Staff at Good Samaritan Society - Larimore committed four medication errors while administering just 26 medications to residents during the February 10-13 inspection. The errors included crushing Isosorbide Mononitrate ER, a heart medication, and Slow-Mag, a delayed-release calcium and magnesium supplement.
On February 12 at 8:28 a.m., inspectors watched medication aide #4 dispense both tablets from Resident #2's medication card, place them in a cup with other scheduled medications, pour everything into a plastic sleeve, and crush all the medications together. The aide then mixed the crushed contents into pudding and gave it to the resident.
The facility's own policy, dated January 31, 2024, states that "some medications, such as sustained release medications among others, are not to be crushed or chewed." Drug manufacturer instructions for Slow-Mag specifically warn to "swallow the tablet whole and do not crush, chew, or break it."
Crushing extended-release medications can cause the entire dose to be released at once instead of slowly over time, potentially creating dangerous blood level spikes or rendering the medication ineffective.
The same day, a nurse made errors while preparing insulin pens for two different residents. At 11:55 a.m., nurse #3 prepared a Humalog insulin pen for Resident #4 by applying a needle, dialing the pen to two units, and dispensing the insulin into a sink with the needle pointed down.
Twenty-two minutes later, the same nurse repeated the identical error while preparing an Insulin Lispro pen for Resident #5.
The facility's insulin policy requires staff to prime insulin pens by holding them "with the needle pointing upwards" and pressing the button "until at least a drop of insulin appears." Priming with the needle pointed down can introduce air bubbles that affect dosing accuracy.
During an interview on February 13, an administrative staff member acknowledged that staff should prime insulin pens vertically and never crush delayed or extended-release medications.
Beyond medication errors, inspectors found the facility struggling with basic food service operations. Snacks sat abandoned at nursing stations instead of being delivered to residents, including diabetics who sometimes needed them to prevent low blood sugar episodes.
Resident #15, who is diabetic, told inspectors that snacks "are delivered to the nurse's station and that's where they stay, they are not delivered to residents in their rooms." The resident said this happens "way too often and I'm a diabetic and I sometimes need that snack."
Resident council meeting minutes from November 2024 through February 2025 documented ongoing complaints about inconsistent snack distribution. In November, residents noted that "evening snack pass is happening more often but still not consistently." By December, they reported that "evening snack pass is inconsistent; residents still need to ask for evening snack."
On February 11, inspectors watched the problems unfold in real time. At 3:04 p.m., snacks arrived on a cart at the nursing station. Seven minutes later, Resident #12 removed plastic wrap from a plate of snack bars and touched them while several staff members stood nearby. When another resident asked a nursing aide for a snack at 3:15 p.m., the aide had to be warned that the bars had been contaminated by the other resident's hands.
The dietary manager told inspectors his department provides snacks and places them by the nurse's station, "but we are not responsible for delivering them." Nobody else had claimed responsibility either.
The kitchen itself presented food safety hazards. The walk-in freezer had condensation and ice buildup on the ceiling and floor, with boxes of food sitting directly on the iced floor. Federal food safety guidelines require food to be stored in clean, dry locations where it won't be exposed to contamination from drips or condensation.
Inspectors found a closed medication box and an unopened bottle of cola in the walk-in refrigerator on February 10. The dietary manager acknowledged these personal items "should not be in here" since the facility has a separate employee refrigerator. Three days later, inspectors discovered six large bundles of flowers stored in the same walk-in refrigerator.
The facility's own policy prohibits storing "employee food/fluids" in the preparation kitchen cooler, freezer, or dry storage areas.
The dietary manager himself lacked proper qualifications for his position. During a February 10 interview, he admitted he was "currently enrolled in a certified dietary manager course but has not completed it." Federal regulations require dietary managers to have completed certification as a dietary manager, food service manager, or obtained national certification for food service management and safety.
Staff also failed to post accurate daily staffing information throughout the inspection period. The forms displayed in the hallway by the residents' dining room contained incorrect numbers of unlicensed staff working each shift from February 10-13. An administrative nurse and staffing scheduler confirmed the posted information was wrong.
These violations occurred at a facility that has struggled with maintaining federal compliance standards. State agency files indicated the facility had previously failed to maintain compliance, though specific details were not provided in the inspection report.
The medication errors alone affected three of the five residents observed during medication administration. For diabetic residents like #15 who depend on both proper medication dosing and timely snacks to manage blood sugar levels, the combined failures created multiple opportunities for harm.
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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