Below 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 Luther Manor during CMS and state inspections, most recent first.
A resident with quadriplegia who relied on baclofen to manage muscle stiffness and spasms experienced a significant medication error when an RN misread a pharmacy communication about a future stop date and discontinued baclofen without a physician’s order. The resident subsequently developed altered mental status, facial redness, and behavioral changes, leading to transfer to the ED and hospital admission, where acute encephalopathy likely due to baclofen withdrawal was diagnosed. The medical director, DON, and administrator all stated that a physician’s order and clarification on discontinuation of such a medication would have been expected before stopping it.
A resident with mild cognitive impairment and a known elopement risk, who had refused a wander guard and was to be checked every three hours, was last documented as seen at midday and later left the building by independently using the front door keypad code, remaining unsupervised outside until returning the next day. The front door keypad code had been unchanged for years, was posted in reverse on a laminated sign above the keypad, and was known to some residents, allowing them to open the door. At the same time, after an EMR system update, staff stopped routinely completing the required elopement risk assessment on all new admissions, and several newly admitted residents had no documented elopement screening despite facility policy requiring universal admission screening.
Failure to implement and document pressure ulcer prevention and monitoring led to facility-acquired stage II pressure injuries in two residents. One resident with intact cognition and mild Braden risk developed a coccyx ulcer that later involved both buttocks, with several wound assessments showing increased size without physician notification and no documentation that prevention measures such as PRN dressings or barrier cream were used before the wound appeared. Another resident with dementia, malnutrition, and a history of buttock injury had a flat pressure-reduction cushion, no cushion in his wheelchair at observation, and a newly developed right buttock ulcer that was not initially measured; the DON and wound nurse confirmed there was no documentation showing prevention measures were in place before the ulcers developed.
Unsafe resident handling and supervision failures led to multiple accidents. A resident with quadriplegia sustained a shearing injury when an RN pulled a mechanical lift sling from under him, a resident with dementia and Parkinson’s fell from a lift chair after staff left the remote within reach, a resident needing a sit-to-stand lift with 2 staff fell when only 1 CNA assisted, and a resident at risk for elopement exited the facility and remained outside unsupervised for several minutes.
Controlled medication counts were repeatedly left undocumented on several medication carts, an RN was found to have stolen resident oxycodone after cutting tablets in half without proper count verification, and an LPN administered the wrong insulin to a resident with DM and hyperglycemia after insulin pens were stored together in one cart container instead of separate resident-specific containers.
The facility failed to report a fall incident and multiple verbal abuse allegations to SD DOH within required time frames. A resident who required two-person assistance with a sit-to-stand mechanical lift was transferred by one CNA, slipped from the sling to the floor, and was later reported to SD DOH beyond the 24-hour requirement. In a separate situation triggered by a staff member’s quality-of-care concerns, a resident reported being told to shut up and sit up or help would be withheld, and two other residents described rude and inappropriate comments by a CNA; these abuse allegations were not reported within the mandated 2-hour window. Another resident’s frequent call light use for leg pain and repositioning led to findings that a CNA used profanity when speaking with staff about a resident. The DON acknowledged that these events were not reported in accordance with the facility’s abuse/neglect policy and state reporting timelines.
Failure to assess a resident for safe self-administration of nebulizer medication. A resident was found alone in his room with a nebulizer treatment running, but the mask was not properly positioned over his nose and mouth. The CMA said she was unsure whether the treatment could be given without supervision and could not find a physician order for self-administration. The resident was nonverbal, had quadriplegia, cognitive communication deficit, traumatic brain injury-related diagnoses, and required extensive assistance with cares.
Inaccurate MDS Ventilator Coding: A resident’s quarterly MDS was incorrectly coded to show use of both an invasive mechanical ventilator and a non-invasive mechanical ventilator, even though she was observed on oxygen via nasal cannula, denied ventilator use, and had no physician order, care plan indication, or facility history supporting ventilator use. The MDS nurse acknowledged the coding errors, and the DON confirmed the resident did not use either type of ventilator.
Care plans were not revised to match current resident needs for three residents. A resident with dysphagia and a removed NG tube still had care plan and Kardex entries showing NPO status and tube feedings despite current oral liquid intake and changing diet orders. Another resident with PTSD had no care plan focus for trauma history, triggers, or interventions, and a third resident receiving olanzapine had no care plan focus for antipsychotic use, target behaviors, or non-pharmacological interventions.
Failure to identify PTSD triggers and trauma-informed interventions: A resident with PTSD, depression, insomnia, and mood disorder reported a history of trauma and identified conflict and bombing in the Middle East as a PTSD trigger, but his care plan did not include PTSD, potential triggers, or specific interventions. Staff interviews confirmed the resident’s trauma assessments repeatedly documented no trauma history, his VA counselor visits were not current, and the DON and RN were unaware of his identified trigger and the missing care plan details.
A resident with a history of falls, dementia, and muscle weakness sustained an injury after staff failed to follow the care plan requiring a silent TABs alarm in both the bed and recliner. The alarm was left in the recliner instead of being placed on the bed, and staff interviews and observations confirmed that only one alarm was being used and transferred between locations, contrary to the care plan. Additional required interventions, such as signage, were also not in place, and staff were not consistently aware of or following the prescribed fall prevention measures.
A resident with a history of stroke and dysphagia received water through a straw, despite a care plan specifying no straws and special hydration needs. The restriction was documented in the care plan but was not transferred to the Kardex, leaving front-line staff unaware of the requirement. Staff interviews confirmed reliance on the Kardex for such information, resulting in the resident not receiving care as ordered.
A resident with a history of UTIs was found with two Buprenorphine patches on their skin, leading to altered mental status. The facility failed to remove the previous patch before applying a new one, due to a delay in medication delivery and lack of adherence to the patch management process. Staff interviews revealed confusion about medication availability and inconsistent verification of patch removal.
A resident with a history of stroke was injured during a transfer with a sit-to-stand mechanical lift due to inadequate staff assistance and supervision. Despite the care plan requiring two staff members for transfers, only one was often present, leading to a fall and head injury. The resident expressed fear and discomfort with the lift, but it continued to be used without proper reevaluation. The facility failed to ensure proper documentation and communication of transfer needs, contributing to the deficiency.
The facility failed to properly store, label, and maintain cleanliness of food items in the kitchen and kitchenette areas. Observations revealed unlabeled and undated food, spoiled items, and unsanitary conditions. Cleaning logs were incomplete, and the director of dining services acknowledged the issues.
A resident's care plan was not updated after her catheter was removed, despite confirmation from the resident and staff that she no longer had it. The care plan still required Enhanced Barrier Precautions for a Foley catheter, which had been discontinued. Staff interviews revealed a lack of communication and adherence to the facility's policy on care plan updates.
Significant Medication Error from Unauthorized Discontinuation of Baclofen
Penalty
Summary
The deficiency involves a failure to ensure that a resident was free from significant medication errors when an RN discontinued a critical medication without a physician’s order. The resident, who had quadriplegia and was receiving baclofen as a primary medication to manage involuntary muscle stiffness and spasms, experienced an abrupt discontinuation of this drug. RN C received a Consultant Pharmacist Communication to Physician asking the physician to clarify whether baclofen and duonebs, which had a stop date of 2/1/2027 on the MAR, should be discontinued at that time or continued. RN C misread the year on the stop date, believed the medications should have been discontinued on 2/1/2026, and independently stopped the resident’s baclofen on 3/18/26 without waiting for the physician’s verification or obtaining an order. Following the discontinuation, the resident developed a change in mental status, facial redness, and behavior that was described as not acting himself on 3/20/26. He was sent to the ED for evaluation at approximately 9:00 p.m. and was admitted to the hospital later that evening. He was diagnosed with acute encephalopathy, likely due to baclofen withdrawal after the abrupt discontinuation. Interviews confirmed that the medical director, who was the resident’s primary physician, would have expected to be contacted before any medication was discontinued and expected nursing staff to obtain clarification on how a medication like baclofen should be discontinued to ensure it was done safely. The DON and administrator both confirmed that a physician’s order was expected before discontinuing a resident’s medication, and the DON identified this event as a significant medication error.
Failure to Secure Exit Door and Consistently Assess Residents for Elopement Risk
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent accidents, specifically related to elopement risk and door security. One resident, who was admitted with an identified elopement risk and had a BIMS score of 11 indicating mild cognitive impairment, refused a wander guard, so staff were to perform and document three-hour rounding to verify his whereabouts. On the day of the incident, his last documented three-hour check occurred at 12:00 p.m., and he was later reported missing at 8:00 p.m. after dietary staff noted his absence from the evening meal. A review of camera footage showed that he had tested and successfully used the front door keypad code earlier in the day and exited the building at 5:04 p.m., remaining outside the facility unsupervised for about 18.5 hours until he returned in a private vehicle the following day. The report further documents that the front door keypad code had been in place for several years and was not changed immediately after the elopement. The keypad was located near the front door with a laminated paper above it displaying the code written backwards, which could be read and used by anyone with intact cognition. Observations showed a visitor reading the laminated sign and entering the code to exit. Staff interviews confirmed that some residents, including the eloping resident, knew and used the door code to go outside. The resident whose room was closest to the front door stated he had watched people use the keypad, learned the code, tested it earlier in the day, and then chose a time when staff were busy to leave the building. The code remained unchanged from the time of his elopement until several days later. In addition, the facility did not consistently assess newly admitted residents for elopement risk as required by its elopement policy. The policy stated that all residents would be assessed for elopement risk during the pre-admission and/or admission process using a user-defined assessment (UDA) in the electronic medical record system, with results used to individualize care plans. After a software update to the Point Click Care (PCC) system in December 2025, the elopement assessment no longer opened automatically, and the nurse responsible for admission assessments reported that she only completed elopement assessments if residents expressed a desire to leave or had certain clinical risk factors. The admission checklist was also no longer used. Record review showed that three newly admitted residents during the review period had no documented admission elopement screening assessments in their EMRs, and leadership acknowledged that not all residents were being screened on admission as required by policy.
Failure to Implement and Document Pressure Ulcer Prevention and Monitoring
Penalty
Summary
The provider failed to monitor and implement pressure ulcer healing and prevention interventions for two residents who were identified as being at risk for pressure injuries and who developed facility-acquired stage II pressure ulcers. One resident had intact cognition, a Braden score of 16 indicating mild risk, and diagnoses including stage I and stage II pressure ulcers. The other resident had moderately impaired cognition, diagnoses including adult failure to thrive, pain, malnutrition, dementia, and muscle spasms, and a history of pressure injury to the buttock. Both residents were observed with pressure reduction cushions in use at some point, but the record did not show when those cushions were placed or whether prevention measures were implemented before the wounds developed. For the first resident, wound documentation showed a coccyx pressure ulcer that changed in size over time, later involved the left buttock, and at times was described as open, red, or with shearing and sanguineous drainage. Several wound assessments documented increases in wound size without indicating that the physician was notified. The record also showed a physician order for Mepilex dressing and zinc oxide cream related to a stage I pressure ulcer, but the wound nurse confirmed that PRN Mepilex was not documented as applied for prevention before the pressure ulcer developed, and the Triad cream was ordered the day after the coccyx pressure ulcer was discovered. The resident stated he had a wound on his buttocks but thought it had healed, and he did not know whether the trapeze bar or pressure reduction cushions had been in place before the wound developed. For the second resident, staff and the resident’s wife reported that he had arrived with a pressure reduction cushion that later went flat and was removed, and that another cushion was obtained after he developed a buttock wound. At the time of observation, there was no pressure reduction cushion in his wheelchair, the cushion in his recliner was flat, and he spent most of his time in his recliner or bed. The wound assessment for the newly developed stage II pressure ulcer on the right buttock was not measured initially, and there was no further documented measurement until later, when it was recorded as healed. The care plan did not indicate when the cushion was placed in the wheelchair or recliner, and the EMR did not show documentation of repositioning schedules or barrier cream documentation sections for either resident. The DON and wound nurse confirmed there was no documentation to support that pressure ulcer prevention measures were implemented before the residents developed their pressure ulcers.
Unsafe Transfers, Lift Chair Fall, and Elopement Supervision Failure
Penalty
Summary
The facility failed to protect residents from accident hazards and provide adequate supervision in several incidents involving unsafe transfers, a lift chair fall, and an elopement. One resident with quadriplegia and a nonhealing right buttock wound had a care plan for skin integrity impairment related to a shearing injury, with interventions including turning and repositioning and pressure-relieving surfaces. Staff interviews and the wound nurse’s statement indicated that RN/former DON DD attempted to pull a mechanical lift sling from under the resident and caused a shearing injury to the right buttock. The wound later required a wound vac, and staff described the injury as avoidable. A second resident with dementia and Parkinson’s disease had a BIMS score of 3 and a lift chair assessment showing he was unable to safely use the chair remote and needed his wife or son to operate it. His care plan directed that the remote be placed out of his reach. After staff transferred him to the recliner and left the room, the chair control activated, the chair lifted him, and he fell to the floor, striking his head and sustaining a skin laceration above his right eyebrow. The fall documentation noted that he had been sitting in the recliner with the remote tucked over the chair before the fall. A third resident with aphasia, hemiparesis, and a BIMS score of 0 required a sit-to-stand mechanical lift with two staff members for transfers. During a toilet-to-wheelchair transfer, CNA N used the lift without the assistance of a second staff member, and the resident slipped out of the sling, fell to the floor, and rolled onto his right side. The resident reported bumping his head, and the provider later determined the transfer did not follow the resident’s care plan. In a separate incident, a resident with dementia, anxiety, depression, and a history of fractures who was identified as at risk for elopement left the facility through the front entrance and remained outside unsupervised for about five minutes before staff intervened. The resident had been making statements that she wanted to go home, had a WanderGuard added to her care plan, and was observed outside near the front entrance before staff were able to engage her.
Controlled Drug Count Failures, Medication Theft, and Insulin Administration Error
Penalty
Summary
The facility failed to ensure controlled medication counts were completed and documented for multiple medication carts, including Mystic Ranch, Park View, Focus, East, and [NAME] Lane. Review of the controlled drug count records for December 2025 through February 2026 showed repeated missing signatures indicating that the on-coming and off-going nurses did not document that controlled medication counts were completed with no discrepancies at shift changes. The records reflected omissions across several carts and multiple dates, and the DON stated she reviewed the records intermittently but was not auditing them routinely. The facility also failed to prevent the theft of resident 94’s controlled pain medication, oxycodone. The resident’s oxycodone 5 mg tablets were received from the pharmacy, and RN FF cut the tablets in half to create the ordered 2.5 mg dose for resident 94. The tablets were not counted after being cut and placed into the locked medication drawer, and the bottle was later found to have a discrepancy of six halved tablets that could not be accounted for. Facility video footage showed RN FF placing a pill in her hand, putting it in her mouth, and drinking water, and she later stated she had a problem during the phone discussion with administration. The facility also failed to ensure insulin was administered according to the physician’s order for resident 10. Resident 10 had diagnoses including hyperglycemia and Type 2 DM with diabetic neuropathy and was ordered Novolog on a sliding scale, scheduled Novolog with meals, and daily Tresiba. LPN CC administered the wrong insulin after taking both Tresiba and Novolog pens to the resident’s room, and she realized during the injection that she had started giving Novolog instead of Tresiba. The resident’s primary provider was notified, the resident was sent to the ER for overnight observation, and the facility’s investigation found that insulin pens had previously been stored together in one bulk container on the medication cart rather than in separate resident-specific containers.
Failure to Timely Report Fall Incident and Verbal Abuse Allegations to SD DOH
Penalty
Summary
The deficiency involves the facility’s failure to report certain incidents and allegations to the South Dakota Department of Health (SD DOH) within required time frames. For one resident who required a sit-to-stand mechanical lift with two-person assistance per the care plan, a CNA performed the transfer alone. During the transfer, the resident slipped from the sling, slid to the floor onto his bottom, and rolled onto his right side. An LPN immediately assessed the resident and found no injury, but the incident, which occurred on 11/28/25 at 11:30 a.m., was not reported to the SD DOH until 12/1/25, exceeding the 24-hour reporting requirement for such events. The facility also failed to timely report allegations of verbal abuse involving another resident. After a CNA left her shift early and raised quality of care concerns, the administrator and DON interviewed residents and staff. One resident reported that a CNA told her not to sing and to “shut up” and “sit up or I am not going to help you.” Two additional residents reported that the same CNA made rude and inappropriate comments, including “You would not have these issues if you went out to the dining room” and “Don’t be cocky.” Although the CNA denied making rude or inappropriate comments, these allegations of verbal abuse were not reported to the SD DOH until six days after the DON was notified, well beyond the required two-hour reporting window for abuse allegations. A third deficiency involved another resident and additional allegations of verbal abuse. Following the same initial staff report of quality of care concerns, the facility investigated and learned that a CNA reported the resident had used the call light several times during the night for leg pain and repositioning needs. The CNA stated she did not use profanity toward residents while providing care but acknowledged using profanity at times when talking with other staff members about a resident, as an expression of how she felt. The DON later confirmed that reports of resident abuse and neglect were required to be reported to the SD DOH within two hours, and all other reportable events within 24 hours, and acknowledged that the verbal abuse allegations related to these residents, as well as the earlier fall incident, were not reported within the required time frames. The facility’s own abuse and neglect policy required immediate reporting, but not later than two hours, for allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of property, or serious bodily injury, and within 24 hours for other allegations without serious bodily injury.
Failure to Assess Resident for Safe Self-Administration of Nebulizer Medication
Penalty
Summary
The facility failed to ensure that one sampled resident was assessed for the ability to safely self-administer nebulizer medication before being left alone in his room with the nebulizer machine running. During observation, the resident was found lying in bed with the nebulizer mask positioned on the right side of his face without covering his nose and mouth while the machine was administering the breathing treatment. The CMA who had placed the mask on him stated she was not sure whether he could receive the treatment without supervision and could not find a physician order for self-administration in the EMAR. The resident had an order for Ipratropium-Albuterol inhalation solution via nebulizer four times daily related to quadriplegia. His EMR showed he was readmitted to the facility, was nonverbal, had no BIMS score completed, and had diagnoses including traumatic subdural hemorrhage with loss of consciousness, unspecified intracranial injury with loss of consciousness, cognitive communication deficit, facial weakness, psychomotor deficit, and convulsions. His care plan noted limited physical mobility, use of a total body lift, two staff members for all cares, and altered respiratory status related to obstructive sleep apnea. The DON stated the resident did not have a physician order to self-administer medication and did not have an assessment completed for his ability to safely self-administer medication, and that such an assessment and order were expected before a resident was left unattended in his room.
Inaccurate MDS Ventilator Coding
Penalty
Summary
Resident 11’s quarterly MDS assessment was coded inaccurately in Section O for both invasive and non-invasive mechanical ventilator use. During observation on 3/3/26, she was sitting in her recliner receiving oxygen through a nasal cannula, there was no invasive or non-invasive ventilator in the room, and she denied being on a ventilator. Her EMR showed diagnoses including COPD, shortness of breath, mild intermittent asthma, and chronic respiratory failure with hypoxia, but there was no physician’s order for an invasive mechanical ventilator or for a non-invasive device such as CPAP or BiPAP, and her care plan did not indicate ventilator use. Review of the 12/16/25 quarterly MDS showed item O0110 F1 coded as if she had used an invasive mechanical ventilator within the prior 14 days and item O0110 G1 coded as if she had used a non-invasive mechanical ventilator within the prior 14 days, without identifying CPAP or BiPAP. The MDS/wound nurse who completed the assessment acknowledged both items were coded incorrectly and attributed the error to human error. The DON also acknowledged that Resident 11 did not use an invasive or non-invasive mechanical ventilator and that the assessment was coded inaccurately.
Care Plans Not Updated for Changed Diet, PTSD, and Antipsychotic Use
Penalty
Summary
The provider failed to ensure resident care plans were revised to reflect current care needs for three sampled residents. Resident 6 had a history of dysphagia and GERD, and her NG tube was removed on 2/25/26 at a GI appointment. At the time of observation, she was on a liquid diet and was eating and drinking by mouth, including broth, Jello, juice, water, and a Boost Breeze supplement. Her EMR showed changing physician diet orders from clear liquids to full liquids and then to a regular minced moist diet with thin liquids, but her care plan and Kardex still listed her as NPO with NG tube feedings and NG tube medication administration. Resident 7 had diagnoses including PTSD, depression, insomnia, and mood disorder, and his BIMS score indicated intact cognition. He told staff he had experienced significant trauma in his life and that conflict and bombing in the Middle East could trigger his PTSD symptoms. His care plan did not include PTSD, his trauma history, potential triggers, or interventions to help staff prevent triggering a traumatic response. Staff interviews confirmed that his PTSD diagnosis and possible triggers were not reflected in the care plan, even though staff expected those items to be addressed. Resident 29 had diagnoses including depression, dementia, and anxiety, and she had a physician order for olanzapine 5 mg at bedtime. Her care plan did not include a focus area for antipsychotic medication use, the behaviors the medication was intended to address, or non-pharmacological interventions for those behaviors. Staff interviews confirmed that her antipsychotic use, related behaviors, potential side effects, and non-pharmacological interventions should have been included in the care plan. The facility policy required individualized, interdisciplinary care plans based on resident needs and physician orders, and the psychotropic medication policy called for non-pharmacological interventions and documentation of attempts.
Failure to identify PTSD triggers and trauma-informed interventions
Penalty
Summary
The provider failed to identify and implement specific care approaches that addressed the mental and psychosocial needs of a resident with diagnosed PTSD to help mitigate trauma triggers and prevent re-traumatization. The resident had a history of trauma, depression, insomnia, and mood disorder, and his BIMS score was 14, indicating intact cognition. During interview, he stated he had experienced a lot of trauma in his life, had spoken with a counselor about it in the past, and knew that seeing conflict and bombing in the Middle East on television could trigger his PTSD symptoms. Record review showed the resident’s care plan addressed depression and noted that he talked with a VA mental health counselor every 6 months or more often if needed, but his last documented visit with that counselor was over a year earlier. His physician orders included psych services as needed, duloxetine for depression, and mirtazapine for insomnia. Although the resident had PTSD listed in his diagnoses, his trauma assessments dated 1/10/25, 4/17/25, and 7/30/25 all indicated he answered no to having experienced trauma or stressful events, and there were no trauma assessments documented after 7/30/25. Staff interviews confirmed the care plan did not identify PTSD, potential triggers, or interventions to prevent re-traumatization. The MDS/wound nurse stated a resident with PTSD should have PTSD identified on the care plan along with triggers and pharmacological and non-pharmacological interventions, and acknowledged this resident’s care plan did not include those items. The RN stated she was aware of the PTSD diagnosis but did not know the resident’s triggers, and the DON stated she was aware the resident was a military veteran with PTSD but was not aware that his trauma assessments were inaccurate or that he identified Middle East conflict and bombing as a trigger. The facility’s trauma-informed care policy required trauma assessments within five days of admission and PRN, and stated staff should provide culturally competent, trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization.
Failure to Implement Fall Prevention Interventions as Care Planned
Penalty
Summary
A deficiency occurred when staff failed to implement fall prevention interventions as described in the care plan for a resident with a history of repeated falls, muscle weakness, dementia, and use of anticoagulants. The resident was found on the floor next to his bed with a laceration near his right eye, requiring emergency department treatment and sutures. The facility's investigation revealed that the silent TABs alarm, intended to alert staff when the resident attempted to stand, was left in the resident's recliner instead of being placed on the bed, as required by the care plan. The certified nursing assistant who assisted the resident to bed forgot to move the alarm, resulting in the alarm not being in place at the time of the fall. Further review of the resident's medical record and care plan showed that the resident was care planned to have a silent TABs alarm in both his bed and recliner at all times, with instructions to ensure the alarm was used, plugged in, and functioning when the resident was in either location. However, multiple progress notes documented that the alarm was not consistently placed under the resident at bedtime and was often found in the recliner while the resident was in bed. Staff interviews confirmed that only one alarm was being used and transferred between the bed and chair, rather than having two alarms as specified. Some staff were unaware of the care plan requirements, and others reported that attempts to use two alarms resulted in malfunctions, leading to the removal of the second alarm without alternative interventions being consistently implemented. Observations confirmed that the resident's room did not have two alarms as required, and the STOP, Wait for assistance sign, which was supposed to be in place as an additional intervention, was not visible. Interviews with nursing and administrative staff revealed a lack of awareness regarding the specific fall prevention interventions required for the resident, and documentation of these interventions was inconsistent. The facility's fall prevention policy emphasized the need to identify risk factors and implement interventions before a fall occurs, but these procedures were not followed in this case.
Failure to Communicate Hydration Restrictions Leads to Care Plan Deviation
Penalty
Summary
Staff failed to follow the care plan regarding hydration needs for a resident with a history of stroke, hemiplegia, and dysphagia. The resident was observed receiving medications with pudding and water through a straw, despite care plan instructions specifying mildly thickened liquids with meals, thin liquids in the room only after oral care, and no use of straws as per speech therapy recommendations. The certified medication aide administering the medication was unfamiliar with the resident's specific needs, and the water mug in the resident's room contained a straw, contrary to the care plan. Interviews with dietary and nursing staff revealed that the restriction on straw use was documented in the care plan but was not transferred to the Kardex, the tool used by front-line caregivers to access residents' care needs. Both the CNA and RN confirmed reliance on the Kardex for such information, and the DON was unaware of the no-straw requirement. The facility's policy required care plans to reflect current care needs and ensure appropriate care and services, but the failure to update the Kardex led to staff not being informed of the resident's hydration restrictions.
Failure to Remove Previous Buprenorphine Patch Leads to Double Application
Penalty
Summary
The deficiency involved a failure to properly manage the administration of Buprenorphine transdermal patches for a resident, leading to the application of two patches simultaneously. The resident, who had a history of neurogenic bladder and urinary tract infections, was found with two Buprenorphine patches on his skin when evaluated at a hospital for altered mental status. The resident had an order to apply one patch every seven days, but due to a delay in delivery, a second patch was applied without removing the first one. The incident occurred because the nurse who applied the second patch was unaware that the previous patch had not been removed. The facility's process for managing transdermal patches was not followed correctly, as evidenced by the lack of signatures on the narcotic patch placement form and the failure to verify the removal of the previous patch. Interviews with staff revealed that there was confusion about the availability and delivery of the medication, and the process for checking and removing old patches was not consistently followed. The director of nursing service acknowledged the incident and reported it to the South Dakota Department of Health. Despite the resident's history of UTIs, the hospital suspected that the altered mental status was due to the double application of Buprenorphine patches. The facility had not provided new education to all staff regarding the process for applying and removing transdermal patches, and there was no updated policy since the incident, indicating a gap in ensuring compliance with medication administration procedures.
Deficiency in Resident Transfer Safety and Supervision
Penalty
Summary
The report identifies a deficiency in the safety and supervision of a resident who required assistance during transfers with a sit-to-stand mechanical lift. The resident, who had a history of stroke resulting in weakness in the left leg and arm, was involved in an incident where he was dropped in the shower room, leading to a head injury and a hospital visit. Despite the care plan indicating the need for two staff members to assist with the lift, observations revealed that only one staff member was often present during transfers, which compromised the resident's safety. Interviews with staff members, including CNAs and LPNs, highlighted a lack of awareness and adherence to the care plan. One CNA admitted to transferring the resident alone, believing he required only one assist, while another staff member was unaware of the resident's discomfort and fear of using the lift. The resident expressed concerns about the lift's safety, indicating that it caused discomfort and fear during transfers. Despite these concerns, the lift continued to be used without proper reevaluation or adjustment to the resident's needs. The facility's failure to ensure proper documentation and communication of the resident's transfer needs contributed to the deficiency. The Kardex, which contained updated care instructions, was not consistently checked by staff, leading to improper transfer methods. Additionally, the facility's fall prevention policy was not effectively implemented, as evidenced by the lack of timely updates to the care plan and inadequate staff training on the use of mechanical lifts. This oversight resulted in the resident's fall and subsequent injuries, highlighting a significant lapse in the facility's duty to provide a safe environment for its residents.
Deficiencies in Food Storage and Sanitation
Penalty
Summary
The provider failed to ensure proper storage, labeling, and cleanliness of food items in the kitchen and kitchenette areas. Observations revealed multiple instances of unlabeled and undated food items, including cookies, butter, peanut butter, and various items in the walk-in refrigerator and freezer. Additionally, spoiled food items such as celery and salad were found, and some items were past their discard dates. The kitchen environment was unsanitary, with hardened substances on a metal cart, crumbs and substances on equipment like the Magic Bullet, and a lack of soap in the hand-washing sink. The serving area outside the kitchen also exhibited deficiencies, with food crumbs and debris between equipment, and unlabeled and undated food items such as cookies and blueberries. The refrigerator in this area contained expired and spoiled items, including thickened water and a salad labeled for a resident. The kitchenette in the 500-wing had similar issues, with unlabeled and undated food items, and expired thickened juices. The review of cleaning logs showed incomplete cleaning tasks, with many tasks left uncompleted over several weeks. The director of dining services acknowledged the issues, including the lack of awareness about the empty soap dispenser and the incomplete cleaning logs. The provider's policies on date marking and cleaning schedules were not adhered to, contributing to the deficiencies observed.
Failure to Update Care Plan After Catheter Removal
Penalty
Summary
The provider failed to update the care plan for a resident after the removal of her catheter. The resident, who was moderately cognitively impaired, confirmed during an observation and interview that she no longer had a catheter. However, her care plan still indicated the need for Enhanced Barrier Precautions due to an indwelling Foley catheter, which had been initiated months earlier. The resident's electronic medical record showed that the catheter was discontinued, and subsequent assessments confirmed its absence, yet the care plan was not updated to reflect this change. Interviews with facility staff, including a registered nurse and a certified nurse assistant, revealed that the care plan had not been revised to remove the catheter information. The RN responsible for updating care plans acknowledged that the care plan should have been updated and indicated that the nurse manager should have communicated the change. The facility's policy emphasizes the importance of care plans in coordinating services based on individual needs, but this was not adhered to in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 97 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sioux Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Norton | 0.6 mi | — | 21 | 0 |
| Bethany Home Sioux Falls | 0.9 mi | ★★★★★ | 3 | 0 |
| Good Samaritan Society Sioux Falls Village | 2.4 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society Sioux Falls Center | 2.8 mi | ★★★★★ | 19 | 0 |
| Dow Rummel Village | 2.9 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.