Good Samaritan Society - Bottineau

In the surveyor’s words

From the most serious findings on record at Good Samaritan Society - Bottineau, in the surveyor’s own words.

• Immediate jeopardy, patternF550May 24, 2023

  Based on observation; information received from the complainant; review of the North Dakota Long Term Care Ombudsman Program's Guide to Resident Rights; and resident, family, and staff interview, the facility failed to treat residents with respect and dignity and care for residents in a manner and an environment that promotes, maintains, or enhances of their quality of life for 4 of 10 sampled residents (Resident #1, #2, #3, and #9) and 6 supplemental residents (Resident #13, #14, #15, #18, #19, and #20). Failure to protect residents from wandering and aggressive residents and the unwanted physical touch of a visitor violated their right to live in a safe environment free from abuse/neglect and resulted in negative psychosocial outcomes. […]

• Immediate jeopardy, patternF600May 24, 2023

  Based on observation; information received from the complainant; record review; review of facility policy; and resident, family, and staff interview, the facility failed to ensure residents remained free from physical abuse and neglect for 4 of 10 sampled residents (Resident #1, #2, #3, and #9) and 6 supplemental residents (Resident #13, #14, #15, #18, #19, and #20) and failed to protect 2 of 2 sampled residents from resident to resident abuse (Resident #5 and #7). Failure to provide services necessary to avoid mental anguish and emotional distress resulted in fear, anxiety, an unsafe environment for residents, and actual psychosocial harm. During the on-site complaint survey, the team determined a potential Immediate Jeopardy (IJ) situation existed on 05/17/23 at 3:34 p.m. […]

• Immediate jeopardy, patternF689May 24, 2023

  Based on observation, information received from the complainant, record review, and resident and staff interview, the facility failed to ensure an environment free of accident hazards for 1 of 1 coffee/hot water machine in the dining room. Failure to ensure appropriate coffee/water temperatures resulted in serving temperatures above the acceptable range and may result in serious burns/injuries to residents. During the on-site complaint survey, the team determined an Immediate Jeopardy (IJ) situation existed on 05/17/23 at 3:34 p.m. The IJ resulted from temperature readings obtained from the coffee/hot water machine, a lack of temperature monitoring by staff, and an injury to a resident. […]

• Immediate jeopardy, isolatedF600Jul 16, 2025

  Based on review of the facility reported incident (FRI) investigation, record review, review of facility policy, and staff interview, the facility failed to provide an environment free of mental/physical abuse for 1 of 1 sampled resident (Resident #1) Failure to prevent Resident #1 form the abusive actions of other residents (Resident #2 and #3) resulted in Resident #1 experiencing fear, anxiety, and injury.During the on-site FRI investigation survey, the team consulted with the State Survey Agency (SSA) on 07/10/25 at 12:19 p.m. and determined an immediate jeopardy (IJ) situation existed on 04/30/25. The facility failed to protect residents from abuse which resulted in resident-to-resident altercations. […]

• Actual harm, isolatedF684May 13, 2025

  Based on record review, the facility failed to provide necessary care and services for 1 of 1 closed record (Resident #1) who experienced multiple medical incidents and a decline in health status. Failure to notify the provider and resident representative of the initial choking event and further medical incidents, delayed physician and representative input for testing/monitoring/treatment, contributed to the resident's decline followed by hospitalization, and may have contributed to the resident's subsequent death. Findings include: Review of Resident #1's medical record occurred on 05/13/25. A Minimum Data Set (MDS)Assessment, dated 03/10/25, identified severely impaired cognition, and dependent on staff for all activities of daily living (ADLs). […]