Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - Lakota during CMS and state inspections, most recent first.
Two residents with pressure ulcers did not receive adequate care as per physician's orders and facility policy. One resident had multiple pressure ulcers with inconsistent weekly assessments and measurements, while the other was observed without required heel protector boots, leading to increased ulcer size. An administrative staff member confirmed the lack of adherence to interventions and documentation requirements.
A facility failed to obtain a physician order for a resident's indwelling urinary catheter, despite the resident's history of urinary retention and recurrent UTIs. The resident returned from the hospital with a catheter, but the facility did not document an order for its use or specify the frequency of changes. An administrative staff member confirmed the lack of documentation.
The facility failed to monitor a resident's respiratory condition, leading to a hospital transfer, and did not apply a positioning device for another resident, resulting in poor posture. Additionally, the facility did not follow physician orders for a third resident's arm swelling treatment.
The facility failed to provide an air gap for the main kitchen's food-preparation sink, as required by the North Dakota Plumbing Code. This deficiency was observed when a continuous drainage pipe was found without a visible air gap, potentially allowing contamination. The environmental services director confirmed the absence of the air gap, indicating non-compliance with the code.
The facility failed to maintain food safety and sanitation standards in the main kitchen and resident nutrition center. Observations showed food items lacking date marking, discolored broccoli, and improperly stored meat products. Expired test strips were used for sanitation testing, and ice packs were stored with food. The nutrition services director confirmed the lack of compliance with policies.
A facility failed to notify a resident's physician about missed blood tests for a resident with chronic kidney disease. The resident had orders for a BMP, but staff were unable to draw blood on two occasions due to difficulty finding a vein. The facility's policy required immediate notification of the physician for significant treatment changes, but there was no documentation of such notification. An administrative nurse confirmed the missed draws and stated the provider would be notified on the next rounds.
The facility did not provide the State LTC Ombudsman with a notice of transfer for a resident reviewed for hospital transfers. The resident's medical record showed multiple hospital transfers, but there was no evidence of transfer notices being sent to the ombudsman. An administrative staff member confirmed the oversight during an interview.
The facility failed to accurately code the MDS for two residents, affecting the reflection of their current status and needs. One resident with mental health conditions was incorrectly coded in Section A1500, while two residents had inaccurate weight loss documentation in Section K. These errors could impact care planning and provision.
A facility failed to adhere to prescribed wound care orders for a resident with a stage IV pressure ulcer. The resident's care plan required specific steps, including cleansing, applying collagen powder, packing with calcium alginate, and using specific foam dressings and skin protectant. However, during an observation, a nurse did not apply the calcium alginate, 2x2 nonbordered foam, or skin protectant, deviating from the physician's orders.
The facility failed to provide appropriate G-tube care for two residents. One resident's tube feeding bag was not labeled with necessary information, and another resident continued to receive tube feeding despite a dietician's recommendation to discontinue it due to weight gain. An administrative nurse confirmed these deficiencies.
The facility failed to adhere to oxygen therapy orders and tubing protocols for three residents. One resident wore oxygen continuously at 2 lpm against orders for 1 lpm as needed, with undated tubing and no record of tubing changes. Another resident wore oxygen at 2 lpm instead of the prescribed 3 lpm at rest and 5 lpm with activity, with similar issues in tubing documentation. A third resident wore oxygen at 3 lpm continuously, contrary to orders, with undated tubing and no evidence of regular changes.
A facility failed to identify tampering with a controlled medication container for a resident. A medication aide found a tablet of Gabapentin taped into a Hydrocodone/acetaminophen container, indicating tampering. This occurred despite a policy requiring nurses to check for tampering.
The facility experienced an 8% medication error rate due to improper administration for two residents. A resident received Ipratropium-Albuterol Inhalation without necessary assessments and documentation, while another resident was given Potassium Chloride ER tablets incorrectly crushed in pudding. The errors were confirmed by administrative staff, highlighting non-compliance with medication administration protocols.
The facility failed to follow infection control standards for two residents under enhanced barrier precautions. A nurse did not wear the required PPE while handling a resident's tube feeding, and a therapy staff member assisted another resident with exercises without donning a gown and gloves. These actions were confirmed by an administrative nurse.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing or prevent the development of pressure ulcers for two residents. For the first resident, the medical record review revealed a history of urinary tract infections and clostridium difficile, with multiple pressure ulcers identified. Despite physician's orders for weekly skin assessments and specific wound care, the facility staff did not complete weekly assessments and measurements for the resident's wounds. The records showed inconsistencies in documenting wound measurements, with some assessments missing measurements entirely and others not conducted weekly as required by the facility's policy. The second resident's medical record indicated two unstageable pressure ulcers, with physician's orders for heel protection and offloading to prevent further deterioration. Observations showed the resident in a recliner without the required heel protector boots, contrary to the physician's orders. The facility staff also failed to complete weekly wound measurements for this resident, with records showing gaps in documentation and an increase in the size of the pressure ulcers over time. An interview with an administrative staff member confirmed the facility's failure to ensure interventions were followed and that the medical records lacked the necessary weekly wound measurements. This deficiency in care and documentation could potentially lead to the deterioration of existing pressure ulcers and the development of new ones, as the facility did not adhere to its own policies and physician's orders for pressure ulcer management.
Failure to Obtain Physician Order for Indwelling Catheter
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident with an indwelling urinary catheter. The resident, who had a history of urinary retention, pressure ulcers, resistance to multiple antimicrobial drugs, and recurrent urinary tract infections (UTIs), returned to the nursing home from the hospital with a catheter. Despite the presence of the catheter, the facility did not obtain a physician's order for its use or specify how often it should be changed. Progress notes indicated that the catheter was draining yellow urine and was replaced on a specific date, but there was no documented physician order for the catheter in the resident's medical record. An administrative staff member confirmed the absence of this order during an interview.
Failure to Monitor Health Changes and Follow Care Plans
Penalty
Summary
The facility failed to provide adequate care and services to maintain the highest level of well-being for Resident #30, who experienced a change in health status that led to a hospital transfer. Despite the resident's complaints of increased shortness of breath and the need for higher oxygen levels, the facility did not monitor or assess the resident's condition on an ongoing basis. The medical record showed a lack of evidence of physician notification and respiratory assessments, resulting in a delay in treatment and subsequent hospital admission. Additionally, the facility did not ensure proper care for Resident #1, who was care planned for a positioning device to prevent leaning in her wheelchair. Observations revealed that the resident was frequently seen leaning to the left without the required positioning device in place. Staff interviews confirmed that the positioning pad was supposed to be used but was not consistently applied, indicating a failure to assess and address the resident's positioning needs. Furthermore, the facility did not follow physician orders for Resident #16, who required a geri-sleeve and sling for swelling in the left arm. Observations showed that these devices were not applied as ordered, and a nurse admitted to forgetting to apply them. This oversight resulted in the facility's failure to adhere to the physician's orders, potentially impacting the resident's condition.
Lack of Air Gap in Kitchen Sink
Penalty
Summary
The facility failed to provide an air gap for the food-preparation sink in the main kitchen, as required by the 2018 North Dakota Plumbing Code. This deficiency was identified during an observation on June 17, 2024, at 10:30 a.m., where it was noted that a continuous drainage pipe passed into the wall without a visible air gap. The absence of an air gap in the food-preparation sink has the potential to allow contamination in the event of a sewer backup and bacterial migration, which is a violation of the plumbing code. The North Dakota Plumbing Code, specifically Section 801.2 and 801.3.3, mandates that food-preparation sinks must be indirectly connected to the drainage system by means of an air gap. This requirement is to ensure that there is a minimum vertical distance of not less than 1 inch from the lowest point of the indirect waste pipe to the flood-level rim of the receptor. During an interview on the same day, the environmental services director confirmed the lack of an air gap, highlighting the facility's non-compliance with the plumbing code.
Food Safety and Sanitation Deficiencies in Kitchen and Nutrition Center
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards in both the main kitchen and the resident nutrition center. Observations revealed multiple instances of food items lacking proper date marking, including individual servings of mandarin oranges, a large container of blended shredded cheese, and various other food items such as lemon lime juice, Italian dressing, and picante sauce. Additionally, discolored broccoli was found, and several packages of meat products in the walk-in freezer were not sealed or dated. A section of pipe in the freezer was covered with ice, dripping water onto a box of food below, causing water damage and ice accumulation. The ice and water dispenser panel was also found to be covered in mineralization and debris. Expired test strips were used for testing cleanser solutions and chlorine levels in the dishwasher, compromising the effectiveness of sanitation procedures. In the resident nutrition center, several food items, including cheddar cheese dip, pizza rolls, and ice cream, were found without open dates. Ice packs were improperly stored with food items, which was confirmed by an administrative staff member. The nutrition services director acknowledged the lack of date marking and stated that staff are expected to follow policy and procedures.
Failure to Notify Physician of Missed Blood Tests
Penalty
Summary
The facility failed to notify a resident's physician of a change in condition, specifically missed blood tests, for a resident with chronic kidney disease. The resident had physician orders for a basic metabolic panel (BMP) on two occasions, which were not completed due to unsuccessful blood draws. Despite several staff attempts, they were unable to find a vein in the resident's upper extremities. The facility's policy required immediate notification of the physician when there is a need to alter treatment significantly, but the medical record lacked documentation of such notification. An administrative nurse confirmed the missed blood draws and stated that the provider would be notified on the next rounds.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to provide the State Long Term Care Ombudsman with a notice of transfer for a resident who was reviewed for hospital transfers. This deficiency was identified through a record review and staff interview. The resident's medical record showed hospital transfers on three separate occasions, but there was no evidence that the facility provided the ombudsman with copies of the transfer notices. An administrative staff member confirmed during an interview that the facility did not send the notices to the ombudsman prior to the survey date.
Inaccurate MDS Coding for Mental Health and Weight Loss
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, which is essential for reflecting their current status and needs. For one resident, diagnosed with schizoaffective disorder, bipolar type, generalized anxiety disorder, and personality disorder, the facility incorrectly coded Section A1500 of the MDS. Despite a PASRR Level II Outcome indicating a mental health condition, the MDS inaccurately recorded a 'no' response regarding the resident's serious mental illness status. This error was confirmed by a social services staff member during an interview. Additionally, the facility inaccurately documented weight loss for two residents in Section K of the MDS. For one resident, a significant change MDS indicated weight loss, but the records did not support a 5% or more weight loss in 30 days or a 10% or more weight loss in 180 days. Similarly, another resident's quarterly MDS noted weight loss without evidence of the specified percentage loss in the records. These inaccuracies in the MDS coding could potentially impact the development of comprehensive care plans and the care provided to the residents.
Failure to Follow Wound Care Orders for Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate treatment and services for the healing of pressure ulcers for one resident with a current pressure ulcer. The resident had a healing stage IV pressure ulcer on the coccyx, with specific physician's orders for wound care that included cleansing the wound, applying collagen powder, packing with calcium alginate, covering with specific foam dressings, and applying skin protectant. During an observation, a nurse did not follow these orders completely, as they only cleansed the wound with saline spray, applied collagen powder, and covered it with a 4x4 bordered dressing, omitting the calcium alginate, 2x2 nonbordered foam, and skin protectant. This deviation from the prescribed wound care regimen was identified during the survey.
Deficiencies in G-tube Care and Communication
Penalty
Summary
The facility failed to ensure appropriate gastrostomy tube (G-tube) care and services for two residents, leading to deficiencies in their care. For one resident, the facility did not label the tube feeding bag with necessary identifying information such as the type of formula, date, time, or nurse's initials. This resident was observed with an empty tube feeding bag connected, with formula still visible in the tubing, indicating a lack of proper labeling and monitoring. An administrative nurse confirmed that the expectation was for all tube feeding bags to be labeled with at least the date and time, which was not adhered to in this case. For another resident, the facility failed to communicate and implement the dietician's recommendations regarding tube feedings. Despite a dietician's note advising the discontinuation of nighttime tube feeding due to continued weight gain, the facility continued to administer the tube feeding as per the previous orders. This resident was observed to have G-tube feeding bags and a pump in their room, and staff confirmed the continuation of tube feeding at night, contrary to the dietician's updated recommendations. An administrative nurse acknowledged the failure to discontinue the feeding as recommended.
Failure to Adhere to Oxygen Therapy Orders and Tubing Protocols
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards and the residents' plans of care for three residents receiving oxygen therapy. Resident #2 was observed wearing oxygen via nasal cannula at 2 liters per minute (lpm) continuously, despite physician orders specifying 1 lpm as needed for specific conditions. Additionally, the oxygen tubing was undated, and there was no evidence in the medication administration record (MAR) of regular tubing changes. Resident #15 was observed wearing oxygen at 2 lpm, contrary to physician orders for 3 lpm at rest and 5 lpm with activity. The tubing was also undated, and the MAR lacked documentation of tubing changes. Resident #30 was observed wearing oxygen continuously at 3 lpm, although the physician's orders specified no oxygen at rest and 1 lpm with exertion. The resident reported needing more oxygen recently and wearing it at all times. The oxygen tubing was undated, and the MAR did not show evidence of tubing changes. An administrative nurse acknowledged the need to clarify the residents' oxygen orders and expected staff to change the oxygen tubing weekly.
Failure to Recognize Tampered Medication Container
Penalty
Summary
The facility failed to recognize tampering with a controlled medication container for a resident. During an observation, a medication aide discovered that one of the 16 tablets of Hydrocodone/acetaminophen, an opioid pain medication, was different from the others and taped into the container. An administrative nurse identified the tablet as Gabapentin, a non-opioid pain medication, confirming that the medication card had been tampered with. This incident occurred despite the facility's policy requiring on-coming nurses to physically examine controlled medication containers for evidence of tampering, such as open packages or medications that look different from others.
Medication Administration Errors Result in 8% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an 8% error rate during medication administration for two residents. For Resident #136, a medication aide administered Ipratropium-Albuterol Inhalation without completing the required pre and post-assessment, and failed to document vital signs and the total time spent with the resident, as per the physician's orders. This oversight was confirmed by an administrative nurse, indicating non-compliance with the facility's medication administration policy. For Resident #7, a medication aide incorrectly crushed and administered Potassium Chloride ER tablets in pudding, contrary to the proper method of dissolving the tablets in water or juice. The medical record lacked specific instructions on how to administer this medication, leading to the error. An administrative staff member confirmed the incorrect administration and the absence of detailed orders, contributing to the medication error.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control standards for two residents under enhanced barrier precautions. Resident #27, who had a tube feeding order, was observed with a sign on the door indicating enhanced barrier precautions. However, a nurse added water to the resident's tube feeding bag, flushed the line, and disconnected the tube feeding without wearing the required gown and gloves. This was confirmed by an administrative nurse during an interview, who stated that staff are expected to wear PPE for tube feedings. Similarly, Resident #31 was also under enhanced barrier precautions, as indicated by a sign on the door. A therapy staff member entered the room and assisted the resident with therapy exercises without donning the necessary gown and gloves. This was also confirmed by an administrative nurse, who acknowledged that therapy staff should wear gowns and gloves when working with residents under enhanced barrier precautions.
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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 Lakota
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nelson County Health System Care Center | 20.7 mi | ★★★★★ | 2 | 0 |
| Eventide Heartland | 23.4 mi | ★★★★★ | 10 | 0 |
| Aneta Parkview Health Ctr | 30.3 mi | ★★★★★ | 1 | 0 |
| Good Samaritan Society - Park River | 33.5 mi | ★★★★★ | 20 | 0 |
| Good Samaritan Society - Larimore | 35.1 mi | — | 28 | 0 |
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