Good Samaritan Society New Underwood
412 South Madison, New Underwood, SD 57761 · Non profit - Corporation · 41 certified beds · (605) 754-6489 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- it has 2 actual-harm citations
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $26,595 in federal fines (most recent 2025-06-10)
- its independent health-inspection rating is low (2/5)
- nursing-staff turnover (65%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 27.0% | 21.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.3% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.1% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.4% | 2.9% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 5.7% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.3% | 5.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 27.6% | 19.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 11.2% | 17.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.2% | 96.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.6% | 4.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 26.6% | 25.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 32.2% | 24.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.6% | 2.0% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 95.5% | 78.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 20.8% | 19.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 0.0% | 12.0% | 12.0% | check this* — see note marked star below the table |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 65.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 23 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 15% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.2%CMS range 6.1–17.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 65.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 47.8% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 60.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.79 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 41 beds and averages 37.2 residents a day — about 91% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.82 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.79 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.62 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.23 hrs/resident/day on weekends vs 3.06 on weekdays — 27% thinner on weekends — a notable drop. RN hours go from 0.95 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 65% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · Gcited before2025-06-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Review of the provider's 3/28/25 SD DOH FRI regarding resident 1 revealed: *On 3/28/25, CNA C was walking with resident 1 to her room after lunch when resident 1 lost her balance and fell backwards. *CNA C was not using a gait belt (a waist strap gripped as support for safe mobility and transfers) while walking with resident 1, and was not able to intervene when resident 1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2025-01-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. with resident 23 revealed: *She was sitting up in her chair. -She stated that the staff uses a sling to move her from her bed to her chair and she eats all of her meals sitting in her chair in her room. 3. Observation of wound care on 1/29/25 at 10:03 a.m. revealed a pressure ulcer on resident 23's left buttock that had already been…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-12-08 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
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. *Inside the dry food storage room, there were: -Seven boxes of unopened rice with no date markings on them. -One 16-oz opened bag of unopened Instant Mashed Potato flakes with a best by date of 2/10/25. -Twelve bags of unopened gravy mix with no date markings on them. -One undated bulk-sized, opened bag of Cherrios.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-12-08 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, review of Resident Council minutes, and policy review, the provider failed to ensure that grievances regarding long call light response wait times reported at resident council meetings were addressed and documentation reflected:*The staff's efforts to resolve those grievances.*Efforts to resolve those grievances were approved as effective resolutions by the resident council.Findings include:1. Interview on 12/2/25 at 10:45 a.m. and again on 12/8/25 at 12:15 p.m. with resident 15 revealed she was an active resident council participant. The group had monthly meetings. The council's concern since May 2025 was long call light response times, especially during the late afternoon and early evening hours. That response time ranged between 30 minutes to one hour. Resident 15 was able to move within the facility independently, use her call light, and verbally advocate for herself. She felt the call light response times did not impact her as much as other residents, like her roommate. Her roommate had significant physical and verbal impairments. Sometimes, resident 15…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-12-08 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure that nursing professional standards were followed by: *One of one observed registered nurse (RN) (F) who did not following the physician's order for one of one sampled resident (3) during a skin wound treatment.*One of one RN (H) who did not document if three doses of an antibiotic were administered to one of one sampled resident (3) as ordered.Findings include:1. Interview on 12/1/25 at 1:30 p.m. with resident 3 revealed she was hospitalized in September 2025 because her suprapubic catheter (flexible tubing surgically placed through the abdomen into the bladder to drain urine) was not working properly. She required intravenous (IV) antibiotics after she was discharged from the hospital and returned to the facility. 2. Review of resident 3's electronic medical record (EMR) revealed that on 9/25/25, she was transferred to the emergency department (ED) for evaluation of a non-functioning catheter. She was admitted to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-12-08 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure the staff followed standard infection control practices for:*Not having placed two of two sampled residents (4 and 20) on enhanced barrier precautions (EBP) (glove and gown use when providing contact care).*Posting clear signage indicating the type of precaution for three of three sampled residents (5, 12, and 19). *Appropriate hand hygiene (HH) (handwashing with soap and water or use of a hand sanitizer) and glove use by three of three staff members (registered nurse RN (F), certified nursing assistant CNA (G), and clinical care leader CCL (C) during treatment, care, and transition in care for three of four sampled residents (1,3, and 20). *Appropriate personal protective equipment (PPE) (gown and glove) application and removal by one of one CCL (C) and removal by one of one CNA (G). *Not having placed barriers by two of two staff RN (F) and CCL (C) during medication administration and treatments of two of two…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-08 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the provider failed to ensure the staff protected the resident's right to personal privacy for:*One of one sampled resident (1) during administration of her medications through an alternative method by one of one registered nurse (RN) (F).*One of one sampled resident (3) during her skin treatment by one of one RN (F).Findings include:1. Observations on 12/1/25 at 2:20 p.m. of registered nurse (RN) F in resident 1's room revealed that resident 1 was seated in her wheelchair facing the television. A window on the left side of the resident faced a parking lot and a road. The door to her semi-private room was open to the hallway on her right side. Resident 1's roommate was lying in bed and could see resident 1. Without closing the room door, drawing the privacy curtain between resident 1 and her roommate, or closing the window curtain, RN F lifted the front of resident 1's shirt, exposed the resident's abdomen to reach her feeding tube (a tube surgically placed in the abdomen for administration of liquid nutritional formula). After RN…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-08 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review, interview, and policy review, the provider failed to:*Report an incident to the South Dakota Department of Health (SD DOH) for one of one sampled resident (5) who left the facility without staff knowledge (eloped) on 11/24/25.Findings include:Refer to citation writing at F689.
- Potential for harm · Dcited before2025-12-08 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and policy review, the provider failed to ensure the care plans were reviewed and revised to reflect the current care needs for four of six sampled residents (5, 12, 19, and 20).Findings include:1. Observation and interview on 12/1/25 at 2:11 p.m. in the north hall with resident 20 in her room revealed:*Resident 20 was in her room, sitting in her wheelchair with her feet resting on the wheelchair foot pedals.*Resident 20 stated she was unable to walk due to a broken left leg and that she had open sores on her heels.*There was a pair of black and gray soft padded boots on top of her bed.-She stated she was supposed to wear them throughout the day, but she didn't like them.*There was no precaution sign posted outside or inside the door of her room related to the open sores on her heels.*There was no personal protective equipment (PPE), such as gloves and gowns, available for use inside resident 20's room or near her door. 2. Review of resident 20's electronic medical record (EMR) revealed: *She had a pressure sore (injury to skin and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to:*Identify and implement interventions to help prevent elopement for one of one sampled resident (5) who eloped (left the facility without staff knowledge) when he pressed the exit bar on the door long enough to release it. Findings include:1. Review of a nurse progress note dated 11/24/25 at 3:30 p.m. titled 'Safety Event-Incident Report' regarding resident 5 revealed:*Resident 5 left the facility through the southwest door. *He propelled his wheelchair out onto the sidewalk and into the gazebo.*An unidentified dietary staff member arriving at work saw resident 5 outside and helped him back into the building through the southwest door.*He was evaluated after the event, and his condition remained unchanged.*Resident 5 complained that it was cold. Resident 5 refused education when the nurse tried to discuss the risks of leaving the facility unattended.*A 72-hour safety check and charting were started for every shift.*The physician was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-08 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the provider failed to ensure the posted daily staff information included the total number and the actual hours worked by registered nurses, licensed practical nurses, licensed vocational nurses, and certified nursing assistants per shift.Findings include:1. Observation on 12/2/25 at 9:30 a.m. of the posted nurse staffing information revealed: *It was posted near the front entrance door and on a wall near the nurses' station.*There were three sections for each shift and four categories of staff listed in each section: RN (registered nurse), LPN (licensed practical nurse), LVN (licensed vocational nurse), and CNA (certified nurse aide). *The nurse category sections listed the number of nursing staff scheduled for each shift.*There were no documented actual hours or total number of nurse staffing hours worked on the form. 2. Interview on 12/4/25 at 2:33 p.m. with director of nursing (DON) B revealed:*She was unsure of all the required details for the posted nurse staffing data, such as the total number and actual hours worked per…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-08 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolatedHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and policy review, the provider failed to ensure an effective, comprehensive quality assurance and performance improvement (QAPI) program was implemented to track and measure performance; systematically analyze underlying causes of a systemic quality deficiency; develop and implement corrective actions or performance improvement activities; and evaluate the effectiveness of the corrective actions, and to revise those actions as needed.Findings include:1. Interview on 12/2/25 at 10:45 a.m. and on 12/8/25 at 12:15 p.m. with resident 15 revealed she was an active resident council participant. Social Services Supervisor (SSS) D facilitated those monthly council meetings. Since May 2025, the council had been concerned about long call light response times, especially during the late afternoon and early evening hours. That response time ranged between 30 minutes to one hour. 2. Review of the provider's June 2025 through November 2025 resident council minutes confirmed that during each of those monthly meetings, the council had identified a concern…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · Dcited before2025-07-09 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the facility failed to ensure that an allegation of verbal abuse by a certified nursing assistant (CNA) A to a resident (1) was reported with the required time frame by CNA B. Findings include: 1. Review of the provider's 7/7/25 FRI revealed:*On 6/30/25, CNA B heard CNA A call a resident (1) a (profanity), while providing care to that resident.*CNA B asked CNA A to repeat what she said, CNA A said, Not you, [resident 1], then CNA A walked out of the room.*CNA B had not reported the incident to the provider until 7/7/25 at 10:00 a.m.-Resident 1 was assessed at that time and was unable to explain or report the occurrence.*CNA A was suspended pending investigation. 2. Review of resident 1's electronic medical record revealed:*She was admitted on [DATE].*Her 6/3/25 Minimum Data Set (MDS) assessment indicated she was rarely understood or able to understand others and was severely…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-01-30 · tag F0677 — failed to help fully-dependent residents with daily care — widespreadProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
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. with licensed practical nurse (LPN) F revealed: *Residents were to be bathed at least once per week. *CNA/bath aide N was in charge of bathing residents. *If CNA/bath aide N was ill or unable to work, another CNA would be given the task of bathing residents that day if staffing permitted. *If staffing did not permit, the resident would be offered their bath on a different day…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-01-30 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review the provider failed to ensure: *Medications for three of three residents (30, 32, and 35) were properly labeled. *An insulin pen for one of one resident (89) was dated when opened. *Two of two medication carts were locked when left unattended. *An outdated medication for one of one resident (22) was properly disposed of. Findings include: 1. Observation on 1/30/25 at 7:36 a.m. of the medication cart in the 200-hallway revealed: *The medication cart was unlocked. *No staff were present at the medication cart. *Registered nurse (RN) J exited a resident room, returned to the medication cart, and charted medication administration. Observation on 1/30/25 at 11:16 a.m. revealed the medication cart in the 100-hallway was not locked and there was no staff at or within eyesight of the medication cart. 2. Observation on 1/29/25 at 10:58 a.m. of the medication cart in the 100-hallway revealed a Lantus (long-acting) insulin pen that belonged to resident 89 without a date on the pen that would have indicated when the pen was removed from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-01-30 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure: *Contact precautions were appropriately implemented and utilized for one of one sampled resident (10) with a feeding tube and a history of MRSA Bacteria [Methicillin-resistant Staphylococcus aureus], VRE [Vancomycin-resistant Enterococci], and MDR [multidrug-resistant organism] infections. *Enhanced barrier precautions (EBP) were appropriately implemented and utilized for one of one sampled resident (23) with an indwelling urinary catheter and daily dressing changes. *One of one resident (27) was separated from other residents while awaiting further tests following a positive QuantiFERON (blood test for tuberculosis) result. Findings include: 1. Observation on 1/28/25 at 5:47 p.m. of resident 10's room and tube feeding placement revealed: *There was a sign on her door that stated to use contact precautions. -Directions on the sign included to put on gloves and a gown before entering the room and to remove the gown…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-30 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and policy review, the provider failed to follow their policy for: *Maintaining a physical inventory count of controlled substances at each shift change by two qualified staff for two of two medication carts. *Maintaining a system of receipt for controlled medications (medications that risk abuse or addiction)received from the pharmacy to ensure accurate medication reconciliation of those medications for four of four (2, 6, 17, and 25) residents. Findings include: 1. Review on 1/29/25 of the January 2025 Narcotic Control Sheet (sheet used to document the count of controlled medications between shifts) and the Controlled Drug Records located in the 100-hall medication cart revealed: *The form indicated: -When signed at each change of shift by off-going and on-coming nurse of medication aide, verifies the correct number of schedule 2 narcotics in lock box. -Both nurses and/or medication aides must sign. -Sign-off times on the form were 0630 (6:30 a.m.), 1430 (2:30 p.m.), and 1830/2230 (6:30 p.m./10:30 p.m.). *There were areas where signatures were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-30 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to ensure: *Two of two sampled residents' (12 and 2) PRN (as needed) psychotropic medications had been discontinued after fourteen days. *An appropriate diagnosis for the use of a psychotropic medication administered to two of two sampled residents (2 and 28). Findings include: 1. Review of resident 12's electronic medical record (EMR) revealed: *A 12/20/24 physician's order for .25 milligrams lorazepam (anti-anxiety/psychotropic medication) to have been administered every 24 hours PRN for combativeness with personal cares. -The physician's order note regarding that same medication indicated: If PRN, order stop date=14 days. Review of resident 12's December 2024 and January 2025 medication administration records (MAR) revealed. *She was administered PRN lorazepam on 12/23/24 and 1/7/25. -The PRN lorazepam order had not been discontinued after 14 days. Interview on 1/30/25 at 12:15 p.m. with director of nursing (DON) B regarding resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-01-30 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the provider failed to ensure: *Kitchenware was stored in a clean and sanitary manner. *Food items in one of one refrigerator designated for resident use and one of one side-by-side refrigerator in the dining room were properly labeled and dated. *One of one refrigerator designated for resident use and one of one side-by-side refrigerator were maintained in a clean manner. *Kitchenware was handled in a manner to mitigate the risk of cross-contamination by one of one lead cook (G) during two of two observed meal services. Findings include: 1. Observation on 1/28/25 at 10:40 a.m. during the initial kitchen tour revealed: *Multiple plastic water pitchers and pitcher lids were stored inside one of the slide-out drawers of the six-drawer kitchenware storage unit. -The pitchers sat upside down inside of that drawer. Two pitchers and one of the lids sat on top of an area that was damp with water. *A four-drawer Tool Shop cabinet held kitchen utensils. -A piece of black foam sat on the bottom of the inside of those drawers. Food crumbs…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-30 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review the provider failed to ensure the care plans were reviewed and revised to reflect the current care needs for two of fourteen sampled residents (2 and 35). Findings include: 1. Observation on 1/28/25 at 10:40 a.m. of resident 2 revealed: *She was sitting in the hallway on a bench. *She had a four-wheel walker in front of her. *She loudly requested staff to remove another resident that was talking to her, stating, She is bothering me. *She got up from the bench and walked to an exit door. *She pushed on the door but did not exit. Observation on 1/28/25 at 3:38 p.m. of resident 2 revealed she had a Wander guard (wearable door alarming device) on her left ankle. Interview on 1/29/25 at 4:34 p.m. with certified nursing assistant (CNA) T regarding resident 2 revealed: *Interventions for behaviors and falls were included in her care plan. *When she exhibited behaviors staff were to offer her picture books, assist her to call her daughter, and turn on old…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-30 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to adhere to professional standards of practice for: *Following a physician-ordered pain assessment scale prior to the administration of narcotic pain medication for one of one sampled resident (88). *Obtaining physician clarification regarding the type of pain scale assessment ordered by that provider for use with one of one sampled resident (88). *Completing a safety smoking assessment for one of one sampled resident (11) who smoked. Findings include: 1. Observation on 1/28/25 at 10:00 a.m. of resident 88 in her room revealed: *The resident was transferred from her wheelchair to her bed by two caregivers. -She wore a sling on her left arm and verbalized Ow when that arm was touched or moved by the caregivers during the transfer process. Review of resident 88's electronic medical record (EMR) revealed: *She was admitted on [DATE] and her diagnoses included a left humerus (the long bone in the upper arm extending from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the provider failed to: *Implement and document physician-ordered bowel management interventions for one of one sampled resident (88). *Follow a physician-ordered therapeutic diet for one of one sampled resident (88). Findings include: 1. Observation on 1/28/25 at 10:00 a.m. of resident 88 in her room revealed: *The resident was transferred from her wheelchair to her bed by two caregivers. -She wore a sling on her left arm and verbalized Ow when that arm was touched or moved by the caregivers during the transfer process. Review of resident 88's electronic medical record (EMR) revealed: *She was admitted on [DATE] and her diagnoses included a left humerus (the long bone in the upper arm extending from the shoulder joint to the elbow) fracture and vascular dementia. *Her 1/16/25 Brief Interview for Mental Status (BIMS) assessment score was 1. That indicated her cognition was severely impaired. Review of resident 88's 1/16/25 through 1/27/25…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and policy review, the provider failed to ensure a registered dietician's (RD) recommendations had been implemented for one of one sampled resident (6) at nutritional risk related to her weight loss. Findings include: 1. Observations on 1/28/25 at 10:09 a.m. and 12:15 p.m. of resident 6 in her room revealed: *She had been asleep in her bed. *There was an opened bottle of Boost + (a nutritional supplement) with a straw inside of it, a lidded plastic mug with eight ounces of water and a straw inside of it, and an unopened container of Medtrition Gelatein (a jello-type protein supplement) on her nightstand beside her bed. Interview on 1/28/25 at 10:15 a.m. with director of nursing (DON) B regarding resident 6 revealed: *She was hospitalized mid-January 2025 with an upper respiratory infection. During her hospital stay, she developed a COVID-19 infection. -The resident had a physical decline and a decline in behaviors (slapping, kicking, biting, and pinching) since her return from the hospital. Review of resident 6's electronic medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to ensure an in-room call light system was accessible for three of three sampled residents (10, 28, and 32) who needed staff assistance for their care needs. Findings include: 1. Observation on 1/28/25 at 5:14 p.m. of resident 28 revealed: *She was sitting in her wheelchair beside her bed. *A staff member was present in the room. *The call light was clipped to the call light cord at the receptacle on the wall. *The staff member exited the room and closed the door without moving the call light to be accessible to resident 28. Review of resident 28's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 1/10/25 Brief Interview of Mental Status (BIMS) assessment score was 2, which indicated she had severe cognitive impairment. *Her diagnoses include Alzheimer's disease, left wrist fracture, and pubic rami (pelvic) and sacral (lower spine) fractures from falls. Review of resident 28's 1/29/25 care plan revealed: *She was at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-11-16 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on Payroll Based Journal (PBJ) record review, employee timecard review, staffing schedules, and electronic medical record review, the provider failed to submit PBJ data accurately for three of three federal fiscal quarters (Quarter 1, 2023; Quarter 2, 2023; and Quarter 3, 2023). Findings include: 1. Review of PBJ records submitted to the Center for Medicaid and Medicare (CMS) services revealed the provider submitted the following for no licensed nursing coverage 24 hours per day for: -Quarter 1, 2023 for seven days: 10/8/22, 10/9/22, 10/16/22, 10/23/22, 10/30/22, 11/20/22, and 12/04/22. -Quarter 2, 2023 for six days: 1/8/23, 1/14/23, 1/15/23, 1/21/23, 2/12/23, and 3/5/23. -Quarter 3, 2023 for four days: 5/20/23, 6/3/23, 6/24/23, and 6/25/23. Review of the provider's employee timecards, staffing schedules and resident's electronic medical records documentation revealed the provider had licensed nursing coverage 24 hours per day for the period referenced above. Interview with director of nursing (DON) B on 11/16/23 at 10:50 a.m. regarding PBJ online reporting revealed: *The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-11-16 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, policy review the provider failed to ensure: *Hand hygiene was completed per facility policy during two of two observed water passes to all residents. *Oxygen tubing and nasal cannulas had been replaced for two of two sampled residents (1 and 9) on a routine basis. *An insulin pen was stored in a sanitary manner after use for one of one sampled resident (10). *Oxygen tubing was stored in a sanitary manner for one of one sampled resident (9) when not in use. 1. Observation on 11/14/23 at 11:04 a.m. of certified nursing assistant (CNA) E during the water pass to residents in the north hall revealed she had: *A push-cart with clean water cups with straws, that had contained ice water, on the top shelf of the cart. -There had been enough cups on the top shelf for every resident in the facility. *Brought clean water cups into a resident's room without performing hand hygiene. *Removed the used water cups from the same room and placed them on the second shelf of the cart. *Not performed hand hygiene before picking up two clean cups from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-16 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the provider failed to ensure one of one observed counter ice machine was maintained in sanitary condition. Findings include: 1. Observation on 11/14/23 at 12:05 p.m. of the counter ice machine located in the dining room had: *Three cracks extending from the bottom plastic cup holder upwards about three inches high. *Two cracks directly underneath of the ice dispenser. *There was a clear plastic funnel for the dispensing ice to flow through. -That funnel was not in place on the ice dispenser. --It was sitting on the counter next to the ice dispenser. Random observations throughout the survey on 11/14/23 from 11:15 a.m. to 4:00 p.m. and again on 11/16/23 from 7:32 a.m. through 11:00 a.m. revealed the plastic funnel was not in place on the ice dispenser. Interview on 11/16/23 at 8:48 a.m. with administrator A regarding the ice machine revealed: *He was not aware of the unsanitary condition of the ice machine prior to the surveyor bringing it to his attention. *He stated he would order a new full front for the ice machine. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-16 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the provider failed to ensure physician orders for pressure ulcer interventions had been implemented in an appropriate amount of time for one of one sampled resident (86). 1. Observation on 11/16/23 at 9:18 a.m. of resident 86 in his room revealed: *He was seated in his recliner with the foot rest in the elevated position. *The heels of his feet were resting on the outer edge of the footrest. -On his feet were red felt booties. *There was a square foam pad positioned between his thighs which caused his legs to spread outward. *His eyes were closed. Review of resident 86's electronic medical record revealed: *He was admitted on [DATE]. *His diagnoses included: heart failure, urinary tract infection, chronic kidney disease, morbid obesity, malignant neoplasm of the prostate. *His 11/3/23 admission skin observation documentation revealed the following wounds: -A pressure ulcer on his right heel that measured 2.2 centimeters (cm) by (x) 1.5 cm by 0.2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-16 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review the provider failed to ensure two of two cooks (G and L) on two of two observed opportunities had prepared pureed food for residents with adequate nutritional value. Findings include: 1. Observation and interview on 11/14/23 at 9:00 a.m. with cook G revealed: *Two stainless containers with pureed looking food on the counter. -He stated it was pureed food for residents and they mixed water with it instead of milk/cream due to the amount of phlegm the milk products produced for residents. Observation and interview on 11/14/23 at 11:15 a.m. with cook G regarding pureed food revealed: *He used water to puree the chicken and mix vegetables. *He had been instructed by dietary supervisor O to use water, due to residents coughing and having congestion. -He was not aware water would deplete the nutritional value of the pureed food. 2. Observation and interview on 11/16/23 at 7:31 a.m. with cook L revealed: *She pureed two servings of eggs with one-half cup of water. -The eggs were too runny so she added two squirts of thickener. *She pureed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$26,595 in federal fines across 2 penalties.
- $11,190 — penalty dated 2025-06-10
- $15,405 — penalty dated 2025-01-30
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to GOOD SAMARITAN SOCIETY — 92 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.0 | -1.0 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 3 of 5 | 4.0 | -1.0 vs chain |
| Quality measures | 3 of 5 | 2.8 | +0.2 vs chain |
The other 91 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 91; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SANFORD | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2019 |
| THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 01/01/2019 |
| DIAMOND, KENNETH | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 08/01/2021 |
| HUBBELING, PAUL | Individual | W-2 MANAGING EMPLOYEE | — | since 08/23/2023 |
| MORRISON, TONY | Individual | W-2 MANAGING EMPLOYEE | — | since 01/01/2019 |
| CAIN, JAMES | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| DYKHOUSE, DANA | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| ENGBRECHT, WESLEY | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| GASSEN, WILLIAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 05/30/2024 |
| GULSVIG, NEIL | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| HERSETH SANDLIN, STEPHANIE | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| LUNDEEN, MARK | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| MOLBERT, LAURIS | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| NORTH, ANDREW | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| SHULKIN, DAVID | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| TEIKEN, BRENT | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| VENTLING-HERRMANN, MARNIE | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| FLUIT, JOEL | Individual | CORPORATE OFFICER | — | since 10/01/2022 |
| MIDDLETON, AIMEE | Individual | CORPORATE OFFICER | — | since 01/27/2022 |
| OLSON, NICHOLAS | Individual | CORPORATE OFFICER | — | since 04/08/2024 |
| ROGERS, MICHAEL | Individual | CORPORATE OFFICER | — | since 06/13/2022 |
| SCHEMA, NATHAN | Individual | CORPORATE OFFICER | — | since 01/01/2022 |
CMS files one row per role, so the 23 rows in the source record cover these 22 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $607K paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in SD
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the South Dakota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 435104. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-08, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.