Good Samaritan Society - Larimore
GOOD SAMARITAN SOCIETY - LARIMORE in LARIMORE, ND — inspection on November 5, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the provider visit note failed to include reference of any skin issues or pressure ulcers.*10/08/25 .
Pressure ulcer to Sacrum/buttocks .
Comments: Fax sent to Dr. [name] wit [sic] wound updated to obtain order for wound clinic VA [veterans administration] referral . *10/11/25 at 5:40 p.m.
Health Status .
Late Entry: [entered into the electronic medical record on 10/24/25 at 12:18 p.m.] .
Received order to refer resident to VA for wound care.
Order entered and left voicemail for social worker to schedule appointment.*10/18/25 Wound name .
Unstageable pressure ulcer to buttock/Sacrum area .
Length 6.7 cm .
Width 6 cm .
Comments: resident encouraged to reposition self .*10/20/25 . unstageable p/u [pressure ulcer] with tunneling to Sacrum area. Is there drainage leaking around the dressing? Yes.
Describe the condition of tissue surrounding the dressing: macerated [soft and draining due to moisture exposure] and reddened. Is there a presence of possible complications .? Yes .
Describe: increasing drainage, odor, slough [shedding of dead tissue], and necrotic [dead] tissues and tunneling .
Describe dressing .
Calcium alginate [an absorbent dressing] and Mepilex .
Comments: Resident sent to . ER [emergency room] via ambulance .An emergency room note, dated 10/20/25, identified Resident #3 presented with ulcers and pain.
The resident was hospitalized with a stage 4 (the most severe type of pressure ulcer involving deep tissue damage, exposing muscle, tendon, or bone) pressure injury of the buttocks and acute cellulitis (bacterial skin infection that affects the deeper layers of the skin).During an interview on 11/5/25 at 4:00 p.m., an administrative staff member (#1) confirmed nursing staff failed to follow up with the requests for Resident #3's wound clinic referrals sent to the provider on 10/2/25 and 10/8/25, confirmed the provider failed to evaluate the resident's wound on 10/07/25, confirmed there were nine days between Resident #3's wound clinic referral order and coordination of the referral, and the medical record lacked documentation of repositioning.
The facility failed to implement a repositioning schedule and ensure wound care follow up in a timely manner which resulted in deterioration of Resident #3's pressure ulcers.
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