Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Canistota during CMS and state inspections, most recent first.
A resident with a suprapubic catheter, diabetes, CKD, dermatitis, and morbid obesity had ongoing pink, moist, reddened, and excoriated skin in the abdominal fold and around the catheter site, with drainage, bleeding, and pain reported by the resident. Staff repeatedly cleansed the area and applied barrier cream, but the resident said the site was sore and that she wanted a sponge used. Assessments documented MASD on the abdomen and perineum, yet the record showed limited treatment documentation, no measurements, and inconsistent recognition of the worsening skin condition.
The facility failed to determine and accurately document code status wishes for multiple residents at admission. Several residents had no EMR documentation of their preferences, and one resident with severely impaired cognition had conflicting CPR and DNR entries in the chart, with no documentation showing the resident wished to receive CPR. Interviews confirmed the facility did not use a signed form to record code status wishes and relied on standing orders, hospital discharge information, or verbal statements documented in progress notes.
Food storage and sanitation practices were not followed in the kitchen and food storage areas. Dented #10 cans were found in dry storage, dust was observed on a ceiling conduit and on a fan blowing into the clean dishwashing area, and residue covered the dishwasher and nearby wall. A FSA carried clean items and frozen desserts against her apron and later used her hand to open a trash can lid despite a step pedal being available; the CDM and administrator acknowledged the deficient practices.
Infection Control and Environmental Cleaning Failures: Staff did not follow whirlpool disinfection instructions, as a CNA did not know how to flush the whirlpool jets and the tub was later observed with standing water, suds, hair, and a dry scrub brush left in the room. Staff also did not promptly clean bowel movement from two residents’ bedroom floors and soiled linens/clothing were observed in one resident’s room before the area was later cleaned.
Inaccurate PASRR coding was found on comprehensive MDS assessments for two residents. One resident had diagnoses including schizoaffective disorder, bipolar type, TBI, and epilepsy, and his PASRR outcome explanation said A1500 should be coded yes, but the MDS coded A1500 no and left A1510 blank. Another resident with anxiety, behavior, psychotic, and mood disturbance diagnoses also had a PASRR outcome explanation directing A1500 to be coded yes, yet the MDS coded A1500 no and left A1510 blank; the SW said she completed A1500 and the RN/MDS coordinator confirmed the item should have been coded yes.
PASRR screening was inaccurate for two residents with mental health diagnoses, including anxiety, psychosis, mood disturbances, major depressive disorder, and trauma-related psychosocial concerns. One resident had severely impaired cognition and a Level I PASRR that incorrectly marked serious mental illness as No, while the other was admitted with a hospital-completed Level I PASRR that omitted mental health diagnoses. The SW acknowledged the errors and stated that Level II PASRR requests should have been submitted.
Two CNAs transferred a resident with Huntington's disease between her wheelchair and mattress without a gait belt, despite her care plan calling for hand-held assistance from two CNAs and use of a gait belt. The CNAs used their hands under her arms and held the waistband of her pants while prompting her to stand, turn, lie down, and return to her wheelchair. The CNA later acknowledged the gait belt was not used, and the RN and DON stated they expected a gait belt to be used for the resident's transfers.
The facility failed to provide bed-hold notifications to residents and their representatives during hospital transfers. A resident was transferred to the hospital without documentation of bed-hold information being provided, and another resident experienced similar issues during two hospital transfers. Staff interviews revealed confusion over responsibility for issuing notifications, with the social worker and charge nurse not effectively communicating or following the facility's policy.
The facility failed to follow food safety guidelines and proper cleaning procedures in the main kitchen. Uncovered bowls of cereal were improperly stored, and dishes with food residue were found, despite staff washing them by hand due to a broken dishwasher booster heater. Facility policies on food storage and warewashing were not adhered to, leading to deficiencies in maintaining cleanliness standards.
A resident admitted from a psychiatric facility did not receive a baseline care plan summary within 48 hours as required. Despite having moderate cognitive impairment and multiple diagnoses, there was no documentation of a power of attorney or evidence that the care plan was reviewed with her. Interviews revealed the care plan was completed weeks later, contrary to the facility's policy.
A resident with Huntington's Disease, who is cognitively intact, was denied her preference for ice cream, leading to distress and aggressive behavior. Despite a care plan indicating the provision of snacks, staff failed to accommodate her requests, citing scheduled meal times. Interviews revealed a lack of awareness and communication regarding the resident's preferences, and the facility's policy on resident rights was not followed.
A resident with Huntington's Disease and Major Depressive Disorder, who was cognitively intact, experienced distress when her preference for ice cream was not honored by staff, leading to aggressive behavior. The care plan was not updated to reflect her preference for ice cream, despite the facility's policy on person-centered care. This oversight occurred during a transition in facility administration.
A resident with severe cognitive impairment and a history of elopement risk managed to leave the facility unnoticed after a CNA bypassed a door alarm and failed to rearm it. The resident exited the building and was found wandering on a nearby road. Despite having a wander guard and being redirected multiple times, the resident's elopement occurred due to the door alarm not being reactivated.
Failure to Address Moisture-Associated Skin Damage Around Suprapubic Catheter
Penalty
Summary
The provider failed to ensure appropriate treatment and care were provided for a resident with a suprapubic catheter and recurrent moisture-related skin irritation in the abdominal fold and perineal area. The resident had diagnoses including neuromuscular dysfunction of the bladder, type 2 diabetes with chronic kidney disease, cystostomy status, dermatitis, and morbid obesity. She reported that her catheter site bled daily and that the area around her groin was painful and irritated. Observations showed pink, moist, reddened, and excoriated skin in the abdominal fold and around the suprapubic catheter insertion site, with drainage and granulation tissue present. Record review showed repeated skin assessments documenting pink, moist abdominal fold and groin areas over multiple weeks, with intermittent irritation, moisture, and drainage. The resident’s skin assessments noted that treatment such as Nystatin powder had been used earlier, but later assessments documented no treatment or only cleaning of the area. On 3/17/26, the skin assessment described an abdominal fold with intermittent serous drainage and only cleaning as the intervention. On 3/24/26, the nurse’s progress note identified one skin condition on the perineum as moisture-associated skin damage that had not been evaluated and another on the abdomen as moisture-associated skin damage that was being monitored, with no measurements documented. Interviews and observations showed staff were aware the resident had moisture and drainage at the suprapubic site and in the abdominal fold, but the resident’s complaints of soreness, bleeding, and irritation were not consistently addressed through physician notification or documented treatment changes. The resident stated staff cleaned the site with wipes and did not use a sponge or ointment as she wanted. Staff reported cleansing the area during catheter care and applying barrier cream, but they were not aware of gauze or creams being ordered for the insertion site, and the split sponge order had been discontinued months earlier. During a later assessment, the resident grimaced and voiced pain while the nurse cleansed the area, and the nurse then obtained supplies including a split drain sponge and InterDry sheets. The facility policy required skin changes such as abrasions to be reported and monitored, and catheter care policy required observation of surrounding tissue for inflammation, swelling, discharge, burning, or discomfort.
Failure to Document Residents’ Code Status Wishes at Admission
Penalty
Summary
The facility failed to ensure that residents’ code status wishes were determined and accurately documented in the EMR at admission for 13 of 16 sampled residents, including residents 1, 3, 5, 6, 9, 23, 26, 40, 42, 44, 46, 51, and 58. Review of the records showed that several residents had no documentation in the EMR indicating their code status wishes at the time of admission. For resident 46, the EMR contained conflicting information: a banner indicated a preference for CPR, while the care plan stated the resident had a DNR order and a physician’s order also indicated DNR. The resident’s BIMS score was 3, indicating severely impaired cognition, and there was no documentation in the EMR showing that the resident’s code status wishes were for CPR. Interviews with the administrator and social worker showed the facility did not have a form for residents or representatives to sign to indicate code status wishes. The administrator stated a signed physician admission standing order with DNR code status was used if the resident did not have a formal advance directive. The social worker stated the facility reviewed advance directives during admission, but did not review code status wishes with residents when they were admitted and did not use a form to document those wishes. She stated code status was sometimes based on hospital discharge documentation or standing orders from the medical director, and that the resident’s or family’s preference was documented in an admission progress note and communicated to nursing staff, but the facility did not have documentation showing the resident’s code status preference at the time of admission.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The provider failed to ensure standard food safety and sanitation practices were followed in the kitchen and food storage areas where residents' food was stored, prepared, and served. During observation of the dry food storage room, a #10 can of applesauce and a #10 can of dill pickles were found with severe dents at the sealed seam, and a yellow conduit tube on the ceiling had a dust-like substance hanging from it in multiple areas. In the dishwashing area, a tan-colored residue covered the top of the dishwasher and extended onto the wall next to it, and behind the dishwasher a pipe wrapped with yellow insulation had a silver covering that was peeling back in two areas. An oscillating table-top fan attached to the wall also had dust buildup on the blades and grille while blowing air into the clean dishwashing area where clean dishes were present. During observation, a food service assistant held a clean Cambro container against her apron, then carried frozen dessert containers against her apron before serving them to residents. Later, the same staff member performed hand hygiene, dried her hands, and then used one clean hand to open the trash can lid even though the can had a step-on pedal. In interview, the certified dietary manager stated she was not aware of the dented cans, the dust on the conduit tube, or the fan blowing into the clean dishwashing area, and confirmed the staff member should not have carried clean dishes or food products against her apron or used her hand to open the trash can. The administrator acknowledged the deficient practices and stated dietary staff had been trained.
Infection Control and Environmental Cleaning Failures
Penalty
Summary
The provider failed to ensure staff followed infection prevention practices related to whirlpool disinfection. During an observation, a CNA was seen cleaning the whirlpool by filling it with water and disinfectant, scrubbing the interior surfaces, and stating he would let the solution sit for ten minutes before draining and rinsing the tub. He was not sure how to flush disinfectant from the whirlpool jets and stated he did not know where the flush button was. A later observation of the whirlpool found the door open, about one-fourth inch of water in the bottom, suds between the tub edge and the door, water filling the reservoir, hair on the drain plug and chain, and a dry scrub brush on top of the whirlpool with no other scrub brush available in the room. The provider also failed to ensure prompt cleaning of bowel movement on resident bedroom floors. One resident’s room was observed with two dried dark brown areas on the floor identified as bowel movement, and the next day a staff member was seen on her knees scrubbing the substance with a washcloth. Another resident’s room was observed with a brown stain on the pillow, a brown streak on the sheet, a formed piece of bowel movement on the floor, and additional bedding and shorts with an incontinent brief inside them smeared with bowel movement. Later that morning, those areas were observed clean. The DON, RN MDS nurse, and environmental services supervisor stated resident rooms were to be swept and mopped daily, that no housekeepers were scheduled on weekends, and that nursing staff were expected to clean urine or bowel movement on the floor immediately. The DON also stated she expected fluids to be cleaned up immediately and bed linens changed when soiled.
Inaccurate PASRR Coding on MDS Assessments
Penalty
Summary
The facility failed to ensure accurate MDS coding for PASRR-related items for two sampled residents. One resident was admitted with diagnoses including schizoaffective disorder, bipolar type, traumatic brain injury, and epilepsy. His level I PASRR was coded as yes for serious mental illness and suspected intellectual disability, and the PASRR outcome explanation stated the facility should mark yes for MDS item A1500; however, the 11/05/25 comprehensive MDS coded A1500 as no, left A1510 uncoded, and coded A1550 as none of the above. His care plan also reflected antipsychotic medication for schizoaffective disorder and anticonvulsant medication for epilepsy. A second resident was admitted with diagnoses including anxiety, behavior, psychotic, and mood disturbance. His level I PASRR was coded as no for serious mental illness even though the form indicated that if the diagnoses were checked, yes should be marked. The PASRR outcome explanation stated the facility should mark yes for MDS item A1500, but the comprehensive MDS coded A1500 as no and left A1510 blank. During interview, the social worker stated she was responsible for completing A1500 on comprehensive MDS assessments, and the RN/MDS coordinator confirmed that A1500 for the second resident should have been coded as yes.
PASRR Screens Were Inaccurate for Residents With Mental Health Diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not reviewed for accuracy for two sampled residents with documented mental health-related diagnoses. One resident had diagnoses including anxiety, behaviors, psychosis, and mood disturbances, and a BIMS score of 3 indicating severely impaired cognition. His Level I PASRR completed on admission marked the question about a confirmed or suspected serious mental illness diagnosis as No, and the social worker acknowledged that the Level I PASRR had been completed incorrectly and that a Level II PASRR request should have been submitted. The second resident had diagnoses including psychosis, major depressive disorder, anxiety, traumatic brain injury, and other signs and symptoms involving cognitive functions and awareness, and his care plan referenced psychosocial well-being deficits related to reliving trauma. He was admitted with a Level I PASRR completed by the hospital social worker, but the social worker later reviewed it and did not notice that his mental health diagnoses were not included. She stated that a Level II PASRR request should have been submitted after admission, and that she did not add the additional mental health diagnoses or complete a new, accurate Level I screen. The RN/MDS coordinator also agreed that one resident's PASRR on the comprehensive MDS assessment was coded incorrectly and should have been marked yes.
Failure to Use Gait Belt During Resident Transfers
Penalty
Summary
Two CNAs transferred a resident with Huntington's disease between her wheelchair and her mattress without using a gait belt, even though her care plan directed that she be transferred with hand-held assistance from two CNAs and the use of a gait belt. During the observation, the CNAs stood on each side of the resident, placed one hand under each of her arms and their other hands on the waistband of her pants, prompted her to step onto the mattress and turn, and lowered her to a lying position. After changing her incontinence brief, they again prompted her to stand by holding their hands and then assisted her back into her wheelchair in the same manner. The resident's record showed she needed two-person assistance and a gait belt for transfers. One CNA stated the resident could not use a mechanical lift because she had previously thrown herself out of it, and later acknowledged she did not use a gait belt and probably should have. The RN and DON both stated they expected the CNAs to use a gait belt when transferring the resident. The provider's care plan policy and safe resident handling policy were also reviewed.
Failure to Provide Bed-Hold Notifications During Hospital Transfers
Penalty
Summary
The provider failed to issue bed-hold notifications to residents and their representatives during hospital transfers, as required by policy. Resident 9 was transferred to the hospital and admitted, but there was no documentation indicating that bed-hold information was provided to her or her power of attorney (POA). Similarly, Resident 46 was transferred to the hospital on two occasions, and while a bed-hold was eventually signed for one of the transfers, there was no documentation of bed-hold information being provided for the other transfer. Interviews with staff revealed a lack of clarity and communication regarding the responsibility for issuing bed-hold notifications. The social worker, responsible for issuing these notifications, was not informed of the hospitalization of Resident 46, which occurred on a Sunday. The administrator confirmed that the facility had a checklist for transfers and expected the social worker to issue notifications during business hours and the charge nurse to do so during nights and weekends. However, the bed-hold notifications were not being issued appropriately, as confirmed by both the social worker and the administrator.
Deficiency in Food Safety and Dish Cleaning Procedures
Penalty
Summary
The provider failed to adhere to necessary food safety guidelines for the storage of resident food items and proper cleaning procedures for dishes in the main kitchen. During an observation, it was noted that three uncovered bowls of breakfast cereal were stacked on top of each other inside a cupboard above the steam table. Additionally, three soup bowls and three soup cups with food residue were found inside another cupboard. Interviews with the cook and the nutrition and food services supervisor revealed that the booster heater of the commercial dishwasher had been out of order for two weeks, leading staff to wash dishes by hand. Although staff were monitoring water temperatures and sanitizer levels, the presence of food residue on dishes indicated a failure in maintaining cleanliness standards. The facility's policies on food supply storage and warewashing were not followed, as evidenced by the uncovered and improperly stored food items and inadequately cleaned dishes. The provider's policy required that opened or prepared foods be placed in enclosed containers, dated, labeled, and stored properly, which was not done. Furthermore, the manual warewashing policy required that all utensils and wares be scraped, washed, rinsed, and sanitized, which was not effectively carried out, as shown by the food residue on the dishes. The booster heater was scheduled for replacement, but the deficiency in maintaining food safety and cleanliness standards persisted during the survey period.
Failure to Provide Baseline Care Plan Summary to Resident
Penalty
Summary
The provider failed to ensure that a resident, who was admitted from an inpatient psychiatric facility, had reviewed and was provided a summary of her baseline care plan within 48 hours of admission. The resident, diagnosed with unspecified mood disorder, mild neurocognitive disorder, liver cell carcinoma, and long-term use of anticoagulants, had a BIMS score indicating moderate cognitive impairment. There was no documentation of a power of attorney until a later date, and the baseline care plan was not signed as completed until several weeks after admission. Furthermore, there was no evidence in the electronic medical record that a baseline care plan summary had been reviewed with the resident. Interviews with the director of nursing and the MDS nurse revealed that the baseline care plan was completed much later than required, and there was no documentation of the care plan being reviewed with the resident at the time of admission. The resident herself did not recall reviewing or signing a baseline care plan upon admission. The facility's care plan policy, revised shortly before the interviews, mandates that a baseline care plan be developed upon admission and that a written summary be provided to the resident and their representative, which was not adhered to in this case.
Failure to Accommodate Resident's Snack Preferences
Penalty
Summary
The deficiency involves the failure of the facility to accommodate a resident's snack time preferences, specifically regarding the provision of ice cream. The incident occurred when the resident, who has Huntington's Disease and is cognitively intact with a BIMS score of 15, requested ice cream after having already been given some earlier. The staff denied her request, leading to the resident becoming upset and exhibiting aggressive behaviors such as yelling, swearing, and kicking staff. This incident resulted in the resident being taken to her room to calm down. The resident's medical record indicated a significant weight loss, and her care plan included providing a diet as ordered with smaller portions per her request and general snacks/hydration between meals. Despite this, the staff did not accommodate her request for ice cream, which she preferred due to its ease of swallowing. Observations and interviews revealed that the resident had a history of requesting ice cream and other snacks at various times, including early morning, and was often told to wait until scheduled meal times, which contributed to her distress. Interviews with staff, including CNAs, RNs, and the DON, highlighted a lack of awareness and communication regarding the resident's preferences and the facility's policy on resident rights and choices. The facility's policy emphasized promoting and facilitating resident self-determination through support of resident choice, which was not adhered to in this case. The administrator confirmed that there was no documentation of the investigation or education provided following the incident, and the care plan had not been updated to reflect the resident's preferences.
Failure to Update Care Plan for Resident's Snack Preferences
Penalty
Summary
The provider failed to update the care plan to reflect a resident's current snack preferences, specifically her preference for ice cream. The incident occurred when the resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including Huntington's Disease and Major Depressive Disorder, requested ice cream after having already received her evening snack. The staff informed her that she could not have more ice cream, which led to the resident becoming upset and exhibiting aggressive behavior. The care plan did not document the resident's preference for ice cream or the staff's education to provide it even if she had already consumed her normal amounts for the day. The resident expressed frustration over her lack of independence and her preference for ice cream due to its ease of swallowing, a preference supported by her friend who regularly brought ice cream to the facility. Despite the facility's policy emphasizing person-centered care and supporting residents in making their own choices, the care plan was not updated to reflect these preferences. The incident occurred during a transition period for the facility's administration, which may have contributed to the oversight.
Resident Elopement Due to Door Alarm Bypass
Penalty
Summary
The deficiency involved a resident identified at risk for elopement who managed to leave the facility without staff knowledge. On the night of the incident, the resident wandered throughout the building, and staff redirected him away from the doors multiple times. However, at 4:41 a.m., a certified nursing assistant (CNA) responded to the resident's attempt to exit through a door by entering a bypass PIN code, which turned off the door alarm. The CNA redirected the resident but then left to respond to another resident's call light, leaving the door unmonitored. The resident, who had severe cognitive impairment and a history of elopement risk, turned around and exited the building through the same door at 4:41 a.m., unnoticed by staff. The door alarm had been bypassed and did not reactivate immediately, allowing the resident to leave the facility. The resident was found wandering on a nearby road at 6:30 a.m. and was returned to the facility without injuries. The resident's medical record indicated a Brief Interview for Mental Status (BIMS) score of three, signifying severe cognitive impairment, and diagnoses including dementia with behavioral disturbances, anxiety disorder, and major depressive disorder. The resident's care plan had previously identified the risk of elopement, and a wander guard was in place to alert staff to his movements. Despite these measures, the failure to ensure the door alarm was rearmed after being bypassed led to the resident's elopement.
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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 Canistota
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diamond Care Center | 10.7 mi | ★★★★★ | 13 | 0 |
| Tieszen Memorial Home | 12 mi | ★★★★★ | 0 | 0 |
| Oakview Terrace | 18.6 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society Sioux Falls Village | 26.1 mi | ★★★★★ | 0 | 0 |
| Bethany Home Sioux Falls | 27.6 mi | ★★★★★ | 3 | 0 |
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