Dunseith Com Nursing Home

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

[director of nursing] heard hollering, she went to hallway to find [Resident #1] and [Resident #2] close to each other with their wheelchairs. Both residents were moving arms to get away from each other. [Resident #1] had [Resident #2]'s right arm and was holding it. DON and CNA [certified nurse aide] were able to separate residents, and [Resident #1] let [Resident #2] arm released [sic]. During the separation, [Resident #1] hit [Resident #2] on the right side of his face with his right fist closed. DON and CNA immediately separated residents. Vital signs take [sic] on both residents. Not sure how it initially started.The FRI, dated 12/22/25, stated, . Resident [#1] was involved in resident-to-resident altercation. Resident [#1] was sitting in

the activity room with a few other residents watching television and socializing. During this time, nurse was alerted by loud shouting in the activity room among the residents. CNA and nurse went to assess concerns, staff was [sic] informed by residents present in the activity room [Resident #3] was hit in her mouth by resident's [Resident #1] closed fist. [Resident #3] confirms this occurred. She reports her mouth is sore.

Vital signs taken, skin and mouth assessed, there is no indication of broken skin or bruise at this time.During an interview on 12/22/25 at 1:30 p.m., administrative staff members (#1 and #2) reported [Residents #1, #2 and #3] did not have any injuries following the incidents, care plans for all resident's involved were reviewed and updated, [Resident #1] is closely monitored by all staff, and staff education was completed. The facility failed to protect Resident #2 and #3 from verbal and physical abuse.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Dunseith Com Nursing Home

15 1st St NE Dunseith, ND 58329

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, review of the facility reported incident (FRI), and staff interview, the facility failed to report an incident of abuse to the administrator and the State Survey Agency (SSA) within the required time frames for 1 of 1 sampled resident (Resident #6) who experienced mental, verbal, and physical abuse from staff.

Failure to ensure incidents of abuse are reported immediately, but not later than 2 hours after the allegation is made, may result in continued abuse, fear, anxiety, and psychosocial harm. Findings include:Review of Resident #6's medical record occurred on all days of survey. Diagnoses included anxiety and conduct disorder. The Minimum Data Set (MDS), dated [DATE REDACTED], identified moderate cognitive impairments and delusions. A Behavior/Mood Event report, dated 12/04/25 at 5:28 pm., stated, . resident was yelling and refusing to get up and changed before supper. Three aides were needed in order to get her to cooperate.

Gait belt was needed in order to get her toileted .Review of the initial FRI, received by the SSA on 12/10/25, stated the following, Date of allegation: 12/04/2025 . Several CNAs [certified nurse aides] were involved in

an incident with resident [Resident #6] during attempts to get her up for supper. Staff consistently reported that [Resident #6's] bed was wet, she was distressed, yelling, and at times refusing to get up or cooperate.

Multiple CNAs [names of CNAs] were in and out of the room. During attempts to move [Resident #6], she ended up naked on the bathroom floor. Conflicting accounts were given about how she got to the floor, though several reported she refused to stand or get herself up. A gait belt was applied directly to her bare skin, and staff lifted her with it at least once. Several CNAs mainly [two CNA's names] reported to have hollered at [Resident #6], pointing in her face, and insisted that she apologize. [CNA name] entered later, found [Resident #6] crying on the floor, and noted scratches on [Resident #6's] left arm. No staff could provide a clear explanation for the scratches. [CNA name] refused to leave [Resident #6] on the floor and ultimately calmed, cleaned, dressed, and brought her to supper. Charge Nurse [name] reported she was only told that [Resident #6] had a behavior and that a gait belt was used. She was not informed about yelling, the resident being on the floor naked, the number of staff involved, or any injuries. Overall, staff consistently note yelling toward the resident, difficulty during the transfer, [Resident #6's] distress, and that

the full details were not reported to the charge nurse at the time. During an interview on 12/22/25 at 4:10 p.m. an administrative nurse (#1) stated facility staff failed to report the incident in a timely manner and it not acceptable for staff to holler at or threaten residents.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Dunseith Com Nursing Home

15 1st St NE Dunseith, ND 58329

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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and staff interview, the facility failed to review and revise care plans to reflect the resident's current status for 1 of 7 sampled residents (Resident #1). Failure to update/revise care plans limited the staff's ability to communicate residents needs and ensure continuity of care.Findings Include:- Review of Resident #1's medical record occurred on all days of survey. Diagnoses included chronic pain and dementia with agitation. The admission Minimum Data Set (MDS), dated [DATE REDACTED], identified behaviors directed towards others that significantly disrupt care or living environment.Review of Resident #1's progress notes from 10/09/25 to 12/21/25 identified the following:* 21 occasions of pain and/or requested pain medication. * Two occasions of verbal and/or physical aggression with other residents. * 23 occasions of verbal and/or physical aggression with staff. Resident #1's current care plan lacked problems, goals, and interventions addressing pain and verbal/physical aggression towards others. During an interview on 12/22/25 at 1:30 p.m., two administrative staff members (#1 and #2) confirmed Resident #1's care plan required updates/revisions.

Event ID:

Facility ID:

If continuation sheet