Good Samaritan Society - Larimore

In the surveyor’s words

From the most serious findings on record at Good Samaritan Society - Larimore, in the surveyor’s own words.

• Immediate jeopardy, isolatedF675May 25, 2021

  Based on record review, review of the facility policy, incident report, and staff interview, the facility failed to follow the physician's order for a regular diet with cut up meat for 1 of 1 resident closed record reviewed (Resident #1). Failure to serve meat ordered by the physician resulted in Resident #1 experiencing a choking episode resulting in death. During an on-site facility incident investigation on [DATE] the survey determined a deficiency at F675. Based on the review of the results of the survey, the State Survey Agency (SSA) team determined an Immediate Jeopardy (IJ) situation existed, but this was not conveyed to the facility until [DATE]. The facility failed to follow the physician's orders for cut up meat when serving shrimp to a resident. […]

• Actual harm, isolatedF686Nov 5, 2025

  Based on record review, facility policy/procedure review, and staff interview, the facility failed to provide the necessary treatment/services to promote healing and prevent the worsening of pressure ulcers for 2 of 2 sampled residents (Residents #2 and #3) with pressure ulcers. Failure to consistently implement interventions to prevent worsening of an existing pressure ulcer and identify changes resulted in delayed treatment and deterioration of the resident's pressure ulcers. Findings Include:Review of the facility policy titled, Physician/Practitioner Orders occurred on 11/05/25. This policy, dated 04/06/25, stated, . PURPOSE: To provide individualized care to each resident by obtaining appropriate, accurate and timely physician/practitioner orders. […]

• Actual harm, isolatedF689Jul 9, 2025

  Based on record review, review of the facility reported incident (FRI), and review of facility policy, the facility failed to properly utilize assistive devices necessary to prevent accidents for 1 of 1 sampled resident (Resident #1) who fell during a staff assisted transfer. Failure to utilize the gait belt resulted in Resident #1's fall/fracture and placed all residents transferred with a gait belt at risk for injury. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident.Findings Include:The surveyor determined a deficient practice existed on 06/17/25. The facility implemented corrective action immediately and completed corrective action on 07/07/25. […]

• Actual harm, isolatedF692Feb 1, 2024

  Based on observation, record review, review of facility policy, and staff interview, the facility failed to maintain acceptable parameters of nutritional status for 1 of 2 sampled residents (Resident #81) with weight loss. Failure to routinely monitor and evaluate weights, ensure timely weight loss interventions and consistently implement them, accurately document intakes, and periodically review existing interventions and evaluate the need for updated interventions resulted in continued weight loss for Resident #81. Findings include: Review of the facility policy titled Weight and Height occurred on 02/01/24. This policy, dated 09/18/23, stated, . PURPOSE . To ensure that the resident maintains acceptable parameters of nutritional status regarding weight . […]

• Actual harm, isolatedF689Dec 21, 2022

  Based on record review, review of facility policy, and staff interview, the facility failed to provide appropriate devices to secure a wheelchair and provide sufficient supervision to prevent accidents for 1 of 1 sampled resident (Resident #1) during a van transport. Failure to safely transport a wheelchair bound resident resulted in a fall and a fracture for Resident #1 and placed all residents requiring van transportation at risk for falls and injury. Findings include: Review of the facility policy titled Abuse And Neglect occurred on 12/21/22. This policy, revised 10/13/22, stated, .Purpose . The location will have evidence that all alleged or suspected violations are thoroughly investigated. Procedure . 2. […]