Good Samaritan Society - Pipestone

In the surveyor’s words

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

• Immediate jeopardy, isolatedF805Jan 7, 2026

  Based on interview and document review, the facility failed to follow physician orders for a texture modified diet for 1 of 3 residents (R1) reviewed for diet orders. This resulted in an immediate jeopardy (IJ) for R1 when he was served a regular texture diet and choked while eating, which resulted in R1 requiring emergency department (ED) services and admission to a higher level of care hospital. The facility implemented corrective action prior to the investigation so the deficiency was issued at Past Noncompliance. The IJ began on 12/29/25 at 5:00. p.m. when the dietary cook and nursing assistant (NA)-B served R1 with a regular texture tuna fish melt on a bun and sweet potato tots. […]

• Immediate jeopardy, isolatedF678May 10, 2022

  Based on observation, interview and document review, the facility failed to ensure resident wishes for Do Not Resuscitate (DNR) or cardiopulmonary resuscitation (CPR) were performed for 1 of 1 (R1) resident whose Provider Orders for Life Sustaining Treatment (POLST) identified DNR and CPR was performed when resident was found unresponsive and as a result R1 was resuscitated, sent to the Emergency Department (ED) by Ambulance and sustained fractured ribs. This resulted in an Immediate Jeopardy (IJ) for R1. The IJ began on [DATE], at 12:45 p.m., when R1 was found unresponsive and LPN-A initiated CPR without confirming R1's code status, which was documented as DNR. […]

• Actual harm, isolatedF689Jan 13, 2021

  Based on observation, interview and document review, the facility failed to conduct adequate assessment, provide appropriate supervision, or an assistive device to prevent a fall for 1 of 3 residents (R1). R1 self-transferred without her walker or appropriate supervision resulting in a fall with [MEDICAL CONDITION]. Findings include: Facility incident report records indicated R1 fell on [DATE] at 6:58 p.m., and later complained of pain resulting in a trip to the Emergency Department (ED) for evaluation where R1 was diagnosed with [REDACTED]. R1's 1/5/21 at 6:58 p.m., Risk Management report identified R1 was found on the floor with her legs in front of her and a blanket folded under her left leg. The report further indicated R1's walker was tipped over and faced away from the resident. […]

• No harm, potential for more than minimal, widespreadF812Aug 5, 2026

  Based on observation, interview and document review, the facility failed to ensure infection control measures were followed during observation of 1 of 1 meal service. This had the potential to affect all 52 residents who dined in the facility.Findings include: Observation on 7/29/26 at 11:29 a.m., identified cook-A completed preparation of the noon meal consisting of chicken with mushroom gravy, noodles, and broccoli. Cook-A was placing the food items onto the steam table when she turned and went to the cabinet, opened the door, removed a saltshaker, and shook salt into her bare hand. After filling the palm of her hand with salt she returned to the stove, where she dumped the salt from her hand into the cooking noodles. […]

• No harm, potential for more than minimal, widespreadF880May 21, 2025

  Based on interview and document review, the facility failed to ensure employee illnesses were tracked to identify when employee would be able to return to work after an illness, dependent upon their symptoms for 3 of 5 sampled staff (trained medication aide (TMA)-A, nursing assistant (NA)-A, and dietary aide (DA)-B). In addition, the facility failed to ensure 1 of 5 sampled staff (dietary aide) had completed tuberculosis testing (TST) upon hire. This had the potential to affect all 62 residents in the facility. […]