Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 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.
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.
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 | ★★★★★ | 12 | 1 |
| Riverview Healthcare Center | 13.5 mi | ★★★★★ | 11 | 1 |
| Flandreau Santee Sioux Tribe Care Center | 14.2 mi | ★★★★★ | 1 | 0 |
| Avera Sunrise Manor | 19.6 mi | ★★★★★ | 0 | 0 |
| Palisade Healthcare Center | 22.9 mi | ★★★★★ | 5 | 1 |
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