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 Tyndall during CMS and state inspections, most recent first.
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 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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Illustrative
What surveyors actually found near you
We read the 5 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 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 | ★★★★★ | 0 | 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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.