Good Samaritan Society de Smet

In the surveyor’s words

From the most serious findings on record at Good Samaritan Society de Smet, in the surveyor’s own words.

• Actual harm, isolatedF684Oct 23, 2025

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, interview, record review, resource packet review, and facility assessment review, the provider failed to ensure sufficient caregiver staff were available to meet the needs of:*One of one sampled resident (1) who relied on staff assistance for repositioning and developed a Stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to her coccyx (tailbone) after she admitted to the facility.*One of one sampled resident (2) who relied on staff assistance for toileting and incontinence care and reported certified nursing assistant (CNA) H turned off the resident's call light without assisting the resident with toileting, which contributed to the resident being… […]

• Actual harm, isolatedF686Oct 23, 2025

  Based on complaint intake report review, record review, interview, and resource packet review, the provider failed to develop and implement pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) prevention interventions for one of one sampled resident (1) identified at risk for developing pressure ulcers, and dependent on staff assistance with repositioning, who developed a Stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to her coccyx (tailbone) after she admitted to the facility.Findings include:1. Review of the 10/17/25 anonymous complaint intake report regarding resident 1 revealed:*Resident 1 had been admitted to the facility on [DATE], after a surgery to place a rod in her left leg. […]

• Actual harm, isolatedF600Jan 2, 2025

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review, the facility failed to protect the resident's right to be free from neglect when one of one sampled resident's (1) physician orders following a left lower extremity (LLE) fracture were not followed to promote healing. Findings include: 1. Review of the provider's 10/23/24 SD DOH FRI regarding resident 1 revealed: *On 10/21/24 resident 1 was being transferred with a sit-to-stand lift (mechanical lift used to assist from a seated to a standing position) and she was lowered to the floor. -CNA E assisted her up from the floor with a full body mechanical lift to the wheelchair. -Resident 1 complained of left leg pain that afternoon. […]

• Actual harm, isolatedF686Jan 2, 2025

  Based on observation, interview, record review, and policy review, the provider failed to initiate preventative interventions for one of one sampled resident (1) who was at risk for and developed a pressure ulcer to her left heel after fracturing her left lower leg during a fall. Findings include: 1. Observation on 1/2/25 at 2:45 p.m. of resident 1's room revealed: *Two light blue padded heel protector boots were on the bed. *An air mattress was present and inflated on the bed frame. *Resident 1 was seated in her wheelchair listening to an audiobook with her back towards the door. *There was a gait belt, pillow, and hangers on the recliner seat. Observation and interview on 1/2/25 at 3:02 p.m. […]

• No harm, potential for more than minimal, widespreadF812May 22, 2025

  Based on observation, interview, and policy review, the provider failed to follow standard food safety practices for: *Two of two observed cooks (I and P) who had not changed their gloves or washed their hands while serving resident food items to prevent potential contamination. *One of one observed dietary aide (DA) (H) who had not performed hand hygiene (hand washing) while serving resident food items to prevent potential contamination. Findings include: 1. Observation on 5/19/25 at 5:17 p.m. […]