Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - Bottineau during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dementia experienced multiple incidents of mental and physical abuse from other cognitively impaired residents, including being punched, slapped, and tipped backward in a wheelchair, resulting in a head injury. Facility staff failed to supervise and intervene effectively to prevent these altercations, despite facility policy prohibiting abuse by anyone.
The facility did not thoroughly investigate multiple allegations of physical abuse between residents or ensure resident protection during the investigation process. Incidents included one resident being struck by another and another found tipped backward in a wheelchair after a verbal altercation. Required investigative steps and protections were not consistently documented or implemented.
A resident with severe cognitive impairment and total dependence for ADLs experienced a choking episode and subsequent health decline. Staff did not notify the provider or representative after the choking event or other significant changes in condition, including vomiting, hypotension, tachycardia, and low oxygen saturation. There was no documentation of provider orders for changes in care or for transport to the ER, resulting in delayed medical intervention and contributing to the resident's decline and hospitalization.
The facility did not notify the physician and/or resident representative of significant changes in condition for two residents: one who experienced a choking episode and subsequent acute changes, and another who sustained a skin tear. Documentation did not show timely notification as required by facility policy.
A resident with severe cognitive impairment and a history of wandering and aggression entered another resident's room and was found holding scissors to the resident's throat. A CNA intervened, and the resident became aggressive, requiring staff assistance. The threatened resident appeared confused and somewhat shaken, but did not report feeling scared. Facility policy required protection from abuse by anyone, including other residents.
The facility inaccurately coded the MDS for three residents, affecting the reflection of their current status and needs. One resident was incorrectly noted to have a feeding tube, another's pressure ulcer was not documented, and a third's routine use of an antipsychotic medication was omitted. These errors were confirmed by an administrative staff member.
The facility failed to follow professional standards of practice for two residents with indwelling catheters. One resident had a Foley catheter placed without specific instructions for care and maintenance in the physician orders. Another resident had an indwelling catheter without any physician orders or care instructions transcribed. These deficiencies highlight a lack of adherence to required documentation and care protocols for catheter management.
The facility experienced a 16% medication error rate due to improper administration of Fiasp insulin and polyethylene glycol. A nurse failed to prime the insulin pen correctly and did not maintain the needle in the skin for the required time. Additionally, a medication aide used insufficient water to dissolve polyethylene glycol, leaving residue in the cup. These errors were confirmed by administrative staff.
The facility failed to follow infection control standards during catheter care for two residents. A CNA did not use PPE correctly and failed to perform hand hygiene, while another CNA did not tie a gown properly, leading to potential contamination. These actions violated infection control policies and professional standards.
A resident at high risk for falls experienced multiple falls and injuries due to inadequate supervision and failure to update the care plan with effective interventions. Despite the facility's policy requiring updates and monitoring, the care plan remained unchanged, leading to continued falls and a fracture.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to provide an environment free from mental and physical abuse for a resident with severe cognitive impairment, Alzheimer's disease, dementia, and anxiety disorder. This resident experienced multiple incidents of abuse from other residents, all of whom also had severe cognitive or behavioral impairments. On several occasions, altercations occurred in common areas, including one incident where a resident was punched multiple times, another where slapping occurred between two residents, and a third where a resident was tipped backward in a wheelchair and sustained a large hematoma to the head requiring emergency room care. These events were captured on facility video footage and confirmed by administrative staff interviews. The facility's own policy stated that residents must not be subject to abuse by anyone, including other residents. Despite this, staff failed to adequately supervise the residents and did not implement interventions to prevent repeated mental and physical abuse. The lack of effective supervision and intervention allowed for ongoing resident-to-resident altercations, resulting in fear, anxiety, and physical injury to the affected resident.
Failure to Investigate and Protect Residents During Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of physical abuse involving three residents. Specifically, the facility did not ensure that all allegations of abuse were fully investigated or that residents were protected during the investigation process. The facility's own policy required that an investigation team review all events by the next working day, assign someone to complete the investigation, update care plans with new interventions, and interview relevant parties. However, documentation showed that these steps were not consistently followed for the incidents involving the sampled residents. In one incident, a resident sitting in a wheelchair was physically struck multiple times by another resident, and staff intervention occurred only after the altercation escalated. In another event, two residents were found swearing at each other, with one resident discovered tipped backward in his wheelchair holding his head. The facility lacked evidence of comprehensive investigations into these events and did not demonstrate that all residents were protected during the investigation period.
Failure to Notify Provider and Representative After Multiple Medical Incidents
Penalty
Summary
Facility staff failed to provide necessary care and services for a resident with severely impaired cognition and total dependence for ADLs, who experienced multiple medical incidents and a decline in health status. After a choking episode, staff did not notify the provider or the resident's representative, nor did they document the event in subsequent communications regarding the resident's new onset behaviors. The resident was placed on a trial pureed diet, but there was no evidence of timely provider notification or order changes following the choking event. Further, when the resident exhibited additional changes in condition—including vomiting, hypotension, tachycardia, and decreased oxygen saturation—there was again a lack of timely provider notification and no documented provider order for transport to the emergency room. The medical record also failed to show consistent provider notification regarding odorous urine and other changes in condition. These omissions delayed physician and representative input for testing, monitoring, and treatment, contributing to the resident's decline, hospitalization, and may have contributed to the subsequent death.
Failure to Notify Physician and Representative of Change in Condition
Penalty
Summary
The facility failed to notify the physician and/or resident representative of significant changes in condition for two residents. For one resident who experienced a choking episode, the medical record did not show that the physician or the resident's representative were informed of the incident, a subsequent change in urine, or acute changes in the resident's status, including vomiting, abnormal lung sounds, hypotension, tachycardia, and low oxygen saturation. Although the family was eventually notified and the resident was transported to the emergency room, there was no documentation of timely notification to the physician or representative regarding these significant events. For another resident who sustained a skin tear to the upper left leg, the medical record did not indicate that the resident's representative was informed of the injury. Facility policy requires immediate notification of the physician and resident representative in the event of significant changes in physical status or the need to alter treatment. An administrative nurse confirmed that staff are expected to notify the appropriate parties in such situations, but this was not documented in the records reviewed.
Failure to Prevent Resident-to-Resident Abuse Involving Sharp Object
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of wandering, and aggressive outbursts entered another resident's room and was found sitting at the head of the bed holding a pair of scissors aimed at the resident's throat. The incident was discovered when a roommate alerted a CNA, who intervened and attempted to remove the scissors. The resident with the scissors became aggressive and tried to hit the CNA, requiring additional staff assistance to remove him from the room. The source of the scissors was unknown, and the resident was known to wander into other rooms to look out windows. At the time of the incident, the resident who was threatened was asleep and later appeared confused about the situation, with a CNA noting she seemed a little shaken. Interviews with the involved residents and staff indicated that neither the threatened resident nor her roommate reported feeling scared, although the CNA observed some distress. The resident who entered the room had a documented history of dementia, rejection of care, and wandering, and was independent with ambulation. Facility policy required protection of residents from abuse by anyone, including other residents.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, which is crucial for reflecting their current status and needs. For one resident, the quarterly MDS inaccurately identified the presence of a feeding tube, despite the absence of any physician's orders indicating such a device during the assessment period. Another resident's MDS did not document an unhealed pressure ulcer, even though a nurse's note indicated the presence of a blister on the resident's heel shortly after returning from the hospital. Additionally, the MDS for a third resident failed to reflect the routine use of an antipsychotic medication, Seroquel, as prescribed by a physician. This discrepancy was confirmed during an interview with an administrative staff member, who acknowledged the incorrect coding of the MDS assessments for these residents. These inaccuracies in the MDS could potentially impact the development of comprehensive care plans and the care provided to the residents.
Failure to Obtain and Document Physician Orders for Catheter Care
Penalty
Summary
The facility failed to adhere to professional standards of practice regarding the management of indwelling catheters for two residents. For Resident #5, the physician orders dated June 26, 2024, included the placement of a Foley catheter, but lacked specific instructions for catheter changes, care, and maintenance. Observations during the survey confirmed the presence of the indwelling urinary catheter, and an administrative staff member acknowledged the absence of detailed care instructions in the physician orders. Similarly, for Resident #11, observations on September 16 and 17, 2024, showed the resident with an indwelling urinary catheter, yet the physician orders did not include an order for the catheter or instructions for its care and maintenance. An administrative staff member confirmed that the facility staff failed to transcribe the necessary physician orders for the indwelling catheter. These deficiencies indicate a failure to obtain and document appropriate physician orders for catheter care, which is essential for maintaining professional standards of quality care.
Medication Administration Errors Result in 16% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, as evidenced by a 16 percent error rate observed during medication administration for three out of five residents. Specifically, errors were noted in the administration of Fiasp insulin and polyethylene glycol. For Resident #25, a nurse primed the insulin pen incorrectly by leaving the needle cap on and pointing the pen down, contrary to the manufacturer's instructions. Additionally, another nurse administered insulin without priming the pen and failed to keep the needle in the skin for the recommended duration, leading to improper dosing. Further errors were observed with the administration of polyethylene glycol to Residents #9 and #17. A medication aide used insufficient water to dissolve the powdered laxative, resulting in undissolved residue remaining in the cup after administration. This was contrary to the manufacturer's instructions, which specified using four to eight ounces of liquid. These errors were confirmed by three administrative staff members during an interview, acknowledging the failure to adhere to the manufacturer's recommendations for medication administration.
Infection Control Deficiencies in Catheter Care
Penalty
Summary
The facility failed to adhere to infection control standards during catheter care for two residents, leading to potential infection risks. For Resident #5, a CNA did not don a gown or gloves before assisting with a transfer, failed to perform hand hygiene prior to donning PPE, and used a contaminated urine container in a shared bathroom sink. The resident had an indwelling urinary catheter, and the care plan indicated the need for enhanced barrier precautions (EBP), which were not followed. For Resident #11, a CNA wore a gown and gloves but did not tie the gown at the waist, causing it to fall into the workspace. The CNA changed gloves without performing hand hygiene and placed a measuring container on the floor without a barrier. The CNA also failed to rinse or cleanse the container after use. Another CNA involved in the care did not don the gown and gloves in the correct order and failed to perform hand hygiene after removing PPE. These actions violated the facility's infection control policies and procedures, as well as professional standards for PPE use.
Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision and interventions to prevent accidents for a resident identified as high risk for falls. The resident, who had cognitive loss, balance deficits, and a visual deficit, experienced multiple falls over a period from March 22 to April 10, 2024. Despite being identified as high risk, the care plan only included two interventions: educating the resident and family about safety reminders and providing a fall mat to the bedside. These interventions were insufficient, as evidenced by the resident's continued falls and subsequent injuries. The facility's policy on fall prevention and management was not effectively implemented. The policy required the completion of a Falls Tool for screening and identifying fall risk factors, updating the care plan with new interventions, and monitoring the effectiveness of these interventions. However, the facility staff failed to update the care plan with new interventions after each fall, despite the resident experiencing five falls within a short period. The documentation showed that the care plan was not updated with additional interventions, and the staff did not implement any of the suggested interventions from the facility's document titled 'Suggested Resident Interventions to Manage Falls.' The resident's falls resulted in significant injuries, including a right elbow fracture. The facility's failure to implement and monitor effective fall prevention interventions and to modify the care plan as necessary contributed to the resident's continued falls and injuries. Interviews with administrative nurses confirmed that the care plan was not updated with new interventions, highlighting a lack of adherence to the facility's fall prevention policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bottineau
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dunseith Com Nursing Home | 16.8 mi | — | 3 | 0 |
| Rolette Community Care Center | 28.9 mi | — | 11 | 1 |
| Heart Of America Care Center | 37.4 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.