Good Samaritan Society - Lakota

In the surveyor’s words

From the most serious findings on record at Good Samaritan Society - Lakota, in the surveyor’s own words.

• Actual harm, isolatedF684Jun 19, 2024

  1. Based on observation, record review, review of facility policy, and staff and resident interview, the facility failed to provide care and services to maintain the resident's highest level of well-being for 1 of 1 sampled resident (Resident #30) with a change in health status followed by a transfer to the hospital. Failure to monitor and assess the resident's condition on an on-going basis resulted in worsening respiratory symptoms, a delay in treatment, and an admission to the hospital. Findings include:Review of the facility policy titled Notification of Change occurred on 06/19/24. This policy, dated 12/04/23, stated, . A facility must immediately inform the resident, consult with the resident's physician . when there is: . […]

• Actual harm, isolatedF689Oct 11, 2023

  Based on observation, record review, review of facility policy, staff interviews, and information from a complainant, the facility failed to ensure resident safety for 1 of 1 resident (Resident #1) closed record reviewed for smoking safety. Failure to ensure the safety of a resident who smoked placed the resident at risk for adverse events, serious injury, and death. Findings include: Review of the facility policy titled [Facility Name] Smoking Procedure for Residents, Employees and Visitors occurred on [DATE]. This policy dated [DATE] stated, . Smoking and tobacco use in the location is not permitted. On [DATE], all locations of the [Facility Name] implemented a procedure to establish a smoke-free environment. This policy applies to residents, employees, and location visitors. […]

• Actual harm, isolatedF578Nov 7, 2022

  Based on information provided by the complainant, record review, policy review, and staff interview, the facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment for 2 of 9 sampled residents (Resident #1 and Resident #3) and 1 closed record resident (Resident #4) reviewed for advanced directives. Failure to ensure all methods of communication and/or documentation of code status accurately reflected the resident/resident representative wishes has the potential to limit his/her access to life-sustaining services or unwanted treatment, and did result in unwanted treatment for Resident #4. […]

• No harm, potential for more than minimal, widespreadF921Jun 19, 2024

  Based on observation, review of the North Dakota Plumbing Code, and staff interview, the facility failed to provide an air gap for 1 of 1 food-preparation sink (main kitchen) observed. Failure to provide the required air gap for a food-preparation sink has the potential to allow contamination of the sink in the event of sewer back up and bacterial migration. Findings include: Review of the 2018 North Dakota Plumbing Code, Section 801.2 Air Gap, or Air Break Required, stated, Indirect waste piping shall discharge into the building drainage system through an air gap or air break as set forth in this code. […]

• No harm, potential for more than minimal, patternF725Jun 16, 2026

  Based on observation, review of facility policy, confidential resident interviews, and staff interviews, the facility failed to ensure sufficient nursing staff to meet resident needs for four confidential residents (Residents A, B, C, and D) who required staff assistance. Failure to provide sufficient staffing and answer call lights in a timely manner does not promote a resident's right to physical, mental, and psychosocial well-being.Findings include: Review of the facility policy titled call lights occurred on 06/16/26. This policy, dated July 2025, stated, . Purpose. To ensure residents always have a method of calling for assistance. To promptly answer resident's call light. When resident's call light is observed/heard go to resident's room promptly. […]