North Dakota Veterans Home audit questions meal prep in wake of choking death

A state audit of the North Dakota Veterans Home in Lisbon raises concerns on performance and finance issues, including the care required when serving meals after a resident choked to death.

Other issues include thousands of dollars in overtime pay to a salaried administrator, insufficient performance evaluations and questionable approval of expenditures. 

The report released Thursday notes that the Veterans Home disputes several points in the audit. 

In a statement on Friday, the Veterans Home said it looks forward to addressing the findings during the Legislative Audit and Fiscal Review Committee meeting on Nov. 30.

A Medicare inspection report on the Veterans Home filed in September found no deficiencies at the home.

“This reflects the dedication, professionalism, and commitment of our employees who provide quality care and services to our Veterans and residents every day,” said Dane Grebel, administrator of the Veterans Home.

A report summary said the average number of deficiencies found at a North Dakota nursing home is 5.6; the national average is 9.2.

The home provides basic and skilled nursing care to military veterans. During the audit period, there were 110 residents at the Veterans Home. 

In preparing to conduct the audit covering the two-year period that ended June 30, 2025, Auditor Josh Gallion said his staff found a report from the North Dakota Department of Health and Human Services detailing the choking death at the Veterans Home in March 2025. 

He said that report is why the audit team, which includes a medical auditor, focused on meal service as part of its work. 

“We’re more than just numbers,” Gallion said Thursday. 

A resident died after a staff member did not chop the person’s food dietary restrictions required, the Health and Human Services report said. 

When the audit team visited the Veterans Home, it reviewed dietary restriction records and  inspected meals served to six residents with restrictions. 

The audit said that a printed dietary card for one resident intended to guide kitchen and staff did not match to the last updated dietary restriction from the resident’s doctor.

The Veterans Home response said the resident was not served an incorrect diet. It cited a recommendation from a doctor that was not consistent with the doctor’s notes. The recommendation was later corrected.

Gallion said the Veterans Home was not aware of the discrepancy until the audit team pointed  it out. 

Performance evaluations

Three employees were disciplined after the death, but those actions were not reflected in performance evaluations for two staff members who did not have any ratings below “meeting expectations,” the audit found. 

“The North Dakota Veterans home is not consistently considering previous performance during performance evaluations,” the audit report said. 

The Veterans Home response said disciplinary action was noted in their personnel files, that it believes it complied with state rules on performance evaluations and that a “meeting expectations” rating does not mean an employee had no performance concerns. 

Overtime

Other issues raised in the audit related to finances. 

The audit found that a salaried administrator at the home was routinely being paid overtime despite no written authorization. 

Gallion, in an interview, said the practice had been going on since the administrator was hired in 2003, resulting in nearly $360,000 in overtime pay. 

Overtime paid in the two-year audit period was $56,766, the audit says. 

The practice predates the hiring of Grebel, who has been the administrator since May 2024.

A response from the Veterans Home said that while there was no written authorization of the overtime, that it was approved by the administrator. 

The response also noted an administrative staff shortage.  

Other issues

The audit also found that some accounting practices were being performed by staff that were not qualified. 

An administrative assistant approved approximately $9.7 million of expenditures during the audit period. 

The Veterans Home response noted that the audit did not identify any errors in those approvals. It said that demonstrates that there are adequate controls in place. 

The audit also found that $37,412 in state money was used for purposes other than was intended by the Legislature. 

The Veterans Home disputed that finding and blamed part of the problem on expense coding errors. 

The Veterans Home received more than $6 million for the state general fund for the period covered by the audit.

Reach North Dakota Monitor deputy editor Jeff Beach at [email protected]