Good Samaritan Society - Bottineau

Inspectors wroteBased on record review, review of facility reported incident (FRI), review of the facility policy, and resident and staff interview, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #20) who displayed sexual behaviors towards another resident. Failure to protect Resident #21 and all residents from sexual abuse may result in physical harm, pain, mental anguish, and emotional distress. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interviews, the facility failed to follow infection control standards for 4 of 8 sampled residents (Resident #8, #15, #34, and #36) and 1 supplemental resident (Resident #37) observed during cares. Failure to follow infection control standards related to hand hygiene, glove use, and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility.

Inspectors wroteBased on review of Medicare Part A letters/notices and staff interview, the facility failed to ensure the resident and/or their 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 prior to the end of services for 1 of 3 residents (Resident #45) reviewed for termination of Medicare Part A services. Failure to ensure the resident and/or their representative received the SNFABN and NOMNC at least two days prior to the end of skilled services limited the resident/representative's ability to exercise their rights regarding Medicare Part A services. Findings Include:Review of Medicare Part A beneficiary notices identified Resident #45 discharged from Medicare Part A on 11/28/25. The SNFABN and the NOMNC showed the resident signed the forms on 11/28/25. [...]

Inspectors wroteBased on observation, record review, and facility policy review, facility staff failed to properly utilize assistive devices necessary to prevent accidents for 1 of 2 sampled residents (Resident #34) observed during a pivot transfer. Failure to use a gait belt during a transfer placed the resident at risk for injury and/or pain. Finding Include: Review of the policy titled Safe Resident Handling Program (SRHP) Resource Packet - . LTC [Long Term Care] . occurred on 03/11/26. This policy, dated 07/07/25, stated, . Follows resident plan of care (Kardex)/service plan for mobility device, . The Care Plan is part of the communication process to the caregiver. Ambulation: (SPECIFY: X staff assist, mobility device and harness size, and any restrictions) and (SPECIFY assist device: Gait belt, walker etc.). Review of the policy titled Ambulation of Resident . LTC . [...]

Inspectors wroteBased on observation, record review, review of the facility policy, and staff interview, the facility failed to ensure safe transfers for 2 of 7 sampled residents (Residents #1 and #34) and 1 of 1 supplemental resident (Resident #22) observed during transfers. Failure to assess the need for mechanical lifts and to use a gait belt placed residents at risk of serious injury.

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 11 sampled residents (Resident #4, #5, #26, #34, and #48) and 3 supplemental residents (Resident #19, #22 and #40) observed during cares. Failure to follow infection control practices during resident cares related to handling soiled linen, hand hygiene, glove use, and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to provide reasonable accommodation of needs regarding call lights for 1 of 18 sampled residents (Resident #19) observed during cares. Failure to ensure residents can reach/access the call light may result in unmet needs and the inability to call for help.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to report an alleged violation of abuse and neglect to the State Survey Agency (SSA) for 1 of 2 residents (Resident #36) with an unwitnessed fall resulting in an injury and hospital admission. Failure to report alleged incidents to the SSA placed Resident #36 and other residents at risk for possible abuse and/or injury.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview, the facility failed to complete a Significant Change in Status Assessment (SCSA) for 2 of 2 of sampled residents (Resident #2 and #5) who experienced a significant change in status. Failure to determine the need for and complete a SCSA in response to a resident's decline limited the facility's ability to accurately assess the resident's status and identity and implement appropriate care approaches.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 12 sampled residents (Resident #2, #5, and #21) reviewed. 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 record review, review of professional reference, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 2 of 18 sampled residents (Resident #3 and Resident #6). Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on observation, record review, review of facility policy, review of manufacturer's instructions, review of professional reference and staff interview, the facility failed to ensure staff followed professional standards of practice for 1 of 2 supplemental residents (Resident #3) observed during medication administration. Failure to properly prepare insulin pens (Resident #3) may result in residents receiving the wrong medication dose and/or result in adverse health consequences.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide treatment and services to aid in the healing of a pressure ulcer for 1 of 2 sampled residents (Resident #26) with a current pressure ulcer. Failure to implement interventions as ordered may result in a new pressure area and delayed healing/deterioration of an unstageable pressure ulcer.

Inspectors wroteBased on observation, record review, facility policy review, and staff interview, the facility failed to provide appropriate toileting for 1 of 5 sampled residents (Resident #2) observed during toileting. Failure to provide timely toileting may result in a loss of dignity and placed the resident at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and fall and/or injuries.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure resident records contained the hospice election form for 1 of 1 sampled resident (Resident #21) receiving hospice services. Failure to obtain the form limits staff's ability to ensure coordination of care between the facility and the hospice.

Inspectors wroteBased on observation, review of facility policy, and resident and staff interviews, the facility failed to provide a safe, sanitary, and comfortable environment for 2 of 18 sampled residents (Resident #5 and #26), and 2 of 5 supplemental residents (Resident #14 and #19). Failure to ensure residents' fans, walls, and wheelchairs are clean, and failure to remove non-working refrigerators in resident rooms may affect the well-being, comfort, health, and safety of the residents.

Inspectors wroteBased on review of the facility reported incident (FRI) investigation, record review, review of facility policy, and staff interview, the facility failed to provide an environment free of mental/physical abuse for 1 of 1 sampled resident (Resident #1) Failure to prevent Resident #1 form the abusive actions of other residents (Resident #2 and #3) resulted in Resident #1 experiencing fear, anxiety, and injury. During the on-site FRI investigation survey, the team consulted with the State Survey Agency (SSA) on 07/10/25 at 12:19 p.m. and determined an immediate jeopardy (IJ) situation existed on 04/30/25. The facility failed to protect residents from abuse which resulted in resident-to-resident altercations. [...]

Inspectors wroteBased on review of the facility reported incident (FRI) and review of facility policy, the facility failed to conduct a thorough investigation of physical abuse for 3 of 3 sampled residents (Resident #1, #2, and #3). Failure to investigate all allegations of abuse and ensure all residents were protected during the investigation placed Residents #1, #2, and #3 and all facility residents at risk for possible abuse, mental an emotional distress, and/or physical injury. thoroughly investigate allegations of abuse for 1 of 1 sampled resident (Resident #1). Failure to thoroughly investigate all abuse allegations, ensure Resident #1 was protected during each investigation, and implement corrective actions/evaluate their effectiveness following each investigation, placed Resident #1 and other residents at risk for possible abuse.

Inspectors wroteBased on record review, the facility failed to provide necessary care and services for 1 of 1 closed record (Resident #1) who experienced multiple medical incidents and a decline in health status. Failure to notify the provider and resident representative of the initial choking event and further medical incidents, delayed physician and representative input for testing/monitoring/treatment, contributed to the resident's decline followed by hospitalization, and may have contributed to the resident's subsequent death.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to notify the resident's physician and/or resident representative of a change in condition for 1 of 1 closed record (Resident #1) who experienced a choking episode and 1 of 3 sampled residents (Resident #2) with a skin tear. Failure to notify the physician and/or resident representative of changes in condition may have prevented the physician from altering treatment/care and prevented the resident representative from making informed decisions regarding medical care.

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 4 sampled residents (Resident #32) and 3 supplemental residents (Resident #15, #19, and #30) observed during personal cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP), hand hygiene, and disinfecting equipment has the potential to spread infection throughout the facility.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure timely electronic data submission of a required Minimum Data Set (MDS) death discharge assessment for 1 of 1 closed record (Resident #18). Failure to follow the MDS data submission specifications did not meet the intended regulatory requirements.

Inspectors wroteBased on review of the facility reported incident and investigation documents, record review, policy review, and resident and staff interview, the facility failed to protect the resident's right to be free from abuse and psychosocial harm for 1 of 3 sampled residents (Resident #1) who experienced abuse by another resident. Failure to ensure an environment free from abusive behavior placed residents at risk for abuse, fear, anxiety, physical injury, and/or psychosocial harm. This citation is considered past non-compliance based on review of the corrective action the facility implemented following the incident.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision and interventions to prevent accidents for 1 of 1 closed record (Resident #4) reviewed for falls. Failure to implement and monitor the effectiveness of fall prevention interventions, modify the care plan as necessary, and implement new interventions resulted in Resident #4's continued falls, pain, and subsequent fracture.

Inspectors wroteBased on observation, policy review, and resident and staff interview, the facility failed to provide an environment that maintained, enhanced, and respected each resident's dignity and individuality on 1 of 4 days of survey (October 2, 2023). Failure to provide non-plastic silverware did not promote the residents' dignity or enhance their quality of life.

Inspectors wroteBased on observation, review of the Food and Drug Administration (FDA) 2022 Food Code, and staff interview, the facility failed to store food under sanitary conditions in 1 of 1 kitchen. Failure to store food in a sanitary environment in the walk-in freezer has the potential to result in contamination of food and could result in a foodborne illness.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and staff interview, the facility failed to ensure timely electronic data submission of required Minimum Data Set (MDS) discharge assessments for 1 supplemental resident (Resident #42). Failure to follow the MDS data submission specifications does not meet the intended regulatory requirements.

Inspectors wroteBased on record review, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of nursing practice for 1 of 2 sampled residents (Resident #29) receiving insulin. Failure to carry out a physician's order and document administration of medication as ordered may result in adverse health effects.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide required assistance with activities of daily living (ADLs) for 2 of 9 sampled residents (Residents #2 and #17) and one supplemental resident (Resident #16). Failure to shave residents may result in poor personal hygiene and decreased self-esteem. Review of the facility policy titled Activities of Daily Living occurred on 10/04/23. This policy, dated 11/29/22, stated, . Policy. Any resident who is unable to carry out activities of daily living will receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene. ADLs are those necessary tasks conducted in the normal course of a resident's daily life. Included in these are the following: General Personal, Daily Hygiene/Grooming: . shaving . [...]

Inspectors wroteTHIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 05/24/23. Based on review of nurse staffing schedules and staff interview, the facility failed to provide the services of a registered nurse (RN) for eight consecutive hours a day, seven days a week, for 2 of 96 days reviewed (07/22/23 and 09/10/23). Failure to ensure sufficient, qualified nursing staff are available eight consecutive hours a day has the potential to affect the health and safety of all the residents residing in the facility.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 1 of 5 residents (Resident #39) observed during medication administration. Three medication errors occurred during staff administration of 40 medications, resulting in a 7% error rate. Failure to properly administer medications may result in residents receiving an ineffective dose and experiencing adverse reactions.