Good Samaritan Society Luther Manor
Sioux Falls, South Dakota · CCN 435044
21 surveys since 2011, 9 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 72
- Surveys
- 21
- Harm or worse
- 9
- Immediate jeopardy
- 0
Findings where a surveyor recorded actual harm to a resident.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 92
- Ownership
- For profit - Corporation
- Chain
- GOOD SAMARITAN SOCIETY
- County
- Minnehaha
- Medicare-certified since
- 1990
CMS ratings
- Overall
- 2
- Health inspection
- 2
- Staffing
- 4
- Quality measures
- 2
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat more weighted findings than its peer group.
Weighted by harm level, against 19 facilities of 66–99 beds in South Dakota.
Last survey on record
Jun 4, 2026
158 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.94 | 3.70 |
| Registered-nurse hours per resident day | 0.95 | — |
| Annual nurse turnover | 43.5% | 46.6% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $111,701 across 4 penalties
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G627.3% | H— | I— |
| No harm, potential for more than minimal | D1150.0% | E522.7% | F— |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6895×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F6844×
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- F6572×
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- F6862×
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- F5541×
Allow residents to self-administer drugs if determined clinically appropriate.
In the surveyor’s words
From the most serious findings on record at Good Samaritan Society Luther Manor, in the surveyor’s own words.
- Actual harm, isolatedF689Jun 4, 2026
Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who eloped (left the facility without staff knowledge) through the front door after visitors entered the facility and walked a block and a half east of the facility, fell with his walker, and sustained injuries.Findings Include: 1. Review of the provider's [DATE] SD DOH FRI report revealed that on [DATE] at 10:45 a.m., police alerted the staff that resident 1 was in an ambulance due to falling outside of the facility. A neighbor called 911 after seeing the resident lying on the sidewalk 1.5 blocks away from the facility. […]
- Actual harm, isolatedF760Apr 1, 2026
Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, record review, interview, and policy review, the provider failed to ensure that one of one sampled resident (1) was free from a significant medication error when his baclofen (a primary medication for managing involuntary muscle stiffness and muscle spasms in quadriplegia) was discontinued by registered nurse (RN) C without a physician's order which resulted in the resident being transferred to the emergency department (ED) for evaluation and treatment, and had a subsequent three-night hospitalization for observation of his condition. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.Findings include:1. […]
- Actual harm, isolatedF686Mar 5, 2026
Based on observation, record review, interview, and policy review, the provider failed to monitor and implement pressure ulcer (skin and/or underlying tissue injury due to prolonged pressure) healing and prevention interventions for one of one sampled resident (7) who was identified at risk for developing pressure ulcers and developed a stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to his coccyx (tailbone), right buttock, and left buttock and one of one sampled resident (7) who was identified at risk for developing a pressure ulcer developed a stage II pressure ulcer to his right buttock. Findings include:1. Observation and interview on 3/3/26 at 10:58 a.m. […]
- Actual harm, isolatedF689Mar 5, 2026
Based on interview, record review, policy review, South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, and staffs' training records review, the provider failed to ensure the residents were protected from risk of injury or harm by staff members failing to safely use lift devices and to provide supervision for:*One of one sampled resident (100) who sustained a skin injury to his buttocks after a total body lift (a mechanical lift and sling used to lift a person's full body) was pulled out from under him by registered nurse (RN)/former director of nursing (DON) DD.*One of one sampled resident (36) identified as unable to safely operate a lift recliner chair and sustained a skin laceration to his head when he fell from that chair onto the floor after being left… […]
- Actual harm, isolatedF689Jun 18, 2025
Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to implement fall prevention interventions as described in the care plan for one of one (1) resident who fell and sustained injuries that required treatment at an emergency department. Findings include: 1. Review of the SD DOH FRI submitted on 2/2/25 at 10:34 a.m. revealed: *On 2/1/25 at 10:20 p.m., resident 1 was found lying face down on the floor next to his bed. -There was noticeable blood on the floor. -Resident 1 had a laceration near his right eye. -He was transported to the emergency department for further evaluation. -He received six sutures and was transported back to the facility. […]
Read 23 findings in full →The most serious and the most recent: 23 of 72 on record.
Every survey on record
FindingsAt actual harm or above
- Jun 4, 2026Complaint2 findings · 1 harm
- Apr 1, 2026Complaint2 findings · 1 harm
- Mar 5, 2026Standard and complaint8 findings · 2 harm
- Jul 23, 2025Complaint1 finding
- Jun 18, 2025Complaint2 findings · 1 harm
- Jan 23, 2025Complaint1 finding
- Oct 17, 2024Standard3 findings · 1 harm
- Sep 8, 2023Standard3 findings
Show the 13 earlier surveys
- Oct 26, 2022Standard1 finding
- May 20, 2021Standard3 findings · 1 harm
- Feb 17, 2021Infection control1 finding
- Feb 22, 2019Standard2 findings
- Jun 27, 2018Complaint1 finding · 1 harm
- Jan 10, 2018Standard2 findings
- Nov 9, 2016Standard3 findings
- Dec 3, 2015Standard6 findings
- Nov 6, 2014Standard7 findings
- Jul 31, 2014Complaint3 findings · 1 harm
- Sep 18, 2013—10 findings
- Sep 6, 2012—1 finding
- Jun 15, 2011—10 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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