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 Tyndall during CMS and state inspections, most recent first.
A resident with a mild Braden risk score, right-sided contracture, and hemiplegia developed an open area in the right antecubital space that progressed to a stage III and then stage IV pressure injury. The record lacked documentation showing when the old arm brace was applied or removed, and the care plan did not include implemented interventions to prevent the injury before it was identified. Staff interviews indicated weekly skin checks were done, but the DON was unaware of documented brace management or staff training specific to the old brace.
A facility failed to maintain a homelike environment when multiple resident rooms had peeling paint, exposed drywall, and wall damage, and two residents shared a bathroom without a door. Staff and maintenance were aware of the missing bathroom door and some room damage, but the repairs were not completed or scheduled, and maintenance documentation did not reflect the wall issues in several rooms.
Staff failed to answer call lights promptly for two residents who reported long waits for assistance. One resident said delayed responses led to two episodes of incontinence and that her longest wait was about an hour, while the other reported delays when requesting help and pain medication. EMR review showed both residents had intact cognition and required one-staff assistance with transfers and ADLs. Call-light reports documented multiple response times over 20 minutes, with the longest waits reaching 44 minutes and 27 minutes. Staff, the DON, and the administrator acknowledged that call lights should be answered as soon as possible, but delays occurred when staff were caring for other residents.
A resident with sleep apnea, COPD, and CAD had a physician order for CPAP at HS, but the CPAP mask repeatedly came unsnapped, had a tear, and was later documented as not staying connected by the clips and Velcro. The resident reported disrupted sleep and inability to tolerate the mask, while notes also showed the mask and tubing were left in the bathroom and the resident objected due to cross contamination concerns. Facility leaders were aware of the equipment problems, but no documentation of a replacement mask or confirmed replacement parts was found before survey exit.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed environmental risks and insufficient oversight, resulting in unsafe conditions for residents.
The facility did not fully investigate or document incidents of missing controlled medications, including Fentanyl patches, Tramadol, and Xanax, for several residents. Staff did not consistently follow procedures for medication destruction and narcotic count verification, and required two-person signatures were often missing. The DON relied on staff interviews without comprehensive documentation or pharmacy involvement, and there was no evidence that misappropriation was ruled out.
A resident with a history of schizophrenia and other chronic conditions expressed suicidal ideation and exhibited behavioral changes, which were observed and reported by staff. Despite these warning signs and documentation in the medical record, an LPN and an RN did not complete required suicide risk evaluations or update the care plan as per facility policy, only doing so after the resident engaged in self-harm.
Two residents in a LTC facility experienced falls due to inadequate fall prevention measures. One resident, admitted for rehabilitation, fell due to an inaccessible call light and high bed position. Another resident with multiple sclerosis and cognitive impairments fell in the bathroom after unhooking herself from a lift, with no supervision specified in her care plan. The facility failed to implement and document effective fall prevention interventions.
The facility failed to maintain infection control practices, with shared lift equipment found unclean and a RN not following hand hygiene protocols during medication administration. Observations showed buildup on stand aids, and the RN missed several hand hygiene opportunities, using unsanitized scissors to open a nutrition supplement packet.
A resident with cognitive impairments and a history of falls was not provided with updated care plan instructions for supervision during bathroom use, leading to a fall and injuries. Despite expectations for staff supervision, the care plan was not revised to reflect this need, and communication methods were insufficient to ensure staff awareness.
A potential insulin medication error was averted when a surveyor intervened during a medication administration. An RN prepared insulin pens for a resident, verified by an LPN, but the dose was altered before administration. The surveyor noticed the discrepancy, preventing the administration of an incorrect dose. Interviews confirmed the facility's policy of dual verification for insulin dosages.
Failure to Prevent Pressure Injury From Arm Brace
Penalty
Summary
The facility failed to implement pressure ulcer prevention interventions for a resident with a mild Braden Scale risk score of 15 who had spastic hemiplegia affecting the right dominant side, peripheral vascular disease, right-sided contracture, and a non-pressure chronic ulcer on the right upper arm. The resident was observed sitting in a recliner wearing a right arm brace, and she reported that she had previously had an open wound on her right arm that had healed. Her electronic record showed that she had developed an open area in the right antecubital space that was initially identified during a weekly skin assessment as moisture-associated skin damage. The wound in the right antecubital space measured 1.2 cm by 0.8 cm by 0.2 cm and was treated with a non-stick dressing. The resident’s record also showed physician orders for a brace to address extension and contracture, including an order for the brace to be placed on in the morning and removed at bedtime. However, there was no documentation on the treatment MAR showing when the old brace was applied or removed. The wound was later evaluated by the wound clinic, where it was measured as a full-thickness wound with exposed fat tissue and moderate drainage, and the wound clinic identified it as a stage III pressure injury. Subsequent wound clinic documentation later identified it as a stage IV pressure injury before it healed. The care plan identified the resident as having an actual and potential risk for pressure ulcer development due to increased need for assistance and right arm contracture, but it did not contain evidence of interventions implemented to prevent the antecubital pressure injury before it was identified. Staff interviews showed that weekly skin assessments were used to monitor for breakdown, that CNAs were expected to report skin concerns to nursing, and that nurses were responsible for applying and removing the brace, but the DON was unaware of documentation showing the old brace was managed on a schedule and was unsure who was responsible for putting it on and taking it off. The DON also stated there was no documented education specific to the old brace and no documented staff training in its application and removal.
Damaged Room Surfaces and Missing Bathroom Door
Penalty
Summary
The provider failed to maintain a safe, clean, comfortable, and homelike environment for residents in multiple rooms. Observation on 7/14/26 found resident 24’s room had peeling paint, more than five gouges in the drywall, and two exposed drywall areas. Observation on 7/14/26 also found resident 10’s shared room had a large area behind her recliner with more than five gouges, exposed drywall, and peeling paint. On 7/15/26, resident 44’s room had several areas of peeling paint and exposed drywall behind her recliner, plus more than five eight-inch areas of peeling paint and exposed metal on the heat register and more than ten scratches with peeling paint and exposed drywall by the window. The bathroom door was also missing from the shared room of residents 18 and 32. During observation and interview on 7/14/26, both residents stated the door had been removed a few days earlier for repair and had not been replaced. Resident 18 said she sometimes used the bathroom in an empty room across the hall if she wanted a door, and resident 32 said staff tried to pull the curtain around resident 18’s bed and close the bedroom door when she used the bathroom. On 7/16/26, CNA H confirmed the bathroom door was still absent and stated resident 32 preferred to use the bathroom in the empty room across the hall because she wanted a bathroom with a door. Maintenance mechanic J stated he was aware the bathroom door had been removed for repair but the repair was not finished and he was unsure when it would be rehung. He also stated he was unaware of the exposed drywall and peeling paint in residents 10, 24, 35, and 44’s rooms and found no maintenance requests for those areas on the clipboard. Administrator A acknowledged awareness of the damaged drywall, peeling paint, and missing bathroom door, and said the wall repairs were not scheduled. Review of the maintenance request sheets showed no documentation for the wall damage in residents 10, 24, 35, and 44’s rooms, and the only bathroom-door entry noted the door was falling apart and a new one was coming.
Delayed Response to Resident Call Lights
Penalty
Summary
The provider failed to ensure staff responded promptly to resident call lights for two residents who reported extended wait times for assistance. One resident stated that call lights were often answered slowly, especially because her room was at the far end of the hallway, and she reported two episodes of incontinence because staff did not respond in time. Her EMR showed intact cognition with a BIMS score of 15 and a care plan requiring one staff member, a front-wheeled walker, and a gait belt for toilet transfers. The other resident reported delays when requesting staff assistance, including when asking for pain medication, and said the facility often appeared short-staffed. His EMR showed intact cognition with a BIMS score of 14 and a care plan requiring one staff member, a non-mechanical stand aid, and a gait belt for toilet transfers, dressing, and bathing. Call-light reports showed repeated delays for both residents, including multiple response times over 20 minutes and the longest waits reaching 44 minutes for one resident and 27 minutes for the other. Staff interviews confirmed that call lights were expected to be answered as soon as possible, but delays occurred when staff were caring for other residents, and the DON and administrator stated that all staff were responsible for answering call lights promptly.
CPAP Mask Not Maintained or Replaced
Penalty
Summary
Safe and appropriate respiratory care was not provided for a resident with a physician’s order for CPAP therapy at bedtime for sleep apnea. The resident, whose diagnoses included sleep apnea, COPD, and CAD, stated that for the past couple of months she had been unable to wear her CPAP mask because the strap came unsnapped during the night and she could not tolerate it. She reported that the mask coming unhooked disrupted her sleep and that she had not had a good night’s sleep during that time. Record review showed the resident had a 7/23/25 order to wear her CPAP mask at bedtime and off in the morning. A 5/11/26 nurse’s note documented that the resident’s CPAP nasal mask had a tear and needed replacement, and that the resident had a ResMed AirFit nasal mask size small. A 6/18/26 nurse’s note documented the resident was refusing to wear her CPAP mask, that the mask and tubing were hanging in the bathroom, and that the resident objected because her roommate was on contact precautions and she did not want her equipment in the bathroom due to cross contamination. Additional notes showed ongoing problems with the CPAP equipment. On 7/11/26, the resident stated the CPAP mask was not staying connected by the clips and Velcro, and that tape had been used to keep it together, leaving a mark on her neck; two visible purplish marks were documented behind her ear and on the left side of her neck. The resident’s care plan reflected that she wore CPAP at night while sleeping. During interviews, DON B, the administrator, RN/MDS D, and CCL E were aware of issues with the CPAP mask, but documentation of a replacement mask or confirmation of replacement parts could not be located before survey exit. The provider’s policy stated the device should be inspected and all components secured.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents, and there was insufficient oversight to mitigate these hazards. The report specifically notes the lack of preventive measures and supervision necessary to maintain resident safety in the affected area.
Failure to Investigate and Document Missing Controlled Medications
Penalty
Summary
The facility failed to ensure full investigations were completed to rule out potential misappropriation of controlled medications for four of six sampled residents who had physician-ordered controlled medications. Multiple incidents were identified where controlled substances, including Fentanyl patches, Tramadol, and Xanax, were found to be missing during medication counts between nursing shifts. In each case, staff searched for the missing medications, notified the DON and administrator, and completed incident reports, but there was no documentation of comprehensive investigations to determine the cause of the missing medications or to rule out misappropriation or diversion. Interviews and document reviews revealed that staff were not consistently following established procedures for the destruction of controlled substances, such as Fentanyl patches, and for the verification of narcotic counts at shift changes. There were numerous days where required two-person signatures were missing from narcotic count verification forms across all medication carts. Staff reported frequent distractions during medication passes, which contributed to medication errors and discrepancies in controlled medication counts. Additionally, some staff were unaware of recent education or changes in procedures related to controlled medication administration and destruction. The DON confirmed that investigations into missing medications were limited to interviews with involved staff and that there was no documentation to support that misappropriation had been ruled out. The facility's policies required collaboration with pharmacy staff and thorough documentation during investigations of missing or diverted medications, but these steps were not followed. Furthermore, there was no evidence that the pharmacy was involved in the investigation process, and required audits and staff education on drug diversion and misappropriation were not documented as completed.
Failure to Complete Suicide Risk Evaluations for Resident Expressing Suicidal Ideation
Penalty
Summary
The facility failed to ensure that suicide risk evaluations were completed for a resident who exhibited and verbalized significant changes in mental health status, including suicidal ideation. Multiple staff members, including CNAs and environmental services, observed and reported changes in the resident's behavior, such as increased irritability, frequent shirt changes, giving away personal belongings, and direct statements expressing a desire to die or commit suicide. These observations and comments were communicated to nursing staff, but no suicide risk evaluation was completed at the time of the initial comments. The resident had a complex medical history, including paranoid schizophrenia, COPD, diabetes type two, CHF, and chronic kidney disease. The resident's psychiatric medication, clozapine, was tapered off following a cardiologist's recommendation, which led to increased behavioral symptoms and further mental health deterioration. Despite weekly behavioral health visits and multiple documented statements of suicidal ideation in the electronic medical record, suicide risk assessments were not performed after these statements, nor was the care plan updated to reflect the resident's expressed suicidal thoughts until after a self-harm incident occurred. Nursing staff, including an LPN and an RN, acknowledged that they did not complete suicide risk evaluations following the resident's comments, as they did not believe the resident was serious. Both staff members had received education on suicide precautions but were either unaware of the specific assessment required or did not apply it. The facility's policy required a suicide risk evaluation and care plan update when a resident verbalized suicidal ideation, but these procedures were not followed until after the resident harmed himself.
Deficiencies in Fall Prevention for Two Residents
Penalty
Summary
The report identifies deficiencies in fall prevention and management for two residents in a long-term care facility. Resident 55, who was admitted for rehabilitation after a fall with fractures, was found on the floor with a laceration and bruising. Despite being at medium risk for falls, her care plan lacked specific interventions prior to the incident. Observations revealed that her bed was in a high position, and her call light was not accessible, contributing to her fall. The facility failed to implement adequate fall prevention measures, such as ensuring the bed was in the lowest position and the call light was within reach. Resident 22, who has multiple sclerosis and cognitive impairments, fell in the bathroom after unhooking herself from a lift. Her care plan did not specify the need for supervision while using the toilet, despite a history of attempting to unhook lift straps. The facility's practice allowed residents to be left alone in the bathroom while attached to lift equipment, but this was not documented in her care plan. The lack of clear guidance and supervision contributed to her fall and subsequent injuries. The facility's fall prevention policy outlines procedures for identifying risk factors and implementing interventions, but these were not effectively applied in the cases of residents 55 and 22. The report highlights the failure to communicate and document fall risks and interventions, as well as the inadequate assessment and supervision of residents with cognitive impairments and mobility issues.
Infection Control Deficiencies in Equipment Cleaning and Hand Hygiene
Penalty
Summary
The provider failed to maintain infection prevention practices by not ensuring that shared resident lift equipment was kept clean and sanitary according to the manufacturer's recommendations. Observations revealed a buildup of unidentified substances in the footwells of both motorized and non-motorized stand aids across different hallways. The black anti-slip coverings were loose, torn, and peeling, exposing more buildup. Interviews with staff, including the activities director and LPN, indicated a lack of awareness regarding the deep cleaning of the equipment, and the director of nursing was unaware of the buildup and did not know if a deep-cleaning schedule was in place. Additionally, during a medication administration observation, a registered nurse (RN) failed to perform appropriate hand hygiene. The RN did not sanitize hands before putting on gloves, used the same gloves to handle multiple tasks, and did not clean or sanitize scissors used to open a packet of powdered nutrition supplement. The RN admitted to missing several hand hygiene opportunities and was unaware of the need to sanitize the scissors. The director of nursing expected staff to adhere to hand hygiene protocols, which were not followed in this instance. The facility's hand hygiene policy outlined specific infection control practices, including performing hand hygiene before and after glove use, before medication preparation, and when moving between patient and healthcare zones. The RN's actions during the medication administration did not align with these guidelines, contributing to the deficiency in infection control practices.
Failure to Update Care Plan for Resident Supervision
Penalty
Summary
The provider failed to revise and update the care plan for a resident to reflect her need for supervision while using the bathroom. The resident, who has multiple diagnoses including multiple sclerosis, Alzheimer's disease, and dementia, was observed with bruising on her face and a lump on her forehead after a fall. She reported falling on her head, possibly from her bed while reaching for something on the floor. Her care plan, last revised a year prior, did not include the requirement for staff supervision during bathroom use, despite her impaired cognitive function and history of falls. Interviews with facility staff revealed that the expectation was for staff to supervise the resident during bathroom use following her fall. However, this change was not documented in her care plan. The facility's communication methods for updating care information included verbal communication, a wing binder, a bulletin board, and the resident's care plan/Kardex, though it was noted that CNAs rarely used the Kardex. The facility's Fall Prevention and Management policy outlined procedures for identifying fall risks and implementing interventions, but the resident's care plan did not reflect these necessary updates to prevent further incidents.
Potential Insulin Medication Error Averted
Penalty
Summary
The provider failed to ensure that a diabetic resident was free from a potential insulin medication error. During a medication administration observation, RN G prepared insulin pens for a resident scheduled to receive 10 units of Admelog insulin and 40 units of Tresiba insulin. After priming and dialing the pens to the correct doses, RN G had LPN J verify the dosages. However, as RN G walked back to the resident's room, the surveyor heard a noise suggesting the dose might have been altered. Upon reaching the resident's room, the Tresiba pen was found to be dialed at 32 units instead of the prescribed 40 units. The surveyor intervened before the incorrect dose was administered, and RN G adjusted the pen to the correct dosage before administering the insulin. Interviews with LPN J and the Director of Nursing confirmed that the facility's policy required two licensed nurses to verify insulin dosages before administration. Both LPN J and the Director of Nursing acknowledged that administering the incorrect dose would have constituted a medication error, potentially affecting the resident's blood sugar levels. The resident's medical record confirmed the physician's order for 40 units of Tresiba insulin daily. The manufacturer's instructions and the facility's policy on insulin administration were reviewed, highlighting the importance of verifying the correct dosage before administration.
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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 Tyndall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society Scotland | 13.2 mi | ★★★★★ | 3 | 0 |
| Good Samaritan Society - Wagner | 22 mi | — | 0 | 0 |
| Menno-olivet Care Center | 22.1 mi | ★★★★★ | 1 | 0 |
| Avera Sister James Care Center | 23.5 mi | ★★★★★ | 4 | 0 |
| Sd Human Services Center - Geriatric Program | 24.3 mi | ★★★★★ | 0 | 0 |
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