The December 4 incident at Dunseith Com Nursing Home involved several certified nursing aides who were trying to get Resident #6 ready for supper. According to the facility's own incident report, the woman ended up naked on the bathroom floor while staff hollered at her and pointed in her face, demanding she apologize.
Federal inspectors found the facility violated reporting requirements by failing to notify administrators and state authorities within the mandatory two-hour window. The incident wasn't reported to the State Survey Agency until December 10, nearly a week after it occurred.
Resident #6 has anxiety, conduct disorder, moderate cognitive impairments and delusions, according to her medical records. On the evening of December 4, she was yelling and refusing to get up and changed before supper, prompting three aides to enter her room.
The facility's incident report described what happened next in stark detail. Staff consistently reported that the resident's bed was wet and she was distressed, yelling, and at times refusing to get up or cooperate. Multiple CNAs were in and out of the room during attempts to move her.
During the transfer attempts, she ended up naked on the bathroom floor.
Staff gave conflicting accounts about how she got to the floor, though several reported she refused to stand or get herself up. What happened next violated basic dignity standards for nursing home care.
A gait belt was applied directly to her bare skin, and staff lifted her with it at least once. The device, typically used over clothing to help transfer residents safely, was placed against her naked body.
Two CNAs were reported to have hollered at the resident while she lay on the floor, pointing in her face and insisting that she apologize. The woman was crying during the ordeal.
Another CNA entered the room later and found the resident still on the floor, crying. This aide noticed scratches on the woman's left arm. No staff could provide a clear explanation for how the scratches occurred.
The third aide refused to leave the resident on the floor and ultimately calmed, cleaned, dressed, and brought her to supper.
Meanwhile, the charge nurse on duty received only partial information about what had occurred. She was told that Resident #6 had exhibited a behavior and that a gait belt was used. She was not informed about the yelling, the resident being naked on the floor, the number of staff involved, or the injuries.
The facility's own incident report acknowledged that staff consistently noted yelling toward the resident, difficulty during the transfer, the woman's distress, and that full details were not reported to the charge nurse at the time.
Federal regulations require nursing homes to report suspected abuse immediately, but no later than two hours after an allegation is made. The facility failed to meet this standard.
During an interview on December 22, an administrative nurse acknowledged that facility staff failed to report the incident in a timely manner. The nurse stated it was not acceptable for staff to holler at or threaten residents.
The violation occurred despite clear federal requirements designed to protect vulnerable nursing home residents. Facilities must report incidents of suspected abuse to the administrator and state authorities within strict timeframes to ensure proper investigation and prevent continued harm.
Failure to report abuse incidents promptly can result in continued abuse, fear, anxiety, and psychological harm to residents, according to federal guidelines. The delayed reporting in this case meant that nearly a week passed before state authorities were notified of the incident involving multiple staff members and a vulnerable resident with cognitive impairments.
The incident began as a routine evening care situation. Resident #6 needed to be changed and prepared for supper, a daily occurrence in nursing homes across the country. But what should have been a standard transfer became an episode involving multiple staff members, yelling, and a resident left naked and injured on a bathroom floor.
The conflicting staff accounts about how the resident ended up on the floor raised additional concerns for inspectors. When multiple staff members cannot provide consistent explanations for how a resident was injured or ended up in a compromising position, it suggests inadequate supervision and potential cover-up attempts.
The use of a gait belt directly against bare skin violated standard care practices. These devices are designed to be used over clothing to provide a secure grip during transfers while maintaining resident dignity. Applying the belt to naked skin not only compromised the resident's dignity but could have caused additional discomfort or injury.
The scratches on the resident's arm remained unexplained even after the facility's investigation. When nursing home residents sustain unexplained injuries during care interactions involving multiple staff members, it raises serious questions about the level of force used and the adequacy of staff training.
The charge nurse's lack of knowledge about the full scope of the incident highlighted communication failures within the facility. Proper incident reporting requires that supervisory staff receive complete and accurate information about what occurred, not sanitized versions that omit crucial details about resident treatment and injuries.
The administrative nurse's admission that the facility failed to report the incident properly and that yelling at residents was unacceptable came only after federal inspectors arrived to investigate. This reactive acknowledgment, rather than proactive reporting and correction, demonstrated the facility's inadequate response to protecting resident welfare.
The resident involved in this incident continues to live at Dunseith Com Nursing Home, a facility that has now been cited for failing to protect her from abuse and failing to report that abuse according to federal requirements designed to safeguard vulnerable nursing home residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dunseith Com Nursing Home from 2025-12-23 including all violations, facility responses, and corrective action plans.