LARIMORE, ND - Federal health inspectors determined that Good Samaritan Society - Larimore failed to provide appropriate pressure ulcer care and prevent new pressure ulcers from developing, resulting in documented actual harm to at least one resident. The findings, issued on November 5, 2025, came during a complaint investigation that examined the facility's wound care practices under federal regulatory tag F0686.
The citation carried a Scope/Severity Level G rating, indicating isolated incidents of actual harm that did not rise to the level of immediate jeopardy. The facility submitted a plan of correction and reported the deficiency addressed as of November 21, 2025.
Complaint Investigation Reveals Wound Care Deficiencies
The complaint-based survey at the Larimore facility focused specifically on pressure ulcer prevention and treatment — one of the most closely monitored areas in nursing home regulation. Under federal standards, long-term care facilities are required to ensure that residents who are admitted without pressure ulcers do not develop them unless clinically unavoidable, and that residents who arrive with existing pressure ulcers receive treatment and services to promote healing, prevent infection, and prevent the development of additional wounds.
Good Samaritan Society - Larimore was found deficient in meeting these requirements. The deficiency fell under the Quality of Life and Care Deficiencies category, which encompasses standards directly tied to resident health outcomes and day-to-day clinical care.
Federal tag F0686 specifically requires facilities to base pressure ulcer interventions on a resident's comprehensive assessment, ensure consistent implementation of care plans, monitor wound status regularly, and revise approaches when healing does not progress as expected. A citation under this tag indicates that inspectors found breakdowns in one or more of these essential clinical processes.
Understanding Pressure Ulcers and Their Medical Significance
Pressure ulcers — also referred to as pressure injuries, bedsores, or decubitus ulcers — are localized areas of tissue damage that develop when sustained pressure restricts blood flow to the skin and underlying tissue. They most commonly occur over bony prominences such as the sacrum, heels, hips, and shoulder blades, particularly among individuals with limited mobility.
These wounds are classified across a staging system that ranges from Stage 1 (intact skin with non-blanchable redness) through Stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle). Additional categories include unstageable wounds and deep tissue pressure injuries. Each stage carries progressively greater risks of complications.
Pressure ulcers are far more than surface-level skin conditions. They represent a systemic threat to vulnerable residents. Open wounds serve as entry points for bacterial infections, including cellulitis, osteomyelitis (bone infection), and sepsis — a life-threatening systemic inflammatory response. For elderly nursing home residents who often have compromised immune systems, diabetes, cardiovascular disease, or nutritional deficiencies, even a Stage 2 pressure ulcer can escalate rapidly without proper intervention.
The pain associated with pressure ulcers is also significant. Advanced wounds can cause persistent, severe discomfort that interferes with sleep, appetite, mobility, and overall quality of life. Chronic wound pain frequently leads to decreased participation in rehabilitation activities, further compounding the mobility limitations that contributed to wound development in the first place.
What Appropriate Pressure Ulcer Care Requires
Federal regulations and established clinical guidelines set clear expectations for pressure ulcer prevention and management in long-term care settings. Appropriate care involves multiple coordinated interventions that must be tailored to each resident's individual risk factors and clinical status.
Risk Assessment: Upon admission and at regular intervals thereafter, facilities must conduct standardized pressure ulcer risk assessments using validated tools such as the Braden Scale. These assessments evaluate factors including sensory perception, moisture exposure, activity level, mobility, nutrition, and friction or shear forces. Residents identified as high-risk require immediate implementation of preventive measures.
Repositioning Protocols: One of the most fundamental prevention strategies involves regular repositioning of residents who cannot independently change positions. Clinical standards typically call for repositioning at least every two hours for bed-bound residents and every hour for those seated in wheelchairs. Proper repositioning technique includes using support surfaces, pillows, and foam wedges to offload pressure from vulnerable areas.
Nutrition and Hydration: Adequate nutritional intake plays a critical role in both preventing pressure ulcers and supporting wound healing. Protein, calories, vitamins (particularly Vitamin C and zinc), and adequate hydration are essential components. Facilities are expected to identify residents with nutritional deficits and implement dietary interventions, including nutritional supplements when appropriate.
Skin Inspection and Monitoring: Routine skin assessments — conducted during bathing, repositioning, and other care activities — allow clinical staff to identify early signs of pressure-related tissue damage before wounds progress. Early identification of Stage 1 pressure injuries enables prompt intervention that can prevent progression to more serious stages.
Wound Treatment: When pressure ulcers do develop, facilities must implement evidence-based wound care protocols. This includes appropriate wound cleansing, selection of moisture-retentive dressings suited to wound characteristics, infection management, pain control, and ongoing monitoring of wound dimensions and healing trajectory. Care plans must be revised when wounds fail to show expected improvement.
Support Surfaces: Specialized pressure-redistribution mattresses, overlays, and cushions are standard components of both prevention and treatment programs. These devices are designed to distribute body weight more evenly and reduce sustained pressure on vulnerable tissue.
A citation for failing to meet F0686 standards indicates that one or more of these clinical processes was not adequately implemented, documented, or monitored — resulting in measurable harm to the resident.
The Significance of a Severity Level G Citation
The Scope/Severity Level G designation assigned to this deficiency provides important context about the nature and extent of the findings. The Centers for Medicare & Medicaid Services (CMS) uses a grid system that combines scope (how many residents were affected) with severity (the degree of harm) to classify deficiencies.
Level G indicates an isolated deficiency — meaning the problem affected a limited number of residents rather than representing a facility-wide pattern — that resulted in actual harm. This places the citation in the middle tier of the severity scale, above Level D (isolated, potential for more than minimal harm) but below Level J (isolated, immediate jeopardy to resident health or safety).
An "actual harm" determination means that inspectors found evidence that the deficient practice directly caused negative health consequences for the affected resident. This is distinct from citations where only a potential for harm is identified. Federal inspectors documented that the failure to provide appropriate pressure ulcer care produced measurable adverse outcomes.
While a Level G citation does not trigger the most severe enforcement responses — such as immediate imposition of civil monetary penalties or denial of payment for new admissions — it does carry regulatory consequences. Facilities cited at this level must submit a credible plan of correction, and the deficiency becomes part of the facility's public inspection record.
Facility Response and Corrective Action
Good Samaritan Society - Larimore submitted a plan of correction following the November 5 survey and reported that corrective measures were implemented as of November 21, 2025 — sixteen days after the citation was issued. While the specific corrective actions taken by the facility are detailed in the full plan of correction available through CMS records, typical responses to F0686 citations include staff retraining on wound assessment and prevention protocols, revision of individual care plans, implementation of enhanced monitoring systems, and audits of wound care documentation and outcomes.
Good Samaritan Society is a national nonprofit organization affiliated with the Evangelical Lutheran Church in America that operates senior care facilities across multiple states. The Larimore location is part of this broader network of long-term care and senior housing communities.
Broader Context: Pressure Ulcers in Long-Term Care
Pressure ulcer prevention remains one of the most persistent challenges in nursing home care. According to CMS data, F0686 is consistently among the most frequently cited deficiency tags during federal nursing home surveys nationwide. The prevalence of pressure ulcer citations reflects both the clinical complexity of prevention in high-risk populations and the resource demands of consistent implementation of prevention protocols.
Staffing levels play a significant role in pressure ulcer outcomes. Adequate numbers of trained nursing staff are necessary to carry out the frequent repositioning, skin inspections, nutritional monitoring, and wound care that effective prevention and treatment programs require. Facilities with lower staffing ratios face greater challenges in maintaining the consistent, around-the-clock attention that pressure ulcer prevention demands.
The financial and human costs of pressure ulcers in long-term care are substantial. Treatment of advanced pressure ulcers can require extended courses of wound care, antibiotic therapy, surgical intervention, and in severe cases, hospitalization. For residents, the development of a preventable pressure ulcer represents a significant decline in health status and quality of life.
How to Review the Full Inspection Report
The complete survey findings, including detailed documentation of the deficiency and the facility's plan of correction, are available through the CMS Care Compare website and through NursingHomeNews.org's facility profile for Good Samaritan Society - Larimore. These records provide additional detail about the specific circumstances identified during the complaint investigation.
Families and advocates reviewing nursing home inspection reports should pay particular attention to the scope, severity, and pattern of citations over time. A single deficiency may reflect an isolated incident, while recurring citations in the same regulatory area — particularly wound care — can indicate deeper systemic issues with clinical staffing, training, or 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.
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