Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Good Samaritan Society - Bottineau during CMS and state inspections, most recent first.
Infection Control Lapses During Resident Care: Staff failed to follow hand hygiene, glove use, and EBP requirements during resident care. A resident with a pressure ulcer requiring EBP received meal assistance, hygiene, transfer, and colostomy care without consistent gown use, glove changes, or hand hygiene. Similar lapses were observed during toileting, transfers with a sit-to-stand lift, and cleaning of equipment for other residents, and an administrative nurse stated staff were expected to perform hand hygiene when entering and exiting rooms, between glove changes, and to follow EBP precautions.
A resident did not receive the SNFABN and NOMNC at least 2 days before Medicare Part A skilled services ended. The notices were signed on the same day the resident was discharged from Part A, and an administrative staff member confirmed the forms were not given in advance.
A CNA failed to follow the resident’s care plan during a pivot transfer by not using the planned walker and gait belt. The resident was moved from a recliner to a wheelchair by being pulled under the arm, and the wheelchair and recliner slid during the transfer.
Unsafe transfers and room safety issues were observed for multiple residents. Staff did not follow care plans for transfer methods, including using a sit-to-stand lift or manual lifting instead of ordered total-lift assistance, and one resident’s door alarm was found disconnected when the resident walked into the hallway. Cleaning chemicals were also observed in a resident room despite facility policy prohibiting them.
Infection control lapses occurred during resident care when staff failed to perform hand hygiene, changed gloves without cleaning hands, handled soiled linen and resident care tasks without proper hand hygiene, and did not consistently use gowns for residents on EBP. Staff were observed providing toileting, incontinence, and transfer care to multiple residents while missing required hand hygiene steps and, in some cases, using gloves from pockets or moving from contaminated care to other tasks without cleaning hands.
Call Light Not Left Within Reach: A resident’s call light was repeatedly left out of reach during observations, including after the resident asked for it back so the resident could lie down. The call light remained out of reach later that day, and when two CNAs assisted the resident with a transfer, they did not place the call light within reach before leaving the room. An admin staff member confirmed staff were expected to leave the call light within reach before exiting.
Failure to report alleged abuse/neglect after an unwitnessed fall: A resident with dementia and moderate cognitive impairment was found on the bathroom floor with head lacerations and active bleeding, with an initial SpO2 of 68 on RA and no explanation for the fall. The facility completed an internal investigation, determined the injury was not significant or of unknown origin, and did not submit an FRI to the SSA; the resident was later admitted to the hospital for pneumonia and subsequently died.
Failure to complete a SCSA for two residents with significant declines in status. One resident’s MDS showed new wandering and increased assistance needs for toileting, bathing, dressing, and footwear, while another resident’s MDS showed increased wandering, new mood and behavior indicators, and worsening ADL dependence. The record lacked evidence that staff identified or completed a SCSA for either resident, and an administrative staff nurse confirmed both residents declined and a SCSA should have been completed.
MDS coding was inaccurate for three residents. Two residents had quarterly MDSs with Section C, D, and/or GG left dashed even though the report states the facility did not assess their cognitive status, mood, or functional abilities, and an admin staff member said dashes were used when nursing staff did not complete the assessments. Another resident had a physician order for hospice and a care plan noting terminal prognosis and hospice, but the admission MDS did not code hospice services.
Care plans were not reviewed and revised to reflect the current status of two residents with diabetes. One resident had an order for insulin and the other had an order for glipizide, but both care plans lacked monitoring for signs and symptoms and interventions for hypoglycemia and hyperglycemia. An administrative nurse stated staff failed to update the care plans.
Improper mixing of a NovoLog 70/30 insulin pen occurred during medication administration for a resident when an MA primed and immediately administered the insulin without following the required mixing protocol. Facility policy and the manufacturer’s instructions both required the pen to be rolled and turned before use, and a staff nurse later stated she was unaware of the mixing process for this insulin pen.
Failure to provide ordered pressure ulcer care occurred for a resident with DM, protein calorie malnutrition, and an unhealed unstageable sacral/coccyx pressure ulcer. Staff left the resident seated in a wheelchair for over 5 hours without repositioning, cleaned a BM-soiled dressing without notifying the nurse, and did not apply ordered pressure-relieving boots or float the heels after care. Repositioning documentation was inconsistent, with gaps ranging from 2 to 24 hours.
Failure to Provide Timely Toileting: A resident who required 1-assist toileting and q2h brief checks was found with a urine-saturated brief and shorts during an observation, with the last documented toileting 3.5 hours earlier. Review of the toileting log showed multiple additional missed q2h toileting episodes, with gaps of 4 to 11 hours that resulted in urinary and bowel incontinence; an RN stated the expectation is to check and change a resident in a brief every 2 hours.
A resident who had elected hospice services had a care plan noting hospice care, but the medical record did not contain the hospice election form. An administrative staff member confirmed the form was missing from the record.
Unsafe and Unsanitary Resident Room Conditions: Staff failed to keep resident areas clean and comfortable for multiple residents. A resident's fan had heavy dust and a wall beside the bed had an unidentified brown substance, two residents had a foul-smelling refrigerator in their room that was not theirs and read 78 degrees, and a CNA returned a resident to a soiled wheelchair without cleaning the cushion. Another resident's wheelchair seat pad also had crumbs, and staff stated they expected fans, dirty walls, and nonworking appliances to be addressed promptly.
A resident with severe cognitive impairment and dementia experienced multiple incidents of mental and physical abuse from other cognitively impaired residents, including being punched, slapped, and tipped backward in a wheelchair, resulting in a head injury. Facility staff failed to supervise and intervene effectively to prevent these altercations, despite facility policy prohibiting abuse by anyone.
The facility did not thoroughly investigate multiple allegations of physical abuse between residents or ensure resident protection during the investigation process. Incidents included one resident being struck by another and another found tipped backward in a wheelchair after a verbal altercation. Required investigative steps and protections were not consistently documented or implemented.
A resident with severe cognitive impairment and total dependence for ADLs experienced a choking episode and subsequent health decline. Staff did not notify the provider or representative after the choking event or other significant changes in condition, including vomiting, hypotension, tachycardia, and low oxygen saturation. There was no documentation of provider orders for changes in care or for transport to the ER, resulting in delayed medical intervention and contributing to the resident's decline and hospitalization.
The facility did not notify the physician and/or resident representative of significant changes in condition for two residents: one who experienced a choking episode and subsequent acute changes, and another who sustained a skin tear. Documentation did not show timely notification as required by facility policy.
A resident with severe cognitive impairment and a history of wandering and aggression entered another resident's room and was found holding scissors to the resident's throat. A CNA intervened, and the resident became aggressive, requiring staff assistance. The threatened resident appeared confused and somewhat shaken, but did not report feeling scared. Facility policy required protection from abuse by anyone, including other residents.
The facility inaccurately coded the MDS for three residents, affecting the reflection of their current status and needs. One resident was incorrectly noted to have a feeding tube, another's pressure ulcer was not documented, and a third's routine use of an antipsychotic medication was omitted. These errors were confirmed by an administrative staff member.
The facility failed to follow professional standards of practice for two residents with indwelling catheters. One resident had a Foley catheter placed without specific instructions for care and maintenance in the physician orders. Another resident had an indwelling catheter without any physician orders or care instructions transcribed. These deficiencies highlight a lack of adherence to required documentation and care protocols for catheter management.
The facility experienced a 16% medication error rate due to improper administration of Fiasp insulin and polyethylene glycol. A nurse failed to prime the insulin pen correctly and did not maintain the needle in the skin for the required time. Additionally, a medication aide used insufficient water to dissolve polyethylene glycol, leaving residue in the cup. These errors were confirmed by administrative staff.
The facility failed to follow infection control standards during catheter care for two residents. A CNA did not use PPE correctly and failed to perform hand hygiene, while another CNA did not tie a gown properly, leading to potential contamination. These actions violated infection control policies and professional standards.
A resident at high risk for falls experienced multiple falls and injuries due to inadequate supervision and failure to update the care plan with effective interventions. Despite the facility's policy requiring updates and monitoring, the care plan remained unchanged, leading to continued falls and a fracture.
Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to follow infection control standards related to hand hygiene, glove use, and enhanced barrier precautions for 4 of 8 sampled residents and 1 supplemental resident observed during cares. The facility policy stated that enhanced barrier precautions include the use of gown and gloves during high-contact resident care activities, and the hand hygiene policy required hand hygiene when entering and exiting a room, before donning gloves, after removing gloves, and when moving from a contaminated body site to a clean body site during care. Resident #8 had a care plan requiring enhanced barrier precautions related to a pressure ulcer. During multiple observations, a CNA provided meal assistance and personal care without applying a gown during high-contact care, did not wear gloves for all high-contact tasks, and did not perform hand hygiene before glove application, after removing gloves, or before exiting the room. During another observation, two CNAs provided transfer and hygiene care with a mechanical lift, and one CNA later cleaned the lift and assisted the resident without hand hygiene between glove changes or after removing gloves. During a later observation, a CNA performed colostomy care, removed gloves and reapplied gloves without hand hygiene, removed the resident’s gown before completing care, and placed soiled laundry directly on the floor. Additional observations showed similar lapses for other residents. A CNA cared for Resident #37 on the toilet, removed gloves, assisted the resident into a chair, and exited without hand hygiene. For Resident #34, a CNA transferred the resident with a sit-to-stand lift, left the bathhouse without hand hygiene, returned and provided toileting care without hand hygiene, and then cleaned the lift and pushed the resident into the hallway without hand hygiene. For Resident #36, a CNA transported the resident, applied gloves without hand hygiene, provided toileting care, cleaned the lift, and moved the resident into the hall without hand hygiene. For Resident #15, two CNAs used a sit-to-stand lift for toileting care; one CNA removed gloves and then operated the lift and assisted the resident to stand without hand hygiene, while the other CNA continued care after removing gloves without hand hygiene. An administrative nurse stated staff were expected to perform hand hygiene when entering and exiting rooms, in between glove changes, and to follow EBP precautions.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to ensure that the resident and/or the resident’s representative received the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) and the Notice of Medicare Non-Coverage (NOMNC) at least two days before Medicare Part A skilled services ended for Resident #45. Review of Medicare Part A beneficiary notices showed that Resident #45 was discharged from Medicare Part A on 11/28/25, and both the SNFABN and NOMNC were signed by the resident on that same date. During an interview on 03/10/26 at 11:48 a.m., an administrative staff member confirmed that the forms were not provided at least two days in advance.
Improper Transfer Assistance During Pivot Transfer
Penalty
Summary
Facility staff failed to properly use assistive devices during a pivot transfer for Resident #34. The resident’s care plan stated that transfers between surfaces required assist of 1 staff with use of a walker, and the plan did not identify a gait belt as contraindicated. Facility policy reviewed during survey stated that staff should follow the resident’s care plan for mobility devices and use a gait belt unless contraindicated. During observation on 03/09/26 at 11:12 a.m., Resident #34 was seated in a recliner in the solarium. A CNA positioned a wheelchair at a 90-degree angle to the recliner and locked the brakes, then instructed the resident to stand and grabbed under the resident’s right arm instead of using the planned walker and a gait belt. As the resident held onto the wheelchair and leaned left, the recliner and wheelchair slid left. The CNA then pulled the resident over the right armrest into the wheelchair seat and told the resident, "You hurt my back."
Unsafe Transfers and Environmental Safety Lapses
Penalty
Summary
The facility failed to ensure safe transfers for residents whose care plans required specific transfer methods. One resident’s care plan directed a total lift with assist of 2 staff and a large sling for transfers in and out of bed, but a CNA placed a mechanical sit-to-stand lift outside the room, stated the resident was not on the hallway’s Hoyer lift list, and later said she used the sit-to-stand lift to transfer the resident from bed. An administrative nurse stated staff were expected to follow the care plan and use a total lift with assist of 2 staff. A second resident’s care plan directed transfer between surfaces with a total lift x2 and stated the resident was unable to weight bear. During one observation, two CNAs used a gait belt and attempted to stand the resident from a recliner, then lifted the resident with the gait belt to a wheelchair after the resident could not bear weight. A CNA stated the resident had been a mechanical lift but that administrative staff said he could pivot. During another observation, a CNA assisted the resident with toileting by positioning the wheelchair next to the toilet, directing the resident to hold the grab bar, and lifting under the resident’s armpits to stand and transfer off the toilet; a nurse later assisted in the same manner. The CNA and nurse did not use a mechanical lift or a gait belt. A third resident’s care plan directed assist of 1 staff with transfers, but a CNA used a stand lift to toilet the resident instead of the care-planned method. The facility also failed to have a nurse assess and update the care plan for a change in condition requiring the use or discontinuation of a mechanical lift. In addition, the facility failed to ensure a resident’s door alarm remained connected when the resident walked into the hallway without the alarm sounding, and a spray bottle of carpet spot remover was observed on another resident’s bedside table despite the facility policy stating cleaning supplies should not be in resident rooms.
Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to follow infection control standards during resident care for multiple residents, including handling soiled linen, hand hygiene, glove use, and enhanced barrier precautions (EBP). The facility policy on hand hygiene stated that staff should clean their hands when entering a patient room, before donning gloves, after removing gloves, when moving from a contaminated body site to a clean body site during care, and when exiting a patient room. The policy on standard, enhanced barrier, and transmission-based precautions stated that EBP includes gown and glove use during high-contact resident care activities such as transfers, dressing, hygiene, changing briefs, changing linens, device care, and wound care. During observation, a CNA assisted Resident #4 by placing an ungloved hand between the resident’s skin and brief to pull clothing up, then sat in a chair and typed on a computer without performing hand hygiene. With Resident #5, the CNA entered for toileting care without hand hygiene, applied gloves, transferred the resident to the toilet, removed gloves, applied new gloves, completed perineal care, applied a clean brief, pulled up pants, removed soiled gloves, applied clean gloves again, and transferred the resident back to the wheelchair before performing hand hygiene. With Resident #19, two CNAs entered for incontinence care, and one CNA failed to perform hand hygiene before entering the room; after care, that CNA removed soiled gloves, bagged soiled linen, exited the room, and failed to perform hand hygiene. Resident #22’s care plan required EBP for an indwelling catheter, including gown and glove use for high-contact care. A CNA entered the room without hand hygiene or a gown, applied gloves, and assisted the resident to the toilet; later, a nurse entered the bathroom without a gown, removed gloves from a pocket, completed perineal care, pulled up pants, and helped transfer the resident back to the wheelchair, with both staff members removing gloves and performing hand hygiene afterward. Similar failures were observed with Resident #26, Resident #34, Resident #40, and Resident #48, including missing hand hygiene between glove changes, failure to apply gowns for EBP, handling gloves from pockets, and moving from resident care to other tasks without hand hygiene. An administrative staff member stated staff were expected to perform hand hygiene before entering and exiting resident rooms, between glove changes, after resident care, and to apply gowns and gloves when providing high-contact care for residents on EBP.
Call Light Not Left Within Reach
Penalty
Summary
The facility failed to reasonably accommodate a resident’s need for access to a call light for 1 of 18 sampled residents, Resident #19. The facility policy titled Call Light stated that residents should always have a method of calling for assistance and that when leaving the room, the call light should be placed within easy reach of the resident. During an observation on 09/08/25 at 4:18 p.m., Resident #19 asked the surveyor to give the call light back so the resident could lie down, and the call light was not within reach. A later observation on 09/08/25 at 5:05 p.m. showed the call light still out of reach, and at 5:15 p.m. staff assisted the resident to the dining room. On 09/09/25 at 1:41 p.m., two CNAs assisted Resident #19 with a transfer but did not place the call light within reach before leaving the room. An administrative staff member confirmed that staff were expected to place residents’ call lights within reach before exiting the room.
Failure to Report Alleged Abuse/Neglect After Unwitnessed Fall
Penalty
Summary
The facility failed to report an alleged violation of abuse and neglect to the State Survey Agency for Resident #36 after an unwitnessed fall that resulted in injury and hospital admission. The facility policy titled Abuse and Neglect-Rehab/Skilled, Adult Day Services, Therapy & Rehab, dated 04/04/25, stated that all identified events of alleged or suspected abuse/neglect, including injuries of unknown origin, are to be promptly reported. Review of the resident’s record showed diagnoses including non-Alzheimer’s dementia, and the admission MDS identified moderate cognitive impairment. Progress notes documented that the resident was found slumped against the bathroom door with the head and shoulders leaning against it, with an obvious laceration and active bleeding to the right frontal/parietal skull and an additional laceration to the right rear parietal/occipital skull. The resident’s vital signs were obtained and the initial SpO2 was 68 on room air, and the resident was unsure how the fall occurred or why they were up. The resident was later admitted to the hospital for pneumonia, and the hospital notified the facility of the resident’s death. During interview, an administrative staff member stated the facility completed an internal investigation, did not find the injury to be significant or of unknown origin, and did not complete a Facility Reported Incident notification.
Failure to Complete SCSA for Two Residents with Declines in Status
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for 2 of 2 sampled residents who experienced a significant change in condition. The Long-Term Care Facility RAI 3.0 User’s Manual states that a significant change is a major decline or improvement in a resident’s status that will not normally resolve without staff intervention, affects more than one area of health status, and requires interdisciplinary review and/or care plan revision. It also states that a SCSA is appropriate when there are two or more areas of decline or improvement, including a decline in ADL physical functioning where a resident is newly coded as needing partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since the last assessment. Resident #2’s record showed an SCSA MDS with no wandering and lower levels of assistance for toileting, bathing, lower body dressing, upper body dressing, and footwear, followed by a quarterly MDS showing wandering 1-3 days and substantial/maximum assistance with toileting, bathing, lower and upper body dressing, and putting on/taking off footwear. Resident #5’s record showed an annual MDS with no mood indicators, no behaviors, wandering 1-3 days, substantial/maximum assistance with lower body dressing, and partial/moderate assistance with rolling left to right, followed by a quarterly MDS showing mood indicators, verbal behaviors 4-6 days, other behaviors 1-3 days, wandering 4-6 days, dependent lower body dressing, and substantial/moderate assistance with rolling left to right. The record lacked evidence that staff identified or completed a SCSA for either resident’s changes in behaviors and decline in ADLs, and an administrative staff nurse confirmed both residents declined and that a SCSA should have been completed.
MDS Coding Errors for Cognitive, Mood, Functional, and Hospice Items
Penalty
Summary
The facility failed to ensure accurate coding of the MDS for 3 of 12 sampled residents. For Resident #2, a quarterly MDS dated [DATE] showed Section C and Section D dashed. The RAI Manual states that if the resident interview cannot be conducted and staff cannot determine the information by observation, a dash may be used; however, the report states the factors listed on page C-24 did not apply to Resident #2, and the facility failed to assess the resident's cognitive abilities and mood. For Resident #5, a quarterly MDS dated [DATE] showed Section C, Section D, and Section GG dashed, and the facility failed to assess the resident's cognitive abilities, mood, and functional abilities. During interview, an administrative staff member stated that if nursing staff does not complete those assessments, dashes are used. For Resident #21, a physician's order dated 06/27/25 stated, "Admit to skilled nursing facility under HOSPICE care," and the current care plan stated the resident had a terminal prognosis and was on hospice care. The RAI Manual states that O0110K1 is used to code residents identified as being in a hospice program for terminally ill persons, but the facility failed to code hospice services on the admission MDS dated [DATE]. An administrative staff member later confirmed that hospice had not been coded on the resident's MDS.
Care Plans Not Updated for Diabetes Monitoring Needs
Penalty
Summary
The facility failed to review and revise care plans to reflect the current status of 2 of 18 sampled residents, Resident #3 and Resident #6. Resident #3 had diagnoses of diabetes and a physician’s order for insulin, but the care plan did not include monitoring for signs and symptoms or interventions for hypoglycemia and hyperglycemia. Resident #6 had diagnoses of diabetes and a physician’s order for glipizide, but the care plan also lacked monitoring for signs and symptoms and interventions for hypoglycemia and hyperglycemia. The record review, review of professional reference material, and staff interview showed that the care plans were not updated to address these diabetes-related needs, and an administrative nurse stated that staff failed to update the care plans for both residents.
Improper Mixing of NovoLog 70/30 Insulin Pen
Penalty
Summary
The facility failed to ensure staff followed professional standards of practice for 1 of 2 supplemental residents observed during medication administration, involving Resident #3. Review of the facility policy on insulin administration stated that intermediate or mixed insulins such as 70/30 should be gently mixed before use by rolling the pen between the hands and turning it up and down ten times. The manufacturer's instructions for the NovoLog 70/30 Mix FlexPen also directed that the pen be rolled gently between the hands 10 times and then turned upside down 10 times until the suspension appears uniformly white and cloudy, with immediate injection afterward. During observation on 09/11/25 at 7:18 a.m., MA #7 primed the insulin pen and immediately administered NovoLog Mix 70/30 to Resident #3 without following the mixing protocol. During an interview later that day, staff nurse #1 stated she was unaware of the mixing process for a NovoLog 70/30 insulin pen.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for a resident with diabetes mellitus, protein calorie malnutrition, and an unhealed unstageable pressure ulcer to the sacral/coccyx area. The resident’s care plan directed staff to turn and reposition at least every 2 hours and to provide open heel boots or float the heels, and a physician’s order required bilateral pressure relieving boots while in bed and in chair. The facility policy stated that a resident with a pressure ulcer would receive the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. Observations showed the resident seated in a wheelchair in the hallway for over 5 hours without being repositioned. Later, two CNAs provided a check and change, but the pressure ulcer dressing was soiled with bowel movement and the CNAs cleaned the bowel movement from the dressing, did not notify the nurse, and did not apply the pressure relieving boots. The resident was then left in bed without the boots or heels floated. On another observation, the resident remained in bed without pressure relieving boots or heels floated. When two nurses changed the pressure ulcer dressing, they also exited the room without placing the boots or floating the heels. Repositioning documentation from the prior month showed repositioning occurred inconsistently, with intervals ranging from 2 to 24 hours.
Failure to Provide Timely Toileting
Penalty
Summary
Appropriate toileting was not provided for Resident #2, who required assistance of 1 staff member and had a toileting program to be offered the toilet every 2 hours when awake, with brief checks every 2 hours and as needed. During an observation on 09/09/25 at 3:05 p.m., a CNA assisted the resident to the bathroom and found the incontinent product and shorts saturated with urine. The resident's toileting log showed the last staff-assisted toileting occurred at 11:31 a.m., about 3.5 hours earlier. Review of the resident's toileting log from 08/13/25 through 09/10/25 identified five additional occasions when staff did not toilet the resident every 2 hours. These gaps ranged from 4 to 11 hours between toileting times and resulted in urinary and bowel incontinence. During interview, a nurse stated that if a resident is in a brief, the expectation is to check and change them every 2 hours.
Missing Hospice Election Form in Resident Record
Penalty
Summary
The facility failed to ensure that Resident #21’s record contained the hospice election form for a resident who had elected hospice services on 06/27/25. Review of the medical record on all days of survey showed the resident was on hospice care and the care plan noted the resident was on hospice, but the hospice election form was missing from the record. During an interview on 09/11/25 at 12:30 p.m., an administrative staff member confirmed that the medical record lacked the hospice election form.
Unsafe and Unsanitary Resident Room Conditions
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment for Resident #5, Resident #26, Resident #14, and Resident #19. Review of facility policy stated that daily cleaning procedures are necessary to minimize the prevalence of infection, and that standard precautions are based on the principle that body fluids and secretions may contain transmissible infectious agents. Observations on all days of survey showed a thick layer of dust on the personal fan in Resident #26's room and an unidentified brown substance on the wall beside the resident's bed. During interview, Resident #26 stated he could not use the bed pan for bowel movements and said, “I blew it all over, look at the wall it's still on there.” Observations also showed a refrigerator in Resident #14 and Resident #19's room that emitted a strong foul odor and had a thermometer reading of 78 degrees Fahrenheit; both residents stated it was not their refrigerator, and Resident #19 said it belonged to a prior roommate. On 09/09/25, food crumbs were observed on Resident #5's wheelchair, and a CNA assisted the resident from the toilet and placed the resident back in the soiled wheelchair without cleaning the cushion. The same day, Resident #6's room was observed with crumbs covering the wheelchair seat pad and a shirt on the floor. During interview, two administrative staff stated they expected staff to clean resident fans weekly, clean dirty walls, and remove nonfunctioning appliances immediately from resident rooms.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to provide an environment free from mental and physical abuse for a resident with severe cognitive impairment, Alzheimer's disease, dementia, and anxiety disorder. This resident experienced multiple incidents of abuse from other residents, all of whom also had severe cognitive or behavioral impairments. On several occasions, altercations occurred in common areas, including one incident where a resident was punched multiple times, another where slapping occurred between two residents, and a third where a resident was tipped backward in a wheelchair and sustained a large hematoma to the head requiring emergency room care. These events were captured on facility video footage and confirmed by administrative staff interviews. The facility's own policy stated that residents must not be subject to abuse by anyone, including other residents. Despite this, staff failed to adequately supervise the residents and did not implement interventions to prevent repeated mental and physical abuse. The lack of effective supervision and intervention allowed for ongoing resident-to-resident altercations, resulting in fear, anxiety, and physical injury to the affected resident.
Failure to Investigate and Protect Residents During Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of physical abuse involving three residents. Specifically, the facility did not ensure that all allegations of abuse were fully investigated or that residents were protected during the investigation process. The facility's own policy required that an investigation team review all events by the next working day, assign someone to complete the investigation, update care plans with new interventions, and interview relevant parties. However, documentation showed that these steps were not consistently followed for the incidents involving the sampled residents. In one incident, a resident sitting in a wheelchair was physically struck multiple times by another resident, and staff intervention occurred only after the altercation escalated. In another event, two residents were found swearing at each other, with one resident discovered tipped backward in his wheelchair holding his head. The facility lacked evidence of comprehensive investigations into these events and did not demonstrate that all residents were protected during the investigation period.
Failure to Notify Provider and Representative After Multiple Medical Incidents
Penalty
Summary
Facility staff failed to provide necessary care and services for a resident with severely impaired cognition and total dependence for ADLs, who experienced multiple medical incidents and a decline in health status. After a choking episode, staff did not notify the provider or the resident's representative, nor did they document the event in subsequent communications regarding the resident's new onset behaviors. The resident was placed on a trial pureed diet, but there was no evidence of timely provider notification or order changes following the choking event. Further, when the resident exhibited additional changes in condition—including vomiting, hypotension, tachycardia, and decreased oxygen saturation—there was again a lack of timely provider notification and no documented provider order for transport to the emergency room. The medical record also failed to show consistent provider notification regarding odorous urine and other changes in condition. These omissions delayed physician and representative input for testing, monitoring, and treatment, contributing to the resident's decline, hospitalization, and may have contributed to the subsequent death.
Failure to Notify Physician and Representative of Change in Condition
Penalty
Summary
The facility failed to notify the physician and/or resident representative of significant changes in condition for two residents. For one resident who experienced a choking episode, the medical record did not show that the physician or the resident's representative were informed of the incident, a subsequent change in urine, or acute changes in the resident's status, including vomiting, abnormal lung sounds, hypotension, tachycardia, and low oxygen saturation. Although the family was eventually notified and the resident was transported to the emergency room, there was no documentation of timely notification to the physician or representative regarding these significant events. For another resident who sustained a skin tear to the upper left leg, the medical record did not indicate that the resident's representative was informed of the injury. Facility policy requires immediate notification of the physician and resident representative in the event of significant changes in physical status or the need to alter treatment. An administrative nurse confirmed that staff are expected to notify the appropriate parties in such situations, but this was not documented in the records reviewed.
Failure to Prevent Resident-to-Resident Abuse Involving Sharp Object
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of wandering, and aggressive outbursts entered another resident's room and was found sitting at the head of the bed holding a pair of scissors aimed at the resident's throat. The incident was discovered when a roommate alerted a CNA, who intervened and attempted to remove the scissors. The resident with the scissors became aggressive and tried to hit the CNA, requiring additional staff assistance to remove him from the room. The source of the scissors was unknown, and the resident was known to wander into other rooms to look out windows. At the time of the incident, the resident who was threatened was asleep and later appeared confused about the situation, with a CNA noting she seemed a little shaken. Interviews with the involved residents and staff indicated that neither the threatened resident nor her roommate reported feeling scared, although the CNA observed some distress. The resident who entered the room had a documented history of dementia, rejection of care, and wandering, and was independent with ambulation. Facility policy required protection of residents from abuse by anyone, including other residents.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, which is crucial for reflecting their current status and needs. For one resident, the quarterly MDS inaccurately identified the presence of a feeding tube, despite the absence of any physician's orders indicating such a device during the assessment period. Another resident's MDS did not document an unhealed pressure ulcer, even though a nurse's note indicated the presence of a blister on the resident's heel shortly after returning from the hospital. Additionally, the MDS for a third resident failed to reflect the routine use of an antipsychotic medication, Seroquel, as prescribed by a physician. This discrepancy was confirmed during an interview with an administrative staff member, who acknowledged the incorrect coding of the MDS assessments for these residents. These inaccuracies in the MDS could potentially impact the development of comprehensive care plans and the care provided to the residents.
Failure to Obtain and Document Physician Orders for Catheter Care
Penalty
Summary
The facility failed to adhere to professional standards of practice regarding the management of indwelling catheters for two residents. For Resident #5, the physician orders dated June 26, 2024, included the placement of a Foley catheter, but lacked specific instructions for catheter changes, care, and maintenance. Observations during the survey confirmed the presence of the indwelling urinary catheter, and an administrative staff member acknowledged the absence of detailed care instructions in the physician orders. Similarly, for Resident #11, observations on September 16 and 17, 2024, showed the resident with an indwelling urinary catheter, yet the physician orders did not include an order for the catheter or instructions for its care and maintenance. An administrative staff member confirmed that the facility staff failed to transcribe the necessary physician orders for the indwelling catheter. These deficiencies indicate a failure to obtain and document appropriate physician orders for catheter care, which is essential for maintaining professional standards of quality care.
Medication Administration Errors Result in 16% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, as evidenced by a 16 percent error rate observed during medication administration for three out of five residents. Specifically, errors were noted in the administration of Fiasp insulin and polyethylene glycol. For Resident #25, a nurse primed the insulin pen incorrectly by leaving the needle cap on and pointing the pen down, contrary to the manufacturer's instructions. Additionally, another nurse administered insulin without priming the pen and failed to keep the needle in the skin for the recommended duration, leading to improper dosing. Further errors were observed with the administration of polyethylene glycol to Residents #9 and #17. A medication aide used insufficient water to dissolve the powdered laxative, resulting in undissolved residue remaining in the cup after administration. This was contrary to the manufacturer's instructions, which specified using four to eight ounces of liquid. These errors were confirmed by three administrative staff members during an interview, acknowledging the failure to adhere to the manufacturer's recommendations for medication administration.
Infection Control Deficiencies in Catheter Care
Penalty
Summary
The facility failed to adhere to infection control standards during catheter care for two residents, leading to potential infection risks. For Resident #5, a CNA did not don a gown or gloves before assisting with a transfer, failed to perform hand hygiene prior to donning PPE, and used a contaminated urine container in a shared bathroom sink. The resident had an indwelling urinary catheter, and the care plan indicated the need for enhanced barrier precautions (EBP), which were not followed. For Resident #11, a CNA wore a gown and gloves but did not tie the gown at the waist, causing it to fall into the workspace. The CNA changed gloves without performing hand hygiene and placed a measuring container on the floor without a barrier. The CNA also failed to rinse or cleanse the container after use. Another CNA involved in the care did not don the gown and gloves in the correct order and failed to perform hand hygiene after removing PPE. These actions violated the facility's infection control policies and procedures, as well as professional standards for PPE use.
Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision and interventions to prevent accidents for a resident identified as high risk for falls. The resident, who had cognitive loss, balance deficits, and a visual deficit, experienced multiple falls over a period from March 22 to April 10, 2024. Despite being identified as high risk, the care plan only included two interventions: educating the resident and family about safety reminders and providing a fall mat to the bedside. These interventions were insufficient, as evidenced by the resident's continued falls and subsequent injuries. The facility's policy on fall prevention and management was not effectively implemented. The policy required the completion of a Falls Tool for screening and identifying fall risk factors, updating the care plan with new interventions, and monitoring the effectiveness of these interventions. However, the facility staff failed to update the care plan with new interventions after each fall, despite the resident experiencing five falls within a short period. The documentation showed that the care plan was not updated with additional interventions, and the staff did not implement any of the suggested interventions from the facility's document titled 'Suggested Resident Interventions to Manage Falls.' The resident's falls resulted in significant injuries, including a right elbow fracture. The facility's failure to implement and monitor effective fall prevention interventions and to modify the care plan as necessary contributed to the resident's continued falls and injuries. Interviews with administrative nurses confirmed that the care plan was not updated with new interventions, highlighting a lack of adherence to the facility's fall prevention policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 3 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bottineau
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dunseith Com Nursing Home | 16.8 mi | ★★★★★ | 3 | 0 |
| Rolette Community Care Center | 28.9 mi | ★★★★★ | 11 | 1 |
| Heart Of America Care Center | 37.4 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.