Good Samaritan Society Sioux Falls Center

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported Incident (FRI), interview, and policy review, the provider failed to protect three of three residents (1, 2, and 3) from verbal abuse by certified nursing assistant (CNA) D who yelled and cursed at resident 1, slammed resident 2's door after the resident requested to be assisted by a female staff member, and yelled at resident 3, who needed assistance with his colostomy (a surgically created opening in the abdomen that collects stool) bag. Resident 1 expressed feeling mad about his treatment by CNA D, resident 2 reported hearing resident 3 cry, and resident 3 was reported by licensed practical nurse (LPN) C to have cried and expressed statements of emotional stress after his treatment by CNA D.Findings Include: 1. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the staff provided necessary care for four of four sampled residents (1, 2, 3, and 4) who did not receive a bath, bed bath, or shower as scheduled during the reviewed months of February 2026 and March 2026.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, observation, record review, and policy review, the provider failed to ensure the safety and staff supervision of seven of seven sampled residents (1, 2, 3, 4, 5, 7, and 8) identified as needing supervision while smoking to prevent physical injury or harm, and specifically one of one sampled resident (1) who subsequently sustained a burn to his face.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to report a known serious bodily injury within the required time frame for one of one sampled resident (6) who fell and sustained a hip fracture.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to follow standard food safety practices to ensure:*A clean and sanitary environment was maintained to store, prepare, and serve food to residents in one of one kitchen, one of one kitchenette, one of one dining room serving counters, and two of two dining rooms. *Proper hand-washing and glove use by any observed kitchen staff during the preparation and serving of residents' food items.*Food temperatures were monitored and documented to ensure meals were served at a safe serving temperature to prevent the spread of food-borne illness. *Two of two kitchen personnel (cook H and food service worker X) wore beard nets according to the provider's policy.

Inspectors wroteBased on observation, interview, 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 within 48 hours of their admission to the facility for four of six newly admitted sampled residents (14, 64, 67, and 85) reviewed who admitted to the facility in August 2025.

Inspectors wroteBased on observation and interview, the facility failed to ensure that three of three residents (44, 81, 82) were provided with a nourishing, palatable, well-balanced diet that met their daily nutritional and dietary needs. 1. Interview on 9/3/25 at 8:50 a.m. with resident 81 revealed:*Hot food is frequently served cold.*She would sometimes not eat an item if it was not at an acceptable serving temperature because it was unpleasant to her.*The previous evening, they were served a cold sandwich and a cold bean salad. *No fruit or dessert was provided. 2. Interview on 9/3/25 at 8:50 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the provider failed to provide meals to meet the residents' satisfaction for eight of twenty-five sampled residents (14, 34, 44, 49, 52, 53, 67, and 82) who expressed dissatisfaction with the meal service regarding food quality, temperature, repetition, choices, and not accommodating the residents' food preferences and ordered diets

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure proper infection control practices were followed by allowing clean resident lift slings to lay on the floor, failing to properly clean resident lifting devices, and allowing water to leak from ceiling in a storage closet.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint review, record review, interview, and policy review, the provider failed to protect the resident's right to be free from neglect and abuse for one of one sampled resident (4) who complained of prolonged wait times for his call light to be answered by staff and felt that had caused him to be incontinent of urine or bowel at times. The resident expressed that those instances caused him to feel less than human.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure bathing was provided and documented for two of two sampled residents (14 and 64) who were dependent on staff assistance with bathing.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, and interview, the provider failed to withhold cardiopulmonary resuscitation (CPR) for one of one resident (100) who had a do not resuscitate (DNR) code status (specifies the type of emergent treatment a person wishes to receive if their heart or breathing would stop) and was found unresponsive.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure an air mattress safely fit the resident's bed frame and did not impede the use of assist bars for one of one sampled resident (44) who had an air mattress to relieve pressure from a pressure ulcer and used assist bars for mobility and positioning while in bed, which may have put the resident at risk for accidents and injury.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure: *Food items were appropriately labeled and stored in one of one observed walk-in cooler in one of one kitchen. *The minimum water temperature of the dishwashing machine was used for the cleaning and disinfecting of dishes. *Food was prepared and served in a safe and sanitary manner by two of two dietary staff (dietary director K and cook M) who did not perform appropriate hand hygiene during one of one observed meal service.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure infection control practices had been followed for: *One of two observed administrations of nutritional formula and fluids through a gastric tube (G-tube) feedings for one of one sampled resident (67) by one of two licensed practical nurse (LPN) (F) . *One of one sampled resident (333) tested for signs and symptoms of clostridium difficile (C-Diff) (bacteria that can infect the bowel and cause diarrhea).

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure seven bottles of one bulk medication that was expired were appropriately discarded.

Inspectors wroteBased on observation and interview, the provider failed to have available, prepare, and serve, resident preferred and selected menu items requested by four of four sampled residents (33, 46, 71, and 335) for two of two observed meals (breakfast and noon).

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) complaint intake information, record review, interview, and policy review, the provider failed to ensure consistent repositioning for one of one sampled resident (1) who was completely dependent on staff for all activities of daily living (ADLs) that included mobility and had a high risk for skin breakdown on admission.