Good Samaritan Society Oakes: Abuse Reporting Failures - ND
The October 4 incident occurred at 8:00 p.m. when staff discovered Resident #2 naked beside the clothed female resident, "hand rubbing her inside her pull up," according to a progress note written that night. The male resident told staff the woman "kissed me 3 times."
Federal inspectors found the facility had received clear warning signs for six weeks before the incident but failed to provide adequate supervision or timely psychiatric intervention.
On July 24, administrators had faxed an urgent request to Resident #2's medical provider describing escalating sexual behaviors: "Resident has been exposing genitalia to female staff, lying on bed fully undressed during night & day hours. Will cover himself when told to but exposes himself again. This started about 1 1/2 weeks ago."
The facility requested a psychiatric referral that same day. The provider responded immediately, writing "referral to psychiatry" and diagnosing hypersexuality.
Despite the urgent request and immediate approval, inspection records show Resident #2 never saw a psychiatrist until October 8 — four days after he was found in bed with the female resident and more than ten weeks after the facility first sought help.
During those intervening weeks, administrators documented additional concerning incidents. Resident #2 continued exposing his genitals to staff and fondling himself in front of employees. He also "interlocked arms and touched the abdomen area of a female resident."
The facility's care plan noted specific interventions were needed: "Observe interactions with female residents, specifically resident [ID number]; separate residents if necessary; and provide resident with opportunities for socialization in supervised areas."
But the October 4 progress note revealed those precautions had failed. It stated that while Resident #2 "has touched other residents in the past," staff had never before found residents "in bed together."
Two administrative staff members told inspectors on October 7 that Resident #1 "can be flirtatious with staff and other residents" but claimed this was "the first time staff witnessed the type of behavior between Resident #1 and Resident #2."
Federal inspectors classified the violations as immediate jeopardy to resident health and safety, the most serious category of nursing home deficiency.
Only after the bed incident did administrators implement comprehensive monitoring. On October 5, they initiated one-to-one supervision for Resident #1 when she wandered, with staff instructed to redirect her attention and offer movies or snacks. Both residents received 15-minute safety checks.
The facility updated care plans on October 6 to reflect the new monitoring requirements. Resident #1's plan now included one-to-one supervision, 15-minute checks, and redirection protocols. Resident #2's plan was revised to document the incident and require staff to monitor both residents' whereabouts.
Administrators also conducted immediate education for all staff working October 4, with additional training provided to other employees before their next shifts. The education focused on identifying and reporting resident-to-resident sexual abuse and implementing safety procedures.
The facility assessed both residents for emotional and psychological distress following the incident. Psychiatric appointments were scheduled for both residents on October 8.
Federal regulations require nursing homes to ensure residents are free from sexual abuse and to provide immediate intervention when concerning behaviors are identified. The inspection found Good Samaritan Society - Oakes failed on both counts.
The delay between the July psychiatric referral request and the October appointment meant Resident #2 went nearly three months without professional evaluation for diagnosed hypersexuality. During that period, his documented behaviors escalated from exposing himself to staff to physical contact with female residents.
The facility's acknowledgment that Resident #2 had "touched other residents in the past" raised additional questions about the adequacy of previous interventions and supervision.
Resident #1's characterization as "flirtatious" appeared in administrative interviews after she was found as the apparent victim of unwanted sexual contact. The inspection report did not indicate whether administrators considered her cognitive capacity to consent or her vulnerability to exploitation.
The October 4 progress note described finding Resident #2 "completely naked laying next to her in bed" with his hand inside the female resident's undergarment. The note indicated this level of intimate contact was unprecedented, despite the male resident's documented history of inappropriate touching.
The timing of the incident — occurring during evening hours when staffing levels are typically reduced — highlighted potential gaps in the facility's supervision protocols. The inspection did not detail how long the residents had been together before discovery or what circumstances allowed the encounter.
Federal inspectors found the facility's response adequate to remove immediate jeopardy once the incident was discovered. The implementation of one-to-one monitoring for the vulnerable female resident and 15-minute checks for both residents addressed the supervision failures that had enabled the sexual contact.
However, the inspection revealed systemic problems in the facility's handling of escalating behavioral concerns. The six-week delay between requesting psychiatric services and the actual appointment demonstrated inadequate follow-through on critical resident safety measures.
The mandatory staff education on identifying and reporting sexual abuse, conducted only after the bed incident, suggested previous training had been insufficient to prevent the escalation from exhibitionist behavior to physical contact between residents.
Good Samaritan Society - Oakes operates as part of a larger network of senior care facilities. The inspection findings indicated failures at the local level in implementing timely interventions for residents with documented sexual behavioral issues.
The case illustrated broader challenges nursing homes face in managing residents with dementia-related sexual disinhibition while protecting vulnerable residents from unwanted contact. The facility's initial recognition of the problem, evidenced by the July psychiatric referral request, was undermined by the failure to ensure timely professional intervention.
Both residents remained at the facility following the incident, with enhanced monitoring protocols designed to prevent future inappropriate contact while preserving their right to appropriate social interaction within the nursing home community.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society - Oakes from 2025-10-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
GOOD SAMARITAN SOCIETY - OAKES in OAKES, ND was cited for abuse-related violations during a health inspection on October 15, 2025.
The October 4 incident occurred at 8:00 p.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.