Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 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.
Failure to Review and Offer Baseline Care Plans Within 48 Hours: The facility did not document that baseline care plans were reviewed with the resident or representative and a copy offered within 48 hours for three newly admitted residents. The DON stated one resident’s care plan copy was not available, and the lead social services coordinator said baseline care plans were typically reviewed at the admission care conference, usually 7 to 14 days after admission, and she did not know the 48-hour requirement.
Failure to Follow Hand Hygiene and Glove Use Practices: An LPN, RNs, and CNAs did not follow HH and glove-use practices during wound care, medication administration, and meal assistance. Staff entered resident rooms or provided care without HH, reused unclean gloves during care, and failed to perform HH after removing gloves and before donning clean gloves. The DON and Clinical Care Leader confirmed HH should occur before and after resident contact, after glove removal, and during medication passes.
A resident with moderately impaired cognition had Cortisone 10 and Hempvona cream kept at the bedside and used them without a self-administration assessment or physician order. Staff confirmed no medications were to be left in the room, the care plan did not show self-administration, and the DON verified there was no assessment or order authorizing the creams to be stored and used in the room.
PRN lorazepam was administered to a resident multiple times without documentation of the specific indication for each dose or whether non-pharmacological interventions were attempted first. The resident’s order allowed a range of doses for anxiety and dyspnea, but no parameters guided dose selection, and staff stated they used judgment to choose the dose for agitation or nighttime restlessness. The DON stated she expected attempted non-pharmacological interventions to be documented before PRN anxiety medication was given and expected the lowest ordered dose to be tried first.
Failure to implement a PT-recommended walk-to-dine program for a resident who was supposed to ambulate to meals with a FWW while staff followed with a wheelchair and gait belt. Instead, the resident used his wheelchair to and from meals, and staff did not offer the planned assistance. The EMR showed the walk-to-dine approach in the care plan, but RN/CNA interviews showed uncertainty about the program, and the DON stated the recommendation was not added to the care plan, so the caregiver task was never populated.
Unsecured, unlabeled, and expired medications were found on medication carts and in a medication storage room. An RN left pre-poured meds unattended on top of a cart in a hallway, an opened inhaler was not dated, and expired meds and supplies were present on the north unit cart and in the storage room. The DON stated meds were not to be pre-poured and left unattended, expired items were to be removed, and opened meds were to be labeled by the nurse who opened them.
A resident on a physician-ordered gluten-free diet was not given adequate dietary education or menu choices, and the menus did not list gluten-free substitutes for items crossed out as allergies. Staff also did not provide an early breakfast or a ready-to-eat meal before the resident left for a morning medical appointment. The resident had recently returned from a hospital stay for a small bowel obstruction, and the RD and dietary manager documentation did not show that his diet change, food preferences, or education needs were fully addressed.
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 Review and Offer Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to ensure that the baseline care plan was reviewed with the resident or the resident’s representative and that a copy was offered within 48 hours of admission for three newly admitted residents. Review of the electronic medical record for resident 9 showed admission to the facility on [DATE], but there was no documentation that the baseline care plan was reviewed with the resident or representative or that a copy was offered within 48 hours. A copy of resident 9’s baseline care plan was requested from the facility on 7/29/26, and the DON later stated that a copy was not available. Review of the records for residents 3 and 12 also showed admission to the facility on [DATE], with no documentation that either resident’s baseline care plan was reviewed with the resident or representative or that a copy was offered within 48 hours of admission. The lead social services coordinator stated that baseline care plans were started by the MDS nurse or clinical care leader upon admission, but she reviewed and offered the care plan during the admission care conference, which usually occurred seven to fourteen days after admission. She acknowledged there was no documentation that residents 3 or 12 had their baseline care plans reviewed and offered within 48 hours, and stated she did not know the regulation required this to occur within that timeframe.
Failure to Follow Hand Hygiene and Glove Use Practices
Penalty
Summary
Infection prevention and control practices were not followed during multiple resident care activities involving hand hygiene and glove use. During a dressing change for a resident with a right knee wound, an LPN entered the room without performing hand hygiene, put on gloves, removed the soiled bandage, discarded the gloves, and then put on a clean pair of gloves without performing hand hygiene before applying the new bandage. After removing the second pair of gloves, the LPN washed her hands in the resident’s bathroom sink, had difficulty obtaining paper towels, used a hand towel from the counter to dry her hands, turned off the faucet with her dry hand, and then applied ABHS before leaving the room. The LPN stated she was expected to perform hand hygiene each time she put on clean gloves during the bandage change. An RN did not perform hand hygiene before wound care for a resident with a back bandage, and during medication administration another RN did not perform hand hygiene before preparing or administering medications for several residents. One RN administered medications to one resident, returned to the medication cart without hand hygiene, typed on the computer, then prepared and administered medications to another resident without hand hygiene. The same RN later prepared medications for another resident without hand hygiene, administered them, returned to the cart, and typed on the computer. The RN also prepared and administered insulin to another resident without hand hygiene before preparing the medication, and while wearing the same gloves handled the insulin pen, opened the medication cart, returned the pen, and typed on the computer before removing the gloves and not performing hand hygiene. During the noon meal service, two CNAs did not perform hand hygiene when removing soiled gloves and putting on clean gloves while assisting a resident to eat. One CNA removed unclean gloves, repositioned next to another resident’s wheelchair, and put on clean gloves without hand hygiene before continuing to assist the resident with eating. Another CNA removed unclean gloves, retrieved a box of gloves from the dining room counter, and put on clean gloves without hand hygiene. The DON and Clinical Care Leader stated that handwashing should occur before and after resident contact, after bodily fluid contact, before and after glove use, and before and after each resident during medication passes, and the facility policy stated that gloves are not a substitute for hand hygiene.
Unassessed Self-Administration of Topical Medications
Penalty
Summary
Failure to allow resident self-administration of medications only after clinical determination and proper authorization occurred for one sampled resident who had Cortisone 10 and Hempvona cream on his bedside table. During an observation and interview, the resident stated he used the Cortisone 10 for facial itching and the Hempvona cream for discomfort, and he did not know whether staff knew he had them. A later observation again found both creams in the room. The resident’s EMR showed he was admitted to the facility, had a BIMS score of 12 indicating moderately impaired cognition, and had no medication self-administration assessment completed to determine whether he could safely self-administer the observed creams. The resident’s care plan did not indicate that he self-administered medications, and there was a physician’s order for Hempvona cream to be applied topically PRN but no physician’s order for Cortisone 10 cream. Staff interviews confirmed there was no order for self-administration of the Hempvona cream and that no medications were to be left in the resident’s room. The Clinical Care Leader stated the process for self-administering medications was not followed because the resident was not assessed, no physician’s order was obtained for self-administration, and the medications were not secured. The DON also confirmed there was no self-administration assessment or order for the creams to be stored and administered in the room, and the Hempvona cream was removed from the room.
PRN Lorazepam Given Without Documented Indication or Non-Pharmacological Interventions
Penalty
Summary
The nursing facility failed to ensure that care plan interventions were attempted and documented, and failed to document the indication for administration of a PRN lorazepam order for one resident. The resident was admitted with a physician order dated 5/1/26 for lorazepam 0.5 mg, one to four tablets every two hours as needed for anxiety and dyspnea, with no parameters to guide which dose should be given. The resident’s psychotropic medication consent listed lorazepam, identified the symptom as drowsiness, and did not list any non-pharmacological alternatives as attempted. The resident’s MAR showed multiple administrations of lorazepam between 5/8/26 and 7/28/26, with doses ranging from 0.5 mg to 2 mg. For each documented administration, the record did not state what symptom or behavior prompted the dose, and it did not document whether non-pharmacological interventions had been attempted before the medication was given. Each dose was documented as effective. During interview, RN E stated the resident screamed and became restless in the evening and that non-pharmacological interventions were not always effective in managing his behaviors. During a phone interview, RN D stated she gave the resident lorazepam for agitation and to calm him down when he became ramped up at night. She stated she did not document non-pharmacological interventions or the reason for administration because the order indicated the medication was for anxiety, and she chose the dose within the ordered range based on her judgment. She also stated she did not start with the lowest dose first and had not received guidance on which dose to give. The DON stated she expected non-pharmacological interventions attempted for the resident’s behavior to be documented before PRN anxiety medication was administered and expected the lowest dose to be tried first when a range of doses was ordered.
Failure to Implement Walk-to-Dine Program
Penalty
Summary
The provider failed to implement a PT-recommended walk-to-dine program for a resident who was supposed to use a front-wheeled walker to walk to and from the dining room with staff following behind him with a wheelchair and gait belt. During observation and interview, the resident stated he used his wheelchair to get to breakfast because staff were too busy to follow behind him while he walked with his walker, and he said the purpose of using the walker was to keep his strength up. A dry-erase board in his room also indicated assist x1 with a FWW and gait belt for mobility needs. Repeated observations during meal services showed the resident sitting in his wheelchair in the dining room and using his wheelchair to travel to and from meals, while staff did not offer to walk behind him with a wheelchair as the walk-to-dine program directed. The resident's EMR showed a revised care plan entry for ambulation to walk to dine with staff following with a wheelchair and gait belt, and OT confirmed therapy had recommended walk-to-dine after discharge from therapy services. RN and CNA interviews showed uncertainty about whether the resident was on the program, and the DON stated the process failed because she did not add the recommendation to the resident's care plan, which would have populated the task on the caregiver list.
Unsecured, Unlabeled, and Expired Medications Found
Penalty
Summary
Drugs and biologicals were not properly labeled, securely stored, or kept free of expired items in the facility’s medication storage areas and on medication carts. On the south unit, a registered nurse left pre-poured medications unattended on top of a medication cart in a hallway near the dining room, where residents, unauthorized staff, and visitors could access them. The nurse stated she had prepared the medications and left them there while she went to another room. On the north unit, a medication cart contained an opened Trelegy Ellipta inhaler that was not dated and a box of Bisacodyl suppositories that had expired. In the medication storage room, four Universal Viral Transport for Viruses containers and approximately half a box of Banatrol Plus packets were also expired. During observation and interview, Clinical Care Leader C and an LPN confirmed the expired medications and supplies and acknowledged they should be removed. The DON stated that medications were expected not to be pre-poured and left unattended, that expired medications and supplies were to be removed from carts and storage rooms, that medications were to be checked for expiration before administration and as needed, and that medications were to be labeled by the nurse who opened them. Facility policy also stated that medications must be stored in locked compartments, expired medications must be routinely checked and disposed of according to regulations, and multi-use medications such as inhalers must have an open date written on the label.
Gluten-Free Diet Education, Menu Substitutions, and Early Breakfast Not Provided
Penalty
Summary
The facility failed to provide dietary staff with initial and ongoing education related to a physician-ordered gluten-free diet for a resident who had been hospitalized in April 2026 for treatment of a small bowel obstruction likely due to dietary indiscretion. After the resident returned from the hospital, the registered dietitian documented that the diet order had been changed to gluten-free, but there was no indication that the resident was met with to discuss the change. The former dietary manager completed a post-hospital Food and Nutrition Data Collection assessment on 4/15/26, but the section for resident-specific food likes, dislikes, and preferences was left blank, and the education section did not show that the resident had been instructed about the new diet order. No follow-up assessments were completed after that date. During meal observations and menu review, the resident was given menus labeled gluten restricted, but the menus did not provide gluten-free alternatives for items the resident could not have. At breakfast, pancakes were listed on the main menu and were crossed out with the word “ALLERGY,” but no gluten-free substitute was listed. At lunch, sweet potato fries were crossed out in the same way, again without a gluten-free replacement on the menu. At dinner, breaded cauliflower was crossed out and marked “ALLERGY,” with no gluten-free option listed. The resident stated he did not understand the pancake restriction because he had made and eaten pancakes during a therapy session, and the occupational therapist confirmed that a gluten-free pancake mix had been used in therapy after the resident’s hospital discharge. The resident also did not receive an early breakfast before a morning medical appointment. On the morning of the appointment, he was observed leaving in his wheelchair, and neither kitchen staff nor a caregiver had offered him breakfast early or provided a ready-to-eat breakfast item to take with him. Food service staff stated they relied on the former dietary manager or receptionist to notify them of appointment schedules, and they were not aware of the resident’s appointment. The senior director stated that appointment information was discussed daily in interdisciplinary meetings and that staff were expected to use that information to meet residents’ nutritional needs on appointment days.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 61 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near 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 | ★★★★★ | 11 | 0 |
| Avantara Arrowhead | 3.4 mi | ★★★★★ | 13 | 0 |
| Avantara North | 3.5 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.