Complaint Investigation

Good Samaritan Society - Bottineau

January 22, 2025 · Bottineau, ND · 725 E 10th St

Citations 2

CMS Rating 2/5

Beds 52

Provider ID 355093

Healthcare Facility

Good Samaritan Society - Bottineau

Bottineau, ND · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

GOOD SAMARITAN SOCIETY - BOTTINEAU in BOTTINEAU, ND — inspection on January 22, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical

During an interview on 01/22/25 at 4:58 p.m., Resident #6 stated on the night of the incident she heard rustling, got up from bed and saw Resident #5 sitting by the head of Resident #1's bed.

She observed Resident #5 had his hands folded together but was not holding anything she could see.

She said Resident #1 was awake as she looked up at Resident #5 at times. Resident #6 asked Resident #5 to leave and called for the CNA. Resident #6 denied she, nor Resident #1, were scared.

She stated Resident #5 wandered a lot and they were not frightened of him.

During an interview on 01/22/25 at 5:45 p.m., a CNA (#2) stated Resident #5 sat by Resident #1's head on the night of January 11, 2025, and held a scissors by her throat.

She didn't know what Resident #5 planned to do with the scissors.

She stated Resident #1 was asleep, then she opened her eyes, and it was like she was trying to figure out what was going on.

The CNA (#2) stated later she thought Resident #1 looked a little shook up.

The CNA described the scissors as small and silver, like from a sewing kit.

Based on the following information, non-compliance at 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. * 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. * Primary doctor visited and adjusted Resident #5's medications on 01/13/25. * Family care conference held on 01/14/25 with the interdisciplinary team to address Resident #5's behavior.

FF600

Minimal harm or Few * Family care conference held on 01/14/25 with the interdisciplinary team to address Resident #5's behavior. affected

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.

355093

Form Approved OMB

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

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BOTTINEAU, ND, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GOOD SAMARITAN SOCIETY - BOTTINEAU or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.