Average — CMS composite of the measures below.
The next survey window likely opens around July 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - Pipestone during CMS and state inspections, most recent first.
Bare-hand food handling and poor hand hygiene were observed during meal prep and service. A cook measured salt with her bare hand, returned noodles from the counter to the pan with her hand, and later plated and served noodles while repeatedly touching food with bare hands after leaving the steamtable area and opening a drawer. The CDM stated bare-hand contact with food was not acceptable and staff were expected to use utensils and proper hand hygiene.
A resident with intact cognition and diagnoses including renal dialysis dependence, type 2 DM, and insomnia was prescribed clonazepam and temazepam, but the medical record lacked evidence of informed consent for either psychotropic medication. The DON was unable to locate signed consent, and stated that residents admitted on psychotropic meds needed a consent form signed on admission day.
A resident with Medicare Part A skilled services remaining was given a NOMNC, but the facility did not provide the required SNF-ABN showing the estimated cost if the resident chose to continue services privately. The DON said she believed the SNF-ABN was unnecessary because the resident had Medicaid pending and only issued the NOMNC.
Failure to Monitor Controlled Narcotics in E-kit: The facility failed to monitor controlled narcotic medications in an E-kit stored in a med cart. RN-A stated the plastic numbered tag on the E-kit was not checked daily or documented, and both RN-A and TMA-A said there would be no way to know if the kit had been opened and narcotics removed until the kit was accessed for needed meds. The E-kit contained controlled meds including tramadol, hydrocodone/APAP, lorazepam, and morphine solution, and the DON stated staff should have been monitoring the tag number.
QAPI minutes showed an ongoing PIP for pressure ulcers, but the facility did not document clear interventions, data analysis, or a plan showing how it would reach its stated goals. The minutes contained inconsistent pressure ulcer entries, blank or incomplete PIP sections, and separate short-stay and long-stay references without explanation. The DON confirmed the facility had no documented analysis of the PIP and no laid-out plan for how the project would be carried out.
A resident with moderately impaired cognition and a recent hospitalization for pneumonitis due to aspiration returned with a physician order for an IDDSI Level 5 minced and moist diet with slightly thick liquids. Despite updated care plan and diet notification specifying minced and moist texture, direct supervision, and assisted-side seating, the resident was served a tuna melt on a regular bun with sweet potato tots instead of the ordered minced and moist meal. The cook believed a soggy bun met minced and moist criteria, and an NA, unaware of the new diet order, delivered the meal after the cook prepared and the NA cut the sandwich. During the meal, dietary staff observed the resident eating the sandwich, then making abnormal breathing sounds, turning gray, and actively choking; an LPN found the resident cyanotic and not breathing, performed the Heimlich maneuver multiple times, and the resident was transferred to the ED, where large pieces of bread and cheese and a food bolus were documented. The DON later clarified that the LPN had not verified the diet texture against the physician order and had relied on the cook’s assurance that the meal was correct, contributing to the failure to provide the ordered texture-modified diet.
The facility did not consistently document the resolution of staff illnesses before allowing them to return to work, and failed to ensure a newly hired dietary aide completed the required two-step TB testing. These lapses in infection control and employee health monitoring had the potential to affect all residents.
A resident with a history of acute respiratory failure and hypoxia returned from the hospital with new physician orders for oxygen therapy, but the care plan and medical records were not updated to reflect the revised flow rates. Staff continued to administer oxygen at higher rates than ordered, did not verify the actual flow rate against the updated order, and failed to document the amount of oxygen administered as required. The facility's policy lacked guidance on documentation, and the administrator was unaware of the order change.
A resident with a history of acute respiratory failure and hypoxia received oxygen therapy at incorrect flow rates, as staff failed to follow the most recent physician order and did not update the care plan or MAR. Observations showed oxygen was administered at 3 L/min instead of the ordered 1-2 L/min during the day and 2 L/min at night, and staff did not verify or document the actual flow rate as required.
A resident receiving oxygen therapy did not have their physician orders accurately reconciled or updated in the electronic medical record after returning from the hospital. Staff continued to administer oxygen at a flow rate inconsistent with both the previous and updated orders, and documentation in the care plan and MAR was not revised to reflect the new instructions. Staff did not verify the correct flow rate, and the facility lacked a policy for reconciling physician orders.
A resident was prescribed Bactrim for a UTI following an outpatient visit and completed the antibiotic course without adverse effects. However, the facility did not perform a required antibiotic time-out (ATO) within 48-72 hours after starting the medication, as outlined by CDC guidelines and facility policy. The DON confirmed the omission, noting that the antibiotic was not initiated by facility staff, but acknowledged the responsibility for antibiotic stewardship.
A resident with multiple chronic conditions, including diabetes, heart failure, and pneumonia, consented to receive an updated pneumococcal vaccine but did not receive it. Nursing staff and the DON confirmed the vaccine was not administered, despite facility policy and CDC guidelines requiring it.
Bare-Hand Food Handling During Meal Service
Penalty
Summary
Food handling infection control practices were not followed during meal preparation and service for the noon meal. During observation, cook-A was seen placing prepared food on the steam table, then opening a cabinet, removing a saltshaker, and shaking salt into her bare hand before dumping it into the cooking noodles. When questioned, she stated she had measured the salt to add to the noodles and said that was how she always did it. She then set the pot into the sink, prepared a fresh pot of noodles, and placed them on the steam table. As noodles fell onto the counter while being poured into the steamtable pan, cook-A used her bare hand to toss them back into the pan. At no time during these tasks did she perform hand hygiene or put on gloves. Later in the meal service, cook-A washed her hands, picked up meal slips, identified resident meals, and began plating food. She used a slotted spoon to scoop noodles onto plates, then left the steamtable area, opened a drawer with her bare hand, removed a green-handled scoop spoon, and returned to plating without performing hand hygiene or donning gloves. While serving multiple plates, she repeatedly used her bare hand to scoop noodles hanging off the side of the plates back onto the plates before sending them to the dining room. In interview, cook-A stated she did not realize she had done that and acknowledged she should have used a scoop instead of her hand. The CDM stated touching food with bare hands was not acceptable and that staff were expected to use utensils and appropriate hand hygiene practices. The IP stated all departments were expected to follow appropriate infection control practices by utilizing hand hygiene.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent, including risk and benefit information, for one resident who was reviewed for psychotropic medications. The resident had intact cognition on the comprehensive MDS, was admitted with diagnoses including dependence on renal dialysis, type 2 diabetes, and insomnia, and was prescribed clonazepam 1 mg by mouth daily on Monday, Wednesday, and Friday for dialysis days, as well as temazepam 30 mg by mouth at bedtime. The medical record did not contain evidence of informed consents for either medication, and the DON attempted to locate signed consent without success. During interview, the DON stated that any resident admitted with a psychotropic medication in use needed a consent form signed for that medication on admission day. The facility policy stated that a consent form must be signed for use of an antipsychotic medication and that the Permission for use of Psychotropic Medications form would be used to obtain consent.
Failure to Provide SNF-ABN for Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) to 1 of 3 sampled residents, R1, when Medicare Part A skilled services had days remaining. R1's CMS-10123 Notice of Medicare Non-Coverage (NOMNC) showed that services ended on 7/17/26, but R1 was not given the CMS-10055 SNF-ABN identifying the estimated cost of services if she chose to continue skilled services on her own. During an interview on 8/4/26 at 10:30 a.m., the DON stated she had taken over providing beneficiary notices after a recent staffing change and believed the CMS-10055 was not needed because R1 had Medicaid pending, so only the CMS-10123 notice was provided. The facility's 5/12/26 ABN policy stated the ABN informs the beneficiary of potential non-coverage and the shift of financial liability if Medicare denies the claim.
Failure to Monitor Controlled Narcotics in E-kit
Penalty
Summary
The facility failed to monitor controlled narcotic medications in 1 of 1 emergency kits (E-kits) to prevent potential diversion. During observation and interview, the E-kit was found stored in the medication cart, with a small plastic E-kit box inside a locked box on the cart containing controlled narcotic medications. RN-A stated the nurses did not monitor the plastic numbered tag on the E-kits daily, and the tag was not documented anywhere to confirm the correct tag remained in place. Both TMA-A and RN-A stated there would be no way to know if someone had opened the E-kit and removed narcotics until the nurse accessed it for needed medication, and RN-A acknowledged the kit and the smaller box were not opened regularly, so medication could be missing for quite some time before anyone would notice. Review of the E-kit medication list showed controlled narcotics including Tramadol 50 mg, Hydrocodone/APAP 5/325 mg, Lorazepam 0.5 mg, and Morphine solution 20 mg/ml. The DON stated staff should have been monitoring the number on the plastic tag of the E-kit and the E-kit located inside the locked box on the medication cart, and a policy on monitoring controlled narcotic medications was requested but not provided.
QAPI PIP for Pressure Ulcers Lacked Documented Interventions and Analysis
Penalty
Summary
The facility failed to provide evidence of a required Performance Improvement Project (PIP) focused on pressure ulcers, despite multiple QAPI meeting minutes showing the topic was discussed over time. The minutes reviewed showed changing pressure ulcer goals and data entries, including a goal to reduce pressure ulcers to at or below 2%, later a goal of zero new facility-acquired pressure ulcers, and later a PIP listing pressure ulcers at 10.6% with national and state comparisons of 5.7% and 6.1%. However, the minutes did not include identified interventions, analysis of current facility practices, resident data explaining the increase, or documentation showing how the facility planned to reach the stated goals. The 6/26/26 QAPI minutes also contained inconsistent pressure ulcer entries, including a section for new or worsening pressure ulcers, another section for pressure ulcer trends, and a separate current PIP for short-stay residents with current data listed as 0%. The facility did not explain why pressure ulcers were being separated into short-stay and long-stay residents, and the current PIP section was at times blank or lacked supporting detail. During interview, the DON and administrator stated there had been staff turnover and the person taking minutes had not entered the data, and the DON confirmed the facility had no documented analysis of the PIP project and no laid-out plan showing what the facility was going to do or how it was going to do it.
Failure to Follow IDDSI Level 5 Diet Order Leads to Choking Event
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for a texture‑modified diet for one resident with dysphagia-related risk, resulting in the resident being served an inappropriate regular‑texture meal. The resident had moderately impaired cognition, diagnoses including epilepsy, COPD, and right lower lobe lung cancer, and had recently been hospitalized for pneumonitis due to inhalation of food and vomit. Upon discharge from the hospital, the physician ordered an IDDSI Level 5 minced and moist diet with slightly thick liquids. The resident’s care plan and Diet Notification Form were revised on the same day to reflect a Level 5 minced and moist texture, slightly thick liquids, direct supervision in the dining room, and placement on the assisted side of the dining room, with interventions to monitor and report signs of chewing or swallowing difficulties, coughing, or choking. Despite these updated orders and care plan revisions, on the evening in question the resident was served a tuna melt sandwich on a regular hamburger bun and sweet potato tots, rather than a properly prepared minced and moist meal. The facility’s own IDDSI guidelines specified that Level 5 minced and moist foods require no biting, minimal chewing, and that no regular dry bread is allowed due to high choking risk, with food pieces not to exceed 4 mm in size. The facility’s alternate menu for Level 5 diets indicated that residents on this diet should receive minced tuna salad with minced or pureed bread, minced sweet potato puffs, and pureed dessert, not a regular bun. The cook reported that he prepared tuna melts by placing tuna with mayo and pickle relish on a hamburger bun, wrapping it in foil, baking it, and holding it in the steam table, and believed that a “soggy” bun was acceptable for a minced and moist diet. He gave the plate to a nursing assistant, who cut the sandwich in half and served it to the resident. Multiple staff interviews confirmed that the resident was served and had eaten part of a sandwich on a bun with sweet potato tots. A nursing assistant stated she handed the resident’s dietary card to the cook and received a tuna melt on a bun with sweet potato tots, and that she was unaware of the resident’s new diet change since his recent hospital return. Dietary aides described seeing the resident with a sandwich between buns and sweet potato tots on his plate, with part of the sandwich already eaten, and observed the resident making abnormal breathing noises, turning gray, and then actively choking. The resident was brought to the nurse’s station, where an LPN found him cyanotic, not breathing, non‑responsive, with food debris around his mouth and on his clothing, and performed the Heimlich maneuver multiple times before the resident began agonal breathing and was sent to the ED. ED documentation noted copious solid food removed from the resident’s mouth, large pieces of bread and cheese in the material expelled, and a chest x‑ray showing a food bolus. The DON later clarified that the LPN had not actually verified the diet texture against the physician order at the time of the incident and had relied on the cook’s statement that the meal was correct, contributing to the failure to provide the ordered minced and moist diet. The situation was determined to be an Immediate Jeopardy beginning when the resident was served the regular‑texture tuna melt on a bun and sweet potato tots, which did not meet the IDDSI Level 5 minced and moist requirements and directly conflicted with the physician’s diet order and the facility’s own diet guidelines and menus for texture‑modified diets.
Removal Plan
- Educate all staff regarding IDDSI modified texture and physician ordered diets with competencies
- Review dietary policy and procedure
- Validate resident diets
- Update care plans
- Audit all meals to assure residents on special textured diets receive the proper diet texture foods
Failure to Track Employee Illness Resolution and Complete TB Testing
Penalty
Summary
The facility failed to properly track and document employee illnesses to ensure staff were only returning to work after symptoms had resolved, as required by policy. Specifically, three staff members (a nursing assistant, a trained medication aide, and a dietary aide) were absent from work due to symptoms such as diarrhea, vomiting, and fever, but there was no documentation indicating when or if their symptoms had resolved prior to their return. The absence reports and timecards did not consistently record the resolution of symptoms, and the process for monitoring staff illnesses was identified as inconsistent and in need of improvement by facility leadership. Additionally, the facility did not ensure that a newly hired dietary aide completed the required two-step tuberculosis (TB) testing upon hire. The employee health file showed that only the first step of the TB test was documented, with no evidence of the second step being completed as required by the facility's TB control policy. Facility leadership confirmed that the necessary documentation for the second TB test was missing.
Failure to Update Care Plan and Medical Records After New Oxygen Therapy Orders
Penalty
Summary
The facility failed to revise the care plan for a resident receiving oxygen therapy when new physician orders were received following a hospital discharge. The resident, who had a history of acute respiratory failure with hypoxia and intact cognition, was observed on multiple occasions with oxygen flow rates set at 3 L/min, despite a new physician order specifying oxygen at 1-2 L/min during the day and 2 L/min at night. The care plan and medical records, including the Order Summary Report and Medication Administration Record, were not updated to reflect the new order, and staff continued to administer oxygen at the previous rate of 2 L/min or higher. Staff did not verify the actual flow rate against the updated physician order, nor did they document the amount of oxygen being administered as required. Interviews revealed that direct care staff were not permitted to adjust the oxygen flow rate and only switched the tubing between devices, while a registered nurse was unaware of the updated order and did not ensure the MAR matched the current physician instructions. The administrator confirmed that the medical record was not consistent with the most recent physician order and was unaware of the change. The facility's oxygen administration policy required a physician order and licensed nurse oversight but did not specify documentation procedures for the amount of oxygen administered. No care plan policy was provided during the survey.
Failure to Follow and Update Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that the correct physician order for oxygen therapy was followed and appropriately monitored for a resident with a history of acute respiratory failure and hypoxia. The resident was observed on multiple occasions with oxygen flow rates set at 3 L/min, despite the most recent physician order specifying 1-2 L/min during the day and 2 L/min at night. The care plan and medication administration record (MAR) were not updated to reflect the new order, and staff continued to document and administer oxygen based on outdated instructions. Additionally, there was no evidence that staff were verifying the actual flow rate or reconciling the MAR with the current physician order. Direct care staff were observed switching the resident between an oxygen concentrator and a portable tank, both set at incorrect flow rates. Interviews revealed that staff were unaware of the updated order and did not verify the accuracy of the MAR. There was also no documentation that the resident's family, who may have adjusted the oxygen flow, had been educated not to do so. The facility's oxygen administration policy did not specify procedures for documenting the amount of oxygen administered, contributing to the lack of oversight and consistency in care.
Failure to Reconcile and Update Oxygen Therapy Orders After Hospital Discharge
Penalty
Summary
The facility failed to accurately reconcile and update physician orders for a resident receiving oxygen therapy following a hospital discharge. Despite a new physician order specifying oxygen at 1-2 L/min during the day and 2 L/min at night, the electronic medical record, care plan, and medication administration record (MAR) continued to reflect the previous order of 2 L/min at rest and overnight. Multiple observations showed the resident receiving oxygen at 3 L/min from both the concentrator and portable tank, which did not match either the old or new physician orders. Staff did not verify or adjust the flow rate according to the updated order, and there was no documentation that the MAR had been reconciled with the most recent physician instructions. Interviews revealed that direct care staff were not permitted to change the oxygen flow rate and only switched the tubing between devices. The registered nurse was unaware of the updated order and did not verify the MAR against the new physician order. The administrator also confirmed that the order summary report had not been updated to reflect the change. Additionally, the facility lacked a policy for reconciling physician orders, and the existing oxygen administration policy did not address documentation of the amount of oxygen administered. The resident's oxygen saturation levels were monitored, but there was no evidence that staff checked or documented the actual flow rate as required by the updated physician order.
Failure to Complete Antibiotic Time-Out for Resident on Bactrim
Penalty
Summary
The facility failed to complete a comprehensive assessment for continued use of antibiotics for one resident who was reviewed for antibiotic stewardship. According to the Centers for Disease Control (CDC) guidelines, facilities are required to evaluate residents within 48-72 hours after starting an antibiotic to ensure the medication is effective, a process known as an antibiotic time-out (ATO). In this case, a resident was prescribed Bactrim for a urinary tract infection (UTI) following an outpatient appointment, and the medication was administered as ordered. Documentation showed the resident took the antibiotic as prescribed and completed the course without adverse effects. However, the resident's medical record did not contain evidence that an ATO was performed within the required 48-72 hour window after the initiation of antibiotic therapy. The director of nursing (DON) confirmed that, although the resident did not exhibit signs or symptoms of infection while at the facility and the antibiotic was prescribed externally, the facility did not conduct the ATO as per their usual process. Facility policy requires ongoing infection surveillance and documentation of antibiotic use, but this was not followed in this instance.
Failure to Provide Updated Pneumococcal Vaccination After Consent
Penalty
Summary
The facility failed to ensure that one sampled resident was offered and/or provided updated pneumococcal vaccinations in accordance with CDC guidelines. The resident, who was of advanced age and had diagnoses including diabetes, heart failure, and pneumonia, had previously received PCV13 and PPSV23 vaccines. Documentation showed that the resident consented to receive an updated pneumococcal vaccine dose, but the vaccine was not administered after consent was obtained. Both the registered nurse and the director of nursing confirmed that the updated vaccine had not been given, despite facility policy requiring provision of the vaccine per CDC recommendations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pipestone
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgebrook Care Center | 13.4 mi | ★★★★★ | 11 | 0 |
| Riverview Healthcare Center | 13.5 mi | ★★★★★ | 8 | 1 |
| Flandreau Santee Sioux Tribe Care Center | 14.2 mi | ★★★★★ | 0 | 0 |
| Avera Sunrise Manor | 19.6 mi | ★★★★★ | 5 | 0 |
| Palisade Healthcare Center | 22.9 mi | ★★★★★ | 4 | 1 |
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