Good Samaritan Society - Larimore

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide necessary care and services for 1 of 1 closed record resident (Resident #4) reviewed. Failure to assess, monitor blood pressures, and implement interventions in response to Resident #4's low blood pressure may have contributed to the resident's decline in condition.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment for 4 of 14 sampled residents (Resident #7, #10, #24, and #25) reviewed for advanced directives/code status. Failure to ensure the medical record and other forms of communication accurately reflected the code status discussed and agreed upon by the resident and/or the resident's legal representative limits the facility's ability to communicate to direct care staff and emergency personnel their wishes in the event of a medical emergency.

Inspectors wroteBased on observation, record review, review of the Resident Council meeting minutes, review of the facility bathing schedule, review of facility policy, and resident and staff interviews, the facility failed to ensure residents received the necessary services to maintain good grooming for 3 of 14 sampled residents (Residents #2, #3, and #36) and 1 supplemental resident (Resident #33) observed with unkempt hair and beards. Failure to ensure residents receive assistance with haircuts, grooming, and bathing may decrease the resident's self-esteem and quality of care.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to serve foods at a palatable temperature for 1 of 1 kitchen (tray cart to be served in parlor area). Failure to serve foods at a palatable temperature may result in decreased intake, weight loss, and inadequate nutrition.

Inspectors wroteBased on record review and staff interview, the facility failed to inform 3 of 5 sampled residents (Resident #2, #7, and #17) or their representative on the risks and benefits related to the use of psychotropic medications. Failure to inform the resident or representative of the risks and benefits of psychotropic medication does not allow them to make an informed decision regarding his/her treatment options.

Inspectors wroteBased on observation and review of the Resident Council meeting minutes, the facility failed to provide privacy and ensure dignity during personal cares for 1 of 7 sampled residents (Resident #25) observed during personal cares. Failure to maintain a resident's privacy during cares is a violation of residents' rights and may decrease the resident's self-esteem and quality of life.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide appropriate discharge planning to the resident or their representative for 1 of 2 closed records (Resident A reviewed for discharge. Failure to document the basis for Resident A's transfer and discharge in the medical record does not allow the resident and/or their representative to make informed decisions regarding their further care needs.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to notify the resident and/or representative of emergency room transfer for 1 of 5 sampled residents (Resident #9) reviewed for hospitalizations. Failure to inform the resident and/or their representative of a transfer does not allow for informed decisions regarding care.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 14 sampled residents (Resident #2 and #3). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on observation, record review, and review of facility policy, the facility failed to utilize assistive devices necessary to ensure safe transfers for 1 of 2 sampled residents (Resident #25) observed during gait belt and/or pivot transfers. Failure to utilize appropriate devices for safe transfers placed Resident #25 at risk of injury and/or falls.

Inspectors wroteBased on observation, record review, and review of facility policy, the facility failed to provide appropriate respiratory care for 1 of 2 sampled residents (Resident #25) with orders for continuous oxygen. Failure to administer oxygen according to the physician's orders resulted in Resident #25 experiencing low oxygen saturation levels (level of oxygen circulating in the blood) and may compromise the resident's respiratory status.

Inspectors wroteBased on observation and staff interview, the facility failed to post accurate and complete staffing information on 2 of 2 weekend days (March 14-15, 2026) reviewed. Failure to post accurate staffing data does not allow residents and visitors to be aware of the number of licensed and unlicensed staff on duty each shift.

Inspectors wroteBased on observation, review of professional reference, review of facility policy, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 5 residents (Resident #18 and #19) observed during medication administration. Two medication errors occurred during staff administration of 25 medications, resulting in an eight percent error rate. Failure to administer medications at the correct time may inhibit the effectiveness of the medication, cause subtherapeutic levels, and may have a negative impact on the resident's overall health.

Inspectors wroteBased on observation, review of professional reference, and staff interview, the facility failed to ensure safe and secure storage of medications and/or private health information on 1 of 1 medication cart and failed to ensure medication labels matched provider's orders for 2 of 5 residents (Resident #18 and #19) observed during medication pass. Failure to secure medications and electronic health information may result in unauthorized access and failure to ensure medication labels matched the provider's orders placed residents at risk for medication errors.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to monitor temperatures and follow safe storage practices for 1 of 3 freezer units. Failure to keep freezer temperatures at 0 degrees Fahrenheit or below and monitor freezer temperatures may increase the likelihood of food borne- illnesses.

Inspectors wroteBased on review of the facility's Quality Assurance Performance Improvement (QAPI) meeting sign in sheets, and staff interview, the facility failed to ensure all required members attended meetings at least quarterly for 2 of 4 quarters (November 2025 and February 2026) reviewed. Failure to have the medical director participate in the facility's quality assurance activities may result in an ineffective QAPI program and deprives the committee of the physician's unique contributions for analysis of quality concerns and assisting with decision making based on identified concerns.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to follow professional standards of infection control and prevention for 1 of 2 sampled residents (Resident #24) on enhanced barrier precautions (EBP) and 1 supplemental resident (Resident #22) during medication administration. Failure to practice infection control standards related to hand hygiene and glove and gown use has the potential to spread infection throughout the facility.

Inspectors wroteBased on record review, facility policy/procedure review, and staff interview, the facility failed to provide the necessary treatment/services to promote healing and prevent the worsening of pressure ulcers for 2 of 2 sampled residents (Residents #2 and #3) with pressure ulcers. Failure to consistently implement interventions to prevent worsening of an existing pressure ulcer and identify changes resulted in delayed treatment and deterioration of the resident's pressure ulcers. Findings Include:Review of the facility policy titled, Physician/Practitioner Orders occurred on 11/05/25. This policy, dated 04/06/25, stated, . PURPOSE: To provide individualized care to each resident by obtaining appropriate, accurate and timely physician/practitioner orders. To provide a procedure that facilitates the timely and accurate processing of physician/practitioner orders . POLICY: [...]

Inspectors wroteBased on record review, review of the facility reported incident (FRI), and review of facility policy, the facility failed to properly utilize assistive devices necessary to prevent accidents for 1 of 1 sampled resident (Resident #1) who fell during a staff assisted transfer. Failure to utilize the gait belt resulted in Resident #1's fall/fracture and placed all residents transferred with a gait belt at risk for injury. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings Include:The surveyor determined a deficient practice existed on 06/17/25. The facility implemented corrective action immediately and completed corrective action on 07/07/25. Review of the facility policy titled Gait Belt-Therapy & Rehab occurred on 07/09/25. [...]

Inspectors wroteBased on staff interview, the facility failed to ensure 1 of 1 dietary manager (#9) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services has the potential to result in foodborne illness to residents, staff, and visitors.

Inspectors wroteBased on review of the State Agency (SA) facility files, survey findings, and staff interview, the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) process to evaluate and identify problems and opportunities to improve services/outcomes, decrease or prevent likelihood of problems or occurrence of adverse events, and ensure compliance with federal requirements.

Inspectors wroteBased on review of employee files, review of facility policy, and staff interview, the facility failed to employ an individual who has completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control program. Failure to employ an Infection Control Preventionist (ICP) may affect all residents, staff, and visitors, placing them at risk for acquiring infectious diseases.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 4 of 12 sampled residents (Resident #3, #15, #24, and #183). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on review of resident council minutes, staffing record review, confidential resident and family interviews, and staff interview, the facility failed to provide sufficient nursing staff and related services to meet the residents' needs for 4 of 4 residents (Resident B, C, D, and E) who require staff assistance. Failure to provide sufficient nursing staff may result in residents experiencing unmet needs, poor hygiene, incontinence, and skin issues and may negatively affect the residents' physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, review of resident council minutes, and resident and staff interviews, the facility failed to provide snacks to residents within the facility. Failure to provide snacks may result in hunger, weight loss, and hypoglycemia (low blood sugar) for diabetic residents.

Inspectors wroteBased on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure food is stored in accordance with professional standards for food service sanitation in 1 of 1 kitchen. Failure to ensure food is stored, prepared, and served in a sanitary environment may result in contamination for residents, visitors, and staff.

Inspectors wroteBased on review of the facility reported incident and investigation documents, record review, policy review, and staff interview, the facility failed to protect the resident's right to be free from abuse from 1 of 1 sampled resident (Resident #10) who displayed sexual behaviors towards other residents. Failure to protect residents from sexual abuse may result in fear, anxiety, mental anguish, and physical injury.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to report incidents of resident-to-resident abuse to the State Survey Agency (SSA) for 1 of 1 sampled resident (Resident #10) who exhibited sexual behaviors. Failure to report incidents of sexual abuse may result in unwanted physical and/or sexual contact and may cause all residents to experience fear, anxiety, and psychosocial harm.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 12 sampled residents (#14, #15, and #183). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to implement a baseline care plan to fully reflect the resident's needs for 1 of 2 sampled residents (Resident #179) newly admitted to the facility. Failure to develop and implement a complete baseline care plan may result in care that is inconsistent with residents' needs.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision for 1 of 1 sampled residents (Resident #16) who smoked. Failure to ensure the resident smoked outside in the designated area and to keep cigarettes and lighters locked in a cabinet placed all residents at risk for injury.

Inspectors wroteBased on observation, record review, review of a professional reference, and staff interview, the facility failed to provide appropriate toileting for 2 of 9 sampled residents (Resident #4 and #8) who required staff assistance with toileting. Failure to provide toileting may result in a loss of dignity and placed the residents at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and fall and/or injuries.

Inspectors wroteBased on record review, policy review, and staff interviews, the facility failed to provide the care and services consistent with professional standards of practice for 1 of 1 sampled resident (#183) currently receiving dialysis. Failure to receive dialysis treatment communication may result in an unidentified change in the resident's condition.

Inspectors wroteBased on observation, record review, review of facility policy, review of professional reference, and staff interview the facility failed to ensure a medication error rate of less than five percent for 3 of 5 residents (Resident #2, #4, and #5) observed during medication administration. Four medication errors occurred during staff administration of 26 medications, resulting in a fifteen percent error rate. Failure to properly prepare and administer medications may result in residents receiving an ineffective dose and experiencing adverse reactions.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure posting of accurate staffing information on 4 of 4 days of survey (February 10-13, 2025). Failure to post accurate staffing data does not allow residents and visitors to be aware of the number of licensed and unlicensed staff on duty each shift.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to maintain acceptable parameters of nutritional status for 1 of 2 sampled residents (Resident #81) with weight loss. Failure to routinely monitor and evaluate weights, ensure timely weight loss interventions and consistently implement them, accurately document intakes, and periodically review existing interventions and evaluate the need for updated interventions resulted in continued weight loss for Resident #81.

Inspectors wroteBased on observation, record review, review of facility policy, review of resident council meeting minutes, and resident, staff and family interviews, the facility failed to ensure sufficient nursing staff and related services available at all times to meet the residents' needs for 5 of 16 sampled residents (Residents #9, #11, #12, #24, and #25) who required assistance. Failure to provide sufficient staffing may result in residents experiencing falls, poor hygiene, incontinence, and skin issues and may negatively affect the residents physical, mental, and psychosocial well-being

Inspectors wroteBased on observation, review of facility policy, review of professional reference, review of product information, and staff interview, the facility failed to store, prepare, and serve food in a sanitary manner for 1 of 1 kitchen. Failure to label, date and discard food, monitor and record sanitizing levels of the dishwashing machine, and ensure the appropriate concentration levels of sanitizer solution has the potential to affect food quality and may result in the spread of foodborne illness to residents, staff, and visitors.

Inspectors wroteBased on record review, review of the Centers for Medicare and Medicaid Services (CMS) internet Quality Improvement Evaluation System (iQIES), and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), the facility failed to electronically transmit completed Minimum Data Sets (MDSs) to iQIES for 1 of 17 sampled residents (Resident #230) and 2 supplemental residents (Resident #82 and #181). The facility also failed to transmit entry tracking within 14 days of admission for 3 of 17 sampled residents (Resident #81, #230, and #231) and 2 supplemental residents (Resident #82 and #181). Failure to follow the MDS data submission specifications does not meet the intended regulatory requirements.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise care plans for 5 of 17 sampled residents (Resident #9, #15, #80, #81, and #231). Failure to update care plans with residents' current care needs may negatively impact the care provided to residents.

Inspectors wroteBased on observation and review of facility policy, the facility failed to provide care in a manner that maintained or enhanced resident dignity for 2 of 17 sampled residents (Resident #9 and #11). Failure to provide privacy during toileting does not enhance the residents' quality of life.

Inspectors wroteBased on record review, review of facility policy, and resident interview, the facility failed to ensure residents received the necessary service to maintain personal hygiene for 1 of 16 sampled residents (Resident #12) who required staff assistance for bathing. Failure to provide assistance to residents who cannot perform the bathing task independently may result in poor hygiene, skin issues and decreased self-esteem.

Inspectors wroteBased on observation, record review, review of facility policy, and staff and resident interview, the facility failed to provide care and services to promote the healing or prevent the development of pressure ulcers for 3 of 17 sampled residents (Resident #15, #80, and #81). Failure to provide pressure relief interventions may result in the deterioration of existing pressure ulcers and/or the development of new pressure ulcers.

Inspectors wroteBased on observation, record review, review of facility policy, and staff and resident interview, the facility failed to provide appropriate and sufficient supervision and/or assistive devices for 2 of 15 sampled residents (Resident #11 and #25) observed during transfers. Failure to provide appropriate assistance and assistive devices during transfers placed the residents at risk for accidents, falls, and/or injuries.

Inspectors wroteBased on observation and record review, the facility failed to provide appropriate incontinence care for 1 of 15 sampled residents (Resident #15) who required staff assistance with toileting. Failure to provide incontinence care may result in a loss of dignity and placed residents at risk for skin breakdown and urinary tract infections (UTIs).

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to identify a history of trauma, and/or trauma triggers for 1 of 2 sampled residents (Resident #3) reviewed for Post-Traumatic Stress Disorder (PTSD) and/or Trauma. Failure to identify a resident's history of trauma and/or trauma triggers may cause re-traumatization.

Inspectors wroteBased on review of facility policy, review of the facility's nursing staff schedules, and staff interview, the facility failed to provide the services of a registered nurse (RN) for eight consecutive hours a day, seven days a week, for 2 of 92 days reviewed (10/7/23 and 10/28/23). Failure to ensure sufficient, qualified nursing staff are available eight consecutive hours a day has the potential to affect the health and safety of all residents residing in the facility. Findings Include: Review of the facility policy titled Nursing Services Staff occurred on 01/31/24. This policy, revised October 2023, stated, . The location will use the services of a registered nurse for at least eight consecutive hours a day, seven days a week . Review of the nursing schedule for the time period of 10/01/23 to 12/31/23 showed showed the facility lacked the required RN coverage on 10/07/23 and 10/28/23. [...]

Inspectors wroteBased on record review, facility policy review, and staff interview, the facility failed to ensure residents remained free from significant medication errors for 1 of 1 supplemental resident (Resident #17) reviewed who experienced a medication error. Failure to practice professional standards of medication administration resulted in Resident #17 receiving a double dose of Methadone (a narcotic analgesic), a missed dose of Lorazepam (an antianxiety medication), and an as needed (PRN) dose of Morphine Sulfate (narcotic analgesic) too early which have resulted in negative health outcomes.

Inspectors wroteBased on observation, review of facility policy, and staff interview the facility failed to ensure safe and secure storage of controlled medications for 1 of 1 medication cart. Failure to store medications securely may result in unauthorized access to medications and/or medication errors.