Good Samaritan Society - St. Martin Village

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure the resident's baseline care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was reviewed with and a copy offered to the resident or the resident's representative within 48 hours of the resident's admission to the facility for three of four newly admitted residents (3, 9, and 12).

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure infection prevention and control practices for hand hygiene (HH) (handwashing with soap and water or an alcohol-based hand sanitizer [ABHS]) and glove use were implemented by one of one licensed practical nurse (LPN) (N) during and after one of one sampled resident's (81) dressing change, one of one registered nurse (RN) (I) who did not perform HH before completing one of one sampled resident's (6) wound care treatment, one of one RN (F) who did not perform HH during medication administration for four of five sampled residents (60, 3, 49, and 24), one of one certified nursing assistant (CNA) (G) who did not perform HH during mealtime assistance provided for one of one sampled resident (28), and one of one CNA (H) who did not perform HH after removing her soiled gloves and before putting on a new pair [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (6) observed to have Cortisone 10 (a medicated steroid cream that is used on the skin to treat inflammation and itching) and a container labeled Hempvona cream (a topical cream with hemp-seed oil) located on his bedside table was evaluated for his ability to safely self-administer those medications.1. Observation and interview on 7/28/26 at 10:15 a.m. with resident 6 in his room revealed a tube of Cortisone 10 and a container labeled Hempvona cream. The resident used the Cortisone 10 for facial itching and the Hempvona cream for discomfort. He did not know if the staff knew he had it.2. Observation on 7/29/26 at 2:20 p.m. in resident 6's room revealed the same Cortisone 10 and Hempvona cream on his bedside table.3. [...]

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure the care plan (personalized plan that addresses a resident's care needs, goals, and interventions) interventions were attempted and documented, and the indication for administration was documented for an as-needed (PRN) anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability) medication that was administered to one of one sampled resident (11).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to implement a physical therapist recommended walk-to-dine program for one of one sampled resident (48).

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure drugs and biologicals were labeled, securely stored, and discarded regarding one of one medication cart on the south unit that was left unattended by one of one registered nurse (RN) (F) with pre-poured medications observed on top of the medication cart in a hallway where residents, unauthorized staff, and visitors could access it, one of one sampled resident's (63) medication with a shortened expiration date (medication that expires in a time frame after opening that is before the manufacturer's expiration date) that was not labeled with an open date, and for one of one medication storage room and one of one medication cart on the north unit that had expired medications and supplies.

Inspectors wroteBased on interview, observation, record review, and policy review, the facility failed to provide the dietary staff initial and ongoing education regarding a physician-ordered gluten-free diet, ensure menus were developed, and that an early breakfast was provided before a morning medical appointment for one of one sampled resident (48) to enable the resident to make food choices that he preferred and that his nutritional needs were met.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint review, record review, interview, and policy review, the provider failed to follow their policy for reporting to the SD DOH and one of one sampled resident's (1) representative of the resident's injury of bruising to her left arm and hand with unknown cause (origin).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint review, observation, record review, interview, and policy review, the provider failed to ensure an investigation was completed and documented for one of one sampled resident (1) with an injury of bruising to the resident's left arm and hand with unknown cause (origin).

Inspectors wroteBased on interview, record review, and policy review, the provider failed to follow nursing professional standards of practice for implementing and documenting neurological checks according to the provider's policy for one of one sampled resident (2) who had fallen and sustained a head injury.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to support residents' right to choose and receive the frequency and type of shower or bath consistent with their preferences for 7 of 17 sampled residents (20, 13, 38, 18, 15, 42, and 306).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure two of eight sampled residents' (1 and 51) care plans were revised to reflect their current status and care needs.

Inspectors wroteBased on observation, interview, record review, grievance review, and facility assessment review, the provider failed to have enough sufficient staff available to promote resident's rights, physical, mental, and psychosocial well-being for: *Eleven of fifteen sampled residents (7, 13, 14, 15, 18, 20, 26, 33, 38, 42, and 306) who were dependent on the staff to assist them with grooming, bathing, and toileting. *Five of five additional residents (22, 36, 45, 54, and 55) who had filed grievances on bathing and extended call light response time.

Inspectors wroteBased on observation, interview, record review and policy review, the provider failed to ensure: *Two nurses had signed for the receipt of controlled medications (medications at risk for abuse and addiction) on the controlled drug record for five of five residents (6, 15, 21, 24, and 31) who were prescribed controlled medications *One prescribed controlled liquid medication concentration was documented on the Controlled Drug Record for one of one resident (31). *The destruction of fentanyl patches for one of one sampled resident (6) was accurately documented appropriately by individuals authorized to destroy controlled medications.

Inspectors wroteBased on observation, interview, record review, policy review, and manufacturer's recommendations review, the provider failed to ensure a medication error rate of less than 5 percent related to: *A topical pain medication was not applied according to the manufacturer's recommendations for two of two sampled residents (18 and 42) by one of one observed registered nurse (RN) (S). *An oral medication was given to one of one sampled resident (42) without a physician's order by one of one observed RN (S). Those observations created a medication error rate of 10.71%.

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure: *Medications for two of two residents (28 and 12) were properly labeled. *Medications for four of four residents (28, 50, 6, 12) were dated when opened. *Temperatures for two of two medication rooms (north and south) were monitored for acceptable medication storage temperatures according to the provider's policy. *Expired nutritional supplements and supplies were removed from two of two medication rooms (north and south).

Inspectors wroteBased on record review, observation, interview, and policy review, the provider failed to ensure: *The physician was notified of medications not administered due to unavailability as directed in the provider's policy for one of one sampled resident (20). *A physician's order to take vital signs every six hours was followed for one of one sampled resident (38) for an infection.

Inspectors wroteBased on observation, record review, interview and policy review, the provider failed to ensure residents who used assist/grab bars (bed rails) had: *A routine assessment, when a assist/grab bar was initiated and quarterly, was completed for four of eight sampled residents (6, 8, 33, and 38). *A signed consent for the use for the assist/grab bars for one of six sampled resident (6), with cognitive impairment, and a power of attorney (POA). *Received education on the risks of use versus benefits of the use of assist/grab bars for five of six sampled residents (6, 23, 26, 33, and 38). *Other attempted interventions were documented on five of eight sampled residents (6, 13, 23, 33, and 38).

Inspectors wroteBased on observation, interview, record review, and job description review, the provider failed to assess, document, and implement interventions for one of one sampled resident (51) with a mood disorder.

Inspectors wroteBased on observation, interview, record review and policy review, the provider failed to Follow proper infection control practices and precaution interventions related to: *The use of personal protective equipment (PPE) to help prevent the transmission of infections for three of three sampled residents (1, 31, and 24). *Maintaining the cleanliness of four of four handwashing sinks used by staff (Charting Station 1, Charting Station 2, Charting Area 151, and Charting Area 174) in two of two residential living units (North and South).

Inspectors wroteBased on the South Dakota (SD) Department of Health (DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure a secure environment by silencing alarms on 2 of 8 egress doors located on the north and south units.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure infection prevention and control practices were implemented for the following: *Appropriate glove use by one of one licensed practical nurse (LPN) (F) during skincare treatments for two of two sampled residents (36) and (44). *A water management program (WMP). *Appropriate handling of a glucometer in a cloth case by one of one LPN (F) during a blood sugar check for one of one sampled residents (20). *Appropriate handling of an eye drop bottle by one of two LPN (F) during medication administration for one of two sampled residents (20). *Appropriate handling of plated food during food service.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (112) had a documented diagnosis and was assessed for the removal of her Foley catheter.