The December 4 incident at Dunseith Com Nursing Home involved at least five certified nursing assistants who entered and left Resident 6's room during what staff described as attempts to get her ready for supper. The resident, who has moderate cognitive impairments and delusions according to her medical record, ended up naked on the bathroom floor after staff applied a gait belt directly to her bare skin and lifted her with it.
No staff member could explain how she got the scratches on her left arm.
The facility's own incident report, submitted to the State Survey Agency on December 10, documented that several CNAs "hollered at" the resident, pointed in her face, and "insisted that she apologize" while she remained on the floor. One nursing assistant later found the resident crying and refused to leave her there, ultimately calming her down and helping her get dressed for dinner.
The charge nurse on duty that evening was told only that the resident "had a behavior and that a gait belt was used." She received no information about the yelling, the resident being naked on the floor, the number of staff involved, or the injuries.
Federal regulations require nursing homes to report suspected abuse immediately, but no later than two hours after an allegation is made. Dunseith Com Nursing Home failed to meet either deadline.
The incident began around 5:28 p.m. when Resident 6 was "yelling and refusing to get up and changed before supper," according to a behavior report in her medical record. Staff noted her bed was wet and she was distressed. Three aides were initially needed to get her to cooperate, the report stated.
But the facility's own investigation revealed the situation escalated far beyond what was documented in that initial report. Multiple CNAs went in and out of the room during the incident. At some point, the resident ended up naked on the bathroom floor, though "conflicting accounts were given about how she got to the floor."
Several staff members reported she refused to stand or get herself up from the floor. Rather than calling for additional help or attempting to de-escalate the situation, nursing assistants applied a gait belt directly to the resident's bare skin and used it to lift her at least once.
The resident has anxiety and conduct disorder listed in her medical record, along with moderate cognitive impairments. Her care plan would have included specific approaches for managing behavioral episodes, yet multiple staff members resorted to yelling and demanding apologies from a cognitively impaired resident lying naked on a bathroom floor.
One CNA who arrived later in the incident found the resident crying on the floor and noticed the scratches on her left arm. This nursing assistant took a different approach, refusing to leave the resident on the floor and instead working to calm her down, clean her up, and help her get dressed for supper.
The scratches remained unexplained. No staff member could provide "a clear explanation" for how the resident sustained the injuries to her left arm, according to the facility's incident report.
The charge nurse's lack of information about the full scope of the incident raises questions about communication protocols and supervision. She was told the resident had exhibited challenging behavior and that a gait belt was used - standard information that would typically be reported. But she received no details about the yelling, the resident's nudity, the multiple staff involved, or the unexplained injuries.
This incomplete reporting to the charge nurse meant the facility's immediate response was inadequate. Without full information about what had occurred, supervisory staff could not properly assess the situation, ensure the resident's safety, or take appropriate corrective action with the staff involved.
During a December 22 interview, an administrative nurse acknowledged the facility had failed to report the incident within required timeframes. She stated it was "not acceptable for staff to holler at or threaten residents."
The administrative nurse's comment suggests the facility recognized the incident constituted abuse, yet the delayed reporting meant state authorities could not immediately investigate or ensure the resident's protection. The six-day gap between the incident and the report to the State Survey Agency violated federal requirements designed to protect vulnerable nursing home residents.
Federal inspectors noted that failure to report abuse incidents immediately can result in "continued abuse, fear, anxiety, and psychosocial harm." For Resident 6, who already experiences anxiety according to her medical record, the incident and its aftermath likely compounded her distress.
The inspection found the facility failed to ensure incidents of abuse are reported within required timeframes for the one sampled resident who experienced what inspectors classified as mental, verbal, and physical abuse from staff. The violation affected few residents but posed minimal harm or potential for actual harm, according to the inspection report.
The incident at Dunseith Com Nursing Home illustrates how quickly a routine care situation can deteriorate when multiple staff members respond inappropriately to a resident's distress. What began as helping a resident prepare for dinner escalated into an incident involving yelling, physical lifting with inappropriate equipment, unexplained injuries, and a vulnerable person left naked and crying on a bathroom floor.
The facility's failure to immediately report the abuse meant state authorities lost crucial time in investigating the incident and ensuring appropriate protections were in place for Resident 6 and other vulnerable residents in the facility's care.
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.