Good Samaritan Society New Underwood

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 10, 2025

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who fell as she walked to her room with the assistance of one of one certified nursing assistant (CNA) who had not used a safety device (gait belt) while assisting the resident. That fall resulted in resident 1's development of a hematoma (collection of blood outside blood vessels) to the back of her head and a fractured left femur (thigh bone). CNA C's failure to use a gait belt may have contributed to the accident. Findings include: 1. […]

• Actual harm, isolatedF686Jan 30, 2025

  Based on observation, interview, record review, and policy review, the provider failed to prevent one of one sampled resident (23) from developing a facility-acquired pressure ulcer and to assess and document that facility-acquired pressure ulcer accurately. Findings include: 1. Observation and interview on 1/28/25 at 9:20 a.m. with resident 23 revealed: *She was in bed lying on her back. -She stated, I have a blister on my butt, so they wanted me to lay here a little longer to help it heal, but I hate it. -Resident 23 agreed to the observation of her wound care and stated that her dressing changes were usually done in the morning. 2. Observation and interview on 1/28/25 at 3:43 p.m. […]

• Actual harm, isolatedF686May 13, 2021

  Based on observation, interview, record review, and policy review, the provider failed to ensure a resident (19) who was admitted without pressure injury but was identified as a high risk for development of one did not develop pressure inurys. Findings include: 1. Observation on 5/11/21 at 3:40 p.m. of resident 19 during a brief change revealed: *She was laying on her right side in her bed. *She had foam boots on. -She had a pillow between her knees. *Nursing assistant (NA) O and unlicensed assistive personnel (UAP) P were conducting the brief change. *Resident 19 had a 3.5 inch by 3.5 inch border foam dressing on her coccyx area that fell off during the removal of her brief which revealed a wound to that area. -That wound was approximately the size of a half dollar. […]

• No harm, potential for more than minimal, widespreadF812Dec 8, 2025

  Based on observation, interview, and policy review, the provider failed to follow food safety standards related to food storage practices of packaged food in the kitchen, dry food storage area, food service station area, and walk-in refrigerator.Findings include:1. Observations on 12/1/25 between 11:00 a.m. and noon and again at 4:40 p.m. revealed: *In the kitchen above a service window, there was a clear, plastic tub. The label affixed to the tub identified the contents in that tub as Food Thickener. There was no date marking on that label to support when it was opened and put in that tub. A hand scoop was inside that tub. -Next to that tub was a clear glass dispenser with a piece of masking tape on it that read thickner. There was no date marking on that dispenser. […]

• No harm, potential for more than minimal, widespreadF677Jan 30, 2025

  Based on interview and record review, the provider failed to ensure bathing was provided to 13 of 16 sampled residents (2, 7, 10, 11, 12, 17, 23, 27, 29, 30, 32, 34, and 35), in a census of 36 residents while certified nursing aide (CNA)/bath aide N was not at the facility. Findings include: 1. Interview on 1/29/25 at 1:40 p.m. with CNA L revealed: *Residents were to be bathed at least once per week. Some residents preferred two baths. *CNA/bath aide N was in charge of bathing residents and making the bathing schedule. *He stated that all CNAs were trained and capable of bathing residents. *He was able to show this surveyor the bathing schedule and the completed bath sheet. Interview on 1/29/25 at 2:30 p.m. […]