Good Samaritan Society Luther Manor

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

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.

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.

47.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 118 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 59.7% 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 72 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 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% 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.

Staffing

How full it usually is: this home is certified for 92 beds and averages 86.0 residents a day — about 93% occupied, or roughly 6 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 3.94 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.95 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.52 is at or above 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 3.32 hrs/resident/day on weekends vs 4.20 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.11 to 0.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%. 1 administrator has left in the past year.

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 more than at the previous inspection — worsening. 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.

22 citations, most serious first. The 16 most serious are shown; the remaining 6 are one tap away and print in full.

• Actual harm · Gcited before2026-06-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure 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, observation, interview, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who eloped (left the facility without staff knowledge) through the front door after visitors entered the facility and walked a block and a half east of the facility, fell with his walker, and sustained injuries.Findings Include: 1. Review of the provider's [DATE] SD DOH FRI report revealed that on [DATE] at 10:45 a.m., police alerted the staff that resident 1 was in an ambulance due to falling outside of the facility. A neighbor called 911 after seeing the resident lying on the sidewalk 1.5 blocks away from the facility. The police officer called an ambulance due to resident 1 having abrasions (scrapes in the skin) to the bilateral (both) upper and lower extremities (upper and lower limbs of the body), and notified the facility of the resident's location and condition. Registered nurse (RN) F…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2026-04-01 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, record review, interview, and policy review, the provider failed to ensure that one of one sampled resident (1) was free from a significant medication error when his baclofen (a primary medication for managing involuntary muscle stiffness and muscle spasms in quadriplegia) was discontinued by registered nurse (RN) C without a physician's order which resulted in the resident being transferred to the emergency department (ED) for evaluation and treatment, and had a subsequent three-night hospitalization for observation of his condition. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.Findings include:1. Review of the provider's 3/21/26 SD DOH FRI regarding resident 1 revealed that on 3/20/26, he had a change in [his] mental status, face turning red, and was not acting himself. He was sent to the ED for evaluation at approximately 9:00 p.m. and was then admitted to the hospital from the ED at 10:52 p.m.…

  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.

  Pharmacy Service Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2026-03-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide 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, record review, interview, and policy review, the provider failed to monitor and implement pressure ulcer (skin and/or underlying tissue injury due to prolonged pressure) healing and prevention interventions for one of one sampled resident (7) who was identified at risk for developing pressure ulcers and developed a stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to his coccyx (tailbone), right buttock, and left buttock and one of one sampled resident (7) who was identified at risk for developing a pressure ulcer developed a stage II pressure ulcer to his right buttock. Findings include:1. Observation and interview on 3/3/26 at 10:58 a.m. with resident 7 in his room revealed:*He had a trapeze bar (a bar above the bed used to assist in repositioning and transfers) attached to his bed.*There was a pressure reduction cushion in his wheelchair and recliner.*He stated that he had a wound on his buttocks, but he thought it had healed.*He did not know if he had…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-03-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure 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 interview, record review, policy review, South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, and staffs' training records review, the provider failed to ensure the residents were protected from risk of injury or harm by staff members failing to safely use lift devices and to provide supervision for:*One of one sampled resident (100) who sustained a skin injury to his buttocks after a total body lift (a mechanical lift and sling used to lift a person's full body) was pulled out from under him by registered nurse (RN)/former director of nursing (DON) DD.*One of one sampled resident (36) identified as unable to safely operate a lift recliner chair and sustained a skin laceration to his head when he fell from that chair onto the floor after being left unsupervised.*One of one sampled resident (10) identified as needing to be transferred by two members with the use of a sit-to-stand lift (a mechanical device used to assist from a seated to a standing position) and fell after…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-06-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure 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), observation, interview, record review, and policy review, the provider failed to implement fall prevention interventions as described in the care plan for one of one (1) resident who fell and sustained injuries that required treatment at an emergency department. Findings include: 1. Review of the SD DOH FRI submitted on 2/2/25 at 10:34 a.m. revealed: *On 2/1/25 at 10:20 p.m., resident 1 was found lying face down on the floor next to his bed. -There was noticeable blood on the floor. -Resident 1 had a laceration near his right eye. -He was transported to the emergency department for further evaluation. -He received six sutures and was transported back to the facility. *The provider's investigation of the fall determined that resident 1's silent TABs alarm (a device that flashes at the nurses station to alert staff when resident stands up) was in his recliner at the time of the fall and the resident was in his bed. *The certified…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-10-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure 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

  A. Based on interview, observation, record review, and policy review the provider failed to ensure the safety of one of one sampled resident (14 ) who required the assistance of two staff during transfers with a sit-to-stand mechanical lift. Findings include: 1. Interview and observation on 10/15/24 at 3:45 p.m. with resident 14 revealed: *He had gone to the hospital because he had been dropped from a lift in the shower room and hit his head. *He pointed to his head and said, that's what this bump is from. *He had a raised area on his left forehead and a brace on his left foot. 2. Review of resident 14's electronic medical record (EMR) revealed a progress noted dated 9/9/24: *CNA [certified nursing assistant] called nurse to tub room res laying on the floor, skin tear to left arm above elbow, measures 5x5x5 triangle shaped area, also has a bump on left forehead with abrasion resident right leg is turned inward resident c/o [complaints of] pain when tried to move right leg. Resident stated I was standing up to get on bath chair and I fell. VS [vital signs] and Neuro check done, d/t…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide 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 South Dakota Department of Health (SD DOH) complaint intake report, record review, interview, and policy review, the provider failed to ensure the staff were educated on NPWT (closed drain system that relies on the presence of vacuum to withdraw accumulated fluid from around the wound bed into the collection device) treatments for one of one sampled resident (2) whose wound vac was placed incorrectly, which resulted in the resident developing red, irritate skin above his pressure ulcer on his buttocks. Findings include:1. Review of the 5/13/26 SD DOH complaint intake report, revealed that resident 2 had voiced some concerns with the care he received at the nursing facility where he resided while he was getting a suprapubic catheter ( flexible medical tube used to drain urine from the bladder) placed and a colonoscopy (diagnostic and preventative procedure to examine the lining of your rectum and colon) at the hospital. Resident 2 expressed that he did not want to the nursing facility following his…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-04-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure 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 observation, interview, record review, South Dakota Department of health (SD DOH) facility-reported incident (FRI) review, and policy review, the provider failed to ensure:*The front door code was changed following an elopement (when a resident who needs supervision leaves the premises or safe area without authorization or necessary supervision) from the facility for one of one sampled resident (2) who knew that door code and remained outside unsupervised for about 18.5 hours on 3/28/26 through 3/29/26.*Three of four sampled newly admitted residents (3, 4, and 5) were assessed for their elopement risk per provider policy. Findings include:1. Review of the SD DOH FRI initial report received on 3/28/26 revealed that resident 2 had been reported missing to director of nursing (DON) B at 8:00 p.m. on 3/28/26. Dietary staff told DON B that resident 2 was not at the evening meal which was unusual for him, and the last he was reported seen was by registered nurse (RN) F at approximately 5:30 p.m. that day when…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-03-05 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure the staff completed and documented controlled medications (medications at risk for abuse and addiction) supply counts for five of five medication carts (Mystic Ranch, Park View, Focus, East, and [NAME] Lane), failed to prevent the theft of one of one sampled resident's (94) controlled pain medication (oxycodone) by registered nurse (RN) FF, and failed to ensure insulin was administered according to the physician's order for one of one sampled resident (10) who was evaluated at an emergency room after being administered the wrong insulin by licensed practical nurse (LPN) CC.Findings include:1. Review of the provider's 12/18/25 FRI involving resident 10's medication error revealed: *On 12/17/25 at 8:45 p.m. LPN CC administered the incorrect insulin to resident 10. *His insulin medication orders were to inject Novolog) a fast-acting insulin…

  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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-05 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  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 one of one sampled resident (100) who [NAME] left alone in his room with his nebulizer (a device that converts liquid medication into an inhalable mist) machine administered by certified medication aide(CMA) (EE), was assessed for the resident's ability to safely sefl-adminster that medicaiton. Findings include: 1. Observation on 3/5/26 at 7:56 a.m. revealed resident 100 was alone in his room, lying on his back in his bed. He had a nebulizer mask positioned on the right side of his face without covering his nose and mouth while the nebulizer machine was on and administering the breathing treatment(nebulized medication). 2. Observation, interview, and electronic medication administration record (EMAR) review on 3/5/26 at 8:00 a.m. with CMA EE revealed she was standing at the medication cart and stated she put the nebulizer mask on resident 100. When she entered his room she stated, Oh, you knocked the cup (container that held 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-05 · tag F0609 — failed to report abuse allegations — isolated
  Timely 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

  Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to report incidents to the SD DOH within the required time frame, for one of one sampled resident (10) who fell on the floor while being transferred with a sit-to-stand mechanical lift (a mechanical lift used to assist from a seated to a standing position) by certified nursing assistant (CNA) N without the assistance of another staff member, one of one sampled resident (49) related to allegations of having been verbally abused by CNA K, and one of one sampled resident (44) related to allegations of having been verbally abused by CNA E. Findings include:1.Review of the provider's 12/1/25 submitted FRI regarding resident 10 revealed: *On 12/1/25, the provider completed a review of a fall incident for resident 10 that had occurred on 11/28/25 at 11:30 a.m. *Resident 10 was assisted to the restroom and back to his wheelchair by CNA N with the use of a sit-to-stand mechanical lift. *During the transfer, resident 10 slipped and slid…

  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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-05 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  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 Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 review, the provider failed to ensure one of one sampled resident's (11) Minimum Data Set (MDS) assessments, a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs, were accurately coded in the areas for an invasive mechanical ventilator (a device that delivers air into the lungs through a hole in the neck into the windpipe or a flexible tube inserted in the mouth or nose through the windpipe) and a non-invasive mechanical ventilator (positive air pressure delivered through a mask into the lungs to treat severe breathing difficulties).Findings include:1. Observation and interview on 3/3/26 at 10:22 a.m. with resident 11 in her room revealed:*She was sitting in her recliner with oxygen administered through a nasal cannula (flexible tubing…

  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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-05 · tag F0657 — failed to keep the care plan current — isolated
  Develop 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 resident care plans (personalized plan to address a resident's care needs, goals, and interventions) were revised to reflect their current care needs for three of twenty-five sampled residents (6, 7, and 29). Findings include:1.Observation and interview on 3/3/26 at 9:24 a.m. with resident 6 revealed: *She was currently on a liquid diet. *Her nasogastric (NG) tube (a flexible tube passed through the nose, down the esophagus, and into the stomach to provide nutrition and medication) was removed at the end of February. *She used a NG tube for receiving nutritional formula and medications, but that was removed. 2. Observation on 3/3/26 at 11:57 a.m. of resident 6 in the dining room revealed she was drinking broth and eating Jello for lunch. 3. Interview on 3/5/26 at 7:51 a.m. with certified nursing assistant (CNA) I revealed: *The residents' diet orders were on their dietary meal tickets, and Kardex (a report of 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-05 · tag F0699 — isolated
  Provide care or services that was trauma informed and/or culturally competent.
  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 interview, record review, and policy review, the provider failed to identify and implement specific care approaches that addressed the mental and psychosocial needs of one of two sampled residents (7) with diagnosed post-traumatic stress disorder, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event (PTSD) to mitigate trauma triggers and prevent re-traumatization.Findings include:1. Interview on 3/3/26 at 10:58 a.m. with resident 7 in his room revealed:*He had experienced a lot of trauma in his life.*He had spoken to a counselor about his trauma, but not for quite a while.*He thought his post-traumatic stress disorder (PTSD) was under control, but he knew he could not turn on the television and see the conflict and bombing in the Middle East, or it might trigger his PTSD symptoms.2. Review of resident 7's EMR revealed:*He was admitted to the facility on [DATE].*His 1/30/26 Brief Interview for Mental Status (BIMS) assessment score was 14, which…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-23 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide 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 South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to administer a physician-ordered BiPAP (a device that delivers pressurized air through a specialized mask to assist with breathing) for one of one sampled resident who was lethargic and unresponsive the following morning and was transferred to the hospital. Findings include: 1.Review of the providers [DATE] SD DOH FRI revealed:*Resident 1 was a full code and found not responsive to verbal commands and sent to the hospital on [DATE]. * Resident 1's diagnoses upon admission to long term care on [DATE] were:*Included acute respiratory failure (problems with breathing) with hypercapnia (too much carbon dioxide in the bloodstream) and hypoxia (low levels of oxygen), chronic fatigue (low energy), and hypertension (high blood pressure). *She had a full code status (wishes to receive life-sustaining measures) with CPR (cardiopulmonary resuscitation) to be…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide 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, interview, record review, and policy review, the provider failed to ensure staff followed the care plan regarding the hydration needs for one of two sampled residents (2). Findings include: 1. Observation and interview on 6/18/25 at 8:50 a.m. in resident 2's room with certified medication aide (CMA) G revealed: *Resident 2 was sitting in his wheelchair. *CMA G brought resident 2 his morning pills in a medicine cup with chocolate pudding in it. *He agreed to take his pills. *CMA G administered him the pills with a spoon. *She gave him a drink of water from his water mug through a straw. *She stated this was the first time she had passed medications in that hallway. 2. Review of resident 2's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *He had diagnosis of: -Essential (primary) hypertension (high blood pressure). -Cerebral infarction, unspecified. -Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. -Dysphagia following cerebral…

  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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“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.

Fines & penalties

$92,066 in federal fines across 3 penalties.

• $70,980 — penalty dated 2026-03-05
• $9,620 — penalty dated 2025-06-18
• $11,466 — penalty dated 2024-10-17

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 →

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

CMS files one row per role, so the 55 rows in the source record cover these 28 parties — each is shown once here with every role it holds. Nothing is omitted.

5 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 $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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