Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 - Oakes during CMS and state inspections, most recent first.
A resident with COPD, chronic bronchitis, emphysema, and chronic respiratory failure was observed in bed on O2 with a fan blowing directly at the resident. The fan’s cover/grate and blades were covered with dust, and an administrative nurse stated staff were expected to clean fans every three days.
A resident with anxiety received PRN Hydroxyzine multiple times for generalized anxiety beyond the 14-day limit without provider reevaluation. Facility policy required PRN psychotropic orders to be limited and reviewed for continued use, but staff failed to ensure the order was properly limited and reassessed.
A nurse failed to follow facility policy when preparing and administering insulin pens for a resident receiving Lantus and Novolog. The nurse attached new needles without wiping the pen tips with alcohol, dialed the pens to 2 units while holding them horizontally, and primed them with the needle covers still on. An administrative nurse confirmed the expected practice was to clean the pen before attaching the needle and prime it with the needle upright.
A resident with an unstageable pressure ulcer to the right buttock had wound care documented in the chart, including cleansing and Mepilex use, but the current MD orders and TAR did not include those treatments. Wound assessments also lacked measurements, and staff confirmed the missing documentation and absence of an order for the wound cleanser and dressing.
A resident receiving hospice services had no hospice election form in the medical record. Review of the hospice agreement showed hospice was to provide the facility with the election form for each hospice patient, and an administrative staff member confirmed the form was missing from the record.
Staff failed to follow infection control practices during care for three residents on EBP. A CNA changed a brief for a resident with a chronic wound without wearing a gown, a nurse and CNA entered another resident’s room without hand hygiene before donning PPE, and a nurse changed wound dressings for a resident with an indwelling catheter and buttock wounds without hand hygiene after removing soiled gloves and before applying clean gloves.
Two residents with severely impaired cognition, one with a documented history of inappropriate sexual behaviors, were involved in an incident of nonconsensual sexual contact after staff failed to provide adequate monitoring and timely psychiatric intervention, despite existing care plan interventions and known behavioral risks.
Facility staff did not report an incident of nonconsensual sexual contact between two residents, both with severely impaired cognition, to the State Survey Agency as required by policy. Administrative staff confirmed the failure to report the event, which involved one resident being found naked and straddling another resident with his hand in the other's brief.
Staff did not consistently assess, measure, or document pressure ulcers for two residents, including one with peripheral vascular disease and another with a sacral ulcer, as required by facility policy. Nursing staff interviews revealed confusion about wound assessment responsibilities and frequency, and an administrative nurse confirmed that weekly assessments were not always completed.
The facility failed to provide adequate nursing staff, resulting in reduced care and services for residents. A resident reported decreased bathing frequency and discontinued restorative therapy due to staffing shortages. Another resident experienced long wait times for toileting assistance, leading to an incident of incontinence. Family members expressed concerns about the impact of staffing reductions on resident care. An administrative staff member confirmed the decrease in staff and services.
The facility failed to follow infection control practices, including the use of Enhanced Barrier Precautions (EBP) and hand hygiene. Staff did not wear gowns during high-contact care for residents with conditions like surgical wounds and osteomyelitis, despite EBP requirements. Additionally, staff neglected hand hygiene protocols, such as washing hands before donning gloves and between assisting different residents.
A resident expressed a preference to use the toilet at night instead of a bedpan, but the facility required the use of a bedpan to avoid staffing two CNAs in the area. This decision did not respect the resident's dignity and worsened their back pain, highlighting a failure to provide individualized care.
A facility failed to provide a written bed hold notice to a resident or their representative during a hospital transfer, as required by policy. The policy mandates that written information be given at the time of transfer, detailing the duration of the state bed-hold policy, the reserve bed payment policy, and the facility's policies regarding bed-hold periods. A review of the medical record revealed a lack of documentation indicating that the required notice was provided, which was confirmed by an administrative staff member.
A resident experienced a significant decline in condition after a fall, resulting in increased dependency and incontinence. Despite these changes, the facility did not complete a required significant change in status assessment (SCSA) as outlined in the RAI 3.0 User's Manual.
The facility failed to accurately code the MDS for three residents, leading to discrepancies between the MDS and medical records. One resident's MDS incorrectly indicated independence in walking and required assistance for oral hygiene, while another resident's MDS inaccurately reflected the use of an antianxiety medication instead of an antipsychotic. A third resident's MDS incorrectly showed the use of a diuretic. These errors were confirmed by staff.
A facility failed to refer a resident for dental services within the required timeframe after the resident lost their bottom denture. The facility also did not assess the resident's ability to eat and drink adequately without the denture. The resident reported the loss and suspected it might have been accidentally discarded, leading them to eat soft foods.
The facility did not post daily staffing data for all shifts on 9 of 11 days reviewed, affecting transparency about staff on duty. An administrative staff member confirmed the oversight during an interview.
Dusty Fan in Resident Room
Penalty
Summary
The facility failed to provide housekeeping services to maintain a safe, clean, comfortable, and homelike environment for one sampled resident who was receiving oxygen. Resident #4’s medical record showed diagnoses of chronic obstructive pulmonary disease with acute exacerbation, chronic bronchitis, emphysema, and chronic respiratory failure. Observations on 01/05/25 and 01/06/25 showed the resident in bed with oxygen administered via nasal cannula and a fan blowing air directly at the resident, and the fan’s cover/grate and blades were covered with dust. During an interview on 01/07/2026 at 1:00 p.m., an administrative nurse stated that staff were expected to clean fans every three days.
PRN Psychotropic Medication Not Reevaluated
Penalty
Summary
The facility failed to ensure a resident remained free from unnecessary psychotropic medication use when Resident #29 received PRN Hydroxyzine for generalized anxiety beyond the 14-day limit without reevaluation by a practitioner. The resident had a diagnosis of anxiety, and a physician’s order dated 12/08/25 prescribed Hydroxyzine 25 mg every six hours PRN. Review of the MAR showed the resident received PRN Hydroxyzine on nine occasions between 12/23/25 and 01/05/26. The facility policy on psychotropic medications stated that PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician evaluates the resident for appropriateness of the medication, and if extended beyond 14 days, the physician should document the rationale and duration. During interview, an administrative nurse confirmed staff failed to ensure the provider limited the PRN Hydroxyzine to 14 days and reevaluated it for continued use.
Improper Insulin Pen Preparation and Priming
Penalty
Summary
The facility failed to ensure staff followed standards of practice for insulin preparation and administration for Resident #40 during observation of Lantus and Novolog pen use. Facility policy titled Medicine: Insulin Administration, Insulin Pens, Insulin Pumps required the insulin pen tip to be wiped with alcohol before attaching the needle, the dosage knob to be turned to 2 units to prime the pen, and the pen to be held with the needle pointing upward while pressing the button until at least a drop of insulin appeared. During observation, a nurse applied new needles to the insulin pens without wiping the pen tips with alcohol, dialed both pens to 2 units while holding them horizontally, and primed them with the needle covers still on. An administrative nurse later confirmed that staff were expected to clean the insulin pen with alcohol before attaching the needle and to prime the pen with the needle upright.
Pressure Ulcer Treatment and Documentation Not Fully Ordered
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with an unstageable pressure ulcer to the right buttock. The resident’s record included a Response Request describing a right buttock area with a 4.8 cm by 3.6 cm wound, minimal sanguinous drainage, granulation tissue, and cleansing with wound cleanser followed by Mepilex application, and the physician agreed with that treatment without new orders. However, the current physician’s orders and TAR did not address the wound cleanser or Mepilex dressing. Wound Assessment reports documented the right buttock pressure ulcer with open area and purple discoloration, 100% granulation, minimal drainage, denuded erythematous wound margins, and later excoriation with progressive healing, repositioning/turning, incontinence protection, friction/shear management, and wound treatment. The reports also noted no wound measurements, and staff interviews confirmed the record failed to show wound measurements and that an order for the wound cleanser and Mepilex dressing had not been obtained.
Missing Hospice Election Form
Penalty
Summary
Failure to arrange for hospice services or assist the resident in transferring to a facility that would arrange hospice services was identified when record review, review of the hospice agreement, and staff interview showed that the facility did not ensure Resident #6's record contained the hospice election form. The facility's Hospice and Nursing Facility Services Agreement, dated 04/17/20, stated that hospice would provide the facility with the hospice election form for each hospice patient. Review of Resident #6's medical record on all days of survey showed election of hospice services on 12/31/25, but the record lacked the hospice election form. During an interview on 01/07/26 at 2:00 p.m., an administrative staff member confirmed that Resident #6's medical record did not include the hospice election form.
Infection Control and PPE Use During Resident Care
Penalty
Summary
The facility failed to follow infection control and prevention standards for three sampled residents during observed care. Review of facility policies showed that enhanced barrier precautions required gowns and gloves during high-contact resident care activities, including brief changes and wound care, and that hand hygiene was required before clean tasks and after glove removal. The facility also had a hand hygiene policy stating that staff should perform hand hygiene after glove removal and when moving from a contaminated body site to a clean body site during patient care. Resident #4 had a care plan indicating enhanced barrier precautions for a chronic wound, specifically a stage 2 pressure ulcer on the coccyx. During observation, a CNA changed the resident’s brief while wearing gloves but did not wear a gown. Resident #6 had enhanced barrier precautions posted on the door, and a nurse and CNA applied gowns and gloves before entering the room, but they did not perform hand hygiene before donning PPE and entering. Resident #7 had a care plan for enhanced barrier precautions related to an indwelling catheter, and during a dressing change for buttock wounds, a nurse removed soiled gloves and then applied clean gloves without performing hand hygiene.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from nonconsensual sexual contact, resulting in a deficiency related to abuse prevention. According to the report, one resident with a diagnosis of Alzheimer's disease and severely impaired cognition was found in another resident's room. The second resident, also with severely impaired cognition and a documented history of inappropriate sexual behaviors, was observed naked and straddling the first resident, with his hand inside her brief. Staff discovered the incident when a registered nurse and a certified nurse aide were searching for the first resident, who was known to wander into other rooms. Prior to the incident, the care plan for the resident with a history of inappropriate sexual behaviors included interventions such as observing interactions with female residents, separating residents if necessary, and providing supervised socialization. There was also documentation of recent increased sexualized behaviors, including exposing genitalia and fondling himself in front of staff. A request for psychiatric evaluation had been made due to these behaviors, but the psychiatric visit did not occur until after the incident. The facility's policy stated that residents must not be subjected to abuse by other residents. Despite this, the interventions in place were not sufficient to prevent the incident of nonconsensual sexual contact. The failure to implement effective monitoring and timely psychiatric intervention contributed to the occurrence of abuse between the two residents, both of whom had severely impaired cognition and were vulnerable to such incidents.
Failure to Report Resident-to-Resident Sexual Abuse
Penalty
Summary
Facility staff failed to report an incident of resident-to-resident sexual abuse to the State Survey Agency as required by facility policy. The incident involved two residents, both with severely impaired cognition as identified in their admission Minimum Data Sets. One resident with Alzheimer's disease and psychotic disturbance was found fully clothed on a bed in another resident's room, while the other resident was naked, straddling the first resident, and had his hand in the other's brief. Despite the facility's policy mandating immediate reporting of alleged or suspected abuse to designated agencies, including the State Survey and Certification Agency, administrative staff confirmed that the incident was not reported.
Failure to Consistently Assess and Document Pressure Ulcers
Penalty
Summary
Facility staff failed to provide necessary care and services for two residents with pressure ulcers by not consistently assessing, measuring, and documenting the progression of their wounds as required by facility policy. For one resident with peripheral vascular disease and a right heel pressure ulcer, staff did not measure the ulcer or consistently document wound characteristics over a period of several months. For another resident with a sacral pressure ulcer present from admission until discharge, staff failed to measure the wound at least weekly, with multiple weeks lacking any recorded measurements. Interviews with nursing staff revealed a lack of clarity regarding responsibility and frequency for wound measurement and documentation. Some nurses were unsure of the required frequency for wound assessments, and there was inconsistency in understanding whether registered nurses or licensed practical nurses should perform these tasks. An administrative nurse confirmed that staff are expected to assess and measure pressure ulcers weekly, but acknowledged that this was not always being completed.
Insufficient Staffing Leads to Reduced Care and Services
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by the experiences of four residents and their family members. Resident A, who has intact cognition and requires restorative intervention for limited mobility, reported a reduction in bathing frequency from twice to once per week and the discontinuation of restorative therapy, which was previously provided every other day. The resident expressed that these changes were due to insufficient staffing. Similarly, a family member of Resident C expressed concerns about inadequate staffing, leading to situations where the resident had to remain in soiled conditions for extended periods. Resident D, who also requires restorative intervention due to ADL self-care performance deficits, experienced a similar reduction in bathing frequency and the cessation of the restorative therapy program. A family member of Resident D confirmed that these changes were attributed to staffing shortages. Additionally, Resident B, with intact cognition and requiring toileting assistance, reported long wait times for assistance, resulting in an incident where the resident was unable to reach the bathroom in time. An administrative staff member confirmed that staffing levels were reduced, leading to decreased bathing frequency and the discontinuation of the restorative therapy program.
Infection Control Lapses in PPE and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection control practices for several residents, specifically in the use of Enhanced Barrier Precautions (EBP) and hand hygiene. Observations revealed that staff did not wear gowns during high-contact care activities for residents requiring EBP due to conditions such as surgical wounds and osteomyelitis. For instance, staff members were observed transferring residents and providing toileting care without wearing the necessary gowns, despite clear indications on the residents' doors and care plans that EBP was required. Additionally, the facility's staff did not consistently perform hand hygiene as per the facility's policy. Observations showed that staff donned gloves without completing hand hygiene upon entering residents' rooms and failed to perform hand hygiene between assisting different residents with personal care tasks, such as providing fluids. These lapses in infection control practices were acknowledged by the staff involved and were contrary to the facility's stated policies on hand hygiene and EBP.
Failure to Honor Resident's Nighttime Toileting Preferences
Penalty
Summary
The facility failed to honor a resident's right to dignity and self-determination by not accommodating their nighttime toileting preferences. The resident, who uses a sit-to-stand lift during the day and evening, expressed a preference to use the toilet at night instead of a bedpan. However, the facility required the resident to use a bedpan from 10:00 p.m. to 6:00 a.m. to avoid having two CNAs on duty in that area. The resident reported that using the bedpan exacerbated their back pain, indicating a lack of individualized care and respect for the resident's dignity and personal needs.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident or their representative during a hospital transfer, as required by their policy. The policy, dated December 7, 2023, mandates that written information be given at the time of transfer, detailing the duration of the state bed-hold policy, the reserve bed payment policy, and the facility's policies regarding bed-hold periods. A review of the medical record for Resident #35, who was transferred to a hospital on June 12, 2024, revealed a lack of documentation indicating that the required notice was provided. An administrative staff member confirmed this oversight during an interview on October 2, 2024.
Failure to Complete Significant Change in Status Assessment
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) for a resident who experienced a significant change in condition. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, a significant change is defined as a major decline or improvement in a resident's status that impacts more than one area of health and requires interdisciplinary review and care plan revision. The manual specifies that a SCSA is necessary if there are two or more areas of decline or improvement. The resident in question experienced a fall resulting in a right lower leg fracture and subsequent hospitalization, which led to a decline in their activities of daily living (ADLs). Prior to the fall, the resident was independent in ambulation and personal hygiene, among other activities, and was always continent of bowel and bladder. After the fall and hospitalization, the resident became unable to ambulate, required a wheelchair, and was frequently incontinent. They also became dependent on staff for lower body dressing and required substantial assistance with personal hygiene and other ADLs. Despite these significant changes, the facility's records did not show evidence that staff identified the need for or completed a SCSA following the resident's decline.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, which affected the accuracy of their assessments and potentially the development of their care plans. For one resident, the MDS inaccurately indicated that the resident required only setup or cleanup assistance for oral hygiene and was independent in walking, whereas the medical record showed the resident required partial/moderate assistance for these activities. This discrepancy was confirmed by an administrative staff member during the survey. Another resident's MDS incorrectly coded the use of an antianxiety medication, while the medication administration record (MAR) indicated the resident received an antipsychotic medication during the look-back period. Similarly, a third resident's MDS inaccurately reflected the use of a diuretic medication, which was not supported by the MAR. These errors were also confirmed by an administrative staff member, highlighting the facility's failure to accurately complete the MDS for these residents.
Failure to Provide Timely Dental Services for Lost Denture
Penalty
Summary
The facility failed to assist in obtaining dental services for a resident who lost their bottom denture. According to the facility's policy, a referral for dental services should occur within three days of discovering a lost or damaged denture. However, the facility did not refer the resident for dental services within this timeframe. Additionally, the facility did not assess the resident's ability to eat and drink adequately without the bottom denture. The resident reported missing the denture and expressed concern that it might have been accidentally discarded. The resident also mentioned eating soft foods due to the absence of the denture.
Failure to Post Daily Staffing Data
Penalty
Summary
The facility failed to post daily staffing data for all shifts on 9 out of 11 days reviewed, specifically from September 22 to October 2, 2024. This deficiency was identified through a review of the daily staffing information and the nursing staff schedule, which revealed that the number of staff working was not posted for nine day shifts, two evening shifts, and five night shifts. An administrative staff member confirmed during an interview on October 3, 2024, that the staffing data was not posted for each shift on some days. This failure to post accurate staffing data prevents residents and visitors from being aware of the number of licensed and unlicensed staff on duty for each shift.
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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 Oakes
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Rose Care Center | 17.7 mi | ★★★★★ | 12 | 0 |
| Four Seasons Health Care Inc | 21.7 mi | ★★★★★ | 12 | 0 |
| Prince Of Peace Care Center | 22.9 mi | ★★★★★ | 6 | 0 |
| North Dakota Veterans Home | 28.1 mi | ★★★★★ | 0 | 0 |
| Parkside Lutheran Home | 28.2 mi | ★★★★★ | 10 | 0 |
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