personnel of each shift.
History: Effective July 1, 1996.
General Authority: NDCC 23-01-03, 28-32-02
Law Implemented: NDCC 23-16-01, 28-32-02
33-07-03.2-10. Quality improvement program.
1. The facility shall develop and implement a quality improvement program, approved by the 
governing body, for assessing and improving the quality of services and care provided to 
residents. The written program must describe objectives, organization, scope, and 
mechanisms for overseeing and reporting the effectiveness of monitoring, evaluation, and 
improvement activities.
2. The quality improvement program must include a written plan for all services including 
indicators of care that are important to the health and safety of the residents. 
3. The indicators of the written quality improvement plan must relate to quality of services and 
care provided to residents and must be objective, measurable, and based on current 
standards of practice. 
4. Written documentation of quality improvement activities, including infection control, must be 
prepared and reported to the governing body.
History: Effective July 1, 1996.
General Authority: NDCC 23-01-03, 28-32-02
Law Implemented: NDCC 23-16-06
33-07-03.2-11. Infection control program.
The facility shall develop and implement a facilitywide program, approved by the governing body, 
for surveillance, prevention, and control of infections. This program must be consistent with the centers 
for disease control and prevention standards specific to disease control. The responsibilities of the 
program include:
1. Establishment of an infection control plan that includes the use of techniques and precautions 
in accordance with the standards of practice for each department or service.
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2. Establishment of policies and procedures for reporting, logging, surveillance, monitoring, and 
documentation of infections, and the development and implementation of systems to collect 
and analyze data and activities to prevent and control infections.
3. Development and implementation of policies and procedures including: 
a. The criteria to determine admission eligibility of an individual with a contagious or 
infectious disease; and
b. The immediate isolation of all residents in whom the condition jeopardizes the safety of 
the resident or other residents. 
4. Assignment of the responsibility for management of infection surveillance, prevention, and 
control to a qualified person or persons.
5. Maintenance of proper facilities and appropriate procedures used for disposal of all infectious 
and other wastes. 
6. Development and implementation of a process for inspection and reporting of any employee 
with an infection who may be in contact with residents, their food, or laundry.
History: Effective July 1, 1996.
General Authority: NDCC 23-01-03
Law Implemented: NDCC 23-01-03, 23-16-01
33-07-03.2-12. Education programs.
The facility shall design, implement, and document educational programs to orient new employees 
and keep all staff current on new and expanding programs, techniques, equipment, and concepts of 
quality care. The following topics must be covered with all staff annually:
1. Safety and emergency procedures, including procedures for fire and other disasters.
2. Prevention and control of infections, including universal precautions.
3. Resident rights.
4. Advanced directives.
5. Care of the emotionally disturbed and confused resident.
History: Effective July 1, 1996.
General Authority: NDCC 23-01-03, 28-32-02
Law Implemented: NDCC 23-16-01, 28-32-02
33-07-03.2-13. Medical services.
1. The facility shall have a licensed physician who is specified as the medical director or a 
medical staff organized under bylaws and rules approved by and responsible to the governing 
body. The medical director or medical staff shall be responsible for the quality of all medical 
care provided to residents and for the ethical and professional practices of its members.
2. The duties and responsibilities of the medical director or medical staff must be delineated in a 
formal agreement with the governing body.
3. The medical director or medical staff shall be involved in the development of written medical 
staff policies which are approved by the governing body, which delineate the responsibilities of 
licensed health care practitioners.
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4. The medical director or a member of the medical staff shall participate in the quality 
improvement and infection control program meetings.
History: Effective July 1, 1996.
General Authority: NDCC 23-01-03, 28-32-02
Law Implemented: NDCC 23-16-01, 28-32-02
33-07-03.2-14. Nursing services.
1. Nursing services must be under the direction of a nurse executive (director of nursing) who is 
employed by the facility and is a registered nurse licensed to practice in North Dakota.
2. The nurse executive must have written administrative authority, responsibility, and 
accountability for the integration of nursing services consistent with the overall facility plan and 
philosophy of resident care. The nurse executive shall retain administrative responsibility to:
a. Ensure development, maintenance, implementation, and revision of nursing service 
objectives, standards of practice, policy and procedure manuals, and written job 
descriptions for each level of nursing personnel, including unlicensed staff.
b. Ensure a resident assessment is completed and a comprehensive care plan is 
established in coordination with the resident or legal representative within the required 
time frames.
c. Ensure care plans are implemented so as to assist each resident to attain and maintain 
their highest level of functioning.
3. The facility shall have sufficient qualified nursing personnel on duty at all times to meet the 
nursing care needs of the residents including:
a. At least one registered nurse on duty eight consecutive hours per day, seven days a 
week; and
b. At least one licensed nurse on duty and designated to work charge twenty -four hours a 
day seven days a week.
History: Effective July 1, 1996.
General Authority: NDCC 28-32-02(1)
Law Implemented: NDCC 23-01-03
33-07-03.2-15. Resident assessment and care plan.
1. The facility shall complete and maintain an up-to-date comprehensive resident assessment for 
each resident by using the resident assessment instrument, the utilization guidelines, the 
minimum data set of core elements and common definitions, and the resident assessment 
protocol summary with triggers as specified by the department and approved by health care 
financing administration and published in the state operations manual.
2. In coordination with the resident or resident's legal representative and staff providing resident 
care services, a comprehensive written resident care plan for each resident must be 
developed and maintained consistent with each resident's individual needs and licensed 
health care practitioner's plan of medical care. An initial care plan must be implemented upon 
admission and revised within seven days after the completion of the resident assessment 
instrument.
3. A care plan must be individualized to meet the needs of the resident and must include 
problem and strength identification, measurable resident -centered goals, plans of action, and 
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which professional service is responsible for each element of care. Goals must be 
measurable, behavior oriented, time-limited, and achievable.
4. Resident assessment and quarterly assessment information on each resident must be 
submitted electronically to a location specified by the department in a time frame specified by 
the department.
History: Effective July 1, 1996.
General Authority: NDCC 23-01-03, 28-32-02
Law Implemented: NDCC 23-16-01, 28-32-02
33-07-03.2-16. Dietary services.
The facility shall provide for the dietary needs of the residents and provide dietary services in 
conformance with the food service sanitation manual issued by the department. Dietary services must 
include:
1. A qualified director of dietary services must be designated to be responsible for the dietary 
service of the facility.
a. A director of dietary services is:
(1) A dietitian licensed to practice in North Dakota and registered by the academy of 
nutrition and dietetics or its predecessor or successor organization; 
(2) A graduate of a dietetic technician or dietetic assistant training program approved by 
the academy of nutrition and dietetics or it predecessor or successor organization;
(3) A certified dietary manager, certified by the certifying board for dietary managers;
(4) A graduate of a state-approved course that provides ninety or more hours of 
instruction in dietary service supervision in a health care institution with consultation 
from a licensed and registered dietitian; or
(5) An individual trained and experienced in food service supervision and management 
in a military service equivalent to the program described in paragraph 2 or 4.
b. If the director of dietary services is not a licensed and registered dietitian, regularly 
scheduled consultation from a consultant licensed and registered dietitian must be 
obtained at least monthly.
2. Dietary service personnel and all personnel who are actively engaged in assisting residents 
with eating must be in good health and practice hygienic food handling techniques. 
3. Menus for all diets must be planned in accordance with the recommended dietary allowances 
of the food and nutrition board of the national research council, national academy of science. 
Sufficient food must be prepared as planned for each meal to meet the nutritional needs of 
residents.
a. Menus must be written at least one week in advance. The current week's menus must be 
located in the dietary services area for easy use by dietary services staff.
b. When changes in the menu are necessary, substitutions must provide equal nutritive 
value. The change and the reason for the change must be noted in writing on the menu.
c. Menus of food served must be filed and maintained for thirty days. 
d. Menus must be adjusted to address the requests of the residents when possible.
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4. Therapeutic diets when prescribed by the licensed health care practitioner.
5. At least three meals or the equivalent must be served daily, at regular times.
a. There must be no more than a fourteen -hour span between a substantial evening meal 
and breakfast unless a nourishing snack is provided at bedtime. Up to sixteen hours may 
elapse between a substantial evening meal and breakfast the following day if the 
residents agree to this meal span and a nourishing evening snack is served.
b. A substantial evening meal is an offering of three or more menu items at one time, one of 
which includes a high quality protein item such as meat, fish, egg, or cheese. 
c. Snacks must be offered at bedtime daily. 
6. A current diet manual, approved by the medical staff or medical director, must be readily 
available.
7. Providing each resident with food prepared by methods that conserve nutritive value, flavor, 
and appearance. The food must be attractively served at the proper temperatures and in a 
form to meet individual needs. Equipment must be provided and procedures established to:
a. Maintain hot food above one hundred forty degrees Fahrenheit [60 degrees Celsius] 
during dishing.
b. Ensure that cold foods leave the kitchen at no more than forty -five degrees Fahrenheit 
[7.22 degrees Celsius].
8. Table service for all who can and will eat at a table. For those not eating at a table, the proper 
eating equipment must be available and used. 
9. Facilities for the general dietary needs of the residents, and for the maintenance of sanitary 
conditions in the storage, preparation, service and distribution of food.
History: Effective July 1, 1996; amended effective April 1, 2013.
General Authority: NDCC 23-01-03, 28-32-02
Law Implemented: NDCC 23-16-01, 28-32-02
33-07-03.2-16.1. Paid feeding assistants.
Any individual employed by a facility, or under contract, to feed or assist with the feeding of nursing 
facility residents must either have successfully completed a department-approved paid feeding 
assistant training course or be a certified nurse aide.
1. Instructors of a department -approved paid feeding assistant course must meet the following 
requirements:
a. The primary instructor of the program must be a licensed health care professional with 
experience in the feeding of nursing facility residents. 
b. Certified nurse aides and paid feeding assistants may not be used as instructors in a 
department-approved paid feeding assistant course.
2. A department-approved paid feeding assistant course must have a curriculum which contains, 
at a minimum, eight hours of training.
3. The course must, at a minimum, include the following:
a. Feeding techniques.
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b. Assistance with feeding and hydration.
c. Communication and interpersonal skills.
d. Appropriate responses to resident behavior.
e. Safety and emergency procedures, including the Heimlich maneuver.
f. Infection control.
g. Resident rights.
h. Recognizing changes in residents that are inconsistent with their normal behavior and 
the importance of reporting those changes to the supervisory nurse. 
4. The instructor must verify in writing the successful completion of the course, including a 
competency evaluation of feeding skills, by the individual. The process for evaluation of 
successful completion of the course must be included in the materials submitted to the 
department for review and approval.
5. The nursing facility must maintain a record of all individuals used by the nursing facility as paid 
feeding assistants who have successfully completed a department -approved paid feeding 
assistant training course.
6. The nursing facility must ensure that paid feeding assistants feed only residents who have no 
complicated feeding problems. Complicated feeding problems include difficulty swallowing, 
recurrent lung aspirations, and tube or parenteral intravenous feedings.
7. The charge nurse must assess the residents to determine which residents may be fed by a 
paid feeding assistant. This assessment must be documented and the use of the paid feeding 
assistant to feed the resident must be included in the residents' plan of care.
8. The nursing facility must ensure that paid feeding assistants work under the supervision of a 
registered nurse or a licensed practical nurse. In an emergency, a paid feeding assistant must 
call a supervisory nurse for help using the resident call system if the nurse is not present 
during the feeding of a resident.
9. The nursing facility must ensure that the ongoing competency of paid feeding assistants is 
evaluated and documented at least annually.
10. The initial department approval of a paid feeding assistant course shall be determined based 
on the review of the information submitted by the nursing facility for compliance with these 
requirements. 
11. The nursing facility must notify the department and receive approval of any subsequent 
changes in the curriculum or primary instructor of the course.
12. The department shall determine continued compliance with these requirements during an 
onsite visit to the nursing facility.
13. Failure to comply with these requirements may result in loss of department approval for a paid 
feeding assistant course to be offered by the nursing facility. 
History: Effective July 1, 2004.
General Authority: NDCC 28-32-02
Law Implemented: NDCC 23-16-01
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33-07-03.2-17. Resident record services.
The governing body of the facility shall establish and implement policies and procedures to ensure 
the facility has a resident record service with administrative responsibility for resident records.
1. A resident record must be maintained and kept confidential for each resident admitted to the 
facility. The resident record shall be complete, accurately and legibly documented, and readily 
accessible.
a. The resident or the resident's legal representative have the right to view and authorize 
release of their medical information.
b. The facility shall develop policies which address access to resident records.
c. Resident records may be removed from the facility only upon subpoena, court order, or 
pursuant to facility policies when a copy of the original record is maintained at the facility.
2. All records of discharged residents must be preserved for a period of ten years from date of 
discharge. Records of deceased residents must be preserved to seven years.
a. In the case of minors, records must be retained for the period of minority and ten years 
from the date of live discharge. Records of deceased residents who are minors must be 
preserved for the period of minority and seven years.
b. It is the governing body's responsibility to determine which records have research, legal, 
or medical value and to preserve such records beyond the above -identified time frames 
until such time the governing body determines the records no longer have a research, 
legal, or medical value.
3. An employee of the facility must be assigned the responsibility for ensuring records are 
maintained, completed, and preserved.
4. Each resident record must include:
a. The name of the resident, personal licensed health care practitioner, dentist, and 
designated representative or other responsible person, admitting diagnosis, final 
diagnosis, condition on discharge, and disposition.
b. Initial medical evaluation including medical history, physical examination, and diagnosis.
c. A report from the licensed health care practitioner who attended the resident in the 
hospital or other health care setting, and a transfer form used under a transfer 
agreement.
d. Licensed health care practitioner's orders, including all medication, treatments, diet, 
restorative plan, activities, and special medical procedures.
e. Licensed health care practitioner's progress notes describing significant changes in the 
resident's condition, written at the time of each visit.
f. Current comprehensive resident assessment and plan of care.
g. Quarterly reviews of resident assessments and nurse's notes containing observations 
made by nursing personnel for the past year.
h. Medication and treatment records including all medications, treatments, and special 
procedures performed.
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i. Laboratory and x-ray reports.
j. Consultation reports.
k. Dental reports.
l. Social service notes.
m. Activity service notes.
n. Resident care referral reports.
5. All entries into the resident record must be authenticated by the individual who made the 
written entry, as defined by facility policy and applicable state laws and regulations, and must 
at a minimum include the following:
a. All entries the licensed health care practitioner personally makes in writing must be 
signed and dated by the licensed health care practitioner.
b. Telephone and verbal orders may be used provided they are given only to qualified 
licensed personnel and reduced to writing and signed or initialed by a licensed health 
care practitioner responsible for the care of the patient.
c. Signature stamps may be used consistent with facility policies as long as the signature 
stamp is used only by the licensed health care practitioner whose signature the signature 
stamp represents. Written assurance must be on file from the licensed health care 
practitioner to indicate the practitioner is the sole user of the signature stamp.
d. Electronic signatures may be used if the facility's medical staff and governing body adopt 
a policy permitting authentication by electronic signature. The policy must include:
(1) The staff within the facility authorized to authenticate entries in resident records 
using an electronic signature.
(2) The safeguards to ensure confidentiality, including:
(a) Each user must be assigned a unique identifier generated through a 
confidential access code.
(b) The facility shall certify in writing each identifier is kept strictly confidential. This 
certification must include a commitment to terminate the user's use of that 
particular identifier if it is found the identifier has been misused. Misused 
means the user has allowed another individual to use the user's personally 
assigned identifier, or the identifier has otherwise been inappropriately used.
(c) The user must certify in writing the user is the only individual with user access 
to the identifier and the only individual authorized to use the signature code.
(d) The facility shall monitor the use of the identifiers periodically and take 
corrective action as needed. The process by which the facility will conduct the 
monitoring must be described in policy.
(3) A process to verify the accuracy of the content of the authenticated entries, 
including:
(a) A system that requires completion of certain designated fields for each type of 
document before the document may be authenticated, with no blanks, gaps, or 
obvious contradictory statements appearing within those designated fields. The 
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system must require that correction or supplementation of previously 
authenticated entries must be made by additional entries, separately 
authenticated and made subsequent in time to the original entry.
(b) An opportunity for the user to verify the accuracy of the document and to 
ensure the signature has been properly recorded.
(c) As part of the quality improvement activities, the facility shall periodically 
sample records generated by the system to verify accuracy and integrity of the 
system.
(4) A user may terminate authorization for use of an electronic signature upon written 
notice to the staff member in charge of resident records.
(5) Each report generated by the user must be separately authenticated.
(6) A list of confidential access codes must be maintained under adequate safeguards 
by facility administration.
History: Effective July 1, 1996; amended effective January 1, 2024.
General Authority: NDCC 50-06-16
Law Implemented: NDCC 23-01-12, 23-16-01
33-07-03.2-18. Pharmaceutical services.
The facility shall provide pharmaceutical services to meet resident needs.
1. The facility shall obtain the services of a licensed pharmacist who shall develop policies and 
procedures for the provision of pharmaceutical services within the facility consistent with 
chapter 61-03-02, state laws, and federal laws. These policies and procedures must be 
approved by medical staff or medical director and governing body and must include provisions 
for:
a. The procurement, storage, dispensing, labeling, administration, and disposal of drugs 
and biologicals.
b. Allowing the resident to be totally responsible for the resident's own medication based on 
request of the resident, assessment of the functional capability of the resident by facility 
nursing staff, documentation of the assessment and resultant recommendations, and 
specific approval and order of the licensed health care practitioner. The facility must 
provide a secure storage area for medications self-administered by the resident. 
2. The pharmacist shall review each resident's medications monthly and report any 
discrepancies to the nurse executive or the resident's licensed health care practitioner.
3. All medications administered to a resident must be ordered in writing by a licensed health care 
practitioner. Telephone and verbal orders may be given to qualified licensed personnel and 
must be immediately reduced in writing, signed, and dated by the individual receiving the 
order, and countersigned or initialed by the licensed health care practitioner.
4. When ordered, medications not specifically limited as to time or number of doses must be 
automatically stopped in accordance with a written policy. The resident's attending licensed 
health care practitioner must be notified of stop order policies and contacted promptly for a 
decision concerning renewal of such orders so continuity of the resident's therapeutic regimen 
is not inadvertently interrupted.
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5. Standing orders for drugs must specify the circumstances for drug dosage, route, duration, 
and frequency of administration. The order must be reviewed annually and, if necessary, 
renewed. When a standing order is implemented for a specific resident, it must be entered in 
the resident's record, dated, and signed by the licensed health care practitioner who 
prescribed the order. 
6. All medications must be administered by individuals authorized to do so in accordance with 
state laws and regulations governing such acts. Each dose administered must be properly 
recorded in the resident record.
7. All medications administered by facility staff must be stored in a locked area or locked cart. 
a. Medications requiring refrigeration must be kept in a separate refrigerator which is locked 
or in a separate refrigerator in a lockable medication room near the nurses' station.
b. Medications for "external use only" must be kept in a locked area and separate from 
other medications.
History: Effective July 1, 1996.
General Authority: NDCC 23-01-03, 28-32-02
Law Implemented: NDCC 23-16-01, 28-32-02
33-07-03.2-19. Social services.
The governing body shall ensure social services are provided to ensure each resident attains and 
maintains their highest level of physical, mental, and psychosocial functioning.
1. The facility shall have one or more designated staff members trained in the assessment of 
residents' psychosocial needs and in the provision of services to meet those needs. If a 
designee is not a qualified social worker as defined in North Dakota Century Code chapter 
43-41, the designee shall receive onsite consultation from a qualified social worker on a 
quarterly basis.
2. If the facility does not provide social services directly, the facility must have a contract with an 
agency or individual qualified to provide such services.
3. The facility shall have policies and procedures for the delivery of social services.
History: Effective July 1, 1996.
General Authority: NDCC 23-01-03, 28-32-02
Law Implemented: NDCC 23-16-01, 28-32-02
33-07-03.2-20. Activity services.
The facility shall provide an ongoing program of activity services to meet the needs and interests of 
each resident which promotes or maintains each resident's physical, mental, and psychosocial 
well-being.
1. The facility shall employ a qualified activity coordinator who is responsible for the direction and 
supervision of the resident activity services. A qualified activity coordinator is:
a. An individual certified as a therapeutic recreation specialist by a recognized accrediting 
body;
b. An individual who is eligible for certification as a therapeutic recreation specialist by a 
recognized accrediting body for the first year the individual is eligible;
c. An individual who is activity director certified by a recognized accrediting body;
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d. An individual who is activity consultant certified by a recognized accrediting body;
e. A qualified occupational therapist as defined in North Dakota Century Code chapter 
43-40;
f. A certified occupational therapy assistant;
g. An individual who has the equivalent of two years of full -time experience in a social or 
recreational program within the last five years, one of which was in a resident activity 
program in a health care setting; or
h. An individual who has completed an activity training program approved by the 
department as meeting the requirements in section 33-07-03.2-21; and
(1) Has one year of full-time experience in the past five years in an activity program in a 
health care setting; or
(2) Receives monthly onsite consultation for a minimum of one year after the 
completion of the program from an individual meeting the qualifications described in 
subdivision a, d, e, f, or g.
2. The facility shall have sufficient activity staff to provide an ongoing program of meaningful, 
stimulating, therapeutic, and leisure time activities to meet the needs and suited to the 
interests of each resident.
3. The facility shall have policies and procedures for the delivery of activity services.
4. Each resident's activity plan must be developed in accordance with instructions of the licensed 
health care practitioner.
5. The activity plan must be coordinated with the resident's overall plan of care and altered as 
needed.
6. Activity notes, including observations of resident's participation in activity programs, must be 
recorded and retained in the resident's record.
7. Resident's request to see clergy must be honored and space must be provided for privacy 
during these visits.
8. The facility shall have adequate equipment and material to support independent and group 
activities.
History: Effective July 1, 1996; amended effective April 1, 2026.
General Authority: NDCC 23-01-03
Law Implemented: NDCC 23-16-01
33-07-03.2-21. Approved activity training program.
Only programs that the department determines meet the criteria in this section and approves in 
writing are considered to be an approved activity training program.
1. A department-approved activity training program must have a curriculum which contains, at a 
minimum, ninety hours of training.
2. The primary instructor of a program shall have:
a. A bachelor's degree or be activity consultant certified;
b. Current activity experience as a director or as a practicing consultant; and
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c. Experience in teaching adults.
3. Supplemental instructors shall have a minimum of one year of experience in their field.
4. The theory portion of the program must include, at a minimum, the topics identified in the 
basic education course for activity professionals developed by the national association of 
activity professionals and the national certification council for activity professionals.
5. Training on nursing and nursing -related services, including transferring, positioning, toileting, 
and feeding, may not be included in the curriculum of an activity training program.
6. At the completion of the program, the instructor shall verify in writing to the department the 
successful completion of the program for each participant.
7. A listing of state-approved activity training programs and the date of approval must be 
maintained by the department.
8. An approved activity training program may include only those topics which were submitted to 
and approved by the department for inclusion. Changes which are made to the program must 
be approved by the department prior to implementation or the program is no longer 
considered to be approved.
History: Effective July 1, 1996; amended effective April 1, 2026.
General Authority: NDCC 23-01-03
Law Implemented: NDCC 23-16-01
33-07-03.2-22. Specialized rehabilitative services.
Specialized rehabilitative services shall, at a minimum, include physical therapy, speech and 
language pathology, occupational therapy, and health services for mental illness and mental retardation 
and shall:
1. Be provided upon a written order of a licensed health care practitioner, who shall be 
responsible for the general medical direction of such services as part of the total care of the 
resident.
2. Be provided directly by facility staff or obtained through contract with outside resources.
History: Effective July 1, 1996.
General Authority: NDCC 23-01-03, 28-32-02
Law Implemented: NDCC 23-16-01, 28-32-02
33-07-03.2-23. Diagnostic services.
The facility shall provide or have arrangements for obtaining diagnostic services consistent with the 
needs of the resident.
1. If the facility provides any clinical laboratory testing services to residents, regardless of the 
frequency or the complexity of the testing, the governing body is required to obtain and 
maintain compliance with the applicable parts of the clinical laboratory improvement 
amendments of 1988, 42 CFR part 493.
2. If the facility provides radiology or other diagnostic services to residents, these services must 
be provided in accordance with the current standards of practice and state and federal 
regulations.
History: Effective July 1, 1996.
General Authority: NDCC 23-01-03, 28-32-02
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Law Implemented: NDCC 23-16-01, 28-32-02
33-07-03.2-24. Housekeeping, maintenance, and laundry services.
The facility shall provide housekeeping and maintenance services necessary to maintain a sanitary 
and comfortable environment and laundry services, including personal laundry services, to meet the 
needs of the residents.
1. The facility shall employ sufficient housekeeping and maintenance personnel to maintain the 
interior and exterior of the facility in a safe, clean, orderly, and attractive manner. The facility 
shall establish, implement, and update policies and procedures consistent with current 
standards of practice including procedures to ensure:
a. The facility is kept free from offensive odors, accumulations of dirt, rubbish, dust, and 
safety hazards;
b. Floors are regularly cleaned, polishes on floors provide a nonslip finish, and throw or 
scatter rugs have a nonslip backing;
c. Walls and ceilings are maintained, cleaned, and painted as needed;
d. The grounds are kept free from refuse and litter; and
e. Poisons and chemical compounds must be stored away from resident and food 
preparation and storage areas.
2. The facility shall be maintained free from insects and rodents.
a. Pest control services must be provided by the facility or by contract with a pest control 
company.
b. Windows and doors must be appropriately screened to exclude insects.
c. Harborages and entrances for insects and rodents must be eliminated.
3. The facility shall have available at all times a sufficient supply of linen in good condition for the 
care and comfort of residents and ensure there is sufficient trained staff and facilities available 
to provide these services in a manner that controls the spread of infection.
a. Clean linen and clothing must be stored in clean, dry, dust -free, and easily accessible 
areas.
b. Soiled linen must be sorted and stored in well -ventilated areas, separate from clean 
laundry spaces, and must not be permitted to accumulate.
(1) Soiled linen and clothing must be stored separately in suitable bags or containers.
(2) Potentially infectious soiled linen must be handled with particular attention to avoid 
contamination of clean linen.
(3) Soiled linen may not be sorted, laundered, rinsed, or stored in bathrooms, resident 
rooms, kitchens, or food storage areas.
History: Effective July 1, 1996.
General Authority: NDCC 23-01-03, 28-32-02
Law Implemented: NDCC 23-16-01, 28-32-02
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33-07-03.2-25. Adult day care services.
1. Any facility seeking to develop an adult day care service shall contact the department and 
receive advance approval as a condition of licensure.
2. A facility may use existing space and equipment to deliver adult day care services provided 
services to the residents of the facility are not diminished and their needs are being 
acceptably addressed with the following exceptions:
a. The facility shall provide dining space for congregate dining of adult day care participants 
in addition to space required under section 33-07-04.2-06.
b. The facility shall provide activity space in addition to space required under section 
33-07-04.2-06.
c. The facility shall provide an area allowing privacy for adult day care participants to allow 
for rest periods.
3. A facility accepting persons for adult day care shall develop policies and procedures covering 
all aspects of adult day care including:
a. Medications and treatments shall be provided by facility staff only by order of a licensed 
health care practitioner, and records must be maintained of services provided to 
individual adult day care participants.
b. Individuals having a communicable disease shall not participate in the adult day care 
program.
History: Effective July 1, 1996.
General Authority: NDCC 23-01-03, 28-32-02
Law Implemented: NDCC 23-16-01, 28-32-02
33-07-03.2-26. Secured units.
Secured units, such as those designed for residents with Alzheimer's disease or other dementias, 
must comply with the following:
1. Prior to admission or within seven days of admission, a multidisciplinary team shall evaluate 
the appropriateness of a resident's placement in a secured unit. The multidisciplinary team 
shall, at a minimum, consist of a registered nurse and a licensed social worker who will be 
providing service to the resident in the secured unit, the resident's licensed health care 
practitioner, and the resident or the individual who has legal status to act on behalf of the 
resident;
2. Licensed health care practitioner orders for placement in a secured unit must be documented 
in the resident's record and must be reviewed during the licensed health care practitioner's 
regular visits;
3. Placement in a secured unit may not be used as a punishment or for the convenience of the 
staff; and
4. A resident in a secured unit shall have access to the same services as other residents in the 
facility including provisions for routine and ongoing access to the outdoors as appropriate 
based on the resident's past history, personal preferences, and current condition.
History: Effective July 1, 1996.
General Authority: NDCC 23-01-03, 28-32-02
Law Implemented: NDCC 23-16-01, 28-32-02
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