Good Samaritan Society Sioux Falls Center

In the surveyor’s words

From the most serious findings on record at Good Samaritan Society Sioux Falls Center, in the surveyor’s own words.

• Actual harm, isolatedF600Mar 19, 2026

  Based on South Dakota Department of Health (SD DOH) facility reported Incident (FRI), interview, and policy review, the provider failed to protect three of three residents (1, 2, and 3) from verbal abuse by certified nursing assistant (CNA) D who yelled and cursed at resident 1, slammed resident 2's door after the resident requested to be assisted by a female staff member, and yelled at resident 3, who needed assistance with his colostomy (a surgically created opening in the abdomen that collects stool) bag. Resident 1 expressed feeling mad about his treatment by CNA D, resident 2 reported hearing resident 3 cry, and resident 3 was reported by licensed practical nurse (LPN) C to have cried and expressed statements of emotional stress after his treatment by CNA D.Findings Include: 1. […]

• Actual harm, isolatedF689Feb 4, 2026

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, observation, record review, and policy review, the provider failed to ensure the safety and staff supervision of seven of seven sampled residents (1, 2, 3, 4, 5, 7, and 8) identified as needing supervision while smoking to prevent physical injury or harm, and specifically one of one sampled resident (1) who subsequently sustained a burn to his face. Findings include:1. Review of the 12/11/25 SD DOH FRI revealed:*On 12/11/25 at 10:20 p.m., resident 1 informed registered nurse (RN) M that he went outside into the facility's enclosed courtyard to smoke. When resident 1 lit his cigarette, an ember began to smolder in his winter hat. […]

• Actual harm, isolatedF686Nov 7, 2023

  Based on the South Dakota Department of Health (SD DOH) complaint intake information, record review, interview, and policy review, the provider failed to ensure consistent repositioning for one of one sampled resident (1) who was completely dependent on staff for all activities of daily living (ADLs) that included mobility and had a high risk for skin breakdown on admission. Findings include: 1. Review of the SD DOH complaint intake information revealed: *Resident 1 was admitted to the facility on [DATE] after an extended stay in an acute care facility due to a cardiac arrest with subsequent anoxic brain injury. *The resident had a large pressure wound to the sacral area. *Her tailbone was visible through the resident's sacral area. *The resident was unable to move or speak. […]

• Actual harm, isolatedF686Jun 23, 2021

  Based on observation, interview, record review, and policy review, the provider failed to ensure one of one resident (59) had interventions in place to prevent a pressure ulcer (PU) from developing. Findings include: 1. Review of resident 59's medical record revealed: *He was admitted on [DATE]. *Multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *He was at-risk for developing a PU. *No skin issues were documented on the admission assessment. *On 6/6/21 a small open area was noted to his coccyx. *On 6/10/21 the open area had been noted as a stage II pressure ulcer: -His physician was notified. -A Roho cushion had been in his wheelchair (w/c). *On 6/11/21 a new order for [MEDICATION(S)] to be applied to the pressure ulcer had been received. […]

• No harm, potential for more than minimal, widespreadF812Sep 5, 2025

  Based on observation, interview, record review, and policy review, the provider failed to follow standard food safety practices to ensure:*A clean and sanitary environment was maintained to store, prepare, and serve food to residents in one of one kitchen, one of one kitchenette, one of one dining room serving counters, and two of two dining rooms. *Proper hand-washing and glove use by any observed kitchen staff during the preparation and serving of residents' food items.*Food temperatures were monitored and documented to ensure meals were served at a safe serving temperature to prevent the spread of food-borne illness. *Two of two kitchen personnel (cook H and food service worker X) wore beard nets according to the provider's policy. Findings include: 1. Observation on 9/2/25 at 1:15 p.m. […]