Good Samaritan Larimore: Pressure Ulcer Failures - ND
The resident developed deep tissue injuries on both buttocks by September 25. Within a week, the wounds had progressed to open pressure ulcers measuring 4 centimeters by 3.5 centimeters with drainage leaking around dressings.
By October 2, nursing staff documented purulent drainage, blackening tissue, and a malodorous smell. They contacted the doctor's office about wound complications and awaited orders.
The situation deteriorated rapidly. On October 4, the bilateral wounds had merged into one sacral ulcer measuring 9 centimeters by 8 centimeters. Staff noted the ulcer had "progressed and size increased from last assessment" and updated the doctor on the worsening condition.
Three days later, the physician visited the resident at bedside. But the provider's visit note contained no reference to skin issues or pressure ulcers, despite the gaping wound on the resident's body.
Nursing staff faxed wound updates to the doctor on October 8, requesting orders for a Veterans Administration wound clinic referral. The facility didn't receive those orders until October 11 — three days later. Even then, staff waited until October 24 to enter the late documentation into the medical record, acknowledging they had left a voicemail for the social worker to schedule the appointment.
Nine days passed between the wound clinic referral order and any coordination efforts.
The resident's condition continued declining. By October 18, the pressure ulcer measured 6.7 centimeters by 6 centimeters and had become "unstageable" — meaning the extent of tissue damage couldn't be determined due to dead tissue covering the wound base.
Two days later, the wound showed signs of tunneling beneath the skin. Drainage leaked around dressings, surrounding tissue had become soft and reddened from moisture exposure, and staff documented "increasing drainage, odor, slough, and necrotic tissues."
The resident was sent to the emergency room by ambulance on October 20.
Hospital records show the resident arrived with ulcers and pain. Doctors diagnosed a stage 4 pressure injury of the buttocks — the most severe classification involving deep tissue damage that exposes muscle, tendon, or bone. The resident also developed acute cellulitis, a bacterial skin infection affecting deeper skin layers.
Stage 4 pressure ulcers represent complete destruction of skin and underlying tissue. They often require surgical intervention and carry significant risks of life-threatening complications.
During the November 5 inspection interview, an administrative staff member confirmed multiple failures in the resident's care. Nursing staff had not followed up on wound clinic referrals sent to the provider on October 2 and October 8. The physician had failed to evaluate the resident's deteriorating wound during the October 7 bedside visit.
The administrator also acknowledged nine days had elapsed between receiving the wound clinic referral order and coordinating the actual referral. Medical records lacked documentation showing staff had repositioned the resident to relieve pressure on the wounds.
Pressure ulcers develop when sustained pressure restricts blood flow to tissue. Regular repositioning every two hours is a fundamental prevention strategy. Without documented repositioning, the resident remained at constant risk for further tissue breakdown.
The facility's failure to implement a repositioning schedule and ensure timely wound care follow-up directly contributed to the resident's deteriorating condition. What began as deep tissue injuries in September had progressed to a stage 4 ulcer requiring emergency hospitalization by October.
Federal inspectors determined the facility caused actual harm to the resident through these care failures. The case illustrates how delayed medical responses and inadequate wound management can transform treatable conditions into life-threatening emergencies.
The resident's journey from initial skin breakdown to emergency hospitalization took less than a month — a timeline that highlights how quickly pressure ulcers can progress without proper intervention and medical oversight.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society - Larimore from 2025-11-05 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 - LARIMORE in LARIMORE, ND was cited for violations during a health inspection on November 5, 2025.
The resident developed deep tissue injuries on both buttocks by September 25.
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.