Dunseith Com Nursing Home

Inspectors wroteBased on record review, review of facility reported incident s(FRI), review of facility policy, and staff interviews, the facility failed to ensure residents remained free from abuse for 2 of 2 sampled residents (Resident #1 and #6) intimidated and yelled at by staff members (Resident #6) and verbal outbursts/physical behaviors towards other residents (Resident #1). Failure to protect residents from abuse resulted in physical, verbal, and mental abuse, pain and has to potential to affect all residents.

Inspectors wroteBased on record review, review of the facility reported incident (FRI), and staff interview, the facility failed to report an incident of abuse to the administrator and the State Survey Agency (SSA) within the required time frames for 1 of 1 sampled resident (Resident #6) who experienced mental, verbal, and physical abuse from staff. Failure to ensure incidents of abuse are reported immediately, but not later than 2 hours after the allegation is made, may result in continued abuse, fear, anxiety, and psychosocial harm.

Inspectors wroteBased on record review and staff interview, the facility failed to review and revise care plans to reflect the resident's current status for 1 of 7 sampled residents (Resident #1). Failure to update/revise care plans limited the staff's ability to communicate residents needs and ensure continuity of care. Findings Include:- Review of Resident #1's medical record occurred on all days of survey. Diagnoses included chronic pain and dementia with agitation. The admission Minimum Data Set (MDS), dated [DATE], identified behaviors directed towards others that significantly disrupt care or living environment. Review of Resident #1's progress notes from 10/09/25 to 12/21/25 identified the following:* 21 occasions of pain and/or requested pain medication. * Two occasions of verbal and/or physical aggression with other residents. * 23 occasions of verbal and/or physical aggression with staff. [...]

Inspectors wroteBased on staff interview, the facility failed to ensure 1 of 1 dietary manager (#1) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure the facility had a qualified dietary management to carry out the functions of food and nutrition services may result in foodborne illness to residents, staff, and visitors.

Inspectors wroteBased on observation, review of dishwasher temperature log, review of professional reference, and staff interview, the facility failed to ensure the high temperature dishwasher provided adequate heat sanitization for dishes and utensils washed in 1 of 1 kitchen (main kitchen). Failure to monitor the dish temperatures during the high temperature dishwash cycle may result in inadequate sanitation of dishware and foodborne illness.

Inspectors wroteBased on review of the facility's Quality Assurance Performance Improvement (QAPI) program committee minutes, review of facility policy, and staff interview, the facility failed to ensure the QAA (Quality Assessment and Assurance) Committee, and all the required members met at least quarterly for 2 of 5 quarters (June 2024 and September 2024) reviewed. Failure to meet quarterly and have the medical director participate in the facility's quality assurance activities may result in an ineffective QAPI program and deprives the committee of the physician's unique contributions for analysis of quality concerns and assisting with decision making based on identified concerns.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to ensure staff followed professional standards of practice for 4 of 4 supplemental residents (Resident #8, #9, #10, and #17) observed during insulin preparation and 1 of 1 supplemental resident (Resident #10) reviewed for insulin use. Failure to properly prime an insulin pen and follow physician's orders regarding out-of-range blood sugar levels, may result in residents receiving an inaccurate dose of insulin and/or possible adverse events.

Inspectors wroteBased on review of facility policy and family and staff interviews, the facility failed to provide the resident's representative a copy of quarterly financial statements for 1 of 1 sampled resident (Resident #19) reviewed for personal fund accounts. Failure to provide quarterly statements to the individual designated by the resident to make financial decisions on their behalf prevented the representative from verifying transactions and fund balances.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 1 sampled resident (Resident #1) observed during wound care. Failure to practice infection control standards related to dressing changes has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, record review, review of resident council minutes, resident interview, and staff interview, the facility failed to provide appropriate dementia care and services for 1 of 1 sampled resident (Resident #23) with wandering behaviors and a history of inappropriate sexual behaviors. Failure to adequately assess for necessary care and services and implement effective behavior management interventions resulted in a decreased level of psychosocial well-being for Resident #23 and had a negative impact on other residents.

Inspectors wroteBased on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure food is stored in accordance with professional standards for food service sanitation in 1 of 1 kitchen (main kitchen). Failure to ensure food is safe from contamination from ice/condensation, dirt, and rust has the potential to result in a foodborne illness or adverse effects for patients, visitors, and staff.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 5 of 15 sampled residents (#1, #9, #15, #18, and #22) observed during medication administration and resident cares. Failure to follow infection control standards related to hand hygiene and glove use has the potential to transmit infections to residents, staff, and visitors.

Inspectors wrote2. Based on observation and review of a professional reference, the facility failed to promote privacy and confidentiality of the electronic medication administration records (eMAR) on 1 of 1 treatment carts observed. Failure to promote resident privacy and lock computer screens may result in unauthorized viewing of resident records by other residents, visitors, or unlicensed staff.

Inspectors wroteBased on observation, record review, review of facility policy, review of facility housekeeping logs, and staff interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment for 1 of 15 sampled residents (Resident #1) observed during survey. Failure to maintain a clean, comfortable, and sanitary environment does not provide a homelike living area for residents and fails to promote quality of life.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 15 sampled residents (Resident #21 and #27). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise care plans for 3 of 15 sampled residents (Resident #13, #23, and #179). Failure to review and revise the care plan limited staff's ability to communicate needs, ensure continuity of care, and may negatively impact the care provided to residents.

Inspectors wroteBased on record review, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 1 of 2 sampled residents (Resident #21) reviewed with orders for specific parameters for weight and blood pressure. Failure to notify the physician of weight gain/loss and low systolic blood pressures as ordered placed the resident at risk for delayed treatment and adverse health events.

Inspectors wroteBased on observation, record review, review of facility policy, review of a professional reference, and staff interview, the facility failed to provide appropriate treatment and services for 1 of 8 sampled residents (Resident #18) who required staff assistance with toileting. Failure to provide assistance with toileting may result in a loss of dignity and placed residents at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and risk for fall and/or injuries.

Inspectors wroteBased on review of resident trust account information and staff interview, the facility failed to deposit residents' funds in an interest-bearing account for 2 of 2 resident fund accounts reviewed (Resident #12 and #17). Failure to maintain resident funds in an interest-bearing account does not allow residents to earn interest and receive credit for the interest earned. This practice has the potential to affect all residents who have funds in an account.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure acceptable parameters of nutritional status for 1 of 3 sampled resident (Resident #18) with significant weight loss. Failure to implement interventions, adequately assess the effectiveness of existing interventions, ensure consistent implementation, and re-evaluate the need for updated or additional interventions resulted in a significant weight loss.

Inspectors wroteBased on observation, record review, review of facility policy, and resident, family, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the residents' current status for 5 of 15 sampled residents (Residents #1, #8, #10, #18, and #24). Failure to review/revise the care plans to reflect the residents' current status limited the staff's ability to communicate needs and ensure continuity of care for each resident.

Inspectors wroteBased on observation, record review, review of facility policy, review of professional reference, and resident and staff interview, the facility failed to ensure resident safety for 5 of 15 sampled residents (Residents #10, #12, #18, #19 and #24). Failure to ensure the safety of residents with exit-seeking behavior and residents who smoke and failure to properly dispose of narcotic patches placed the residents at risk for adverse events and injury.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure food is stored, prepared, and served in a sanitary manner for 2 of 2 kitchens (Main and Utility Room C also known as the small kitchenette) and 1 Dry Storage Room. Failure to store food properly, use food by the use by date, and label food may result in the spread of foodborne illness to residents, staff, and visitors.

Inspectors wrote1. Based on observation, record review, review of facility policy, and family and staff interviews, the facility failed to ensure the residents' right for legal representation for 2 of 15 sampled residents (Resident #17 and #24) reviewed for power of attorney/guardianship. Failure to ensure the medical record accurately reflected each resident's legal guardian limited the facility's ability to communicate and obtain authorization for care.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to notify the physician of a change in the resident's weight for 1 of 1 sampled resident (Resident #18) with weight loss. Failure to notify the physician may result in a delay of treatment and further weight loss for Resident #18.

Inspectors wroteBased on record review, review of facility policy, and staff interviews, the facility failed to ensure a possible violation involving verbal abuse was reported to the State Survey Agency and the results of the investigation were reported within five working days for 1 of 1 sampled resident (Resident #19) with an allegation of verbal abuse. Failure to report the incident within two hours and report the results of the facility's investigation to the State Survey Agency placed Resident #19 and other residents at risk of potential abuse.

Inspectors wroteBased on record review, review of facility policy, and resident and staff interviews, the facility failed to thoroughly investigate an allegation of verbal abuse for 1 of 1 resident (Resident #19) with an allegation of verbal abuse. Failure to thoroughly investigate all abuse allegations, ensure residents are protected, and implement safety measures during the investigation placed all residents at risk for possible abuse.

Inspectors wroteBased on observation, record review, review of facility policy, and family and staff interviews, the facility failed to follow professional standards of practice for 1 of 1 sampled resident (Resident #8) observed with a continuous glucose monitor (CGM). Failure to monitor blood glucose levels according to the attending physician's orders and/or obtain a physician's order for the CGM may result in inconsistency of obtaining blood glucose levels and potential errors in the amount of insulin required.

Inspectors wroteBased on observation, record review, review of facility policy, review of professional reference, and resident and staff interview, the facility failed to provide appropriate treatment and services to promote healing and prevent deterioration of pressure ulcers for 1 of 2 sampled residents (Resident #1) reviewed with pressure ulcers. Failure to follow physician's orders, accurately apply wound treatment/dressings, and ensure adequate assessment of the ulcers may result in delayed healing.

Inspectors wroteBased on observation, record review, review of professional reference, and staff interview, the facility failed to provide the necessary care and services to prevent complications for 1 of 1 sampled resident (Resident #10) observed with a feeding tube. Failure to flush a gastrostomy (gastric) tube (tube surgically inserted into the stomach) as ordered before and after administration of medications and/or start of a feeding may result in adverse effects.

Inspectors wroteBased on observation, record review, facility policy review, and staff interview, the facility failed to follow standard infection control practices for 1 of 1 sampled resident (Resident #8) on isolation. Failure to follow infection control practices related to proper procedure for personal protective equipment (PPE) usage and isolation signage may result in the spread of infection to residents, staff, and/or visitors.