Good Samaritan Society Luther Manor

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who eloped (left the facility without staff knowledge) through the front door after visitors entered the facility and walked a block and a half east of the facility, fell with his walker, and sustained injuries. Findings Include: 1. Review of the provider's [DATE] SD DOH FRI report revealed that on [DATE] at 10:45 a.m., police alerted the staff that resident 1 was in an ambulance due to falling outside of the facility. A neighbor called 911 after seeing the resident lying on the sidewalk 1.5 blocks away from the facility. [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint intake report, record review, interview, and policy review, the provider failed to ensure the staff were educated on NPWT (closed drain system that relies on the presence of vacuum to withdraw accumulated fluid from around the wound bed into the collection device) treatments for one of one sampled resident (2) whose wound vac was placed incorrectly, which resulted in the resident developing red, irritate skin above his pressure ulcer on his buttocks.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, record review, interview, and policy review, the provider failed to ensure that one of one sampled resident (1) was free from a significant medication error when his baclofen (a primary medication for managing involuntary muscle stiffness and muscle spasms in quadriplegia) was discontinued by registered nurse (RN) C without a physician's order which resulted in the resident being transferred to the emergency department (ED) for evaluation and treatment, and had a subsequent three-night hospitalization for observation of his condition. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.

Inspectors wroteBased on observation, interview, record review, South Dakota Department of health (SD DOH) facility-reported incident (FRI) review, and policy review, the provider failed to ensure:*The front door code was changed following an elopement (when a resident who needs supervision leaves the premises or safe area without authorization or necessary supervision) from the facility for one of one sampled resident (2) who knew that door code and remained outside unsupervised for about 18.5 hours on 3/28/26 through 3/29/26.*Three of four sampled newly admitted residents (3, 4, and 5) were assessed for their elopement risk per provider policy.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to monitor and implement pressure ulcer (skin and/or underlying tissue injury due to prolonged pressure) healing and prevention interventions for one of one sampled resident (7) who was identified at risk for developing pressure ulcers and developed a stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to his coccyx (tailbone), right buttock, and left buttock and one of one sampled resident (7) who was identified at risk for developing a pressure ulcer developed a stage II pressure ulcer to his right buttock.

Inspectors wroteBased on interview, record review, policy review, South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, and staffs' training records review, the provider failed to ensure the residents were protected from risk of injury or harm by staff members failing to safely use lift devices and to provide supervision for:*One of one sampled resident (100) who sustained a skin injury to his buttocks after a total body lift (a mechanical lift and sling used to lift a person's full body) was pulled out from under him by registered nurse (RN)/former director of nursing (DON) DD.*One of one sampled resident (36) identified as unable to safely operate a lift recliner chair and sustained a skin laceration to his head when he fell from that chair onto the floor after being left unsupervised.*One of one sampled resident (10) identified as needing to be transferred by two [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure the staff completed and documented controlled medications (medications at risk for abuse and addiction) supply counts for five of five medication carts (Mystic Ranch, Park View, Focus, East, and [NAME] Lane), failed to prevent the theft of one of one sampled resident's (94) controlled pain medication (oxycodone) by registered nurse (RN) FF, and failed to ensure insulin was administered according to the physician's order for one of one sampled resident (10) who was evaluated at an emergency room after being administered the wrong insulin by licensed practical nurse (LPN) CC.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure one of one sampled resident (100) who [NAME] left alone in his room with his nebulizer (a device that converts liquid medication into an inhalable mist) machine administered by certified medication aide(CMA) (EE), was assessed for the resident's ability to safely sefl-adminster that medicaiton.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to report incidents to the SD DOH within the required time frame, for one of one sampled resident (10) who fell on the floor while being transferred with a sit-to-stand mechanical lift (a mechanical lift used to assist from a seated to a standing position) by certified nursing assistant (CNA) N without the assistance of another staff member, one of one sampled resident (49) related to allegations of having been verbally abused by CNA K, and one of one sampled resident (44) related to allegations of having been verbally abused by CNA E.

Inspectors wroteBased on observation, interview, record review, and Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 review, the provider failed to ensure one of one sampled resident's (11) Minimum Data Set (MDS) assessments, a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs, were accurately coded in the areas for an invasive mechanical ventilator (a device that delivers air into the lungs through a hole in the neck into the windpipe or a flexible tube inserted in the mouth or nose through the windpipe) and a non-invasive mechanical ventilator (positive air pressure delivered through a mask into the lungs to treat severe breathing difficulties).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure resident care plans (personalized plan to address a resident's care needs, goals, and interventions) were revised to reflect their current care needs for three of twenty-five sampled residents (6, 7, and 29).

Inspectors wroteBased on interview, record review, and policy review, the provider failed to identify and implement specific care approaches that addressed the mental and psychosocial needs of one of two sampled residents (7) with diagnosed post-traumatic stress disorder, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event (PTSD) to mitigate trauma triggers and prevent re-traumatization.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to administer a physician-ordered BiPAP (a device that delivers pressurized air through a specialized mask to assist with breathing) for one of one sampled resident who was lethargic and unresponsive the following morning and was transferred to the hospital.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to implement fall prevention interventions as described in the care plan for one of one (1) resident who fell and sustained injuries that required treatment at an emergency department.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure staff followed the care plan regarding the hydration needs for one of two sampled residents (2).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, record review, observation, interview, and policy review the provider failed to ensure Buprenorphine (pain medication) transdermal (TD) (delivered through the skin) patch was removed before a second Buprenorphine patch was applied to one of one sampled resident (1) whose altered mental state required evaluation at a hospital.

Inspectors wroteA. Based on interview, observation, record review, and policy review the provider failed to ensure the safety of one of one sampled resident (14 ) who required the assistance of two staff during transfers with a sit-to-stand mechanical lift.

Inspectors wroteBased on observation, interview, cleaning log review, and policy review, the provider failed to ensure food items were appropriately stored and labeled and to maintain a clean and sanitary food service environment in one of one kitchen and one of one kitchenette.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure the care plan for one of two sampled residents (73) was updated after her catheter was removed.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure the proper Medicare notices were completed and provided for two of two sampled residents (79 and 84) prior to their discharge from skilled services.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to provide bathing and nursing restorative services in accordance with the care plan for three of five sampled residents (26, 70, and 76).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to follow their policy to ensure: *A thorough wound assessment or wound data collection form by a registered nurse (RN) had been completed for resident 63 when a right heel ulcer was identified on 5/30/23. *Physician notification occurred and had not been delayed one week, with no treatment orders.