Good Samaritan Society New Underwood

Inspectors wroteBased on observation, interview, and policy review, the provider failed to follow food safety standards related to food storage practices of packaged food in the kitchen, dry food storage area, food service station area, and walk-in refrigerator.

Inspectors wroteBased on interview, review of Resident Council minutes, and policy review, the provider failed to ensure that grievances regarding long call light response wait times reported at resident council meetings were addressed and documentation reflected:*The staff's efforts to resolve those grievances.*Efforts to resolve those grievances were approved as effective resolutions by the resident council.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure that nursing professional standards were followed by: *One of one observed registered nurse (RN) (F) who did not following the physician's order for one of one sampled resident (3) during a skin wound treatment.*One of one RN (H) who did not document if three doses of an antibiotic were administered to one of one sampled resident (3) as ordered.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the staff followed standard infection control practices for:*Not having placed two of two sampled residents (4 and 20) on enhanced barrier precautions (EBP) (glove and gown use when providing contact care).*Posting clear signage indicating the type of precaution for three of three sampled residents (5, 12, and 19). *Appropriate hand hygiene (HH) (handwashing with soap and water or use of a hand sanitizer) and glove use by three of three staff members (registered nurse RN (F), certified nursing assistant CNA (G), and clinical care leader CCL (C) during treatment, care, and transition in care for three of four sampled residents (1,3, and 20). *Appropriate personal protective equipment (PPE) (gown and glove) application and removal by one of one CCL (C) and removal by one of one CNA (G). [...]

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure the staff protected the resident's right to personal privacy for:*One of one sampled resident (1) during administration of her medications through an alternative method by one of one registered nurse (RN) (F).*One of one sampled resident (3) during her skin treatment by one of one RN (F).

Inspectors wroteBased on record review, interview, and policy review, the provider failed to:*Report an incident to the South Dakota Department of Health (SD DOH) for one of one sampled resident (5) who left the facility without staff knowledge (eloped) on 11/24/25.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the care plans were reviewed and revised to reflect the current care needs for four of six sampled residents (5, 12, 19, and 20).

Inspectors wroteBased on record review, interview, and policy review, the provider failed to:*Identify and implement interventions to help prevent elopement for one of one sampled resident (5) who eloped (left the facility without staff knowledge) when he pressed the exit bar on the door long enough to release it.

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure the posted daily staff information included the total number and the actual hours worked by registered nurses, licensed practical nurses, licensed vocational nurses, and certified nursing assistants per shift.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure an effective, comprehensive quality assurance and performance improvement (QAPI) program was implemented to track and measure performance; systematically analyze underlying causes of a systemic quality deficiency; develop and implement corrective actions or performance improvement activities; and evaluate the effectiveness of the corrective actions, and to revise those actions as needed.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the facility failed to ensure that an allegation of verbal abuse by a certified nursing assistant (CNA) A to a resident (1) was reported with the required time frame by CNA B.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who fell as she walked to her room with the assistance of one of one certified nursing assistant (CNA) who had not used a safety device (gait belt) while assisting the resident. That fall resulted in resident 1's development of a hematoma (collection of blood outside blood vessels) to the back of her head and a fractured left femur (thigh bone). CNA C's failure to use a gait belt may have contributed to the accident.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to prevent one of one sampled resident (23) from developing a facility-acquired pressure ulcer and to assess and document that facility-acquired pressure ulcer accurately.

Inspectors wroteBased on interview and record review, the provider failed to ensure bathing was provided to 13 of 16 sampled residents (2, 7, 10, 11, 12, 17, 23, 27, 29, 30, 32, 34, and 35), in a census of 36 residents while certified nursing aide (CNA)/bath aide N was not at the facility.

Inspectors wroteBased on observation, interview, and policy review the provider failed to ensure: *Medications for three of three residents (30, 32, and 35) were properly labeled. *An insulin pen for one of one resident (89) was dated when opened. *Two of two medication carts were locked when left unattended. *An outdated medication for one of one resident (22) was properly disposed of.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure: *Contact precautions were appropriately implemented and utilized for one of one sampled resident (10) with a feeding tube and a history of MRSA Bacteria [Methicillin-resistant Staphylococcus aureus], VRE [Vancomycin-resistant Enterococci], and MDR [multidrug-resistant organism] infections. *Enhanced barrier precautions (EBP) were appropriately implemented and utilized for one of one sampled resident (23) with an indwelling urinary catheter and daily dressing changes. *One of one resident (27) was separated from other residents while awaiting further tests following a positive QuantiFERON (blood test for tuberculosis) result.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to follow their policy for: *Maintaining a physical inventory count of controlled substances at each shift change by two qualified staff for two of two medication carts. *Maintaining a system of receipt for controlled medications (medications that risk abuse or addiction)received from the pharmacy to ensure accurate medication reconciliation of those medications for four of four (2, 6, 17, and 25) residents.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure: *Two of two sampled residents' (12 and 2) PRN (as needed) psychotropic medications had been discontinued after fourteen days. *An appropriate diagnosis for the use of a psychotropic medication administered to two of two sampled residents (2 and 28).

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure: *Kitchenware was stored in a clean and sanitary manner. *Food items in one of one refrigerator designated for resident use and one of one side-by-side refrigerator in the dining room were properly labeled and dated. *One of one refrigerator designated for resident use and one of one side-by-side refrigerator were maintained in a clean manner. *Kitchenware was handled in a manner to mitigate the risk of cross-contamination by one of one lead cook (G) during two of two observed meal services.

Inspectors wroteBased on observation, interview, record review and policy review the provider failed to ensure the care plans were reviewed and revised to reflect the current care needs for two of fourteen sampled residents (2 and 35).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to adhere to professional standards of practice for: *Following a physician-ordered pain assessment scale prior to the administration of narcotic pain medication for one of one sampled resident (88). *Obtaining physician clarification regarding the type of pain scale assessment ordered by that provider for use with one of one sampled resident (88). *Completing a safety smoking assessment for one of one sampled resident (11) who smoked.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to: *Implement and document physician-ordered bowel management interventions for one of one sampled resident (88). *Follow a physician-ordered therapeutic diet for one of one sampled resident (88).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure a registered dietician's (RD) recommendations had been implemented for one of one sampled resident (6) at nutritional risk related to her weight loss.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure an in-room call light system was accessible for three of three sampled residents (10, 28, and 32) who needed staff assistance for their care needs.

Inspectors wroteBased on Payroll Based Journal (PBJ) record review, employee timecard review, staffing schedules, and electronic medical record review, the provider failed to submit PBJ data accurately for three of three federal fiscal quarters (Quarter 1, 2023; Quarter 2, 2023; and Quarter 3, 2023).

Inspectors wroteBased on observation, interview, record review, policy review the provider failed to ensure: *Hand hygiene was completed per facility policy during two of two observed water passes to all residents. *Oxygen tubing and nasal cannulas had been replaced for two of two sampled residents (1 and 9) on a routine basis. *An insulin pen was stored in a sanitary manner after use for one of one sampled resident (10). *Oxygen tubing was stored in a sanitary manner for one of one sampled resident (9) when not in use. 1. Observation on 11/14/23 at 11:04 a.m. of certified nursing assistant (CNA) E during the water pass to residents in the north hall revealed she had: *A push-cart with clean water cups with straws, that had contained ice water, on the top shelf of the cart. -There had been enough cups on the top shelf for every resident in the facility. [...]

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure one of one observed counter ice machine was maintained in sanitary condition.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure physician orders for pressure ulcer interventions had been implemented in an appropriate amount of time for one of one sampled resident (86). 1. Observation on 11/16/23 at 9:18 a.m. of resident 86 in his room revealed: *He was seated in his recliner with the foot rest in the elevated position. *The heels of his feet were resting on the outer edge of the footrest. -On his feet were red felt booties. *There was a square foam pad positioned between his thighs which caused his legs to spread outward. *His eyes were closed. Review of resident 86's electronic medical record revealed: *He was admitted on [DATE]. *His diagnoses included: heart failure, urinary tract infection, chronic kidney disease, morbid obesity, malignant neoplasm of the prostate. [...]

Inspectors wroteBased on observation, interview, and policy review the provider failed to ensure two of two cooks (G and L) on two of two observed opportunities had prepared pureed food for residents with adequate nutritional value.