Good Samaritan Society De Smet

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, interview, record review, resource packet review, and facility assessment review, the provider failed to ensure sufficient caregiver staff were available to meet the needs of:*One of one sampled resident (1) who relied on staff assistance for repositioning and developed a Stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to her coccyx (tailbone) after she admitted to the facility.*One of one sampled resident (2) who relied on staff assistance for toileting and incontinence care and reported certified nursing assistant (CNA) H turned off the resident's call light without assisting the resident with toileting, which contributed to the resident being incontinent, remaining in wet garments overnight, inability to sleep, and expressed feeling of distress.

Inspectors wroteBased on complaint intake report review, record review, interview, and resource packet review, the provider failed to develop and implement pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) prevention interventions for one of one sampled resident (1) identified at risk for developing pressure ulcers, and dependent on staff assistance with repositioning, who developed a Stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to her coccyx (tailbone) after she admitted to the facility.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to complete a baseline care plan within 48 hours of her admission to the facility, for one of one newly admitted sampled resident (1) who developed a Stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to her coccyx (tailbone) after she admitted to the facility.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to follow standard food safety practices for: *Two of two observed cooks (I and P) who had not changed their gloves or washed their hands while serving resident food items to prevent potential contamination. *One of one observed dietary aide (DA) (H) who had not performed hand hygiene (hand washing) while serving resident food items to prevent potential contamination.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to maintain the resident's rights and ensure: *Advance directive code status (an individual's desire to be resuscitated with cardiopulmonary resuscitation (CPR), specific limited interventions, or not resuscitated (DNR) if their heart stopped) wishes were identified accurately on the physician's orders and the care plans for two of five sampled residents (12 and 86). *The resident or the resident's representative participated in the determination and periodic review of advance directives related to the resident's code status for four of five sampled residents (18, 28, 30, and 86).

Inspectors wroteBased on interview, observation, record review, and policy review, the provider failed to complete a baseline care plan and provide a written summary of the baseline care plan to the resident or their representative for eleven of eleven recently admitted sampled residents (5, 12, 18, 25, 27, 28, 29, 30, 31, 32, and 86) within 48 hours of their admission to the facility.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure care plans were reviewed and revised to reflect the current care needs for three of twelve sampled residents (12, 28, and 86).

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure expired medications and supplies were discarded in a timely manner in one of one nurse supply storage room and one of one nurse's station storage area.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to accurately document correct doses of tube feedings for one of one resident (31).

Inspectors wrote3. Observation and interview on 5/19/25 at 4:30 p.m. with resident 29 in her room revealed she: *Had an O2 concentrator in her room. -Had nasal canula NC tubing attached to the O2 concentrator that the resident was actively using that was not dated. -Could not verify how long she had been using that NC tubing or how often she received a new one. *Had a coiled NC tubing in a plastic bag that was opened and lying on the floor. -Could not verify if the NC tubing on the floor was new or where it had come from. Review of resident 29's EMR revealed she: *Was admitted on [DATE]. *Had a BIMS assessment score of 3, which indicated she was severely cognitively impaired. *Had a diagnosis of heart failure. *Had a terminal prognosis and was receiving Hospice care. *Had an order in her care plan with a date of 3/19/25 to indicate that she had been receiving oxygen therapy. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure proper infection control practices were followed: *For the cleaning of one of one soiled utility rooms. *To ensure enhanced barrier precautions (EBP) were used according to the provider's policy for one of one sampled resident (16) on EBP by not wearing a gown and gloves when providing direct care.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review, the facility failed to protect the resident's right to be free from neglect when one of one sampled resident's (1) physician orders following a left lower extremity (LLE) fracture were not followed to promote healing.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to initiate preventative interventions for one of one sampled resident (1) who was at risk for and developed a pressure ulcer to her left heel after fracturing her left lower leg during a fall.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, and policy review, the provider failed to ensure an incident involving one of one sampled resident (1) who fell from a mechanical lift during a transfer that resulted in a major injury was reported timely to the SD DOH.

Inspectors wroteA. Based on electronic medical record (EMR) review, menu review, interview, and policy review the provider failed to ensure one of one sampled resident (42) was served an appropriate menu substitution.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure proper glove use and hand hygiene was performed during two of two observed meal services by one of one dietary cook (D) in the dining room.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the care plan for one of one sampled resident (29) was revised to include interventions regarding risks of elopement.