Good Samaritan Society Oakes: Immediate Jeopardy - ND
The October 4 incident at Good Samaritan Society-Oakes triggered an immediate jeopardy citation from federal inspectors, who found the facility failed to protect vulnerable residents despite clear warning signs dating back to July.
Staff discovered the assault at 8:00 p.m. during routine rounds. The male resident, identified as Resident #2 in the inspection report, was "completely naked laying next to her in bed" with his "hand rubbing her inside her pull up," according to nursing notes. The female victim, Resident #1, was found clothed.
The male resident told staff the woman "kissed me 3 times" during the encounter.
For months before the assault, facility staff documented a pattern of sexual misconduct by the male resident. He regularly exposed his genitals to female staff members and "fondled himself in front of staff." He also "interlocked arms and touched the abdomen area of a female resident" in separate incidents.
The facility's own care plan, created before the assault, specifically warned that the resident exhibited "behaviors such as exposing his genitals to staff, fondling himself in front of staff, and interlocked arms and touched the abdomen area of a female resident."
Staff were instructed to "observe interactions with female residents" and "separate residents if necessary." They failed to do so.
On July 24, more than two months before the assault, facility administrators sent an urgent fax to the resident's medical provider describing the escalating behavior. "Resident has been exposing genitalia to female staff, lying on bed fully undressed during night & day hours," the request stated. "Will cover himself when told to but exposes himself again. This started about 1 1/2 weeks ago."
The facility requested a psychiatric referral, writing: "May we have a referral to psych services?"
The provider responded the same day with a diagnosis of "hypersexuality" and approved the psychiatric referral. But the resident never saw a psychiatrist until October 8 — four days after the sexual assault and only after federal inspectors arrived at the facility.
The delay left both residents vulnerable for more than two months.
Nursing notes revealed this was not the first time the male resident had inappropriately touched other residents. Staff wrote that "this resident has touched other residents in the past but they have not been in bed together."
The facility's response to the escalating behavior was inadequate. Their care plan called for staff to "provide resident with opportunities for socialization in supervised areas," but inspectors found no evidence of increased supervision or protective measures.
Two facility administrators told inspectors during interviews that the female resident "can be flirtatious with staff and other residents." They claimed the October 4 incident was "the first time staff witnessed the type of behavior between" the two residents.
But the inspection record contradicts their account. The male resident had been exhibiting sexual misconduct for months, and staff had documented his inappropriate touching of other female residents.
Only after the assault did the facility implement basic safety measures. They began one-on-one monitoring for the female victim when she wandered the halls and started 15-minute safety checks for both residents.
Staff received emergency training on October 5 about "how to identify/report resident-to-resident sexual abuse and the importance of implementing procedures to ensure resident safety" — training that should have occurred months earlier when the warning signs first appeared.
The facility also scheduled psychiatric appointments for both residents, finally following through on the July referral request.
Federal inspectors found the facility's failures constituted immediate jeopardy to resident health and safety, the most serious citation level possible. The designation means inspectors believed residents faced imminent risk of serious injury, harm, impairment, or death.
The citation affects "few" residents according to the inspection report, but the consequences for the victims were severe. Both residents required assessment for "emotional and psychological distress" following the assault.
The female resident now requires constant supervision when moving through the facility, a significant restriction on her freedom that could have been prevented with proper oversight months earlier.
The male resident's hypersexuality diagnosis was established in July, but he received no psychiatric treatment until after he sexually assaulted another resident. The three-month delay in mental health intervention left him without proper medication or behavioral therapy that might have prevented the assault.
Inspection records show the facility knew about the risks but failed to act decisively. They requested help, received medical authorization, but then allowed a vulnerable resident to remain untreated while he escalated from exposing himself to staff to sexually assaulting another resident.
The case highlights broader problems in nursing home oversight of residents with sexual behavioral issues. Facilities often struggle to balance residents' rights with safety concerns, but federal regulations require immediate action when residents pose risks to others.
Good Samaritan Society operates nursing homes in multiple states and markets itself as providing "the highest quality of life" for residents. The Oakes facility's handling of this case fell far short of that promise.
The assault occurred despite clear documentation, medical diagnosis, and specific care plan instructions. Staff had the tools and knowledge to prevent the incident but failed to implement basic protective measures.
Both residents now live with the consequences of the facility's inadequate response to obvious warning signs that escalated over months into a sexual assault that federal inspectors determined could have been prevented.
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 immediate jeopardy violations during a health inspection on October 15, 2025.
Staff discovered the assault 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.