Good Samaritan Society - Oakes
GOOD SAMARITAN SOCIETY - OAKES in OAKES, ND — inspection on October 15, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
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.
Interventions: Observe interactions with female residents, specifically resident (ID number); separate residents if necessary; and provide resident with opportunities for socialization in supervised areas.A faxed request, dated 07/24/25, to Resident #2's provider stated, 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.
May we have a referral to psych [psychiatric] services? The resident's provider responded the same day and stated, referral to psychiatry. Dx: hypersexuality. Resident #2's medical record failed to show a psychiatry visit until 10/08/25, after the incident with Resident #1.Resident #2's progress note, dated 10/04/25 at 11:05 p.m., stated, At 2000 [8:00 p.m.] .this resident and [Resident #1] was found in bed with her clothes on with this resident [Resident #2] hand rubbing her inside her pull up. [Resident #2] was completely naked laying [sic] next to her in bed . [Resident #2] explained she . kissed me 3 times . [Resident #2] has touched other residents in the past but they have not been in bed together .The facility completed the following steps to remove the immediacy and correct the deficient practice:*Assessed Resident #1 and #2 for emotional and psychological distress.*Scheduled psychiatric appointments for Resident #1 and #2 for 10/08/25.*Initiated one to one (1:1) monitoring for Resident #1 when wandering and to redirect and offer a movie or snack on 10/05/25.*Initiated 15-minute checks for both Resident #1 and #2 on 10/05/25.*Updated Resident #1's care plan to reflect 1:1 monitoring, 15-minute checks, and redirection on 10/06/25.*Updated Resident #2's care plan to reflect the incident and for staff to monitor the whereabouts of both residents.*Immediate education provided to all staff working on 10/04/25 and all other staff before the start of their next shift.*Education focused on how to identify/report resident-to-resident sexual abuse and the importance of implementing procedures to ensure resident safety.
During an interview on 10/07/25 at 12:30 p.m., two administrative staff members (#1 and #2) stated Resident #1 can be flirtatious with staff and other residents and this was the first time staff witnessed the type of behavior between Resident #1 and Resident #2.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Good Samaritan Society - Oakes
213 N 9th St Oakes, ND 58474
SUMMARY STATEMENT OF DEFICIENCIES
Survey and Certification Agency . -Review of Resident #1's medical record occurred on 10/07/25.
Diagnoses included Alzheimer's disease with psychotic disturbance.
The admission Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition.-Review of Resident #2's medical record occurred on 10/07/25.
The admission MDS, dated [DATE], identified severely impaired cognition.Progress notes, dated 10/04/25, identified at 8:00 p.m. facility staff found Resident #1 in Resident #2's room fully clothed, and lying on the bed. Resident #2 was naked, straddling Resident #1, and had his hand in the resident's brief.
During an interview on 10/07/25 at 9:58 a.m., two administrative staff members (#1 and #2) confirmed the facility failed to report the sexual interaction between Resident #1 and Resident #2 to the SSA.
Facility ID: