Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dunseith Com Nursing Home during CMS and state inspections, most recent first.
Two residents experienced abuse, including yelling, intimidation, and threats by staff, as well as physical altercations between residents. Staff failed to use proper de-escalation techniques, did not maintain resident dignity, and did not report incidents or injuries promptly to supervisory staff, resulting in unaddressed physical and mental distress.
Staff failed to promptly report an incident where a resident with cognitive impairment and behavioral health diagnoses was subjected to yelling, distress, and improper handling by multiple CNAs during a transfer. The resident was left naked on the bathroom floor, found crying with unexplained scratches, and the full details were not communicated to the charge nurse or reported to authorities within the required timeframe.
A resident with chronic pain and dementia exhibiting agitation experienced multiple episodes of pain and aggressive behavior toward staff and other residents. Despite these documented incidents, the care plan was not updated to address pain management or behavioral interventions, and administrative staff confirmed the need for revisions. The facility also could not provide its care plan policy when requested.
The facility did not ensure that the dietary manager had completed the required certification or education to serve as the director of food and nutrition services, as the manager had not finished the certified dietary manager course and was working under an extension.
The facility did not ensure that its high temperature dishwasher consistently sanitized dishware, as staff only recorded external gauge readings and did not check plate-level temperatures. When a dish thermometer was used, it took multiple cycles to reach the required 160°F, and the facility's own thermometer was not functional, resulting in inadequate monitoring of dish sanitization.
The facility did not ensure its QAA Committee met quarterly as required, missing meetings in two quarters and failing to include the medical director in any meetings, as confirmed by administrative staff and review of meeting minutes.
Staff did not adhere to professional standards during insulin administration, including improper priming of insulin pens and failure to notify a physician about out-of-range blood glucose levels for a resident with diabetes. These actions were not in accordance with facility policy and were confirmed by administrative staff.
A resident's financial power of attorney was not provided with required quarterly financial statements for the resident's personal fund account, as confirmed by both the representative and business office staff. This omission prevented the representative from verifying account transactions and balances.
A nurse did not follow infection control protocols during a wound dressing change for a resident with chronic wounds. Supplies were placed on an unsanitized bedside table without a barrier, and the nurse failed to change gloves or perform hand hygiene between steps, contrary to facility policy. An administrative nurse confirmed the lapse in infection control practices.
The facility failed to provide appropriate dementia care for a resident with dementia, agitation, and insomnia, who exhibited wandering and inappropriate sexual behaviors. The resident frequently intruded into other residents' rooms, causing distress and safety concerns. The facility did not adequately assess or manage these behaviors, nor did they implement effective interventions, compromising the dignity, privacy, and safety of other residents.
The facility failed to ensure food was stored in accordance with professional standards for food service sanitation in the main kitchen. Observations revealed rusty and rough surfaces on food storage racks, a build-up of black debris on the fan grate, and significant ice build-up in the walk-in freezer, including on food items.
The facility failed to follow infection control standards during medication administration and wound care for multiple residents. A nurse did not remove gloves and perform hand hygiene after performing blood sugar checks and administering insulin, and another nurse was observed double gloving while treating a resident's wounds, which is not the facility's practice.
The facility failed to ensure dignity and provide privacy during personal cares for two residents, with staff entering rooms without knocking or announcing themselves. Additionally, a staff nurse left the treatment cart unattended with residents' eMARs visible on multiple occasions, risking unauthorized viewing of resident records.
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident. Observations revealed a strong urine odor, sticky floors, dirty wheelchair cushions, and various debris. Interviews with CNAs and an administrative nurse confirmed the need for cleaning attention, and the facility's policy on routine cleaning and disinfection was not followed.
The facility failed to accurately code the MDS for two residents, affecting the accuracy of their assessments and potentially their care plans. One resident's therapeutic diet was not reflected in the MDS, and another resident's significant weight loss was incorrectly coded as being on a physician-prescribed weight-loss regimen.
The facility failed to review and revise care plans for three residents, limiting staff's ability to communicate needs and ensure continuity of care. One resident was at risk for elopement, another had advanced dementia with behavioral issues, and a third was a fall risk with a recent fracture. Despite these conditions, their care plans lacked necessary interventions.
The facility failed to notify the physician of critical changes in a resident's systolic blood pressure and weight, despite specific orders to do so. This failure was confirmed by an administrative nurse and placed the resident at risk for delayed treatment and adverse health events.
The facility failed to provide timely toileting assistance to a resident, as required by their care plan. Observations and records showed that the resident was not assisted every two to three hours, resulting in wet clothing and a strong odor of urine. Staff confirmed the resident should be toileted regularly, but there were 20 instances of non-compliance, with gaps of 7 to 16 hours between assistance.
The facility failed to deposit residents' funds in an interest-bearing account for two residents. A review of a quarterly statement and an interview with business office employees confirmed that the funds were kept in a non-interest-bearing checking account.
Failure to Protect Residents from Abuse and Inadequate Response to Incidents
Penalty
Summary
The facility failed to protect two residents from abuse, including verbal, mental, and physical abuse by staff, as well as resident-to-resident altercations. One resident with anxiety, conduct disorder, depression, and moderate cognitive impairment was subjected to yelling, intimidation, and threats by multiple CNAs during an attempt to assist her with toileting. Staff were observed hollering at the resident, pointing in her face, and insisting she apologize while she was naked and distressed on the bathroom floor. The resident was found crying with fresh scratches on her arm, which staff could not adequately explain. Staff also threatened to withhold snacks as a form of punishment, and failed to report the incident and injuries to the charge nurse in a timely manner. Another resident with dementia and agitation exhibited behaviors that led to two separate resident-to-resident altercations. In one incident, the resident was found holding another resident's arm and struck the other resident in the face with a closed fist. In a separate event, the same resident hit another resident in the mouth during a verbal outburst in the activity room. Both incidents resulted in staff intervention to separate the residents and assess for injuries, though no significant injuries were noted at the time. The facility's policies on abuse, neglect, and exploitation were not followed, as evidenced by staff's failure to prevent and appropriately respond to abusive behaviors, both from staff to resident and resident to resident. Staff did not use appropriate de-escalation techniques, failed to maintain residents' dignity, and did not ensure timely and accurate reporting of abuse or injuries to supervisory staff.
Failure to Timely Report Resident Abuse Incident
Penalty
Summary
Facility staff failed to report an incident of abuse involving a resident with anxiety, conduct disorder, moderate cognitive impairment, and delusions within the required timeframe. The incident involved multiple certified nurse aides (CNAs) attempting to get the resident up for supper, during which the resident was distressed, yelling, refusing to cooperate, and ultimately ended up naked on the bathroom floor. A gait belt was applied directly to the resident's bare skin, and staff lifted her with it at least once. Several CNAs were reported to have yelled at the resident, pointed in her face, and insisted she apologize. Another CNA later found the resident crying on the floor with scratches on her left arm, which no staff could explain. The resident was then calmed, cleaned, dressed, and brought to supper. The charge nurse was only informed that the resident had a behavior and that a gait belt was used, but was not told about the yelling, the resident being on the floor naked, the number of staff involved, or any injuries. The full details of the incident were not reported to the charge nurse at the time. The facility reported the incident to the State Survey Agency (SSA) six days after the event, which was not within the required two-hour timeframe. An administrative nurse confirmed that the incident was not reported in a timely manner and acknowledged that it was unacceptable for staff to holler at or threaten residents.
Failure to Update Care Plan for Resident with Pain and Aggression
Penalty
Summary
The facility failed to review and revise the care plan for a resident with chronic pain and dementia with agitation, despite multiple documented incidents indicating changes in the resident's condition. The resident's medical record showed 21 instances of pain or requests for pain medication, two occasions of verbal or physical aggression with other residents, and 23 occasions of verbal or physical aggression with staff over a period of approximately two months. The current care plan did not include problems, goals, or interventions addressing the resident's pain or aggressive behaviors. During staff interviews, administrative staff confirmed that the care plan required updates and revisions to reflect the resident's current status. Additionally, the facility was unable to provide a copy of their care plan policy when requested.
Unqualified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the dietary manager had obtained the required qualifications to serve as the director of food and nutrition services. During an interview, the dietary manager stated that she had not completed the certified dietary manager course and had only received an extension to complete it. As a result, the facility did not have a dietary manager who had completed the necessary education for certification as a dietary manager, certified food service manager, or held a national certification for food service management and safety from a recognized certifying body.
Failure to Ensure Adequate Heat Sanitization of Dishware
Penalty
Summary
The facility failed to ensure that the high temperature dishwasher in the main kitchen provided adequate heat sanitization for dishes and utensils. Observations showed that the dishwasher was in use, but the dietary staff only documented temperature readings from the external temperature gauge/dial and did not check dishwash temperatures at the plate level during wash/rinse cycles. When a surveyor's dish thermometer was used, it required up to five wash/rinse cycles before the thermometer registered the required 160 degrees Fahrenheit or above, indicating inconsistent or inadequate sanitization. Additionally, the dietary manager confirmed that staff did not routinely monitor dish temperatures at the plate level and that the facility's dish plate thermometer was not functioning due to a dead battery. The lack of a process or functioning thermometer to verify adequate heat sanitization of dishware contributed to the deficiency, as the facility could not ensure that dishware was being properly sanitized according to professional standards and regulatory requirements.
Failure to Hold Quarterly QAA Meetings with Required Members
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) Committee met at least quarterly and included all required members, as specified in its own policy. Review of QAA Committee meeting minutes revealed that the committee did not meet during two of the five reviewed quarters, specifically in June and September of 2024. Additionally, the medical director did not attend any of the QAA Committee meetings during the review period. An administrative staff member confirmed that the committee had not met on a quarterly basis and that the medical director's required attendance was not ensured.
Failure to Follow Professional Standards in Insulin Administration and Blood Glucose Monitoring
Penalty
Summary
Facility staff failed to follow professional standards of practice during insulin administration for four residents observed. Specifically, nurses were seen priming insulin pens incorrectly, either with the needle cap on or while holding the pen downward, contrary to facility policy which requires the needle cap to be off and the pen to be held upright during priming. These observations were confirmed by an administrative nurse who stated the expected procedure was not followed. Additionally, for one resident with Type 2 diabetes mellitus, staff did not notify the physician when blood glucose readings were outside the parameters set by the physician's order. The resident's medical record showed multiple instances of blood sugar levels below 100 mg/dL and above 450 mg/dL, but there was no documentation that the physician was informed as required by facility policy. This was acknowledged by an administrative nurse during interview.
Failure to Provide Quarterly Financial Statements to Resident's Representative
Penalty
Summary
The facility failed to provide the resident's designated financial representative with quarterly financial statements for the resident's personal fund account, as required by facility policy. Review of the policy confirmed that individual financial records must be made available to the resident through quarterly statements. Interviews revealed that the resident's financial power of attorney had not received any such statements, and a business office staff member confirmed that the statements were not sent. This failure prevented the representative from verifying the resident's financial transactions and fund balances.
Failure to Follow Infection Control Protocol During Wound Care
Penalty
Summary
A deficiency was identified when a nurse failed to follow the facility's infection prevention and control policy during a wound dressing change for a resident with chronic wounds on the posterior left thigh and bilateral buttocks. The facility's policy required sanitizing the overbed table, placing a barrier before setting up supplies, and performing hand hygiene and glove changes between steps of the dressing change. However, the nurse placed supplies directly on the bedside table without sanitizing it or using a barrier, and did not change gloves or perform hand hygiene between removing the soiled dressing, cleansing the wound, and applying the new dressing. The resident's medical record included physician orders for specific wound care and a care plan addressing impaired skin integrity. During the observed dressing change, the nurse removed soiled dressings, cleansed the wounds, and applied new dressings without following the required infection control steps. An administrative nurse confirmed that proper infection control practices were not followed during this procedure.
Failure to Provide Appropriate Dementia Care and Services
Penalty
Summary
The facility failed to provide appropriate dementia care and services for a resident diagnosed with dementia, agitation, and insomnia, who exhibited wandering behaviors and a history of inappropriate sexual behaviors. The resident's medical record indicated multiple incidents of wandering into other residents' rooms, aggressive behaviors, and sexually inappropriate actions towards both residents and staff. Despite these behaviors, the facility did not adequately assess and monitor patterns or trends, nor did they develop an effective behavior management program or person-centered care plan to address these issues. Observations and interviews revealed that the resident frequently wandered into other residents' rooms, sometimes attempting to disrobe or engage in inappropriate behaviors. Staff and other residents reported feeling unsafe and disturbed by these actions. One resident specifically mentioned feeling unsafe and requested a lock on their door due to the frequent intrusions and inappropriate behavior of the resident in question. Staff interviews confirmed the difficulty in redirecting the resident and the negative impact on other residents. The facility's response to the resident's behaviors was insufficient, as they only placed a picture of the resident on his door to help him locate his room more easily. The social service member was unaware of the extent of the resident's sexual behaviors towards others. The facility's failure to implement effective interventions and modify the physical environment compromised the dignity, privacy, and safety of other residents, and did not support the resident in achieving the highest level of functioning.
Failure to Ensure Proper Food Storage Sanitation
Penalty
Summary
The facility failed to ensure food was stored in accordance with professional standards for food service sanitation in the main kitchen. Observations revealed several deficiencies, including rusty and rough surfaces on food storage racks in the walk-in cooler, which a dietary staff member confirmed were difficult to clean. Additionally, there was a build-up of black debris on the grate of the fan on the ceiling. In the walk-in freezer, there was a significant amount of ice build-up on a pipe, the back north wall, the back east wall, and the ceiling. This ice build-up was also found in an open box of sherbet cups, on packages of coffee, and above a bag of garlic toast and other boxes of food. The facility's policy on sanitation inspections, dated 03/01/24, mandates daily inspections of refrigerators and freezers by food service staff and weekly inspections of all food service areas by the dietary manager. However, the observations made on 04/29/24 and 05/02/24 indicated that these inspections were either not conducted as required or were ineffective in identifying and addressing the sanitation issues. The failure to maintain clean and sanitary conditions in the food storage areas has the potential to result in foodborne illness or adverse effects for patients, visitors, and staff.
Infection Control Deficiencies During Medication Administration and Wound Care
Penalty
Summary
The facility failed to follow standards of infection control for five of fifteen sampled residents during medication administration and resident care. Specifically, a nurse did not remove gloves and perform hand hygiene after performing blood sugar checks and administering insulin to multiple residents. The nurse was observed exiting residents' rooms, disinfecting equipment, placing supplies back into the medication cart, and typing on the computer without changing gloves or performing hand hygiene. This was observed with residents who had chronic conditions and infections, including MRSA and VRE, and were on enhanced barrier precautions. Additionally, another nurse was observed double gloving while treating a resident's wounds, which is not the facility's practice. The nurse did not remove gloves and perform hand hygiene before and after cleansing the wounds and applying medications. This failure to adhere to proper infection control practices has the potential to transmit infections to residents, staff, and visitors. An administrative nurse confirmed that double gloving is not the facility's practice.
Failure to Ensure Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to ensure dignity and provide privacy during personal cares for two residents. In one instance, a CNA entered a resident's room without knocking or announcing themselves, which the resident confirmed happens frequently. In another instance, two CNAs were providing care to a resident when a third CNA entered the room without knocking or announcing themselves. These actions violated the facility's policy on promoting and maintaining resident dignity and privacy, which requires staff to knock and announce themselves before entering a resident's room. Additionally, the facility failed to promote privacy and confidentiality of electronic medication administration records (eMAR). A staff nurse left the treatment cart unattended with residents' eMARs visible on four separate occasions. This failure to lock computer screens and ensure the privacy of resident information could result in unauthorized viewing of resident records by other residents, visitors, or unlicensed staff. These actions are contrary to professional guidelines that emphasize the importance of maintaining the privacy and confidentiality of client information stored in computers.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for one resident. Observations in the resident's room and bathroom revealed a strong urine odor, a sticky floor with a rust-colored substance around the toilet, and multiple unclean areas including dried food/drink spills on the wall, dirty wheelchair cushions, dust on a shelf, and various debris on the floor. The housekeeping logs and the resident's medical record did not show any evidence that the resident refused housekeeping services. Interviews with two CNAs revealed that the resident did not like the wheelchair cushions from physical therapy and had thrown them on the floor. The CNAs acknowledged that the cushions should have been returned to physical therapy and that the room needed cleaning attention. An administrative nurse also agreed that the room required cleaning. The facility's policy on routine cleaning and disinfection was not followed, leading to the unsanitary conditions observed in the resident's room.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, which impacted the accuracy of their assessments and potentially the development of their comprehensive care plans. For Resident #21, the medical record showed a physician's order for a low potassium diet dated 04/27/23. However, the annual MDS did not reflect this therapeutic diet in section K0510D. This discrepancy was acknowledged by the dietary manager during the survey interview on 05/02/24. For Resident #27, the medical record indicated a significant weight loss of 10% over three months, from an admission weight of 125 lbs on 01/25/24 to 111.8 lbs on 04/24/24. Despite this, there were no physician orders for a weight loss regimen. The admission MDS incorrectly coded section K0300 as 'yes,' indicating the resident was on a physician-prescribed weight-loss regimen. This error was confirmed by a nurse manager during an interview on 05/01/24.
Failure to Review and Revise Care Plans
Penalty
Summary
The facility failed to review and revise care plans for three residents, which limited staff's ability to communicate needs and ensure continuity of care. Resident #13 was identified as at risk for elopement, with a physician's order for a Wanderguard check three times a day. Despite this, the resident's care plan lacked any mention of wandering or the use of a Wanderguard. Similarly, Resident #23, who had advanced dementia and a history of behavioral issues including wandering and sexually inappropriate behaviors, had no care plan addressing these issues. Observations confirmed the resident's wandering behavior, but the care plan did not reflect any interventions for these behaviors. Resident #179 had a fall resulting in a right elbow fracture prior to admission and was identified as a fall risk with a provider order for maximum fall precautions. Observations showed the resident with a cast, sling, and a chair alarm attached to the wheelchair, yet the care plan lacked any interventions related to fall precautions. An administrative nurse confirmed that the care plan should indicate specific fall precautions for the resident. These deficiencies highlight the facility's failure to update and revise care plans to reflect the current needs and risks of the residents, potentially impacting the quality of care provided.
Failure to Notify Physician of Critical Changes in Resident's Condition
Penalty
Summary
The facility failed to follow professional standards of practice for a resident with specific parameters for weight and blood pressure monitoring. The resident had multiple diagnoses, including chronic obstructive pulmonary disease, chronic bronchitis, hypertension, renal failure, and anemia. Despite physician orders to notify the medical doctor if the resident's systolic blood pressure fell below 100 mmHg or if there was a weight change of 4 pounds or more, the facility did not notify the physician of 12 occurrences of systolic blood pressure below 100 mmHg and four occurrences below 90 mmHg. Additionally, significant weight changes were recorded without notifying the physician, including an 8-pound loss and a 6.4-pound gain within a short period. An administrative nurse confirmed that the staff failed to notify the provider of these changes during an interview. The failure to notify the physician of these critical changes in the resident's condition placed the resident at risk for delayed treatment and adverse health events. The deficiency was identified through a combination of record reviews, professional reference reviews, and staff interviews.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident who required staff assistance with toileting. The care plan for the resident indicated that staff should assist with toileting every two to three hours. However, observations and record reviews revealed that the resident was not assisted as required, resulting in the resident being found with wet clothing and a strong odor of urine on multiple occasions. Specifically, there were 20 instances where staff did not assist the resident with toileting within the specified time frame, with gaps ranging from 7 to 16 hours between assistance. During an interview, two certified nurse aides confirmed that the resident should be toileted every two to three hours. The facility's policy and professional references emphasize the importance of regular toileting to prevent skin breakdown, infection, and other complications. Despite this, the facility failed to adhere to the care plan and policy, leading to the resident experiencing incontinence episodes without timely assistance from staff.
Failure to Deposit Resident Funds in Interest-Bearing Account
Penalty
Summary
The facility failed to deposit residents' funds in an interest-bearing account for two residents. A review of a quarterly statement from the pooled account revealed it was a non-interest-bearing account. During an interview, two business office employees confirmed that they keep petty cash available for residents on weekends and maintain money for each resident in a pooled checking account at the bank. The individual account sheets for the two residents showed that their money was in a non-interest checking account.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dunseith
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rolette Community Care Center | 14.1 mi | ★★★★★ | 11 | 1 |
| Good Samaritan Society - Bottineau | 16.8 mi | ★★★★★ | 15 | 0 |
| Heart Of America Care Center | 31.2 mi | — | 0 | 0 |
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