LARIMORE, ND - Federal inspectors documented serious medication safety failures and food service violations at Good Samaritan Society - Larimore during a February 13, 2025 complaint investigation, with staff committing medication errors at a rate three times higher than federal standards.
Critical Medication Safety Failures Documented
The most serious violations involved dangerous medication administration practices that put residents at immediate risk. Federal standards require nursing homes to maintain medication error rates below 5%, but inspectors observed a shocking 15% error rate during their review of 26 medication administrations.
The facility's medication errors included crushing extended-release medications that should never be altered. A medication aide was observed crushing both Slow-Mag tablets and Isosorbide Mononitrate ER before mixing them with pudding for administration. Extended-release medications are specifically designed to release their active ingredients slowly over time, and crushing them can cause dangerous overdoses or make the medications completely ineffective.
Isosorbide Mononitrate ER is prescribed to prevent chest pain in cardiac patients. When crushed, the medication loses its time-release properties, potentially causing blood pressure fluctuations and cardiac complications. Similarly, Slow-Mag is a delayed-release supplement that can cause stomach irritation when its protective coating is destroyed through crushing.
Improper Insulin Administration Techniques
Nurses also demonstrated improper insulin pen preparation techniques that could lead to inaccurate dosing. Staff were observed priming insulin pens with the needle pointed downward instead of upward, violating both the facility's own policies and manufacturer instructions.
Proper insulin pen priming requires the needle to point upward to ensure any air bubbles rise to the top and are expelled. When primed incorrectly, air bubbles can remain in the medication, leading to inaccurate insulin doses. For diabetic residents, receiving too little insulin can cause dangerous blood sugar spikes, while air bubbles taking up space in the dose can result in inadequate medication delivery.
The facility's own policy clearly states that insulin pens should be primed with the needle pointing upward until "at least a drop of insulin appears." Despite having correct written procedures, staff were not following established protocols during actual medication administration.
Food Safety and Nutrition Concerns
Inspectors also identified multiple food service violations that could expose residents to foodborne illness. The kitchen's walk-in refrigerator and freezer contained numerous items that violated food safety standards, including personal medications, soft drinks, and flowers stored alongside resident food.
The walk-in freezer showed signs of poor maintenance, with condensation and ice buildup on the ceiling and floor. Food boxes were stored directly on the iced floor, creating contamination risks. Personal items in food storage areas violate FDA Food Code regulations designed to prevent cross-contamination.
Inadequate Snack Distribution System
The facility failed to ensure residents received necessary between-meal snacks, particularly problematic for diabetic residents who require regular nutrition to maintain stable blood sugar levels. Resident council meeting minutes documented ongoing complaints about inconsistent snack distribution over several months.
One diabetic resident reported that snacks were delivered to the nursing station but not distributed to residents in their rooms, stating, "This happens way too often and I'm a diabetic and I sometimes need that snack." Inspectors observed snacks sitting unattended at the nurses' station, where residents could contaminate them by touching the food.
Staffing and Qualification Issues
Additional violations included inaccurate daily staffing postings and an unqualified dietary manager. The facility's dietary manager admitted he had not completed required certification coursework, violating federal requirements for qualified food service leadership.
Federal regulations require nursing homes to post accurate daily staffing information so residents and families can see how many licensed and unlicensed staff are working each shift. The facility failed to provide accurate staffing data for all four days of the inspection.
Quality Assurance Failures
The violations indicate broader systemic problems with the facility's quality assurance processes. Federal inspectors noted the facility lacked adequate systems to identify and correct recurring problems, as evidenced by ongoing issues documented in resident council minutes.
The inspection findings reveal multiple areas where established policies existed but were not being followed in practice, suggesting inadequate staff training and supervision. The combination of medication safety failures, food service violations, and administrative oversights points to institutional challenges in maintaining federal compliance standards.
These violations collectively demonstrate the facility's failure to provide the safe, therapeutic environment required by federal regulations. The medication errors alone represent serious risks to resident health and safety, while the food service issues create additional contamination hazards in an environment serving vulnerable elderly residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society - Larimore from 2025-02-13 including all violations, facility responses, and corrective action plans.
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