Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 - St Martin Village during CMS and state inspections, most recent first.
A resident developed significant bruising and swelling on her left hand and forearm of unknown origin, which was not present during a prior family visit. The family was not notified of the injury, and the incident was not reported to the SD DOH as required by facility policy. Staff confirmed that the injury was not related to a recent lab draw and that proper notification procedures were not followed.
A resident with left-sided hemiplegia developed extensive bruising and swelling to her left hand and forearm of unknown origin, which was first noticed by family and later documented by a medical provider. Despite facility policy requiring prompt reporting and investigation of injuries of unknown origin, the LPN did not notify a supervisor, and no investigation was initiated or documented. Staff interviews confirmed that the required procedures were not followed, and no actions were taken to prevent recurrence.
A resident with a history of falls and on anticoagulant therapy sustained a head injury after a fall. Although a nurse performed a physical assessment and checked vital signs, required neurological checks were not completed or documented, both immediately after the incident and upon the resident's return from the hospital, contrary to facility policy.
The facility failed to support residents' bathing preferences due to staffing shortages, affecting seven residents. Despite preferences for more frequent baths, residents often received fewer baths than desired. EMR and care plans did not consistently reflect these preferences, and grievances were not adequately resolved. Staff interviews revealed that CNAs were responsible for baths when bath aides were unavailable, but reassignments led to missed baths.
Two residents' care plans were not updated to reflect their current needs. One resident experienced worsening depression without appropriate counseling interventions, while another had outdated care plan entries related to resolved conditions. Staff interviews revealed a lack of timely updates to care plans, contrary to facility policies.
The facility failed to provide adequate staffing, resulting in delayed call light responses and unmet personal care needs for residents. Many residents did not receive their preferred number of baths, and grievances highlighted extended wait times for assistance. Staff interviews confirmed that the facility was short-staffed, impacting the quality of care provided.
The facility failed to properly document and manage controlled medications for several residents. Observations showed missing signatures and dates on Controlled Drug Records for medications like lorazepam and morphine sulfate. Additionally, the destruction of fentanyl patches was not consistently documented or witnessed by authorized personnel, as required by policy. Interviews with staff confirmed these deficiencies, highlighting a lack of adherence to established procedures for medication management.
A registered nurse in an LTC facility failed to maintain a medication error rate below 5%, resulting in a 10.71% error rate. The nurse administered diclofenac sodium gel to two residents without using the provided dosing card and gave vitamin C to a resident without a physician's order. Interviews revealed that staff did not consistently use the measuring device, contrary to facility policy and manufacturer guidelines.
The facility failed to properly label and date medications for residents, monitor medication room temperatures, and dispose of expired items. Medications for residents were not labeled with names or opening dates, and medication rooms lacked temperature monitoring. Additionally, medications brought by families were not properly labeled, violating facility policies.
A facility failed to notify a physician about unavailable medications for a resident, as required by policy. The resident's orders for Benefiber tablets and Citracal Plus were not fulfilled due to unavailability, and the physician was not informed. Additionally, another resident's vital signs were not consistently monitored every six hours as ordered, due to a lack of awareness and documentation issues. Staff interviews revealed communication gaps regarding medication orders and vital sign monitoring.
The facility failed to properly assess and document the use of assist/grab bars for several residents, including those with cognitive impairments. Routine assessments were not completed, and education on risks versus benefits was lacking. Observations showed residents with bed rails without proper documentation, and staff interviews revealed a lack of adherence to facility policy.
A resident with a mood disorder did not receive adequate assessment and intervention for worsening depression. Despite a physician's recommendation for counseling, the facility failed to provide a male counselor as requested and did not explore alternatives. The resident's depression worsened, with no documented follow-up actions by social services or communication between nursing staff and the physician.
The facility failed to adhere to infection control practices, as staff did not consistently wear gowns when caring for residents on transmission-based precautions. Additionally, handwashing sinks in two residential units were not properly cleaned, with visible lime build-up and residue. Interviews revealed a lack of adherence to PPE policies and uncertainty about cleaning responsibilities.
The provider failed to ensure a secure environment by silencing alarms on two egress doors, leading to a resident eloping from the facility. The resident was outside for six minutes in cold weather before being found by a nurse. Observations revealed that the alarm volume was not loud enough, and the adjusted setting allowed the alarm to silence once the door closed during specific hours. Staff did not follow the elopement checklist, and there was no documentation of staff education on the checklist.
Failure to Report Injury of Unknown Origin and Notify Family
Penalty
Summary
The provider failed to follow its policy for reporting injuries of unknown origin to the South Dakota Department of Health (SD DOH) and to the resident's representative. During a family visit, a resident was found to have significant bruising and swelling on her left hand and forearm, which was not present during a previous visit. The family was not notified of the injury, and digital photographs taken by the family documented the extent of the bruising. Review of the resident's electronic medical record and interviews with staff confirmed that the injury was first documented in a medical provider's note, which stated that no definitive cause for the injury was found. The injury was not related to a recent lab draw, as that procedure was performed on the resident's right arm. Staff interviews revealed that it was the responsibility of the LPN to notify the resident's family and a nurse supervisor or administrator about the injury, especially since the cause was unknown. However, this notification did not occur, and the injury was not reported to the SD DOH as required by the facility's abuse and neglect policy. The policy specifically mandates notification of designated agencies and the resident's family in cases of suspected abuse, neglect, or injury of unknown origin, and that such notifications be documented. The administrator confirmed that these procedures were not followed in this instance.
Failure to Investigate and Document Injury of Unknown Origin
Penalty
Summary
The provider failed to ensure that an investigation was completed and documented for a resident who developed significant bruising and swelling to her left hand and forearm of unknown origin. The resident, who had a history of hemiplegia due to stroke, dysphagia, congestive heart failure, anxiety, and insomnia, was noted by her family to have no visible injuries during a visit, but upon their return a few days later, they observed extensive bruising and swelling. Digital photographs confirmed the presence of purple and black bruising extending from the fingers to the forearm. The injury was first documented by the medical provider, who noted the resident was unable to recall the cause, and staff speculated about possible causes, including a blood draw, which was later ruled out as it was performed on the opposite arm. Despite the identification of the injury, there was no documentation to support that an investigation had been initiated to determine the cause or contributing factors. The LPN who first documented the injury did not report it to a nurse supervisor, and as a result, no investigation was started. The facility's policy required that injuries of unknown origin be promptly reported and thoroughly investigated, but this process was not followed in this case. Interviews with staff, including the LPN, physical therapist, infection preventionist, and administrator, confirmed that the required procedures for reporting and investigating injuries of unknown origin were not adhered to. The lack of investigation meant that no actions were taken to prevent recurrence, and the provider's own policy for abuse and neglect, which mandates prompt reporting and investigation of such events, was not implemented.
Failure to Perform and Document Neurological Checks After Resident Fall with Head Injury
Penalty
Summary
A resident with multiple complex medical conditions, including a history of repeated falls, dementia, cerebral infarction, and use of anticoagulant medication, experienced a fall in her room resulting in a head injury with significant bleeding. Upon discovery, a registered nurse performed a head-to-toe assessment and checked vital signs, but did not conduct or document a neurological assessment as required by the facility's policy. The resident was subsequently transferred to the hospital for treatment of a subdural hemorrhage and later returned to the facility, but neurological assessments were still not performed or documented upon her return. Facility policy mandates neurological evaluations following any fall with a head injury or unwitnessed fall, with specific intervals for ongoing checks and documentation. The administrator confirmed that nurses are expected to follow these protocols and acknowledged that no neurological exams were completed or documented for the resident after the incident. Review of the relevant policies further confirmed the requirement for neurological checks and documentation in such situations, which was not followed in this case.
Failure to Support Resident Bathing Preferences Due to Staffing Issues
Penalty
Summary
The facility failed to support residents' rights to choose and receive the frequency and type of shower or bath consistent with their preferences. This deficiency was identified for seven of the seventeen sampled residents. Interviews with residents and their family members revealed that residents were not receiving baths as frequently as they preferred, often due to staffing shortages. For instance, Resident 20, who had severe cognitive impairment, was scheduled for a bath weekly despite a preference for two or more baths per week. Similarly, Resident 13, who was cognitively intact, expressed a desire for more frequent baths but was told it was not possible due to insufficient staff. The facility's electronic medical records (EMR) and care plans did not consistently reflect the residents' preferences for bathing frequency. For example, Resident 306, who was cognitively intact, had a preference for two or more baths per week, but his care plan did not address this preference. Additionally, there were discrepancies in the documentation of bathing schedules, as seen with Resident 18, who was documented to have received a bath on a day she reported not receiving one. The facility's grievance records also indicated multiple complaints related to bathing preferences, with resolutions that did not always align with the residents' requests. Interviews with facility staff, including CNAs and the Clinical Care Leader, highlighted issues with the bathing schedule and staffing. Staff reported that when a bath aide was unavailable, CNAs were responsible for providing baths according to the schedule. However, there were instances when the bath aide was reassigned to other duties, leading to missed baths. The facility's policies emphasized the importance of accommodating resident preferences, but the implementation of these policies was inconsistent, contributing to the deficiency in supporting resident self-determination regarding bathing preferences.
Failure to Update Resident Care Plans
Penalty
Summary
The provider failed to ensure that the care plans for two residents were revised to reflect their current status and care needs. Resident 51, who was admitted after back surgery, experienced worsening depression and had requested counseling services. However, the care plan did not reflect any individualized accommodations or counseling service referrals, and interventions were not updated to address the resident's increased depressive symptoms. The social service director acknowledged that the interventions were generic and not person-centered, and there was a lack of follow-up on one-on-one visits. Resident 6's care plan was not updated after the resolution of a right heel wound and after she was taken off transmission-based precautions for COVID-19. The care plan still included outdated interventions related to enhanced barrier precautions and transmission-based precautions, which were no longer applicable. The MDS nurse and the clinical care leader/infection preventionist were responsible for updating the care plans but failed to do so in a timely manner, resulting in outdated and inaccurate care plans. Interviews with staff, including the director of nursing, revealed that care plan updating was expected to be an ongoing process and should occur anytime there was a change in resident condition or care needs. However, the care plans for both residents were not updated as required, leading to deficiencies in the facility's compliance with care plan policies. The facility's policies emphasized the need for individualized, person-centered care plans that reflect the current care required for each resident, but these were not adhered to in the cases of residents 51 and 6.
Staffing Deficiencies Lead to Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, resulting in multiple deficiencies related to resident care. Observations and interviews revealed that several residents experienced delays in call light responses, with some waiting up to an hour for assistance. This delay in response time was particularly problematic during nighttime hours and shift changes, leading to residents experiencing discomfort and unmet care needs. Additionally, grievances filed by residents and their families highlighted concerns about extended call light response times and inadequate assistance with personal care tasks such as bathing and toileting. The report also documented that many residents did not receive their preferred number of baths per week, with some going over a week without a bath. This was attributed to the facility being short-staffed, as confirmed by staff interviews. Residents expressed dissatisfaction with the frequency of their baths, and some reported feeling rushed during care. The facility's bathing schedule was not consistently followed, and the reassignment of bath aides to other duties further exacerbated the issue. Interviews with staff, including CNAs, LPNs, and the Director of Nursing, revealed that the responsibility for answering call lights and providing baths was shared among all staff members. However, the facility's staffing levels were insufficient to meet the residents' needs, as evidenced by the numerous grievances and documented instances of unmet care. The facility's assessment claimed appropriate staffing levels, but the experiences of residents and staff indicated otherwise.
Deficiencies in Controlled Medication Management
Penalty
Summary
The facility failed to ensure proper documentation and handling of controlled medications for several residents. Observations revealed that the Controlled Drug Records for residents did not include necessary signatures from nurses or pharmacy representatives to verify the receipt of medications. Specifically, records for medications such as lorazepam, pregabalin, morphine sulfate, tramadol, and buprenorphine lacked documentation of receipt dates and verifying signatures. This lack of documentation was confirmed by registered nurses during interviews, who acknowledged the incomplete records. Additionally, the facility did not accurately document the destruction of fentanyl patches for a resident. The process required two authorized individuals to witness and document the destruction of the patches, but records showed that this was not consistently done. Interviews with nursing staff revealed that the destruction process was not always followed according to policy, and there were instances where the destruction was not documented at all. The facility's policy required two nurses or a nurse and a medication aide to witness and document the destruction, but this was not adhered to in practice. The Director of Nursing and other staff members confirmed the expectations for handling controlled substances, including the need for proper documentation and adherence to policies for medication receipt and destruction. However, the facility's practices did not align with these expectations, leading to deficiencies in the management of controlled medications. The facility's policies outlined the procedures for medication acquisition, reconciliation, and disposal, but these were not consistently followed, resulting in incomplete records and potential risks associated with the handling of controlled substances.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The provider failed to maintain a medication error rate of less than 5 percent, resulting in a rate of 10.71 percent. This deficiency was observed during a medication administration session by a registered nurse (RN) who did not apply a topical pain medication, diclofenac sodium gel, according to the manufacturer's recommendations. The RN administered an unknown amount of the gel to two residents, one on the right lower chest and the other on multiple joints, without using the provided dosing card to measure the correct dose. The medication administration record (MAR) indicated specific dosages that were not adhered to, and the RN admitted to guessing the amount instead of using the proper measuring device. Additionally, the RN administered an oral medication, vitamin C, to one resident without a physician's order, acknowledging this as a medication error. Interviews with a licensed practical nurse (LPN) and the director of nursing (DON) confirmed that the measuring device for the diclofenac sodium gel was not used consistently by staff, despite being available and expected to be used as per the facility's policy and the manufacturer's guidelines. The facility's policy emphasized the importance of following the Six Rights of medication administration and performing three checks to ensure accuracy, which were not followed in these instances.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper labeling and dating of medications for residents, as observed during a survey. Medications for two residents were not properly labeled, and medications for four residents were not dated when opened. Specifically, a Levemir insulin pen for one resident was not labeled with the resident's name, and several medications, including Latanoprost eye drops and Breo Ellipta inhalers, lacked documentation of the date they were opened. This lack of labeling and dating made it difficult to determine the expiration of medications with shortened expiration dates. Additionally, the facility did not monitor the temperatures of two medication rooms, which is necessary for maintaining acceptable medication storage conditions. Although temperature logs for refrigerators were complete, there were no thermometers or temperature logs for the medication rooms themselves. Furthermore, expired nutritional supplements and medical supplies were found in both medication rooms, indicating a failure to routinely check for and dispose of expired items. The facility also failed to ensure that medications brought in by residents' families were properly labeled and reconciled. A Voltaren gel provided by a resident's family lacked a pharmacy label with dosage, instructions, or resident identification, making it impossible to verify administration information against the medication administration record. The facility's policies require medications to be labeled according to state pharmacy regulations and to be dated when opened, but these procedures were not followed, leading to deficiencies in medication management.
Failure to Notify Physician of Medication Unavailability and Incomplete Vital Sign Monitoring
Penalty
Summary
The provider failed to ensure that the physician was notified of medications not administered due to unavailability, as directed in the provider's policy, for a resident. The resident had a physician's order for Benefiber Oral Tablet Chewable for constipation, which was documented as unavailable 13 times in March. The medication aide documented the unavailability because the order was for a tablet, but only powder was available. Additionally, the resident had a physician's order for Citracal Plus Tablet, which was documented as unavailable on two occasions. Despite requests to the pharmacy, the medication was not available, and there was no documentation indicating that the physician was notified of the unavailability. Another deficiency involved a failure to follow a physician's order to take vital signs every six hours for a resident with an infection. The order was intended to monitor for changes in vital signs that could indicate a worsening infection. However, the vital signs were not consistently documented every six hours as ordered. The order was not linked to the electronic medical record's vital signs tab, leading to inconsistent documentation. The LPN responsible for entering the order was unaware of the requirement until informed during a shift report. Interviews with staff revealed a lack of awareness and communication regarding the medication orders and vital sign monitoring. The MDS nurse and LPN were not fully aware of the discrepancies in medication availability and vital sign documentation. The director of nursing expected physician orders to be followed and the physician to be notified if medications were not administered, but this did not occur. The facility's policies required notification of the physician if a medication was unavailable for 24 hours, but this protocol was not followed in these cases.
Deficiency in Assessment and Documentation for Bed Rail Use
Penalty
Summary
The facility failed to ensure proper assessment and documentation for the use of assist/grab bars (bed rails) for several residents. Specifically, routine assessments were not completed when the assist/grab bars were initiated and quarterly for four out of eight sampled residents. Additionally, there was a lack of signed consent for one resident with cognitive impairment and a power of attorney. Furthermore, education on the risks versus benefits of using assist/grab bars was not provided to five of the six sampled residents. Observations revealed that several residents had assist/grab bars in the upright position near the head of their beds without proper documentation or assessment. For instance, resident 33, with moderate cognitive impairment, had no documented attempted alternatives or barriers related to learning. Similarly, resident 26, also with moderate cognitive impairment, had no documentation reflecting education on the risks versus benefits of the assist/grab bars. Resident 6, who was cognitively intact, had no completed Physical Device and/or Restraint Evaluation and Review assessment. Interviews with facility staff, including the MDS nurse and the director of nursing, highlighted a lack of awareness and adherence to the facility's policy regarding the assessment and documentation of assist/grab bars. The MDS nurse was unaware of missing documentation, and the director of nursing expected licensed nurses to complete assessments prior to the application of assist/grab bars. The facility's restraint policy required a licensed nurse to determine if a device could be a restraint and to complete an evaluation and review, which was not consistently followed.
Failure to Address Resident's Mood Disorder
Penalty
Summary
The provider failed to adequately assess, document, and implement interventions for a resident with a mood disorder. The resident, who was admitted after back surgery, exhibited signs of depression, including a flat affect and feelings of imprisonment and loss of control. Despite a physician's recommendation for counseling due to worsening depression, the facility did not provide a male counselor as requested by the resident's spouse, nor did they explore alternative counseling options. The resident's depression was noted to have worsened since admission, and his anti-depressant medication was increased, but no further interventions were documented. The resident's electronic medical record indicated a history of depression, with a PHQ-9 score suggesting mild depression upon admission. However, subsequent physician notes highlighted the resident's poor appetite, feelings of worthlessness, and suicidal thoughts. Despite these concerns, there was no documentation of communication between nursing staff and the physician regarding these issues, nor was there evidence of follow-up actions by the social services department to address the resident's mood disorder. Interviews with staff revealed a lack of awareness and action regarding the resident's psychological needs. The social services staff did not engage directly with the resident to understand his preferences for counseling, and there was no documentation of efforts to monitor or improve his mood state. Additionally, the facility's interdisciplinary meetings focused primarily on weight loss rather than addressing the resident's quality of life issues, contributing to the oversight of his mental health needs.
Infection Control and Environmental Cleanliness Deficiencies
Penalty
Summary
The provider failed to follow proper infection control practices and precaution interventions, particularly in the use of personal protective equipment (PPE) for three residents who were on transmission-based precautions (TBP) or enhanced barrier precautions (EBP). Observations revealed that staff did not consistently wear gowns when providing care to these residents, despite the presence of signs and care plans indicating the need for gowns and gloves. Interviews with the residents confirmed that staff only wore gloves during care, and staff interviews revealed a lack of adherence to the facility's PPE policy. Additionally, the cleanliness of handwashing sinks in two residential living units was not maintained. Observations of four handwashing sinks showed white lime build-up, soap residue, and unidentified brown substances that could be removed with a fingernail. Staff interviews indicated uncertainty about the cleaning responsibilities and frequency, despite a checklist indicating that these sinks should be cleaned daily by housekeeping staff. The facility's infection preventionist and administrator expressed expectations that staff should follow the PPE policy and that handwashing sinks should be cleaned daily. However, the observations and interviews demonstrated a gap between these expectations and the actual practices, leading to deficiencies in infection control and environmental cleanliness.
Failure to Ensure Secure Environment and Adequate Supervision
Penalty
Summary
The provider failed to ensure a secure environment by silencing alarms on two of eight egress doors located on the north and south units. A resident eloped from an alarmed door, but the alarm was silenced when the door closed. The resident was outside the facility for six minutes in temperatures in the 40s, wearing only a light jacket. The resident had no history of elopement and was found by a nurse going to lunch. Observations revealed that the east egress door on the south unit and the north egress door on the north unit had a setup that included a camera, an alarm sounds sign, a keypad requiring a numerical code, and a push bar to activate the door. The alarm would sound when the door was opened without using the keypad but would silence once the door closed. The volume of the door alarms was not loud enough for staff to hear if they were on the opposite side of the unit. Additionally, the adjusted setting was implemented for convenience, allowing the alarm to silence once the door closed during specific hours. Interviews with staff and administrators revealed that door checks were done weekly, and it was the responsibility of the nursing staff to check the individual resident's WanderGuard function. However, when the resident exited the facility, staff did not follow the elopement checklist. The administrator confirmed that staff were educated on the checklist, but there was no documentation of that education. The adjusted setting time frame was more convenient for resident family members to enter the facility without using the front entrance, but it compromised resident safety.
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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 Rapid City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fountain Springs Healthcare | 2.5 mi | ★★★★★ | 11 | 0 |
| Clarkson Health Care | 3.1 mi | ★★★★★ | 1 | 0 |
| Avantara Mountain View | 3.1 mi | ★★★★★ | 10 | 0 |
| Avantara Arrowhead | 3.4 mi | ★★★★★ | 20 | 0 |
| Avantara North | 3.5 mi | ★★★★★ | 2 | 0 |
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