Gaps in infection-prevention and control practices
Insufficient clinical escalation processes leading to hospital transfers
Management follow-through and accountability gaps
Temperature-regulation issues in some resident areas
Variable staffing reliability and workload distribution
Summary of reviews
Reviewers present a mixed view of care quality at this facility. On the positive side, families and visitors frequently highlight compassionate, attentive nursing assistants and capable licensed nursing personnel who provide supportive day-to-day care. The activities program is described as engaging, and the physical environment is generally characterized as well maintained and welcoming. Several reviewers singled out individual caregivers for strong, person-centered interactions, which contributes to an overall sense of a caring staff culture in many areas of the building.
At the same time, multiple accounts point to operational shortcomings that affect resident safety and comfort. A recurrent theme is delayed response to call lights and inconsistent timeliness of assistance, which reviewers link to staffing patterns and workload. Concerns about staff conduct and the tone of communication were also raised, suggesting variability in how staff interact with residents and families. Infection-prevention practices were another area of concern, with at least one reference to an MRSA infection; reviewers described this alongside related hospital transfers, indicating possible gaps in clinical monitoring and escalation protocols.
Facility-level systems and leadership receive mixed evaluations. Some families perceive a lack of consistent management follow-through when issues are raised, which can amplify concerns about clinical and operational problems. Temperature control in certain wards was mentioned as uncomfortable for residents, indicating uneven environmental management. Despite these issues, frontline caregivers are often described as helpful, and positive staff–resident relationships were a counterbalance to operational weaknesses.
Dining was not a prominent focus in the available summaries; general comments about good service suggest that routine meal service may be acceptable to some families, but there is limited detail to form a firm conclusion. Activities are consistently cited as a strength and appear to provide meaningful engagement for residents.
For prospective residents and families, the pattern suggests that quality may vary by unit and by individual staff assignment. Important topics to address on a visit or intake conversation include current staffing levels and scheduling, average call-light response times, infection-prevention protocols and recent infection history, procedures for clinical escalation and hospital transfer, management complaint-resolution processes, and temperature control in resident areas. Meeting direct-care staff and nursing leadership during a tour may help assess whether the facility’s strengths align with a prospective resident’s needs.
Reviews written on Mirador
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Medicare Ratings
1·/ 5
Overall
Health Inspection
Staffing
Quality Measures
Cited by CMS for abuse, or potential for abuse, on its most recent survey cycle.
Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov
Location
Good Samaritan Society - Oakes is located at 213 9th St N, Oakes, ND, 58474.
About Good Samaritan Society - Oakes
Good Samaritan Society - Oakes sits at 213 N 9th St in Oakes, North Dakota, and has been serving the community since 1972 with a focus on seniors and people needing compassionate care, and while folks can find all sorts of services there, such as skilled nursing, assisted living, home health, memory care, and continuing care retirement, it's really meant for those needing help with daily living activities, and you'll see they offer meals so residents don't have to worry about cooking, activities for staying active and social, and indoor spaces where people gather, as well as outdoor spots like a peaceful courtyard with a gazebo and garden, and for therapy needs they've got both inpatient and outpatient rehab, including physical, occupational, speech therapies, and even tube feeding, and they work with hospice needs too. The facility's got 52 certified nursing beds and usually cares for about 41 residents per day, with both single and semi-private rooms, plus studios and different room options, but there aren't any assisted living or basic care beds, and the entire operation is non-profit and connected with the larger Good Samaritan Society and Providence Health & Services networks, with ownership by Sanford and the Evangelical Lutheran Good Samaritan Society. Staff are there 24 hours and can help with things like moving from bed to wheelchair, diabetes insulin monitoring, and emergencies, though it's worth mentioning the nursing staff hours fall below the state average, at 3.53 nurse hours per resident daily, and there's a 40.4% nurse turnover rate, which actually stands better than the state's average turnover rate. Residents pay through private pay, Social Security, Veteran's benefits, or private insurance, depending on what works for them, but there are community, respite, buy-in, and care level fees. For deficiencies, inspection reports document a total of 16, including issues with assessment during significant condition changes, nursing staff coverage, and infection control, with two infection-related deficiencies found, so even as the community strives to serve, challenges have shown up, and those looking might want to keep this in mind. Everything happens in a homelike, welcoming environment, and staff speak English, though sometimes other languages may be spoken, and residents can access information about mental health and substance use disorders, though details about services for that are limited. The community accepts Medicare and Medicaid, remains certified for both, and you'll find details like a monthly updated provider directory and a location map, but right now, the facility isn't accepting new patients, and office hours aren't available, giving a need to check back if making plans.
People often ask...
Good Samaritan Society - Oakes offers assisted living, memory care, and skilled nursing.
There are 4 photos of Good Samaritan Society - Oakes on Mirador.
The full address for this community is 213 9th St N, Oakes, ND 58474.
No, Good Samaritan Society - Oakes does not offer respite care.
Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.
Safety & Compliance
In North Dakota, Health & Human Services' Health Facilities unit licenses care facilities and publishes the health and life-safety deficiencies found during inspections.
License number
SNF-good-samaritan-society-oakes-oakes
Facility type
Skilled Nursing Facility
Inspection Reports
41
Reports
2
Type A Citations
0
Type B Citations
0
Complaints
16
Years
12 Jan 2026Life Safety
12 Jan 2026Life Safety
Identified fire-safety and sprinkler maintenance deficiencies, including a door not latching in a fire barrier between the garage and nursing area, missing self-closing hardware on hazardous-area doors, and outdated sprinkler system maintenance.
NFPA 101 9.7.5, 9.7.7, 9.7.8; NFPA 25Sprinkler System - Maintenance and Testing
07 Jan 2026Inspection
07 Jan 2026Inspection
Investigated multiple deficiencies across environment safety, medication management, wound care, hospice documentation, and infection control, including unsafe fan cleanliness, PRN psychotropic limits not followed, improper insulin pen priming, missing wound measurements and treatments, missing hospice election form, and lapses in hand hygiene and PPE.
CFR 483.10(e)(1); 483.12(a)(2); 483.45(c)(3)(d)(e)Right to be Free from Chemical Restraints
§483.21(b)(3)(i)Services Provided Meet Professional Standards
§483.25(b)(1)(i)(ii)Treatment/Svcs to Prevent/Heal Pressure Ulcer
§483.70(n)(1)-(4)Hospice Services
§483.80Infection Prevention & Control
15 Oct 2025Inspection
15 Oct 2025Inspection
Investigated a complaint alleging resident-to-resident sexual abuse and a failure to report to authorities. Found two residents experienced nonconsensual sexual contact and the incident was not reported to the State Survey Agency as required.
§483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
§483.12(b)(5)(i)(A)(B)(c)(1)(4); §483.12(c)Reporting of Alleged Violations
07 Jul 2025Inspection
07 Jul 2025Inspection
Investigated found lapses in wound assessment and documentation for residents with pressure ulcers.
CFR 483.25(b)Pressure ulcers: Treatment to prevent/heal; skin integrity
08 Jan 2025Inspection
08 Jan 2025Inspection
Investigated a facility-reported incident and found no deficiencies.
08 Oct 2024Life Safety
08 Oct 2024Life Safety
Found deficiencies in exit signage, fire drills, and emergency power system maintenance during a recertification survey.
NFPA 99; NFPA 110Electrical Systems - Essential Electric System
03 Oct 2024Inspection
03 Oct 2024Inspection
Multiple deficiencies identified across resident rights, assessments, staffing, dental services, and infection control with several requirements not met.
CFR 483.10(a)Resident Rights/Exercise of Rights
CFR 483.15(d)Notice of Bed Hold Policy Before/Upon Transfer
CFR 483.20(b)(2)(ii)Comprehensive Assessment After Significant Change
CFR 483.20(g)Accuracy of Assessments
CFR 483.35(a)(1)(2)Sufficient Nursing Staff
CFR 483.35(g)(1)-(4)Posted Nurse Staffing Information
CFR 483.55(b)Routine/Emergency Dental Services in NF
CFR 483.80(a)-(f)Infection Prevention & Control
04 Jan 2024Inspection
04 Jan 2024Inspection
Investigated the complaint and found inadequate supervision linked to resident falls, with missing hourly rounding documentation for at least one resident.
CFR 483.25(d)Free of Accident Hazards/Supervision/Devices
20 Sept 2023Inspection
20 Sept 2023Inspection
Found no deficiencies during the complaint investigation; the provider was in compliance with regulatory requirements.
19 Sept 2023Life Safety
19 Sept 2023Life Safety
Identified multiple life-safety deficiencies related to means of egress, emergency lighting, hazardous areas enclosure, fire drills, and emergency power testing.
NFPA 101, 2012 Edition; 19.2.3.4; 19.2.3.5; 7.1.10.1; ADA Standards for Accessible DesignAisle, Corridor, or Ramp Width
NFPA 101, 2012 Edition; 19.3.2.1; 19.3.5.9; 19.3.2.1Hazardous Areas - Enclosure
NFPA 101, 2012 Edition; 19.7.1.4 through 19.7.1.7Fire Drills
NFPA 99; NFPA 110; NFPA 111; NFPA 70; NFPA 70Electrical Systems - Essential Electric System
25 Apr 2023Inspection
25 Apr 2023Inspection
Verified compliance with infection control regulations during a focused COVID-19 infection control survey conducted on 2023-04-25.
01 Aug 2022Life Safety
01 Aug 2022Life Safety
Identified deficiencies in maintaining the fire alarm system and emergency generator, including missing itemized test documentation and lack of weekly generator inspections and load testing.
NFPA 101: 9.6.1.3; NFPA 70; NFPA 72Fire Alarm System - Testing and Maintenance
NFPA 99; NFPA 110; NFPA 70Electrical Systems - Essential Electric System
14 Jul 2022Inspection
14 Jul 2022Inspection
Found deficiencies across assessments, care planning, medication administration, infection control, elopement prevention, and equipment management.
CFR 483.20(g)Accuracy of Assessments
CFR 483.21(b)(2)(i)-(iii)Care Plan Timing and Revision
CFR 483.21(b)(3)Services Provided Meet Professional Standards
CFR 483.35Competent Nursing Staff
CFR 483.40Treatment/Service for Dementia
CFR 483.45Label/Store Drugs and Biologicals
CFR 483.80Infection Prevention & Control
25 Oct 2021Inspection
25 Oct 2021Inspection
Investigated a complaint alleging a resident was injured when their wheelchair tipped backwards in the van due to inadequate securing; identified failures in transport safety and communication.
CFR 483.25(d)Free of Accident Hazards/Supervision/Devices
20 Apr 2021Life Safety
20 Apr 2021Life Safety
Identified multiple fire-safety deficiencies, including improper manual actuation height for the kitchen hood extinguisher, lack of documented fire-alarm testing, and noncompliant placement of portable extinguishers.
NFPA 70; NFPA 72; 9.6.1.3; 9.6.1.5Fire Alarm System - Testing and Maintenance
NFPA 10; 6.1.3.8.1-3; 9.7.4.1; 19.3.5.12Portable Fire Extinguishers
14 Apr 2021Inspection
14 Apr 2021Inspection
Investigated deficiencies in nutrition/hydration maintenance, infection prevention/control, and vaccination education/consent. Failures were found in weight monitoring, isolation practices, and obtaining vaccine education/consent.
42 CFR 483.25(g)(1)-(3)Nutrition/Hydration Status Maintenance
42 CFR 483.80(a)Infection Prevention & Control
42 CFR 483.80(d)Influenza and Pneumococcal Immunizations
18 Nov 2020Inspection
18 Nov 2020Inspection
Found to be in compliance with COVID-19 infection control requirements during a focused infection control survey, with one COVID-positive resident reported.
28 Oct 2020Inspection
28 Oct 2020Inspection
Identified COVID-19 infection control deficiencies, including failure to screen visitors at entry and to cohort COVID-19 positive residents appropriately.
Verified compliance with infection control requirements for COVID-19 and noted one resident with COVID-19.
17 Mar 2020Inspection
17 Mar 2020Inspection
Found no deficiencies. Infection control practices during the focus inspection were in compliance with applicable regulations.
18 Jul 2019Inspection
18 Jul 2019Inspection
Found failures in care planning, hearing aid management, safe transfers, and oxygen administration affecting multiple residents.
CFR 483.21(b)(2)-(iii)Care Plan Timing and Revision
CFR 483.24(a)-(b) (1)-(5), (i)-(iii)Activities Daily Living (ADLs)/Maintenance Abilities
CFR 483.25(d)Free of Accident Hazards/Supervision/Devices
CFR 483.25(i)Respiratory Care and Suctioning
14 May 2019Life Safety
14 May 2019Life Safety
Identified deficiencies in electrical safety (missing GFCI protection on multiple receptacles) and in fire drill procedures (no emergency phone-call simulation).
NFPA 70; NFPA 101Ground-fault protection and electrical receptacle standards
NFPA 101; 19.7.1.4-19.7.1.7Fire drills
11 Jul 2018Inspection
11 Jul 2018Inspection
Identified multiple deficiencies across notification of changes, PASARR coordination, respiratory care, unnecessary medications, medication administration, resident records, infection control, and essential equipment maintenance.
§483.10(g)(14)-(15)Notify of Changes
§483.20(e)(1)-(2)Coordination of PASARR and Assessments
§483.25(i)Respiratory care, including tracheostomy care and tracheal suctioning
§483.45(d)Unnecessary Drugs-General
§483.45(f)(2)Residents are Free from Unnecessary Drugs
§483.20(f)(5), §483.70(i)(1)-(5)Resident Records - Identifiable Information
§483.80(a)(1)-(4), §483.80(e), §483.80(f)Infection Prevention & Control
Found that fire-rated door assemblies were not inspected or tested as required, leaving opening protections unverified and increasing fire risk.
NFPA 80; 7.2.1.15.2Fire-rated door assemblies inspection/testing
24 May 2017Inspection
24 May 2017Inspection
Identified multiple deficiencies across resident rights, safety, assessments, care planning, medication safety, and infection control, including improper notices, inadequate restraint assessments, incomplete investigations, and lapses in infection prevention and control.
42 CFR 483.10(g)(4)NOTICE OF RIGHTS, RULES, SERVICES, CHARGES
42 CFR 483.10(g)(14)NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)
42 CFR 483.10(e)(1); 42 CFR 483.12(a)(2)RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS
Identified multiple life-safety deficiencies across egress locks, emergency lighting, fire alarm and smoke detector systems, sprinklers, fire drills, risk assessment, and generator testing.
18.2.2.2, 19.2.2.2, TIA 12-4Patient sleeping room doors—locks
7.9.3; 18.2.9.1; 19.2.9.1Emergency lighting—testing and duration
9.7.5, 9.7.7, 9.7.8, NFPA 72, 19.3.4.1Fire alarm system—testing and maintenance
19.3.4.5; 9.6.2.10.1.1; NFPA 72Smoke detection—maintenance and placement
19.3.5.3; 19.3.5.4; 9.7; 9.7.1.1(1); NFPA 13Sprinkler system installation
NFPA 25; 13.2.7.1; 13.3.2.1.1; 9.7.5, 9.7.7, 9.7.8Sprinkler system maintenance and testing
18.7.1.4 - 18.7.1.7; 19.7.1.4 - 19.7.1.7Fire drills on each shift
An on-site review identified multiple deficiencies: residents faced verbal/mental abuse by a peer without adequate safeguards, and several failures in assessments, care planning, medication timing, environmental safety, infection control, and medication storage.
483.13(b), 483.13(c)(1)(i)FREE FROM ABUSE/INVOLUNTARY SECLUSION
483.20(b)(2)(ii)COMPREHENSIVE ASSESS AFTER SIGNIFICANT CHANGE
Identified multiple fire-safety deficiencies, including hazardous-area doors not self-closing, missing third-shift fire drill, and incomplete fire alarm battery testing.
NFPA 101 Life Safety Code 19.3.2.1Hazardous areas safeguarded with self-closing doors
NFPA 101 Life Safety Code 19.7.1.2, 18.7.1.2Fire drills conducted quarterly on each shift
Investigated and identified multiple deficiencies across medication management, care planning, infection control, abuse reporting, and quality assurance, including safety of self-administered meds, inaccurate assessments and care plans, inadequate infection control, and improper staffing practices.
483.10(n)RESIDENT SELF-ADMINISTER DRUGS IF DEEMED SAFE
Identified multiple life safety deficiencies related to fire drills, fire alarm and smoke detector maintenance, sprinkler system maintenance, portable extinguisher inspections, and generator readiness. Found several required inspections were not performed on time.
NFPA 101 Life Safety Code, 19.7.1.2Fire drills not conducted quarterly on each shift
NFPA 72 7-3.2Fire alarm system not tested per NFPA 72 load voltage testing
NFPA 72 7-1.1.2; 9.6.1.3Smoke detectors not maintained/tested per manufacturer specifications
NFPA 25 2-3.2; NFPA 25 9-4.2.1Automatic sprinkler system not continuously maintained
NFPA 10 4-3.1Portable fire extinguishers not inspected as required
NFPA 110 3-5.5.6; NFPA 110 6-3.6; NFPA 110 6-4.2Emergency generator not in compliance with NFPA 110
12 Nov 2014Inspection
12 Nov 2014Inspection
An investigation found that a resident's injury was not reported promptly and not properly investigated, with insufficient documentation of bruising and subsequent follow-up.
—Injury reporting and investigation
02 Jul 2014Inspection
02 Jul 2014Inspection
Investigation found deficiencies in how residents were engaged and cared for, including insufficient individualized activities and related planning.
—
04 Jun 2014Life Safety
04 Jun 2014Life Safety
Found multiple deficiencies related to life-safety systems, including sprinkler coverage gaps, hazardous-area separation, and deficiencies in oxygen/gas storage and electrical/generator maintenance.
NFPA 101 Life Safety Code; NFPA 99; NFPA 13Hazardous areas separation and sprinkler system coverage
NFPA 13; NFPA 99Storage/schedule and sprinkler head spacing; corrective actions
NFPA 99; NFPA 4; NFPA 70Oxygen storage and related piping; weekly generator-related duties
NFPA 99; NFPA 70; NFPA 72Emergency power and load testing
NFPA 99; NFPA 70Electrical equipment and generator inspections/test records
24 Jul 2013Inspection
24 Jul 2013Inspection
Investigated several deficiencies in resident care including lack of dignity in dining assistance, inadequate nutrition/feeding practices, safety concerns with equipment, and insufficient staff training and competency.
483.15(a)Dignity and Respect of Individuality
483.25(d)(1)-(2)Pressure ulcers prevention / Nutrition and appearance
—Medication management / continued interventions
483.25(d)(1)-(2)Nutrition / Pureed foods
Life Safety from FireLife Safety from Fire
483.151-483.154Training/Competency
25 Jun 2013Life Safety
25 Jun 2013Life Safety
Investigated a complaint and found multiple life-safety and maintenance deficiencies, including doors not self-closing, holes in walls and ceilings, inadequate smoke detector testing, and unsafe electrical practices and generator maintenance.
NFPA 101 Life Safety Code StandardSelf-closing doors and separation of hazardous areas
NFPA 101 Life Safety Code StandardSmoke detectors and NFPA 72 testing
NFPA 101 Life Safety Code StandardElectrical wiring and equipment
NFPA 110 Standard for Emergency and Standby Power SystemsEmergency generator maintenance program
NFPA 101 Life Safety Code StandardSmoke detectors and life safety systems
NFPA 101 Life Safety Code StandardElectrical wiring and equipment—power strips
25 Jul 2012Inspection
25 Jul 2012Inspection
Regulatory findings showed failures to follow physician orders for resident care (TED hose), medication administration errors, and inadequate infection-control practices.
483.25 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEINGProvide care/services for highest well being
483.25 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEINGProvide care/services for highest well being
483.25(m)(1) FREE OF MEDICATION ERROR RATES OF 5% OR MOREFree of medication error rates of 5% or more
Investigated fire safety practices and found that key fire drills and alarm testing were not properly coordinated or documented after silent drills.
NFPA 101 Life Safety Code 9.6.1.4; NFPA 70/NFPA 72Life Safety Code fire drills and fire alarm testing/maintenance
10 Oct 2011Inspection
10 Oct 2011Inspection
Investigation identified several deficiencies in resident care, including failure to investigate injuries of unknown origin, inadequate meal assistance, gaps in diabetes monitoring, and improper drug storage and labeling.
—Injury of unknown origin not investigated
—Failure to provide necessary meal assistance
—Diabetes care and glucose monitoring deficiencies
An investigation found deficiencies including resident-to-resident abuse and problems with resident grievances, memory-related care concerns, and documentation gaps.
Type A—Right to prompt grievances resolution
Type A—Freedom from abuse by other residents
26 Jul 2010Life Safety
26 Jul 2010Life Safety
Concluded no deficiencies and found compliance with life safety standards.
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