Good Samaritan Society Tyndall

In the surveyor’s words

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

• Actual harm, isolatedF686Jul 16, 2026

  Based on observation, interview, record review, and policy review, the provider failed to implement pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) prevention interventions for one of one sampled resident (11) who was identified as having a mild risk for developing a pressure ulcer and developed a stage IV (4; open wound with full-thickness skin and tissue loss. Bone, tendon, or muscle may be visible) pressure ulcer to her right antecubital space (the shallow triangular depression directly in front of the elbow joint).Findings include: 1. Observation on 7/15/26 at 2:19 p.m. revealed resident 11 was sitting in her recliner in her room. […]

• Actual harm, isolatedF689Jul 17, 2025

  Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, record review, and policy review, the provider failed to assess for potential accident hazards and safety related to the usage of a lift chair for one of one sampled resident (1) and was transferred to the emergency department (ED) for evaluation and treatment of injuries acquired from the fall.Findings included:1. 1. Review of the providers 7/8/25 SD DOH FRI revealed:*On 7/8/25 at 10:45 a.m., resident 1 was found lying face down on the floor in front of his lift chair.*His lift chair was raised all the way up in the air.*He had a laceration (a cut or tear in the skin) to the left side of his forehead.*A registered nurse (RN) completed neurologic assessment (evaluation of nerve function,… […]

• Actual harm, isolatedF689Jan 24, 2025

  Based on observation, interview, record review, and policy review, the provider failed to identify and implement interventions to prevent falls for two of two sampled residents (22 and 55) who fell and sustained injuries. Findings include: 1. Observation and interview on 1/22/25 at 9:16 a.m. with resident 55 while in the 200-hallway revealed: *She had a large bruise around her left eye. -The bruise was above her eyebrow and extended to her cheekbone. -The bruise was brown with yellowing edges. *When asked about the bruise, she could not remember. Observation on 1/22/25 at 2:09 p.m. revealed that resident 55 was resting in bed with the bed in the lowest position to the floor. […]

• Actual harm, isolatedF686Sep 28, 2023

  Based on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (23 and 42) who were identified as at risk for developing pressure ulcers indicated by the Braden Scale for Prediction Pressure Ulcer scores had interventions in place to prevent those residents acquiring a pressure ulcer. Findings include: 1. Observation on 9/25/23 at 4:00 p.m. of resident 42 revealed he was seated in his recliner with his feet elevated. -Continued observation at 4:30 p.m. revealed he was seated in his wheelchair and was alert. -Continued observation at 6:00 p.m. revealed he was seated in his wheelchair and was in the dining room. *Observation on 9/26/23 at 8:00 a.m. he was not in his room. […]

• No harm, potential for more than minimal, patternF584Jul 16, 2026

  Based on observation, interview, record review, and policy review, the provider failed to ensure a homelike environment was maintained for two of fourteen sampled residents (18 and 32) who did not have a bathroom door and four of fourteen sampled residents (10, 24, 35, and 44) whose walls in their rooms had exposed drywall and peeling paint. Findings include:1. Observation on 7/14/26 at 9:28 a.m. in resident 24's room revealed an approximately ten-inch area between her end table and stationary chair with peeling paint, more than five gouges in the drywall, and two three-to-four-inch areas where the drywall was exposed. 2. Observation and interview on 7/14/26 at 11:19 a.m. with residents 18 and 32 in their shared room revealed that they did not have a bathroom door. […]