Good Samaritan Society Sioux Falls Village

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, observation, and policy review, the provider failed to ensure that one of one certified nursing assistant (CNA) (AA) used a gait belt (a waist strap gripped as support for safe mobility and transfers) while ambulating (walking) one of one sampled resident (91) to the bathroom, resulting in a fall and broken femur for resident 91.

Inspectors wroteBased on the interviews, record review, observation, and policy review, the provider failed to ensure the staff responded promptly to twelve of thirty-one sampled residents (13, 14, 21, 27, 59, 73, 85, 89, 119, 123, 155, and 164) who reported concerns related to extended call light times.

Inspectors wroteBased on the observation, interview, and record review, the provider failed to ensure medications were securely stored in three of ten observed medication carts by registered nurse (RN) V, RN FF, and certified medication aide (CMA) Z.

Inspectors wroteBased on interview, record review, observation, and policy review, the provider failed to protect the resident's rights to dignity and respect for one of thirty one sampled residents (145) who was told by registered nurse (RN) (QQ) to 'stop talking' when asking her about his medications.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to follow standard food safety practices to ensure that one of one licensed practical nurse (LPN) (K) performed hand hygiene (washing hands with soap and water or using hand sanitizer) when she assisted four of four sampled residents (23, 51, 147, and 161) to eat the evening meal, and that one of one cook (P) wore a hairnet over his beard while preparing food in the main kitchen.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure the staff followed infection prevention and control practices by one of one certified medication aid (CMA) (KK) and one of one certified nursing assistant (LL) who did not wear a gown or perform hand hygiene (wash hands with soap and water or sanitize hands) while providing care to one of one sampled resident (14) on enhanced barrier precautions (EBP) (glove and gown use when providing contact care). Findings Include: 1. Observation on 6/30/26 at 3:06 p.m. in resident 14's room revealed she had a magnet on her door frame that indicated she required EBP. When the surveyor went into her room, CNA LL and CMA KK had gloves on, did not have gowns on, and were providing care to resident 14. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the safety and prevention for potential entrapment or injury for 16 residents (5, 18, 19, 47, 67, 72, 83, 97, 99, 103, 108, 112, 126, 137, and 356) who had side rails on their bed and 10 other residents (5, 17, 22, 73, 83, 103, 106, 123, 137, and 453) who had a risk for entrapment related to their mattresses and headboards or footboards. Concerns were identified with: *The safety of the side rails related to their installation, ongoing maintenance, and risk for entrapment. *Documentation for consents for side rail use, alternatives that had been attempted, and education regarding the risk and benefits of side rails. *The safety of mattresses and the potential for entrapment between the headboard and footboard or the gaps within the footboard.

Inspectors wroteBased on observation, record review failed to ensure: *Three of three sampled residents (55,103, and 116), observed with medications stored in their rooms, were assessed for the ability to safely self-administer and store medications, and had physician's orders to self-administer medications according to the provider's policy. *On of One sampled resident's (116) care plan included the resident's self-administration of medications. 1. Observation on 4/14/25 at 3:17 p.m. of resident 103's room revealed: *There was a tube of Triad wound dressing paste (for wound healing) on her bedside table. -The instructions on the pharmacy label read, apply bid [twice daily] as directed. Review of resident 103's electronic medical record (EMR) revealed: *She was admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to support residents' choices for five of five sampled residents (85, 139, 356, 361, and 363) on the rehab unit regarding menu options and food preferences at meals.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure three of three sampled residents (139, 361, and 363) who resided in the Rehab unit were provided activities that were meaningful and of interest to maintain their psychosocial well-being.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure: *One of one sampled resident (112) who used a recliner was evaluated for potential safety risks. *Assess for entrapment of mattresses that were on nine of 159 residents (5, 17, 22, 73, 83, 103, 106, 123, 137) beds. *Foot board railing was assessed for risk of entrapment for one of one sampled resident (453). *Safe, secure storage of chemical in two of two sampled residents rooms (55 and 103).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure sufficient nursing staff for one of one secured unit to safely meet residents' needs, well-being, and the security of 17 of 17 residents (39, 86, 95, 96, 100, 102, 110, 114, 115, 122, 127, 131, 133, 135, 140, 148, and 453). Staff reported concerns with medication errors related to interruptions, difficulty keeping wandering residents within the unit, and difficulty completing all care tasks for residents due to the staffing of the unit. These failures placed those residents at risk for unmet care needs and potentially negative outcomes.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure two of four sampled certified nursing assistant (CNA)/certified medication aides (CMA) (U and KK) who worked in one of one secured memory care unit had an annual performance review completed.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to follow proper infection control practices to ensure *Supplies were not stored under sinks in four of four soiled utility rooms. *Resident care and cleaning supplies were monitored for outdates and disposed of in two of four soiled utility rooms (400 South hall, and 300 hall) and one of four resident shower rooms (100 hall). *Splash guards were properly installed on three of four hoppers (specialized sink for disposing of bodily fluids) in the soiled utility rooms. *One of one biohazard container was covered as directed in the provider's policy to safely contain biohazardous material during storage and transport to prevent leakage, spilling, and potential exposure. [...]

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure their policy related to elopement reporting had been followed regarding an incident of elopement (left the area without staff knowledge) from a secure unit for one of one sampled resident (127).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (139) was provided daily warm showers according to her preferences and according to her physician's orders during her short-term rehab stay.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure: *Proper cleaning and storage of a nebulizer device that converts liquid medication into an inhalable mist) as directed in the provider's policy for one of one sampled resident (116). *Proper storage of nasal cannulas (flexible tubing that delivers oxygen through the nose) while no in use and replacement of soiled nasal cannulas as directed in the provider's policy for one of one sampled resident (116).

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure one of one sampled resident (49), had her PRN (as needed) psychotropic medication discontinued after 14 days as ordered by the physician.

Inspectors wroteBased on observations, interviews, record reviews, and policy reviews, the provider failed to ensure that one of the sampled residents (103), whose care plan included a fall prevention intervention of a soft touch call light within her reach to notify staff when she needed assistance, was accessible to her while in her room.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure one of four certified nursing assistant (CNA)/certified medication aide (CMA) (KK) reviewed , who worked in the secure memory care unit (MCU), had completed the required annual in-service training.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, policy review, observation and interview, the provider failed to ensure the safety of one of one sampled resident (1) who received a burn from a hot coffee. The citation is considered past non-compliance based on a review of the provider's corrective actions following the incident.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure that one of one sampled resident (1) was free from neglect by certified nursing assistant (CNA) (F) who did not provide or a shower as directed in her plan of care.

Inspectors wroteA. Based on review of the South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview and policy review the provider failed to ensure of one of one sampled resident (3) had been accurately accounted for when a door alarm had been activated.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint review, record review, interview, and policy review, the provider failed to ensure one of one sampled resident's (1): *Midodrine (blood pressure medication) had been administered as ordered. *Zofran (anti-nausea medication) had been administered as ordered. *Physician had been notified of a blood glucose (blood sugar) level below 70 as ordered. *Condition had been assessed by a nurse following an intervention that had been provided for a low blood sugar. *Prescribed medications had been taken after they had been prepared. *Medications that had been destroyed were documented.

Inspectors wroteBased on interview, observation, record review, and policy review, the provider failed to ensure interventions were consistently implemented for two of two sampled resident (38 and 83) who developed a pressure ulcer.

Inspectors wroteBased on the initial pool process, resident council interviews, resident interviews, family interviews, call light review, meal tray delivery observation, and policy review the provider failed to ensure there were sufficient staff to provide services to maintain the well-being of each resident including: *Call lights were answered in a reasonable time frame for 13 of 28 sampled residents (14, 37, 49, 66, 68, 69, 75, 80, 81, 84, 96, 137, and 147). *Room meal trays were delivered as scheduled. *Individual resident hygiene needs for nail care for three of three sampled residents (2, 12, and 16) were met. *The call light for one of one observed sampled resident (1) was accessible at all times. 1. Observation and Interview on 12/4/23 at 1:30 p.m. with resident 84 in his room revealed: *He had been resting in bed. *He had an oxygen concentrator in the middle of his room running at 5 liters. [...]

Inspectors wroteA. Based on observation, interview, record review, and policy review, the provider failed to: *Maintain the following essential kitchen equipment in a clean and sanitary manner free from rust, dust, food crumbs, grime, and limescale buildup: -One of one dishwasher located in the main kitchen. -The top of all the steamers and ovens in the main kitchen. *Properly temp foods to prevent the spread of cross-contamination by one of one food service worker (L). *Ensure one of one food service worker (L) performed hand hygiene and changed gloves at the proper times during one of one observed lunch service. *Ensure the mechanically altered foods that were being served to residents during one of one observed lunch service were at a safe hot-holding temperature. *Ensure one of one food service worker (U) had worn a beard guard while working with food to prevent the physical contamination of food.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure sufficient staff to provide services to maintain the well-being of each resident for three of seventeen sampled residents (105,106, and 132) who resided in the special care unit (SCU).

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure that infection control practices were maintained for the following: *One of one sampled resident's (26) Bilevel Positive Airway Pressure (BiPAP) machine was cleaned on a regular basis according to the policy. *One of one certified nurse aide (CNA) (EE) had not cleaned or sanitized a resident mechanical stand aide machine in between resident use. *One of one CNA (EE) had performed hand hygiene after personal care was provided and before assisting one of one sampled resident (12) with putting his nasal cannula back on.

Inspectors wroteBased on interview, observation, and policy review, the provider failed to ensure three of three sampled resident (66, 69, and 37 ) had the choice of food preferences for meal trays served in their rooms.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure the privacy and confidentiality of resident electronic health records had been maintained by two of two observed registered nurses (RN) (F and G ).

Inspectors wroteBased on observation and interview, the provider failed to ensure the medications within two of two medication carts on the rehabilitation wing were appropriately secured when unattended.