Good Samaritan Society Sioux Falls Village

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.

46.5% 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 205 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 59.3% 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 140 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 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% 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 177 beds and averages 161.0 residents a day — about 91% occupied, or roughly 16 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 3.75 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.49 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 3.48 hrs/resident/day on weekends vs 3.86 on weekdays — 10% thinner on weekends. RN hours go from 0.78 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% 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 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.

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

• Immediate jeopardy · J2025-04-24 · tag F0700 — isolated
  Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
  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 safety and prevention for potential entrapment or injury for 16 residents (5, 18, 19, 47, 67, 72, 83, 97, 99, 103, 108, 112, 126, 137, and 356) who had side rails on their bed and 10 other residents (5, 17, 22, 73, 83, 103, 106, 123, 137, and 453) who had a risk for entrapment related to their mattresses and headboards or footboards. Concerns were identified with: *The safety of the side rails related to their installation, ongoing maintenance, and risk for entrapment. *Documentation for consents for side rail use, alternatives that had been attempted, and education regarding the risk and benefits of side rails. *The safety of mattresses and the potential for entrapment between the headboard and footboard or the gaps within the footboard. Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy of F700 was given verbally and in writing on 4/16/25 at 4:21 p.m. to administrator A regarding: *The provider failed to ensure bedrails were securely attached, mattresses…

  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
• Immediate jeopardy · Jcited before2024-06-04 · 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 A. Based on review of the South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview and policy review the provider failed to ensure of one of one sampled resident (3) had been accurately accounted for when a door alarm had been activated. Findings include: Notice: Notice of immediate jeopardy was given verbally and in writing on 5/30/24 at 10:41 a.m. to administrator H and director of nursing (DON) D of the immediate jeopardy related to resident elopement and quality of care at F684. On 5/30/24: * At 10:41 a.m. administrator H and DON D were notified of a request for a removal plan. On 5/31/24: *At 8:35 a.m. the removal was received. *At 8:45 a.m. the removal was accepted. On 6/3/24: *At 8:30 a.m. while on-site the survey team verified the immediacy was removed. Plan: 1.On Monday 30, 2024 at 2:52 p.m. on shift message was sent to all employees that summarized the education summary of elopement. This serves as the immediate education for all employees. If staff are not…

  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 before2026-07-02 · 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), interview, record review, observation, and policy review, the provider failed to ensure that one of one certified nursing assistant (CNA) (AA) used a gait belt (a waist strap gripped as support for safe mobility and transfers) while ambulating (walking) one of one sampled resident (91) to the bathroom, resulting in a fall and broken femur for resident 91. Findings include:1. Review of the provider's 6/23/26 SD DOH FRI revealed that at 8 a.m. on 6/23/26, resident 91 was ambulating to the bathroom using her front-wheeled walker (FWW) (a device with two wheels on the front legs and rubber tips on the back legs, designed for individuals who need stability and partial weight-bearing support) as CNA AA provided contact guard assistance (CGA) (hands-on physical light touch to support an individual without actively supporting their body weight), but did not use a gait belt. Resident 91 lost her balance and fell and suffered an elbow…

  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 plan of correction
• Actual harm · Gcited before2024-11-14 · 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

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, policy review, observation and interview, the provider failed to ensure the safety of one of one sampled resident (1) who received a burn from a hot coffee. The citation is considered past non-compliance based on a review of the provider's corrective actions following the incident. Findings include: 1. Review of provider's 11/5/24 DOH FRI revealed: *Resident 1 received a burn was on her abdomen on 10/31/24. -The origin of the burn is suspected to be caused from hot coffee. -Coffee machines and dispensers were found to be above the temperature per the facility's policy guidelines. -The coffee machine vendor was to calibrate the machines on 11/1/24. -All coffee machines temperatures were being regulated by staff prior to the vendor's service. 2. Review of resident 1's record revealed: *Resident 1's admission date was 2/14/24. *Her diagnoses included Alzheimer's disease, and dementia. *She had a Brief Interview of Mental Status (BIMS) score of 9 which indicated she had moderate…

  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 · Past Non-Compliance
• Actual harm · G2024-09-19 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  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), observation, interview, record review, and policy review, the provider failed to ensure that one of one sampled resident (1) was free from neglect by certified nursing assistant (CNA) (F) who did not provide or a shower as directed in her plan of care. Findings include: 1. Review of the provider's submitted SD DOH FRI revealed: *Staff reported to management that resident 1 did not get her shower or toileting on the day shift on 8/5/24 between 7:42 a.m. and 6:04 p.m. *Camera footage revealed that resident 1 did not get showered and was not assisted to the restroom per her care plan. *Certified Nursing Assistant (CNA) F and CNA G had documented throughout the day that resident 1 did not void, and the resident was repositioned every two hours. *During an interview, CNA F stated that she was not aware that she needed to check on residents and change them during her shift. *Both CNA F and CNA G had been written up with a final…

  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
• Actual harm · G2023-12-07 · 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

  Based on interview, observation, record review, and policy review, the provider failed to ensure interventions were consistently implemented for two of two sampled resident (38 and 83) who developed a pressure ulcer. Finding include: 1. Telephone interview on 12/05/23 at 3:23 p.m. with resident 83's family member revealed: *The family member was concerned that the resident smelled of urine when they would visit and felt that he was not being checked and changed when he was incontinent. *The family member stated that they had voiced their concerns regarding that at the residents care conferences. Interview on 12/6/23 at 7:30 a.m. with registered nurse (RN) manager I and RN J revealed: *Resident had an unstageable pressure ulcer on his left (L) heel that was originally identified in December 2022 during a routine skin check. *Resident had peripheral vascular disease that had made the healing of the pressure ulcer on the heel more difficult. *The resident had a stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with red or pink wound bed or may appear as an…

  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 before2026-07-02 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  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 the interviews, record review, observation, and policy review, the provider failed to ensure the staff responded promptly to twelve of thirty-one sampled residents (13, 14, 21, 27, 59, 73, 85, 89, 119, 123, 155, and 164) who reported concerns related to extended call light times. Findings include: 1. Interview on 6/28/26 at 4:03 p.m. with resident 13 revealed that he felt call lights were not answered in a timely manner. He stated, These [call lights] don't get answered. 2. Review of resident 13's call light response time report (a report of call light usage and time it took for the residents' call lights to be answered by the staff) from 6/1/26 through 6/30/26 revealed that twenty call light response times were more than 20 minutes long, four were more than 30 minutes, one was more than 40 minutes, two were more than 50 minutes, and one response time was greater than 90 minutes. 3. Interview on 6/29/26 at 2:56 p.m. with resident 59 revealed that he had to wait at least 30 minutes to have his call light…

  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 plan of correction
• Potential for harm · Ecited before2026-07-02 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure 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 the observation, interview, and record review, the provider failed to ensure medications were securely stored in three of ten observed medication carts by registered nurse (RN) V, RN FF, and certified medication aide (CMA) Z. Findings include:1. Observation on 6/30/26 at 2:10 p.m. in the 700 hallway outside of resident 75's room revealed there was an opened bottle of liquid Amoxicillin-Pot Clavulanate Oral Suspension (an antibiotic) for resident 181 on top of the medication cart. There were no staff members present. 2. Observation on 6/30/26 from 2:10 p.m. to 2:13 p.m. revealed that CMA X, activities assistant W, and two unidentified visitors walked past the medication cart that had the open bottle of resident 181's unsecured antibiotic medication on top of it. 3. Observation and interview on 6/30/26 at 2:13 p.m. with clinical care leader (CCL) S revealed that she removed the bottle of antibiotic medication from the top of the medication cart and was going to return the medication to the refrigerator. RN V was the nurse assigned to that medication cart, and CCL S was unsure…

  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 plan of correction
• Potential for harm · D2026-07-02 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, observation, and policy review, the provider failed to protect the resident's rights to dignity and respect for one of thirty one sampled residents (145) who was told by registered nurse (RN) (QQ) to 'stop talking' when asking her about his medications.Findings include:1. Observation on 7/1/26 at 8:44 a.m. of resident 145 sitting in his wheelchair in the hallway talking to RN QQ revealed he asked RN QQ, What time should I be getting my meds [medications]? RN QQ replied, They are at 8:00 a.m., but I am behind today. Resident 145 said, Well, I want to know what I get and when I get them. RN QQ said, I'm behind, and this isn't the time, so stop talking. Resident 145 then sat in his wheelchair in the hallway and waited until RN QQ gave him his morning medications at 8:50 a.m.2. Review of resident 145's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His 6/3/26 brief interview for mental status (BIMS) assessment score was 12, which indicated 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.

  Resident Rights Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · D2026-07-02 · tag F0812 — failed to store, cook, and serve food safely — isolated
  Procure 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 standard food safety practices to ensure that one of one licensed practical nurse (LPN) (K) performed hand hygiene (washing hands with soap and water or using hand sanitizer) when she assisted four of four sampled residents (23, 51, 147, and 161) to eat the evening meal, and that one of one cook (P) wore a hairnet over his beard while preparing food in the main kitchen.Findings include:1. Observation on 6/29/26 from 5:21 p.m. to 5:31 p.m. in the 400-hall dining room revealed LPN K did not perform hand hygiene before she assisted residents 23, 51, 147, and 161 at the supper table with their food. She placed a spoon in resident 23's hand, touched his leg and shoulder, and added the pudding onto his plate from the container. At 5:25 p.m., LPN K handed resident 161 her silverware and bowls to begin eating. At 5:27 p.m., LPN K assisted resident 51 and fed her a spoonful of food. At 5:29 p.m., LPN K assisted resident 147 with his supper. She touched resident 147's clothing protector, wheelchair, and 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · Dcited before2026-07-02 · tag F0880 — failed to prevent and control infections — isolated
  Provide 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, and policy review, the provider failed to ensure the staff followed infection prevention and control practices by one of one certified medication aid (CMA) (KK) and one of one certified nursing assistant (LL) who did not wear a gown or perform hand hygiene (wash hands with soap and water or sanitize hands) while providing care to one of one sampled resident (14) on enhanced barrier precautions (EBP) (glove and gown use when providing contact care). Findings Include: 1. Observation on 6/30/26 at 3:06 p.m. in resident 14's room revealed she had a magnet on her door frame that indicated she required EBP. When the surveyor went into her room, CNA LL and CMA KK had gloves on, did not have gowns on, and were providing care to resident 14. Resident 14 was lying partially on her left side, and her nephrostomy tube (a flexible tube surgically inserted into the kidney to drain urine) was clipped and hanging on the right side of the bed. CNA LL and CMA KK placed an incontinence (involuntary urine or bowel leakage) brief under resident 14. CNA LL removed her…

  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.

  Infection Control Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · E2025-04-24 · tag F0554 — pattern
  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, record review failed to ensure: *Three of three sampled residents (55,103, and 116), observed with medications stored in their rooms, were assessed for the ability to safely self-administer and store medications, and had physician's orders to self-administer medications according to the provider's policy. *On of One sampled resident's (116) care plan included the resident's self-administration of medications. 1. Observation on 4/14/25 at 3:17 p.m. of resident 103's room revealed: *There was a tube of Triad wound dressing paste (for wound healing) on her bedside table. -The instructions on the pharmacy label read, apply bid [twice daily] as directed. Review of resident 103's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 2/25/25 Brief Interview for Mental Status assessment score was 0, which indicated she was severely cognitively impaired. *She had a diagnosis of dementia with other behavioral disturbance. *She had an order for Triad Hydrophilic Wound Dress…

  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 · Ecited before2025-04-24 · tag F0561 — failed to honor residents' choices — pattern
  Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
  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 support residents' choices for five of five sampled residents (85, 139, 356, 361, and 363) on the rehab unit regarding menu options and food preferences at meals. Findings include: 1. Observation and interview on 4/15/25 at 8:22 a.m. with resident 363 in her room revealed: *She was waiting for her breakfast and wanted to know what was being served and when her meal would arrive. *She ate most of her meals in her room and never knew when or what she would be served. *She had not received a planned menu and had not chosen what she was served at her meals. *The breakfast meal was typically good, but she would have liked to have a choice about what she ate for lunch and dinner. Observation and interview on 4/16/25 at 9:37 a.m. with resident 363 in her room revealed she: *Was upset because she had gone to the dining room for breakfast that day and had not enjoyed that experience. She stated that she planned to eat the rest 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-04-24 · tag F0679 — failed to provide activities — pattern
  Provide activities to meet all resident's needs.
  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 three of three sampled residents (139, 361, and 363) who resided in the Rehab unit were provided activities that were meaningful and of interest to maintain their psychosocial well-being. Findings include: 1. Observation and interview on 4/15/25 at 8:22 a.m. with resident 363 in her room revealed: *She ate her meals in her room and participated in therapy. *There had not been any activities or programs for her to attend. *She felt alone and like there was no one to talk to. *She did not have an activities calendar of events happening in the facility. Observation and interview on 4/16/25 at 9:37 a.m. with resident 363 in her room revealed she: *Had been encouraged to go to the dining room for her meals for socialization. *Was upset because she had gone to the dining room for breakfast, hoping to talk to other residents, and had not enjoyed that experience. *Stated that she planned to eat the rest of her meals in her…

  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 before2025-04-24 · 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, and policy review, the provider failed to ensure: *One of one sampled resident (112) who used a recliner was evaluated for potential safety risks. *Assess for entrapment of mattresses that were on nine of 159 residents (5, 17, 22, 73, 83, 103, 106, 123, 137) beds. *Foot board railing was assessed for risk of entrapment for one of one sampled resident (453). *Safe, secure storage of chemical in two of two sampled residents rooms (55 and 103). Findings include: 1. Observation on 4/14/25 at 3:42 p.m. of resident 112 in her room revealed she was sitting in her recliner with her feet elevated. Observation and interview on 4/15/25 at 10:43 p.m. with resident 112 in her room revealed: *She was sitting in her electric recliner with her feet elevated and her eyes closed. *She had a pillow under her feet in addition to having the footrest elevated that the chair completely reclined. *She began speaking but kept her eyes closed. *When she was asked if she was able to lower…

  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 before2025-04-24 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  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 sufficient nursing staff for one of one secured unit to safely meet residents' needs, well-being, and the security of 17 of 17 residents (39, 86, 95, 96, 100, 102, 110, 114, 115, 122, 127, 131, 133, 135, 140, 148, and 453). Staff reported concerns with medication errors related to interruptions, difficulty keeping wandering residents within the unit, and difficulty completing all care tasks for residents due to the staffing of the unit. These failures placed those residents at risk for unmet care needs and potentially negative outcomes. Findings include: 1. During the entrance conference on 4/14/25 at 2:45 p.m. with administrator A, she stated the evening meal was served at 5:30. 2. Initial observation on 4/14/25, beginning at 5:34 p.m., of the dining room of the 100 hall, which is the secured unit, revealed: *Many of the residents had already finished eating and were walking around the adjacent day room and hallway. *Some residents had finished eating and were still seated at tables in…

  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.

  Nursing and Physician Services 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

$72,812 in federal fines across 5 penalties.

• $14,472 — penalty dated 2025-04-24
• $7,718 — penalty dated 2024-11-14
• $9,424 — penalty dated 2024-09-19
• $22,055 — penalty dated 2024-06-04
• $19,143 — penalty dated 2023-12-07

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 54 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 $2.9M paid to related parties — landlords or management companies under common ownership — equal to about 13% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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