Good Samaritan Society - Bottineau

F-F600 is considered past non-compliance. The facility implemented corrective actions as follows:

* Room and facility checks performed to assess for/remove sharp objects that could be a safety hazard.

* Continued communication with residents involved to assure they feel safe in their environment.

* Interviewed random residents to assess their feeling of safety in the facility.

* Placed a stop sign on Resident #1's door to deter people from just walking in.

* Trauma User Defined Assessment (UDA) completed on 01/13/25 to assess Resident #1 for any effects from the incident.

* Close monitoring of Resident #5 by staff during each shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 3 355093 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 355093 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - Bottineau 725 E 10th St Bottineau, ND 58318

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 * Education to all staff via facility texting site and communication log read by staff prior to their shift concerning incident, sharp objects, redirection of wandering and agitated residents per their care plan. Level of Harm - Minimal harm or potential for actual harm * Primary doctor visited and adjusted Resident #5's medications on 01/13/25.

Residents Affected - Few * Family care conference held on 01/14/25 with the interdisciplinary team to address Resident #5's behavior.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 3 355093