Good Samaritan Society Sioux Falls Village

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The nursing home failed to ensure that a gait belt was used when a CNA assisted a resident with ambulation to the bathroom, and the resident fell and sustained a broken femur. The incident report stated that the resident was walking with a front-wheeled walker and receiving contact guard assistance from CNA AA, but no gait belt was used. During the walk to the bathroom, the resident lost her balance, fell, and suffered an elbow abrasion and a femur fracture that required surgery. The resident had been admitted with diagnoses including COPD, dementia, and repeated falls, with a history of traumatic brain injury. Her BIMS score was 13, indicating intact cognition, and her fall assessments reflected varying levels of risk, including a moderate risk score on 6/1/26 and a low risk score on 6/23/26. Her care plan stated that for toileting and transferring she required one staff member to assist in a pivot transfer using a gait belt, wheelchair, or sit-to-stand lift as needed. Interviews showed differing understanding among staff about when a gait belt was required. The CNA stated she used the resident's walker because she knew the resident used one, but did not know whether a gait belt was needed. The DON, RN/clinical nurse leader, therapy staff, and other CNAs all described reliance on the care plan or Kardex to determine assistance needs, while the provider's gait-transfer belt policy stated gait belts should be used with assisted ambulation unless medically contraindicated. The resident and family member reported that the resident used a walker for short trips to the bathroom and that the staff did not always use a gait belt when assisting her.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The provider failed to ensure staff responded promptly to residents’ call lights for 12 of 31 sampled residents who reported extended wait times for assistance. Multiple residents stated that call lights were not answered in a timely manner, and call light response reports documented repeated delays, including numerous responses over 20 minutes, over 30 minutes, over 40 minutes, over 50 minutes, over 60 minutes, and in some cases over 90 minutes or more. The facility’s call light policy stated that the purpose was to ensure residents always have a method of calling for assistance and to promptly answer resident call lights. Resident 13 reported that call lights were not answered in a timely manner, and the response report for that resident showed 20 responses over 20 minutes, with several much longer, including one over 90 minutes. Resident 59 said he sometimes waited at least 30 minutes and occasionally called the facility phone number to get help; his report showed 10 responses over 20 minutes and one response of 150 minutes. Resident 164 said she had waited up to 20 minutes and sometimes urinated before help arrived; her report showed two responses over 20 minutes. Resident 21 reported a call light left on for over an hour and later found shut off without anyone asking what she needed; her report showed one response of 127 minutes. Other residents described similar delays and the reports reflected the same pattern. Resident 27 had 92 responses over 20 minutes and 29 over 60 minutes. Resident 85, who had a tracheostomy and needed extensive assistance, reported long waits and her report showed three responses over 20 minutes. Resident 14, who had chronic pain, quadriplegia, and required two staff for repositioning and transfers, reported waiting hours at times; her report showed 23 responses over 20 minutes and one response of 112 minutes. Resident 73, who was legally blind and needed assistance with most care, reported waiting 45 minutes; his report showed four responses over 20 minutes. Resident 119, who required extensive assistance with toileting and used a total lift, reported his call light was on for a long period and his report showed 18 responses over 20 minutes and 6 over 30 minutes. During observations and interviews, staff described expected response times ranging from two to ten minutes, while the DON stated she expected call lights to be answered within 20 minutes. Staff also reported that radios were not consistently available or used, and some staff in resident rooms were not aware when other residents’ call lights were activated.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Medications were not securely stored in three observed medication carts. On 6/30/26, an opened bottle of liquid Amoxicillin-Pot Clavulanate oral suspension for resident 181 was left on top of a medication cart in the 700 hallway outside resident 75's room with no staff present. During the time it remained there, CMA X, an activities assistant, and two unidentified visitors walked past the cart. Clinical care leader S later removed the antibiotic and stated RN V had been assigned to that cart and had left the medication there; RN V acknowledged she had forgotten to return the antibiotic to the refrigerator after leaving the cart. Resident 181 had a physician's order for Amoxicillin-Pot Clavulanate oral suspension via NG tube for acute cystitis without hematuria. On 7/1/26, RN FF was observed preparing medications for residents 47 and 150 and left a bottle of Polyethylene Glycol and a bottle of Fluticasone nasal spray on top of the medication cart while she walked into the dining room to administer medications. RN FF stated she left the Fluticasone nasal spray there so she would not forget to give it to resident 89, who was eating, and said the Polyethylene Glycol bottle was not supposed to be left unsecured. On 7/2/26, RN/clinical nurse leader I and CMA Z were observed with an unlocked medication cart in the 200 hallway with no nurse or medication aide attending it, and the drawers were easily opened. CMA Z stated she thought she had locked the cart. The DON stated medications were expected to be locked in the cart and not left unattended, and refrigerated medications were expected to be returned to the refrigerator after use.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The provider failed to protect a resident's right to dignity and respect when an RN told the resident to "stop talking" during a conversation about his medications. During observation on 7/1/26 at 8:44 a.m., the resident was sitting in his wheelchair in the hallway and asked the RN what time he should be getting his medications and what he would receive. The RN responded that the medications were at 8:00 a.m. but she was behind, then told the resident, "I'm behind, and this isn't the time, so stop talking." The resident remained in the hallway and waited until the RN administered his morning medications at 8:50 a.m. Resident 145 was admitted to the facility on [DATE] and had a BIMS score of 12 on 6/3/26, indicating moderately impaired cognition. His diagnoses included dependent personality disorder, anxiety disorder, obsessive-compulsive disorder, malignant neoplasm of the brain, and schizoaffective disorder, bipolar type. His care plan directed staff to use communication techniques that enhanced interactions, allow adequate time for him to respond, repeat as necessary, not rush him, request feedback clarification, face him when speaking, make eye contact, and explain all procedures, treatments, and medications. Interviews with a CNA, the RN, the DON, and the administrator all identified dignity as treating residents with respect, listening to concerns, and not telling a resident to stop talking.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The provider failed to follow standard food safety practices when an LPN assisted four residents with the evening meal in the 400-hall dining room without performing hand hygiene between resident contacts. During the observation, the LPN placed a spoon in one resident’s hand, touched his leg and shoulder, added pudding to his plate, handed another resident silverware and bowls, fed a spoonful of food to a third resident, and assisted a fourth resident with supper while touching the resident’s clothing protector, wheelchair, thumb, fork, and cranberry juice glass. RN QQ stated that hand hygiene was expected to be completed in between helping residents eat their food, and the infection preventionist also stated that staff were expected to perform hand hygiene in between assisting residents to eat in the dining room. The provider also failed to ensure that a cook with a beard wore a hairnet over his beard while preparing food in the main kitchen. The cook was observed preparing raw chicken and later preparing food at a food preparation table without a hairnet covering his beard, and he acknowledged that he was not wearing one and should have been. The systems chef stated that staff with beards were expected to have them covered with a hairnet anytime they were preparing food. The facility’s Employee Hygiene and Dress Code policy stated that hairnets or hair restraints and beard nets or beard restraints are used when cooking, preparing, assembling food or ingredients, including dish room and storage areas, and a kitchen entry sign stated that hair restraints are required at all times in the kitchen.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The provider failed to ensure infection prevention and control practices were followed when one CMA and one CNA provided care to a resident on enhanced barrier precautions (EBP) without wearing gowns and without performing hand hygiene at required times. During observation, the resident’s door displayed an EBP magnet, and the two staff members entered the room wearing gloves but no gowns while they provided care, including placing an incontinence brief, repositioning the resident, situating pillows, handing the resident a tablet and phone, brushing her hair, and handling garbage and used linens. The staff removed gloves and changed gloves during the care but did not perform hand hygiene each time gloves were removed, and the CMA later sanitized hands only after leaving the room and placing the garbage and dirty linens in the dirty utility room. The resident involved admitted to the facility on 10/27/25, had a BIMS score of 15 indicating intact cognition, and had diagnoses including kidney stones and quadriplegia. She had a right-sided nephrostomy tube and required two staff members for repositioning, dressing, personal hygiene, and transfers with a total body lift. Her care plan directed staff to don gowns and gloves for high-contact care activities, including dressing, bathing, transferring, hygiene, changing linens, repositioning, device care and use, and wound care. The DON stated staff were expected to wear gowns and gloves during all high-contact resident care for residents on EBP, as indicated by the magnet on the resident’s door frame.

Penalty

Inspection fine: $7,718

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with Alzheimer's disease and dementia, who had a moderate cognitive impairment, received a burn on her abdomen from hot coffee. The incident occurred when the coffee machines and dispensers were found to be above the temperature set by the facility's policy guidelines. The resident's care plan was revised to address her impaired ability to manage hot beverages and soups, noting her tendency to enter the serving area and her need for supervision while drinking hot beverages. The facility's policy on hot liquids required that self-service hot liquids be at or below 150 degrees Fahrenheit and that the area be supervised. However, the coffee machines were not calibrated to maintain the appropriate temperature, leading to the resident's burn. The incident highlighted a lapse in monitoring and regulating the temperature of hot beverages, which was not in compliance with the facility's policy at the time of the incident.

Penalty

Inspection fine: $9,424

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involved a failure to provide adequate care to a resident, specifically in terms of neglect by a certified nursing assistant (CNA). The incident occurred when a resident did not receive a shower or toileting assistance as outlined in her care plan. The resident was left without these essential care services during a day shift, despite documentation by CNAs F and G indicating that the resident had been repositioned and checked for voiding throughout the day. However, camera footage contradicted these records, showing that the resident was not showered or assisted to the restroom as required. The resident in question had a severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 00, and had multiple medical diagnoses, including Type 2 diabetes, dementia, and chronic kidney disease. Her care plan required staff to reposition her every two hours and offer toileting assistance, which was not adhered to on the day of the incident. Interviews with staff revealed that CNA F was unaware of the need to check and change residents during her shift, despite having received training and having prior experience in similar roles. Further investigation revealed discrepancies in the documentation of care provided to the resident. CNA F falsely documented that the resident had been repositioned and checked for voiding at specific times, which was not supported by camera footage. The registered nurse on duty, RN C, also noted inconsistencies in CNA F's reports and observed that the resident did not appear to have been showered. This neglect of care was reported to the unit manager, highlighting a significant lapse in the facility's adherence to the resident's care plan and the expectations set for CNAs.

Penalty

Inspection fine: $22,055

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The report details a deficiency involving the elopement of a resident with severe cognitive impairment from a long-term care facility. The resident, who had a history of elopement and was assessed as a high risk for elopement, managed to leave the facility without staff knowledge. The resident was wearing a wander guard, a device intended to prevent such incidents, but there was no documentation of its functionality being checked as required. The elopement was not immediately detected, and the resident was found outside the facility and returned after a significant delay. Another deficiency involved a resident with cognitive impairment and a history of falls who was found on the floor, naked and covered in feces, after a call light went unanswered for an extended period. The resident had a history of falls and required assistance for all activities of daily living. Despite this, the call light system, which should have alerted staff to the resident's needs, was not responded to in a timely manner. The resident's care plan did not adequately address her high fall risk, and staff failed to anticipate her needs, leading to multiple falls. Interviews with staff revealed a lack of awareness and adherence to policies regarding resident safety and monitoring. Staff were not consistently checking the functionality of safety devices like wander guards, and there was a failure to respond to call lights promptly. The facility's policies on monitoring high-risk residents and ensuring their safety were not effectively implemented, contributing to the deficiencies observed.

Removal Plan

• A message was sent to all employees that summarized the education summary of elopement. This serves as the immediate education for all employees. If staff are not able to complete education, they will be required to complete the make-up prior to their next shift.
• RN S was educated on the process for calling DON/Administrator immediately when resident safety is at risk-including elopements. The nurse was also educated on the next step of the policy to initiate a head count of all residents when a door alarm is sounded with no explanation.
• Certified nursing assistant (CNA) T was noted to have missed a toileting round of resident 3. This would have decreased the time of the residents' elopement. The CNA T received a final corrective action for lack of rounding during this shift. This standard will be upheld for any employees that are found to have failed to complete their rounding as ordered/recommended.
• All staff were educated on the importance of rounding on all residents multiple times a shift. Residents with high fall and elopement to chart in the hallways so residents can be in eye site.
• All staff were educated on utilizing our call system as all exit doors are on the call system to notify all staff if an exit door is alarm on the scrolling screen and the radios.
• Assessment of resident was completed, and vital signs taken.
• An elopement drill was completed with day shift. Education was provided to staff involved with elopement.
• A potential elopement alert was initiated due to a phone call from someone in the community stating a resident was outdoors near [NAME] Road. Staff responded to code and facility did head count and everyone was accounted for.
• Hallway and department education is being completed with all staff regarding elopement processes and policy review. Elopement policy/procedure was reviewed, explained what an elopement is, who is considered an elopement risk, steps to take when a potential elopement occurs, who to notify if a resident does elope and how to respond to door alarms and completing head counts if no residents were found when alarm was responded to.
• Resident 3's physician was out to facility and updated again on recent elopement events. Resident 3's physician ordered lab work-up on him as this an increase in his normal behaviors. He also would like an update on how he is doing.
• Elopement Drills will be completed weekly x4. These will be completed on shifts, different days of the week and different locations within the building. Then every other week x 4 weeks.

Penalty

Inspection fine: $22,055

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The provider failed to ensure that medications were administered as ordered for a resident, leading to multiple deficiencies. The resident, who had a history of myocardial infarction, type 2 diabetes mellitus, and nausea, was prescribed Midodrine for hypotension and Zofran for nausea. However, the Midodrine was administered three times daily instead of the ordered twice daily, and there was no documentation regarding the medications found in the resident's room that were not taken. Additionally, the Zofran was administered earlier than the 12-hour interval ordered, without documentation of physician communication. The facility also failed to follow proper procedures for managing low blood glucose levels. The resident experienced a blood glucose level of 69, which should have prompted immediate physician notification and a recheck after 15 minutes, as per the facility's policy. However, the physician was not notified until later, and the repeated blood glucose level was checked 42 minutes after the intervention, not adhering to the 'rule of 15' for hypoglycemic incidents. Furthermore, the facility did not document the destruction of medications found at the resident's bedside, nor did they notify the physician that the resident had not received the medications as ordered. The facility's policies on medication administration, errors, and disposal were not followed, as evidenced by the lack of documentation and communication regarding the medication errors and the improper handling of the medications found in the resident's room.