Good Samaritan Park River: Care Plan Failures - ND
The incident at Good Samaritan Society - Park River illustrates how outdated care plans can create dangerous gaps between what staff are supposed to do and what they actually do. Federal inspectors found the facility failed to update comprehensive care plans for at least two residents, limiting staff ability to communicate needs and ensure proper care.
On August 18 at 4:00 p.m., inspectors observed aide #3 using a sit-to-stand mechanical lift to transfer Resident #28 to the bathroom. But the resident's care plan specifically stated: "Pivot transfer with one assist using the gait belt for toileting. Transfer: Resident requires AX1 staff to stand pivot transfer with gait belt."
When questioned two days later, staff nurse #4 confirmed that Resident #28 routinely transferred using the sit-to-stand lift, not the manual method outlined in the care plan.
The facility's own policy, revised in December 2024, requires that "the plan of care will be modified to reflect the care currently required/provided for the resident." Yet Resident #28's plan remained unchanged despite the fundamental shift in transfer methods.
The disconnect between written plans and actual practice extended beyond transfer techniques. Resident #12 experienced significant weight loss that went unaddressed in their care plan.
Medical records showed the resident lost more than 10 percent of their body weight in a single month. Despite this dramatic decline, the care plan contained only generic, incomplete language: "The resident has unplanned/unexpected weight loss R/T (SPECIFY) E/B (SPECIFY) Resident will maintain weight between (SPECIFY: ______ and ______ lbs.) by review date. Weigh (SPECIFY FREQ.)."
The plan included no specific interventions to address the weight loss. No target weight range. No monitoring frequency. The template remained filled with placeholder text rather than individualized care instructions.
Federal regulations require nursing homes to develop complete care plans within seven days of comprehensive assessments, with regular reviews and revisions by healthcare teams. These plans serve as roadmaps for daily care, ensuring all staff understand each resident's specific needs and limitations.
When care plans lag behind residents' changing conditions, the consequences can be serious. Staff may use inappropriate techniques, miss critical symptoms, or fail to provide necessary interventions. In Resident #28's case, the mismatch between the written plan and actual practice suggests either the plan was dangerously outdated or staff were ignoring established protocols.
The weight loss documented for Resident #12 represents a potentially life-threatening condition in elderly nursing home residents. A 10 percent loss in one month typically signals serious underlying problems requiring immediate intervention. Yet the care plan provided no guidance for addressing the decline.
Inspectors reviewed 14 resident cases during their August investigation, finding care plan deficiencies affected at least two residents. The actual number may be higher, as the inspection focused on a sample rather than comprehensive review.
The facility's December 2024 policy update acknowledging the need to modify care plans suggests management recognized the problem. But the August violations indicate the policy changes failed to translate into practice.
Good Samaritan Society operates nursing homes across multiple states, marketing itself as a faith-based organization committed to quality care. The Park River facility's failure to maintain accurate care plans undermines that mission, creating confusion about basic care requirements.
For Resident #28, the gap between written instructions and actual practice meant staff lacked clear guidance on the safest transfer method. For Resident #12, the incomplete care plan provided no framework for addressing dangerous weight loss.
Both residents remained at the facility during the inspection, their care continuing under plans that failed to reflect their actual conditions and needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society - Park River from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
GOOD SAMARITAN SOCIETY - PARK RIVER in PARK RIVER, ND was cited for violations during a health inspection on August 21, 2025.
On August 18 at 4:00 p.m., inspectors observed aide #3 using a sit-to-stand mechanical lift to transfer Resident #28 to the bathroom.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.