Good Samaritan Society - Oakes

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - Oakes

213 N 9th St Oakes, ND 58474

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, review of facility policy, and staff interview, the facility failed to report an incident of resident-to-resident sexual abuse to the State Survey Agency (SSA) for 2 of 2 sampled residents (Resident #1 and #2) who experienced nonconsensual sexual contact. Failure to report incidents of abuse may result

in unwanted physical and/or sexual contact, fear, anxiety, and psychosocial harm. Findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation Policy occurred on 10/07/25. This policy, dated April 2025 stated, Purpose: To ensure that employees are knowledgeable regarding the reporting and investigative process of abuse and neglect allegations . Notification procedures: Alleged or suspected violations involving . abuse . will be reported immediately to . Designated agencies . including the State 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 REDACTED], identified severely impaired cognition.-Review of Resident #2's medical record occurred on 10/07/25. The admission MDS, dated [DATE REDACTED], 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.

Event ID:

Facility ID:

If continuation sheet