Good Samaritan Society - Oakes

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Oct 15, 2025

  Based on record review, review of facility policy, staff interview, and review of a Vulnerable Adult Protective Services (VAPS) report, the facility failed to ensure residents remained free from abuse for 2 of 2 sampled residents (Resident #1 and #2) who experienced nonconsensual sexual contact. Failure to protect residents from sexual abuse placed all residents at risk for psychosocial harm, physical harm, and mental and emotional distress. This citation is considered past non-compliance based on the review of the corrective actions the facility implemented immediately following the incident. […]

• Actual harm, isolatedF689Oct 25, 2021

  Based on information received from the complainant, record review, and staff interview, the facility failed to provide the necessary assistance to prevent an injury for 1 of 1 discharged resident (Resident #2) whose wheelchair tipped backwards while being transported in the facility van. Failure of the facility to ensure staff properly secured Resident #2's wheelchair in the van resulted in the resident experiencing a widening of a C1 [cervical vertebra near base of skull] anterior arch fracture and the development of a posterior arch fracture. Findings include: The complainant alleged the facility failed to properly secure a resident in the facility van which resulted in a fall with injury during transport. […]

• No harm, potential for more than minimal, widespreadF725Oct 3, 2024

  Based on record review, confidential resident and family interviews, and staff interviews, the facility failed to provide sufficient nursing staff to meet the residents' needs for 4 of 4 confidential residents (Resident A, B, C, and D) and family members (Family member #1 and #2). Failure to provide sufficient nursing staff may result in residents experiencing falls, poor hygiene, incontinence, and skin issues and may negatively affect the residents' physical, mental, and psychosocial well-being. Findings include: - Review of Resident A's medical record occurred on 09/30/24 and identified the resident's most recent Brief Interview for Mental Status (BIMS) scored a 15, indicating intact cognition. The care plan stated, . […]

• No harm, potential for more than minimal, patternF880Oct 3, 2024

  40489 Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control practice for 4 of 12 sampled residents (Resident #17, #22, #32 and #39) and 5 supplemental residents (Resident #2, #6, #13, #21, and #31) observed during cares. Failure to follow infection control practices during resident cares related to hand hygiene, glove use, and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Standard and Transmission -Based Precautions occurred on 10/03/24. […]

• No harm, potential for more than minimal, patternF726Jul 14, 2022

  Based on observation and staff interview, the facility failed to ensure nursing staff were able to locate the necessary equipment and how to operate 2 of 3 suction machines (West Unit). Failure to ensure the suction machines were functional and equipment available placed residents at risk for choking and aspiration. Findings include: Observation on 07/12/22 at 3:36 p.m. showed a supervisory nurse (#3) and two other nurses (#4, and #9) failed to properly set-up and operate the two suction machines located on the West unit. During an interview on 07/12/22 at 3:46 p.m., a supervisory nurse (#3) verified the facility nurses failed to locate supplies and properly set-up the suction machines located on the West unit.