Below 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 De Smet during CMS and state inspections, most recent first.
Two residents who required significant staff assistance experienced unmet care needs due to insufficient overnight staffing. One developed a Stage II pressure ulcer after admission, with incomplete care planning and inadequate repositioning, while another was left incontinent overnight after a CNA failed to provide timely toileting assistance. Staff interviews and records confirmed that only one CNA and one nurse were often responsible for up to 40 residents overnight, making it difficult to meet care needs, especially for those with high acuity.
A resident admitted after orthopedic surgery, who was bedbound and at risk for pressure ulcers, did not have a completed care plan or documented preventive interventions. Staff failed to consistently reposition the resident or document skin care, resulting in the development of a Stage II pressure ulcer and moisture-related skin damage, despite facility protocols requiring such preventive measures.
A resident with multiple complex medical conditions was admitted without a baseline care plan being completed within 48 hours, despite clear risks for pressure ulcers and specific care needs. The care plan lacked essential information about the resident's medical devices, mobility status, and required interventions. Staff responsible for care planning were unavailable and no other nurses were trained to complete the baseline care plan, resulting in reliance on verbal communication and a lack of awareness about the development of a pressure ulcer.
A resident in a LTC facility experienced neglect when staff failed to follow physician orders after a fracture. The resident was not taken to the ER immediately after a fall, and post-discharge care instructions for a leg immobilizer and elevation were not consistently followed. Despite the resident's intact cognition, her attempts to communicate care needs were dismissed, leading to improper care of her fracture.
A resident at risk for pressure ulcers developed a pressure ulcer on her left heel due to inadequate preventative interventions. Despite having heel protectors and an air mattress, the facility failed to conduct a significant change assessment upon the resident's return from the hospital and did not reassess her pressure ulcer risk. Skin assessments were not properly conducted, with documentation inconsistencies noted.
A resident fell from a mechanical lift during a transfer, resulting in a leg fracture. The incident was not reported to the DON until the following day, delaying the investigation and reporting to the SD DOH. The facility's policy requires immediate reporting of such incidents, but inconsistent accounts from the CNA and a lack of timely notification led to a breach in protocol.
Failure to Provide Adequate Staffing Resulting in Unmet Resident Care Needs
Penalty
Summary
The facility failed to ensure sufficient caregiver staff were available to meet the needs of residents who required assistance with repositioning, toileting, and incontinence care. One resident, who was dependent on staff for repositioning due to a full-length leg cast and other medical conditions, developed a Stage II pressure ulcer to her coccyx after admission. Documentation and interviews revealed that her care plan was incomplete, lacking specific interventions for her high risk of pressure ulcers, and that staff were not always able to provide the necessary repositioning and skin care. The resident's Braden Scale score indicated she was at risk, and her skin was already compromised on admission, but the care plan did not address her cast, wound vac, catheter, or specific assistance needs. Another resident, who relied on staff for toileting and incontinence care, reported that a CNA turned off her call light without providing assistance, resulting in an episode of incontinence and the resident remaining in wet garments overnight. The resident and her daughter both described multiple instances where timely assistance was not provided, and the daughter noted an increase in wet clothing over the past month. The facility did not have the capability to audit call light response times, and staffing records showed that on several overnight shifts, only one CNA and one nurse were available to care for up to 40 residents. Staff interviews confirmed that overnight staffing was often limited to one CNA and one nurse, with the CNA responsible for all resident rounds and call lights. Staff described difficulty meeting resident needs during these shifts, especially when caring for residents with high acuity or end-of-life needs. The facility's resource packet and facility assessment did not document current staffing levels or provide clear guidance on how to ensure adequate staffing to meet resident acuity and needs. These actions and inactions led to unmet care needs, including the development of a preventable pressure ulcer and unaddressed incontinence episodes.
Failure to Implement Pressure Ulcer Prevention for High-Risk Resident
Penalty
Summary
A resident was admitted to the facility following surgery to place a rod in her left leg and was dependent on staff for repositioning and pain management. Upon admission, the resident had a full-length cast, was non-weight-bearing, and required moderate to maximum assistance for movement. The initial skin assessment documented a large, red, flaky, and macerated area on her buttocks, but no open wounds. The resident's Braden Scale score indicated she was at risk for developing pressure ulcers, and she was placed on an air mattress. However, the care plan was not completed to address her specific needs, including her cast, wound vac, urinary catheter, transfer status, risk for pressure ulcers, or interventions for prevention. Documentation and interviews revealed that the resident remained in bed for several days, experienced significant pain, and was only repositioned as tolerated. Staff noted that she sometimes refused repositioning due to discomfort, and there was inconsistent documentation of repositioning tasks. Nursing staff and CNAs were unclear about the frequency and extent of repositioning provided, and there was a lack of clear communication and documentation regarding her care. The wound nurse and DON were not present during the resident's stay, and no baseline care plan or wound data collection form was completed. The expectation was that interventions such as frequent repositioning and skin care would be implemented, but these were not documented or consistently carried out. The resident developed a Stage II pressure ulcer to her coccyx and associated moisture-related skin damage to her perineum, which was not present upon admission. The physician confirmed that these skin injuries were preventable and not present when the resident was discharged from the hospital prior to admission to the facility. The facility's own wound care protocols required comprehensive management and documentation for residents at risk, but these were not followed. The lack of a completed care plan, failure to implement and document preventive interventions, and insufficient staff communication contributed to the resident developing a pressure ulcer during her stay.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
A deficiency occurred when the facility failed to complete a baseline care plan within 48 hours of admission for a newly admitted resident who subsequently developed a Stage II pressure ulcer. The resident, who had an intact mental status and multiple complex medical conditions including infection due to a knee prosthesis, Type II Diabetes Mellitus, and Chronic Kidney Disease Stage 3, was admitted with specific physician orders such as a diabetic diet, non-weight-bearing status, wound vac, and intravenous antibiotics. Assessments documented that the resident was at risk for pressure ulcers, required moderate to maximum assistance for mobility, and had significant skin issues upon admission, including redness and maceration on the buttocks. Despite these findings, the resident's care plan did not reflect critical information such as the presence of a full-length leg cast, wound vac, urinary catheter, intravenous antibiotics, transfer and weight-bearing status, level of assistance needed for activities of daily living, risk for pressure injuries, pain management, or necessary interventions to prevent pressure ulcers. There was no documentation that a baseline care plan was completed within the required 48-hour timeframe after admission. Interviews with facility staff revealed that the DON, who was responsible for completing baseline care plans, was not present during the resident's initial days in the facility and no other nurses were trained to complete this task. As a result, staff relied on verbal reports to communicate care needs, and the administrator and DON were unaware that the resident had developed a pressure ulcer during her stay. The facility's policy required a baseline care plan to be developed upon admission and provided to the resident and their representative, but this was not followed in this case.
Neglect in Following Post-Fracture Care Orders
Penalty
Summary
The facility failed to protect a resident from neglect by not following physician orders after the resident sustained a left lower extremity fracture. The incident began when the resident was being transferred using a sit-to-stand lift and was lowered to the floor by a CNA. Following the incident, the resident complained of left leg pain, and orders for an x-ray and doppler were received from her primary care provider. However, these tests were not scheduled until two days later, and the resident was not taken to the emergency room until the x-ray results confirmed a fracture. Upon discharge from the hospital, the resident was given specific orders to wear a leg immobilizer, remain non-weight bearing, and keep her leg elevated. Despite these instructions, the resident's daughter observed that the immobilizer was not always used correctly, and the resident's leg was not consistently elevated. The daughter reported that the CNAs dismissed the resident's attempts to communicate the proper care instructions, and there were instances where the immobilizer was left off when the resident was in bed. The resident's medical history included a fracture of the tibia, urinary tract infection, type 2 diabetes, macular degeneration, chronic kidney disease, arthritis, hearing loss, and folate deficiency. Despite having an intact cognitive status, the resident experienced increased confusion, which was later attributed to a urinary tract infection and pain. The facility's failure to adhere to the prescribed care plan and the resident's reports of improper care contributed to the neglect of the resident's needs, as outlined in the facility's policies on abuse and neglect.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The provider failed to initiate preventative interventions for a resident who was at risk for and developed a pressure ulcer on her left heel after fracturing her left lower leg during a fall. The resident was observed with heel protector boots and an air mattress, but the preventative measures were not adequately implemented. The resident's care plan included interventions for pressure ulcer prevention, such as providing a pressure relief cushion and an air mattress, but these were not effectively utilized to prevent the development of a pressure ulcer. The resident's medical record indicated she was at mild risk for developing a pressure ulcer, with a Braden Scale score of 15. Despite this, a significant change assessment was not completed when she returned from the hospital, and she was not reassessed for a potential change in pressure ulcer risk. Preventative measures in place prior to the development of the pressure ulcer included a daily multivitamin with zinc and nutritional supplements, but these were insufficient to prevent the ulcer. Interviews with staff revealed that the skin assessments were not conducted as required, with documentation being copied and pasted rather than accurately reflecting the resident's condition. The wound nurse documented the pressure ulcer as a suspected deep tissue injury, but the documentation was inconsistent, and the wound was later noted as healed without proper assessment. The facility's policy required systematic assessment and documentation of residents' skin conditions, but these procedures were not followed, leading to the deficiency.
Delayed Reporting of Resident Fall Incident
Penalty
Summary
The provider failed to report an incident involving a resident who fell from a mechanical lift during a transfer in a timely manner to the South Dakota Department of Health (SD DOH). On October 21, 2024, the resident was being transferred using a sit-to-stand lift when she was lowered to the floor by a CNA due to improper positioning and lack of readiness of the wheelchair. The resident complained of left leg pain later that day, and subsequent medical evaluations revealed a fracture in her left lower leg, necessitating emergency orthopedic care. The incident was not reported to the director of nursing until the following day, October 22, 2024, which delayed the investigation and reporting to the SD DOH. The facility's policy mandates immediate reporting of any suspected abuse, neglect, or injuries of unknown origin to the administrator or designated authority. However, the registered nurse involved did not notify the director of nursing on the day of the incident, leading to a breach in protocol. The delay was further compounded by inconsistent accounts from the CNA involved, which did not align with the resident's report, causing a one-day delay in initiating the investigation and reporting the incident.
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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 De Smet
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Lake Norden | 21.6 mi | ★★★★★ | 2 | 1 |
| Good Samaritan Society Howard | 25.4 mi | ★★★★★ | 4 | 0 |
| Estelline Nursing And Care Center | 33.5 mi | ★★★★★ | 0 | 0 |
| Avantara Huron | 33.7 mi | ★★★★★ | 14 | 1 |
| Bethel Lutheran Home | 34.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.