Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Sioux Falls Center during CMS and state inspections, most recent first.
A CNA verbally abused three residents during nighttime care interactions. One resident with moderate cognitive impairment and end-stage renal disease reported that the CNA responded to his call light with profanity and a hostile attitude when he requested help after a bowel movement. Another cognitively intact resident with multiple sclerosis stated that when she requested a female staff member to assist her into bed, the CNA became upset, left, and slammed her door, and she later heard the CNA arguing with a third resident who was crying. That third resident, who had quadriplegia and a colostomy, reported that the CNA did not know how to empty his colostomy bag, refused to get help from another staff member, shouted at him in a non-English language, and left the room, after which the resident was found crying and expressing emotional distress.
Staff did not ensure that four residents received regular weekly bathing and hygiene care according to facility expectations and resident needs. One resident with CHF and hypothyroidism was found in a room with a strong urine odor, urine‑stained bedding, and signs of poor hygiene, and records showed more than three weeks between documented baths without any refusals. Three other residents reported or demonstrated missed baths, with documentation revealing gaps of 14 to 21 days between baths or showers and no recorded refusals. During a period when the full‑time bath aide was on vacation, the DON and administrator stated that weekly baths were expected and that coverage was planned, but the bath aide reported residents sometimes did not receive baths when she was reassigned, and staffing schedules showed multiple weekdays with no staff assigned to provide baths, despite a policy emphasizing bathing for hygiene, comfort, observation, and safety.
The facility failed to control smoking-related hazards and provide required supervision for multiple residents who smoked. Several residents assessed or care planned as needing supervision, smoking aprons, and in one case oxygen removal before smoking, were allowed to access the courtyard and front entrance areas to smoke without staff knowledge or direct oversight. A resident with MS, paraplegia, intellectual disability, and moderately impaired cognition, who had a prior unsafe smoking incident and was care planned to be accompanied by staff, went to the courtyard at night with another resident who knew the door code; his hat brim contacted a lit cigarette, causing smoldering and singeing of his beard and facial areas before staff were informed. Other residents, including those using power wheelchairs and one on oxygen, reported or were observed smoking independently in the courtyard with only intermittent visual checks from staff inside, or outside the front doors without signing out or notifying staff, while keeping their own lighters despite care plan directions. Staff interviews and observations showed inconsistent enforcement of smoking rules, incomplete or outdated Tobacco Use Evaluations, and care plans that did not align with actual practice, resulting in inadequate supervision of residents who required monitored smoking.
A resident slipped from a wheelchair, complained of left hip pain, and a portable X-ray later confirmed a left intertrochanteric femur fracture. The DON and administrator, who were responsible for incident reporting, knew that a confirmed hip fracture diagnosed by an in-house X-ray constituted a serious bodily injury requiring notification to the SD DOH within 2 hours, per the facility’s abuse and neglect policy. However, they delayed reporting and instead submitted the Facility Reported Incident several hours later, applying a 24-hour reporting standard tied to outside medical attention rather than the 2-hour requirement for serious bodily injury.
Unsafe food handling and unsanitary dining conditions were observed throughout the kitchen, kitchenette, and dining rooms. Staff were seen using the same gloves while touching phones, refrigerator handles, menu cards, utensils, and ready-to-eat foods, and one cook did not fully cover his beard or hair. Food temperature monitoring was incomplete, and a sampled breakfast tray showed eggs and gravy below safe serving temperatures. Surveyors also found dirty tables, food debris, sticky surfaces, unclean sinks and equipment, reused plate covers, and meal service that did not match the menu.
A facility failed to complete and provide written baseline care plans to four newly admitted residents within 48 hours of admission. The residents had intact cognition and reported not receiving medication lists or copies of their baseline care plans, with one resident also describing poor communication about wound care, positioning, diet, and another reporting miscommunication between therapy and nursing about discharge goals. The DON stated the plans had been completed but not provided, and the facility policy required a baseline care plan and written summary upon admission.
A facility failed to provide nourishing, palatable meals that matched resident diet orders, preferences, and textures. Residents reported cold hot foods, dry foods, repeated cold sandwiches for supper, and limited choice, while the DDS acknowledged menu items were substituted for ease of preparation and that the menu did not match what was served. Staff also reported menu cards were often not updated, and during breakfast service CNAs had to correct most prepared trays before they were served.
Meals did not consistently match resident diet orders, allergies, or stated preferences. Residents reported cold, repetitive, and unappealing food, missing menu items, and limited choices, while records showed incomplete diet cards and notification forms that omitted allergies, supplements, and preferences. Staff also described frequent tray corrections, menu mismatches, and occasions when the kitchen ran out of requested items or served substitutions that did not align with the resident’s needs.
Infection control practices were not followed when clean lift slings were left on the floor or touching the floor in a clean storage room, a sit-to-stand lift had an unknown substance buildup where residents place their hands, and a ceiling hole in a clean storage area was leaking water into a plastic bin. Staff interviews confirmed the slings were still used even after touching the floor, and the infection prevention specialist acknowledged the leaking ceiling was an infection control concern.
A resident with incontinence, an open wound, and multiple comorbidities experienced repeated delays in staff response to call lights, sometimes waiting over an hour for assistance. These delays resulted in the resident remaining in soiled conditions, contributing to emotional distress and discomfort. Facility records and staff interviews confirmed inconsistent expectations for call light response times, and the facility's policies requiring prompt assistance were not followed, resulting in neglect.
Staff initiated CPR on a resident with a documented DNR order after relying on incorrect verbal confirmation of code status from other staff, rather than verifying the advance directives binder or EMR as required by facility policy. The DNR order was only discovered after CPR had begun and EMS arrived.
Failure to Provide and Document Bathing for Two Residents: Two cognitively intact residents who required staff assistance with bathing did not receive bathing as scheduled, and the EMR lacked documentation of showers, bed baths, or refusals. One resident with paraplegia, MS, and pressure ulcers reported only bed baths since admission, while the other reported only one shower and wanted more frequent bathing. Staff and the DON confirmed bathing and refusals should have been documented, but records did not show the required bathing occurred.
Air mattress did not fit bed frame and blocked use of assist bar. A resident with a stage II pressure ulcer and normal cognition used an air mattress for pressure relief and assist bars for turning and mobility in bed. The mattress extended beyond the bed frame, prevented use of the open-side assist bar, and staff placed a bedside table against the bed at night to keep her away from the edge. The DON was unaware of the fit issue, maintenance staff said the setup was not safe, and the bed/side rail inspection log was reported as inaccurate.
The facility failed to ensure proper food labeling and storage, maintain dishwashing temperatures, and enforce hand hygiene practices. Observations revealed unlabeled food items in the walk-in cooler, dishwashing temperatures below the required 120°F, and dietary staff not washing hands between tasks. These actions violated the facility's policies on food storage, dishwashing, and hand hygiene.
A facility failed to follow infection control practices during G-tube administration and did not implement contact precautions for a resident tested for C-Diff. An LPN did not change gloves between tasks and used unsanitized surfaces, while staff were unaware of the need for C-Diff precautions, leading to inadequate infection control measures.
The facility failed to discard expired medications, with seven bottles of expired aspirin found in the medication cart and storeroom. CMAs confirmed the oversight, and the DON expressed frustration over missing these during monthly checks. The facility's policy requires routine checks and proper labeling of medications.
The facility failed to provide meals that met the dietary preferences and needs of residents, as observed during two meal services. A resident on a heart-healthy diet expressed concerns about meal appropriateness, and another resident did not receive the ordered meal without being informed or offered an alternative. Dietary cards were not used, leading to uniform meal service regardless of individual needs. Breakfast service was delayed, with missing menu items and unavailable condiments, highlighting a lack of coordination in meal delivery.
Failure to Protect Residents From Verbal Abuse by CNA
Penalty
Summary
Non-compliance at F600 occurred when the provider failed to protect three residents from verbal abuse by a CNA. On the night of 3/3/26, a resident with moderate cognitive impairment, an above-the-knee amputation, and end-stage renal disease requiring dialysis activated his call light after a bowel movement. When the CNA responded, he reportedly displayed a bad attitude and asked the resident, using profanity, what he wanted. The resident became angry and told the CNA to leave his room. This interaction was later reported by the resident to an LPN. Around the same time, another cognitively intact resident with multiple sclerosis activated her call light for assistance getting into bed. When the CNA arrived, she requested a female staff member to help her. The CNA became upset, left the room, and slammed the resident’s door. The resident reported hearing the CNA arguing with a third resident across the hall and hearing that resident crying shortly thereafter. The third resident, who had moderate cognitive impairment, quadriplegia, and a colostomy, had requested assistance with emptying his colostomy bag. The CNA did not know how to perform the task, and when the resident asked him to find another staff member to help, the CNA refused to seek assistance. The CNA then began shouting at the resident in a non-English language and left the room. The resident was later found crying by the LPN and expressed emotional distress, including apologizing for being alive and feeling like a burden. These events were reported to the administrator, and an investigation confirmed the residents’ allegations of verbal abuse by the CNA.
Failure to Provide Scheduled Weekly Bathing and Hygiene Care
Penalty
Summary
Staff failed to provide scheduled bathing and hygiene care to four sampled residents over the months of February and March 2026. One resident was observed with a strong urine odor emanating from his closed room, with the smell intensifying when the door was opened. His bed contained large urine stains on the sheets and incontinence pad, and he appeared not to have bathed in some time, with dry, flaky skin and greasy, tangled hair. He reported needing assistance with bathing and expressed a desire to bathe more than once per week, noting that Thursdays were his scheduled bath days. His care plan identified an ADL self-care performance deficit related to CHF and hypothyroidism, with interventions indicating he required assistance of one staff member for bathing and personal hygiene, but the care plan did not document his bathing or showering preferences or frequency. Record review showed that this resident received a whirlpool bath on 2/24/26 and then not again until 3/19/26, indicating a 23‑day gap without a documented bath, bed bath, or shower, and there were no documented refusals during this period. Another resident reported missing showers in recent weeks, explaining that the bath aide had been gone for two weeks and that he also missed a bath due to an appointment; he stated he felt "gross" before being bathed on 3/18/26. His records showed a whirlpool bath on 2/18/26 and the next on 3/18/26, a 16‑day interval without documented bathing or refusals. A third resident stated he did not always receive baths as scheduled and that sometimes there was no bath aide available; his documentation showed a whirlpool bath on 2/20/26 and then a bed bath on 3/6/26, a 14‑day gap without documented bathing or refusals. A fourth resident’s bathing record showed a shower on 2/24/26 and the next on 3/17/26, a 21‑day period without a documented bath, bed bath, or shower and no documented refusals. The interim DON stated residents were to receive a bath each week and that when the full‑time bath aide was on vacation, CNAs were assigned to provide scheduled baths. The administrator also stated he expected residents to receive a weekly bath and that there was a plan to ensure this when the bath aide was on vacation, though he did not specify the plan. The bath aide reported she was responsible for bathing 14 residents per day, that residents were scheduled for baths Monday through Friday, that she was on vacation from 2/23/26 through 3/8/26, and that when she was reassigned to CNA duties, residents did not receive baths. Review of the staff schedule for the bath aide’s vacation period showed that on five of ten weekdays no staff member was assigned to provide resident baths, despite a facility bathing policy emphasizing cleanliness, hygiene, circulation, comfort, observation of resident condition, assistance with personal care, and safety.
Failure to Supervise Resident Smoking and Control Smoking Hazards
Penalty
Summary
The deficiency involves the facility’s failure to ensure a smoking environment free from accident hazards and to provide adequate supervision for residents who required supervision while smoking. Multiple residents who smoked were assessed or care planned as needing supervision, smoking aprons, and in some cases removal of oxygen prior to smoking, yet they were routinely allowed to access smoking areas or leave the building to smoke without staff knowledge or direct oversight. Residents knew door codes to both the courtyard and front entrance, used those codes without informing staff, and smoked in locations and at times outside the designated supervised smoking periods. Staff interviews confirmed that residents commonly kept their own cigarettes and lighters, that some refused to store lighters at the nurses’ station despite care plan directions, and that residents went out the front doors to smoke without notifying staff or signing out. One resident with multiple sclerosis, paraplegia, intellectual disability, moderately impaired cognition (BIMS 11), and a prior history of burning clothing was care planned to require a smoking apron, supervision, and staff accompaniment when smoking. His tobacco assessment documented prior unsafe smoking behavior and the need for supervision and adaptive equipment. Despite this, he was able to go to the enclosed courtyard at night with another resident who knew the door code, without informing staff. While wearing a brimmed hat and attempting to smoke, the hat brim contacted the lit cigarette, began smoldering, and singed his beard and facial areas. Camera footage showed that the two residents remained outside to finish smoking and only reported the incident to the RN after returning inside, at which time a skin assessment revealed reddened but intact skin on his head and face. Other residents who were assessed or care planned as requiring supervision while smoking also smoked without adequate supervision or adherence to facility protocols. One cognitively intact resident, assessed as needing a smoking apron and supervision, was observed outside the front door in his power wheelchair picking up cigarette butts with a reacher, without having signed out and without staff present. Another resident, also assessed as needing supervision and a smoking apron, reported smoking in the courtyard or outside the front doors whenever he wanted, keeping his cigarettes and lighter with him and not informing staff or signing out. Additional residents, including one on oxygen and others with intact cognition but care plans requiring supervision and smoking aprons, described or were observed smoking in the courtyard with only intermittent visual checks from staff inside the activities room, or smoking outside the front doors in the evenings without staff awareness, sign-out, or consistent enforcement of lighter storage and supervision requirements. Staff interviews and observations further demonstrated inconsistent implementation of supervision expectations. Activities staff and CMAs acknowledged that residents 2 and 3 routinely went out the front doors to smoke without staff assistance, that most residents kept their own lighters despite some care plans directing storage at the nurses’ station, and that staff did not remain continuously at the courtyard door while residents smoked. During observed smoking periods, activities staff opened the courtyard door, then returned to desks behind a partition, performed other tasks, or only occasionally glanced out the window while multiple residents who required supervision smoked outside. In at least one instance, an activities assistant stood several feet from the door reading a book and intermittently left the doorway area while a resident smoked alone in the courtyard. The DON and MDS nurse both stated that residents 1, 2, 3, 4, 5, 7, and 8 required supervision when smoking in the courtyard, and that staff were expected to be outside with residents or at the window providing constant supervision, but observations and interviews showed that this level of supervision was not consistently provided. The facility’s documentation and assessment processes related to smoking also contributed to the deficiency. Tobacco Use Evaluations were not consistently completed quarterly or annually as described by the MDS nurse, with gaps noted for several residents, and some evaluations did not clearly specify the level of supervision required. Care plans documented that certain residents were independent with tobacco use while simultaneously listing interventions requiring supervision, smoking aprons, and removal of oxygen, creating inconsistencies between assessed needs and described independence. The DON acknowledged that the Tobacco Use Evaluation addressed smoking on facility property but did not address residents’ independent smoking off property, even though residents in power wheelchairs were leaving the building in cold weather to smoke without documented assessment of their safety in doing so. These combined assessment, care planning, and supervision failures led to residents who required supervision while smoking being unsafely allowed to smoke with inadequate staff oversight, culminating in at least one resident sustaining facial burns.
Failure to Timely Report Serious Bodily Injury to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely report a known serious bodily injury to the South Dakota Department of Health (SD DOH) within the required 2-hour timeframe. A resident slipped from her wheelchair onto her left hip and complained of left hip pain in the afternoon. A portable X-ray was obtained, and by early evening a registered nurse documented that the X-ray results showed a left intertrochanteric femur fracture, and the results were faxed to the physician. The resident’s family initially delayed transfer to the emergency department (ED) while they discussed options, and the resident was ultimately transferred to the ED the following morning, admitted to the hospital, and later died. The facility’s Facility Reported Incident (FRI) to SD DOH was not submitted until late that same morning. Interviews and policy review showed that the DON and administrator were responsible for reporting incidents to SD DOH and were aware that a confirmed hip fracture, even when diagnosed via portable X-ray in the facility, constituted a serious bodily injury that must be reported within two hours of the allegation or identification. The DON stated that reporting after outside medical attention was to occur within 24 hours, but also acknowledged that a confirmed hip fracture required reporting within two hours. The administrator reported he believed that because the resident did not receive outside medical attention immediately after the fall, the incident fell under the 24-hour reporting requirement. The facility’s Abuse and Neglect policy specified that any allegation involving serious bodily injury must be reported immediately, but not later than two hours after the allegation is made. Despite this policy and knowledge that a hip fracture is a serious bodily injury, the facility did not report the incident to SD DOH within the required 2-hour timeframe after the fracture was confirmed.
Unsafe Food Handling and Unsanitary Dining Conditions
Penalty
Summary
Food service practices were not followed in the kitchen, kitchenette, and dining areas, with multiple observations showing unclean food preparation and serving environments, improper hand hygiene and glove use, and incomplete food temperature monitoring. Surveyors observed dirty dishes left on tables in the main dining room while residents were present, food debris and grime on kitchen floors, sinks, counters, shelves, equipment, and walls, and unclean conditions in the rehab unit dining room and kitchenette, including sticky tables, spilled coffee, food crumbs on the floor, and a steam table containing dirty water and food particles. The kitchen hand-washing sink lacked paper towels, and the dish room sink contained food stains and debris. The facility’s food temperature logs were incomplete, and staff stated that food temperatures were taken on arrival from the central kitchen but not checked again after that initial check. A breakfast tray was later observed with scrambled eggs, gravy, milk, and coffee, and the recorded temperatures showed the eggs and gravy were below safe serving temperatures. Surveyors repeatedly observed kitchen staff handling food and food-related items with the same gloves while touching phones, refrigerator handles, menu cards, doors, utensils, and other nonfood surfaces. One food service worker washed his hands, then put on gloves and handled his phone with those gloves; he also did not have his facial hair covered. A cook wore a small chef beanie that did not cover hair below the ears and did not have his beard fully covered while preparing and serving food. Staff were observed using the same gloves while plating sandwiches, toast, cheese, buns, silverware, fruit, soup, and milk, and while touching menu cards, microwaves, refrigerator doors, and serving carts. One staff member removed gloves and put on a new pair without washing hands first, and another used bare and gloved hands together while serving soda and handling an ice scoop. The facility’s own policy described acceptable gloves as single-task, uncontaminated barriers, and staff interviews showed they could not consistently describe when gloves should be removed or when handwashing was required. Dining room service also showed repeated handling and reuse of items in ways that were not consistent with the observed food service practices. Menu cards containing resident diet orders, allergies, assistive device needs, and preferences were handled by staff with and without gloves, dropped and picked up from the floor, placed on meal trays, and returned to a dining room container. Plate covers were reused during meal service. In the rehab unit dining room, residents and CNAs reported dirty and sticky tables, and CNAs stated they had to check trays closely because kitchen staff frequently had issues following diet requirements and meal requests. The facility also served meals that did not match the posted menu, including substitutions such as sausage patties in place of ham or bacon, and the administrator acknowledged that residents were not notified of like-item substitutions. The report also noted that the only staff member with ServSafe Food Manager training was the DDS, and there were no plans for another employee to complete that training.
Failure to Provide Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The provider failed to complete a baseline care plan and provide a written summary of the baseline care plan to four of six newly admitted sampled residents within 48 hours of admission. Residents 14, 64, 67, and 85 all had BIMS scores of 15, indicating intact cognition, and there was no documentation in their EMRs showing that a baseline care plan had been developed and reviewed with them or that they had been provided or offered a copy within the required timeframe. Resident 14 stated he had not received a list of medications or a copy of his baseline care plan when admitted and was frustrated about communication regarding wound care, positioning needs, and diet. Resident 67 stated he had not received a medication list or baseline care plan and reported miscommunication between therapy and nursing about discharge goals. Resident 64 did not recall receiving a baseline care plan, and resident 85's record also lacked documentation that the baseline care plan had been developed, reviewed, or shared. The DON stated that baseline care plans had been completed but had not been provided to residents 14, 64, 67, and 85. The DON expected baseline care plans to be completed within 48 hours of admission and a copy to be provided to the resident, and identified MDS/RN U as responsible for completing them. MDS/RN U stated she normally initiated the comprehensive care plan on the day of admission, printed it, and provided a copy to the resident, but she had been on leave for approximately three weeks when these residents were admitted. She stated that residents 14, 64, 67, and 85's baseline care plans had been completed by MDS/RN T, but had not been provided to them or documented as completed. The facility policy stated that a baseline care plan must be developed upon admission and that the resident and resident representative must receive a written summary.
Failure to Serve Meals Consistent With Resident Diet Orders and Preferences
Penalty
Summary
The facility failed to provide three residents with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs. Two residents reported that hot foods were frequently served cold, and one resident stated that cold or dry foods were difficult to eat, especially because she had no teeth. One resident said she was often served cold sandwiches for supper, preferred warm evening meals, and was not aware of other food choices. Another resident reported that food was frequently very dry and that items that should have been served hot were more often cold than hot. During interviews, the director of dietary services acknowledged that the menu did not match the food served on multiple occasions, including breakfast items listed as ham or bacon being replaced with sausage patties because it was easier to cook and hold temperature. He also stated that cold food complaints were attributed to CNAs taking too long to deliver room trays and that cold sandwiches were served for many suppers because they were on the summer menu. A CNA reported frequent corrections were needed on meal trays even though kitchen staff had access to the same resident menu cards used by CNAs, and she stated that menu cards were frequently not updated by kitchen staff. The dietary process relied on resident menu cards containing diet orders, food textures, allergies, preferences, dislikes, and adaptive equipment needs, but multiple staff members described breakdowns in using that information. The DDS stated he was solely responsible for adding diet orders to the menu cards, while also saying CNAs were responsible for managing resident meal preferences. During breakfast observation, CNAs requested corrections on 14 of 15 prepared meal trays before service. The dietitian confirmed that kitchen staff were responsible for following the menu cards and agreed that documented temperatures on a sample tray did not meet safe food serving temperatures.
Meals Did Not Match Resident Diet Orders, Allergies, or Preferences
Penalty
Summary
The facility failed to provide meals that accommodated resident allergies, intolerances, ordered diets, and stated food preferences for multiple sampled residents. Eight residents were identified as dissatisfied with meal service because of food quality, temperature, repetition, limited choices, and meals that did not match their preferences or diet orders. The report describes repeated problems with residents receiving the same items, missing ordered foods, and trays that did not reflect the menu or the resident’s documented needs. One resident with diabetes, reflux, and pressure ulcers stated he had filled out menu choices but did not receive the foods he requested, was not asked about his preferences, and often received fried foods despite stating they affected his blood sugars. His records showed a consistent carbohydrate, high protein diet with Boost Glucose Control ordered, but the diet notification form and diet card did not include the high protein order, supplements, or food preferences. Another resident with diabetes, obesity, reflux, gall bladder surgery, and a corn allergy stated he did not receive the items he selected, often received substitute foods he could not eat, and had to order food from a restaurant when the facility ran out of the meal he requested. His diet notification form and diet card did not include his corn allergy or food preferences. Other residents reported cold food, repetitive menus, and lack of choices. One resident said supper was often cold and she was repeatedly served cold sandwiches, while another said food was frequently dry and hard to eat because she had no teeth. A resident who preferred room meals reported cold bratwurst served on a cold plate, and another said she had received chicken noodle soup for three consecutive meals because the fryer was broken. A resident who routinely ordered a cheeseburger and fries because he disliked the supper menu said his meal was forgotten on multiple occasions and that a CNA had to obtain food from a nearby restaurant when the kitchen was closed. Staff interviews and observations showed that meal cards were inconsistently updated, dietary staff did not meet with residents to discuss preferences, CNAs frequently had to correct trays for diet orders and allergies, and the kitchen sometimes served items that did not match the menu, including breakfast trays with sausage instead of the listed items.
Infection Control Lapses With Lift Slings, Lift Equipment, and Ceiling Leak
Penalty
Summary
The provider failed to ensure proper infection control practices were followed by allowing clean resident lift slings to lay on the floor, failing to properly clean a resident lifting device, and allowing water to leak from a ceiling in a storage closet. On 9/2/25, observation of a sit-to-stand lift showed an unknown substance build-up where residents would place their hands while being lifted. Observations in the clean storage room on the second floor on 9/3/25, 9/4/25, and 9/5/25 showed several lift slings lying on the floor and multiple slings hanging on the walls touching the floor, despite a posted sign stating that slings should not touch the ground. Staff interviews confirmed that slings were hung after laundry, were known to be touching the floor, and were still used even when they had been on the floor. In addition, observations in the main level clean storage room showed a hole in the ceiling with a black speckled substance around it and water dripping into a plastic bin; the infection prevention specialist stated the hole had been present since around May 2025 and acknowledged it was an infection control concern.
Failure to Protect Resident from Neglect Due to Delayed Call Light Response
Penalty
Summary
A resident with multiple medical conditions, including mixed incontinence, an open wound on the right buttock, spinal stenosis, morbid obesity, and mental health diagnoses, experienced prolonged wait times for staff response to call lights. The resident, who was bedfast and had a history of refusing some care, reported several instances where call lights were not answered for periods ranging from over 20 minutes to more than an hour. During these times, the resident was left incontinent of urine or bowel, which contributed to feelings of humiliation and discomfort. Documentation confirmed that the resident's call light was left unanswered for extended periods on multiple occasions, as evidenced by the facility's call light log and the resident's own statements during interviews. The resident's care plan indicated a need for significant assistance, including daily wound care and regular toileting, due to his risk for skin breakdown and incontinence. Despite these needs, staff interviews revealed inconsistent expectations regarding timely call light response, with some staff expecting a two-minute response and others considering 20 to 30 minutes as prompt. The resident's medical record also showed a Braden score indicating mild risk for skin breakdown and a BIMS score reflecting intact cognition, supporting the resident's ability to accurately report his experiences. Facility policies required prompt response to call lights and protection from neglect, but the documented delays in responding to the resident's requests for assistance resulted in the resident remaining in soiled conditions for extended periods. Staff interviews acknowledged the resident's distress and the impact of delayed care, while administrative staff provided varying definitions of what constituted an appropriate response time. These actions and inactions led to the resident experiencing neglect, as defined by the facility's own policies and regulatory standards.
Failure to Withhold CPR for Resident with DNR Order
Penalty
Summary
Facility staff failed to withhold cardiopulmonary resuscitation (CPR) for a resident who had a documented do not resuscitate (DNR) order. The resident was found unresponsive by a restorative nursing aide, and the Director of Nursing (DON) initiated the facility's code blue process. CPR was started based on verbal confirmation from a certified nursing assistant (CNA) and a registered nurse (RN) that the resident was a full code, without first verifying the resident's code status in the advance directives binder or electronic medical record. The DNR order was only discovered after CPR had already been initiated and emergency medical services (EMS) had arrived. Interviews revealed that staff were trained to check the advance directives binder and the resident's electronic medical record to confirm code status before starting CPR, as per facility policy. However, in this incident, the CNA and RN provided incorrect verbal information regarding the resident's code status, and the DON relied on this information rather than verifying the DNR order. The facility's policy required confirmation of code status prior to initiating CPR, but this step was not followed, resulting in CPR being performed on a resident with a valid DNR order.
Failure to Provide and Document Bathing for Two Residents
Penalty
Summary
The provider failed to ensure bathing was provided and documented for two residents who were dependent on staff assistance with bathing. One resident was admitted with paraplegia, multiple sclerosis, and pressure ulcers, had intact cognition, and had a care plan calling for a shower chair and 2 staff assist. He stated he had not received a shower since admission and had only received bed baths, which he felt were not thorough, and he wanted his hair washed. Review of the EMR showed no documentation that he had received a shower, tub bath, whirlpool bath, sponge bath, shampoo only, or that he was unavailable or refused bathing since admission. A second resident, also cognitively intact, stated she had only received one shower since admission, wanted more showers because her hair felt dirty and her skin felt very dry, and believed showers were not offered because she required more assistance than staff could provide. Her care plan indicated bathing with a shower chair and 1 staff assist, and her bathing documentation showed only one shower. There was no documentation that she had received a tub bath, whirlpool bath, sponge bath, shampoo only, or that she was unavailable or refused bathing since admission. The bath schedule showed that new admissions were required to receive a bath the day after admission and that both residents were scheduled for bathing twice weekly on evening shift. The first resident had not been provided bathing on multiple scheduled dates after admission, and the second resident had not been provided bathing on multiple scheduled dates after admission. Staff interviews confirmed that showers or refusals were expected to be documented in the EMR, that the first resident had been allowed to shower if wound dressings stayed dry, and that the second resident had been allowed to shower if her dialysis port dressing was covered. The DON stated there was no documentation that the first resident had received a bed bath or shower and that refusals should have been documented.
Air mattress did not fit bed frame and blocked use of assist bar
Penalty
Summary
The facility failed to ensure that an air mattress safely fit resident 44’s bed frame and did not interfere with the use of assist bars. Resident 44 had a stage II pressure ulcer and had been using an air mattress for several months for pressure relief. During observation, her air mattress extended approximately five inches over the open side of the bed frame, and the mattress was covered with a smooth nylon cover designed to be used without a bottom sheet. She reported that she had been afraid of falling out of bed and that the arrangement disturbed her sleep. Resident 44’s bed had assist bars attached to both sides, but she was only able to use the wall-side bar. She previously used the open-side assist bar for turning and getting up from bed, but it could no longer be used because the air mattress was larger than the bed frame. Staff placed the long side of her bedside table against the bed at night to remind her not to get too close to the edge. The resident had a BIMS score of 15, indicating normal cognition, and her care plan included use of assist/grab bars for positioning and mobility in bed as well as an air mattress for pressure relief. The DON stated she had created the work order for the air mattress and was not aware of any issue with the mattress size or that the open-side assist bar could not be used. Maintenance staff agreed the mattress did not fit properly and was not safe, and they stated the resident could slide out of bed and onto the floor. The bed and side rail inspection log documented inspection of mattress gaps and side rail function, but the lead maintenance mechanic stated the log was not accurate. The administrator also stated that an assessment was required to ensure proper fit of the mattress to the bed frame and resident safety, and that the assessment completed by maintenance was not accurate.
Deficiencies in Food Storage, Dishwashing, and Hand Hygiene
Penalty
Summary
The provider failed to ensure proper food labeling and storage in the kitchen's walk-in cooler. Observations revealed multiple opened food items, such as mayonnaise, BBQ sauce, Dijon mustard, coleslaw dressing, balsamic vinegar, tuna salad, whipped topping, and blue cheese, without appropriate open or discard dates. Additionally, opened containers of milk and heavy whipping cream were found without open or discard dates. These findings indicate a lack of adherence to the facility's food and supply storage policy, which requires labeling and dating of unused portions and open packages. The dishwashing machine's water temperature was not maintained at the required minimum of 120 degrees Fahrenheit for effective cleaning and disinfecting of dishes. Observations and testing showed that the wash cycle temperatures ranged from 113 to 120 degrees Fahrenheit, with some days lacking documented temperatures. Dietary staff were unsure of the policy for obtaining dishwasher temperatures, and the kitchen general manager noted that the dishwasher rarely reached the required temperature. This failure to maintain proper dishwashing temperatures is contrary to the facility's dishmachine temperatures policy. Dietary staff, including the dietary director and a cook, did not perform appropriate hand hygiene during meal service. The dietary director was observed handling eggs and egg shells with gloves, then touching resident plates and food without changing gloves or washing hands. Similarly, the cook handled eggs and bacon with the same gloves, without washing hands between tasks. Both staff members were uncertain about the facility's hand hygiene policy, which mandates handwashing after glove removal. These actions demonstrate a failure to adhere to the facility's hand hygiene policy, compromising food safety and sanitation.
Infection Control Deficiencies in G-Tube Administration and C-Diff Precautions
Penalty
Summary
The provider failed to ensure proper infection control practices during the administration of nutritional formula and fluids through a gastric tube (G-tube) for a resident. An LPN was observed performing several tasks without changing gloves, such as retrieving items from a medication cart and moving a chair, and did not sanitize the overbed table before placing supplies on it. The LPN also failed to check the placement of the G-tube before administering water and used gloves stored in a pocket with keys and a pen, which compromised the sterility of the procedure. Additionally, the provider did not implement appropriate contact precautions for a resident tested for Clostridium difficile (C-Diff). There was no signage on the resident's door indicating the need for contact precautions, and specific trash or laundry bins were not provided in the room. Staff members, including a registered nurse, laundry technician, and environmental services technician, were unaware of the resident's C-Diff testing and the necessary precautions, leading to a lack of proper infection control measures. The facility's policies on C-Diff and standard transmission-based precautions were not followed. The policy required informing all department directors when a C-Diff infection was identified, using appropriate personal protective equipment (PPE), and cleaning with a sporicidal disinfectant or bleach solution. However, these measures were not implemented, and the cleaning product used was not effective against C-Diff. The DON confirmed that contact precautions should have been initiated when the order for testing was received.
Expired Medications Not Discarded
Penalty
Summary
The facility failed to ensure that expired medications were appropriately discarded, as observed during a survey. On the medication cart for city view residents and in the second-floor medication storeroom, seven bottles of expired aspirin were found. Specifically, two of the three bottles of 325 mg aspirin in the medication cart were expired, with expiration dates of January and February 2024. Additionally, four out of eleven bottles of 81 mg chewable aspirin in the storeroom cupboard had expired in May 2024. Certified Medication Aides (CMAs) confirmed the expiration dates and acknowledged that medications should be checked for expiration before administration. The Director of Nursing expressed frustration over missing the expired medications during her monthly checks of stock medications in the carts and storeroom. She emphasized that all staff responsible for administering medications should check expiration dates before giving them to residents. The facility's medication policy, dated March 29, 2024, requires routine checks for expired medications and their disposal according to state and pharmacy regulations. It also mandates that all medications be labeled with cautionary instructions and expiration dates, with new labels applied by a pharmacist or their agent as needed.
Failure to Meet Residents' Dietary Preferences and Needs
Penalty
Summary
The facility failed to provide meals that met the dietary preferences and needs of residents, as observed during two meal services. Resident 335, who was supposed to be on a heart-healthy diet, expressed uncertainty about the healthiness of her meals, citing an instance where she received macaroni and cheese, pork and beans, a bun, and dessert, which she did not consider heart-healthy. Additionally, she noted that staff were reluctant to retrieve forgotten items from the main kitchen, such as ketchup. During a meal observation, all residents received the same meal, and dietary cards indicating individual dietary needs and preferences were not utilized. Resident 33, who had ordered chicken strips, fries, and coleslaw, was served a different meal without prior notice or an alternative being offered. Further observations revealed that during breakfast service, the food was brought to the dining room without staff present to serve it, resulting in delays. The menu items served did not match the listed menu, with missing items such as fruit cups and whole wheat toast. Condiments were also unavailable, and dietary server H did not use dietary cards to ensure residents received the correct meals. Residents 33 and 71 experienced delays in receiving their meals, which were left on the counter until reheated by CNA R. CNA G was unable to retrieve requested brown sugar for residents 46 and 335 due to other duties, highlighting a lack of coordination and communication in meal service delivery.
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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 Sioux Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dow Rummel Village | 0.8 mi | ★★★★★ | 6 | 0 |
| Bethany Home Sioux Falls | 2.2 mi | ★★★★★ | 3 | 0 |
| Good Samaritan Society Luther Manor | 2.8 mi | ★★★★★ | 11 | 0 |
| Avantara Norton | 3 mi | — | 21 | 0 |
| Avera Prince Of Peace | 4.3 mi | ★★★★★ | 13 | 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.