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Citation history
Health deficiencies cited at Good Samaritan Society Luther Manor during CMS and state inspections, most recent first.
A resident with quadriplegia who relied on baclofen to manage muscle stiffness and spasms experienced a significant medication error when an RN misread a pharmacy communication about a future stop date and discontinued baclofen without a physician’s order. The resident subsequently developed altered mental status, facial redness, and behavioral changes, leading to transfer to the ED and hospital admission, where acute encephalopathy likely due to baclofen withdrawal was diagnosed. The medical director, DON, and administrator all stated that a physician’s order and clarification on discontinuation of such a medication would have been expected before stopping it.
A resident with mild cognitive impairment and a known elopement risk, who had refused a wander guard and was to be checked every three hours, was last documented as seen at midday and later left the building by independently using the front door keypad code, remaining unsupervised outside until returning the next day. The front door keypad code had been unchanged for years, was posted in reverse on a laminated sign above the keypad, and was known to some residents, allowing them to open the door. At the same time, after an EMR system update, staff stopped routinely completing the required elopement risk assessment on all new admissions, and several newly admitted residents had no documented elopement screening despite facility policy requiring universal admission screening.
The facility failed to report a fall incident and multiple verbal abuse allegations to SD DOH within required time frames. A resident who required two-person assistance with a sit-to-stand mechanical lift was transferred by one CNA, slipped from the sling to the floor, and was later reported to SD DOH beyond the 24-hour requirement. In a separate situation triggered by a staff member’s quality-of-care concerns, a resident reported being told to shut up and sit up or help would be withheld, and two other residents described rude and inappropriate comments by a CNA; these abuse allegations were not reported within the mandated 2-hour window. Another resident’s frequent call light use for leg pain and repositioning led to findings that a CNA used profanity when speaking with staff about a resident. The DON acknowledged that these events were not reported in accordance with the facility’s abuse/neglect policy and state reporting timelines.
A resident with a history of falls, dementia, and muscle weakness sustained an injury after staff failed to follow the care plan requiring a silent TABs alarm in both the bed and recliner. The alarm was left in the recliner instead of being placed on the bed, and staff interviews and observations confirmed that only one alarm was being used and transferred between locations, contrary to the care plan. Additional required interventions, such as signage, were also not in place, and staff were not consistently aware of or following the prescribed fall prevention measures.
A resident with a history of stroke and dysphagia received water through a straw, despite a care plan specifying no straws and special hydration needs. The restriction was documented in the care plan but was not transferred to the Kardex, leaving front-line staff unaware of the requirement. Staff interviews confirmed reliance on the Kardex for such information, resulting in the resident not receiving care as ordered.
A resident with a history of UTIs was found with two Buprenorphine patches on their skin, leading to altered mental status. The facility failed to remove the previous patch before applying a new one, due to a delay in medication delivery and lack of adherence to the patch management process. Staff interviews revealed confusion about medication availability and inconsistent verification of patch removal.
A resident with a history of stroke was injured during a transfer with a sit-to-stand mechanical lift due to inadequate staff assistance and supervision. Despite the care plan requiring two staff members for transfers, only one was often present, leading to a fall and head injury. The resident expressed fear and discomfort with the lift, but it continued to be used without proper reevaluation. The facility failed to ensure proper documentation and communication of transfer needs, contributing to the deficiency.
The facility failed to properly store, label, and maintain cleanliness of food items in the kitchen and kitchenette areas. Observations revealed unlabeled and undated food, spoiled items, and unsanitary conditions. Cleaning logs were incomplete, and the director of dining services acknowledged the issues.
A resident's care plan was not updated after her catheter was removed, despite confirmation from the resident and staff that she no longer had it. The care plan still required Enhanced Barrier Precautions for a Foley catheter, which had been discontinued. Staff interviews revealed a lack of communication and adherence to the facility's policy on care plan updates.
Significant Medication Error from Unauthorized Discontinuation of Baclofen
Penalty
Summary
The deficiency involves a failure to ensure that a resident was free from significant medication errors when an RN discontinued a critical medication without a physician’s order. The resident, who had quadriplegia and was receiving baclofen as a primary medication to manage involuntary muscle stiffness and spasms, experienced an abrupt discontinuation of this drug. RN C received a Consultant Pharmacist Communication to Physician asking the physician to clarify whether baclofen and duonebs, which had a stop date of 2/1/2027 on the MAR, should be discontinued at that time or continued. RN C misread the year on the stop date, believed the medications should have been discontinued on 2/1/2026, and independently stopped the resident’s baclofen on 3/18/26 without waiting for the physician’s verification or obtaining an order. Following the discontinuation, the resident developed a change in mental status, facial redness, and behavior that was described as not acting himself on 3/20/26. He was sent to the ED for evaluation at approximately 9:00 p.m. and was admitted to the hospital later that evening. He was diagnosed with acute encephalopathy, likely due to baclofen withdrawal after the abrupt discontinuation. Interviews confirmed that the medical director, who was the resident’s primary physician, would have expected to be contacted before any medication was discontinued and expected nursing staff to obtain clarification on how a medication like baclofen should be discontinued to ensure it was done safely. The DON and administrator both confirmed that a physician’s order was expected before discontinuing a resident’s medication, and the DON identified this event as a significant medication error.
Failure to Secure Exit Door and Consistently Assess Residents for Elopement Risk
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent accidents, specifically related to elopement risk and door security. One resident, who was admitted with an identified elopement risk and had a BIMS score of 11 indicating mild cognitive impairment, refused a wander guard, so staff were to perform and document three-hour rounding to verify his whereabouts. On the day of the incident, his last documented three-hour check occurred at 12:00 p.m., and he was later reported missing at 8:00 p.m. after dietary staff noted his absence from the evening meal. A review of camera footage showed that he had tested and successfully used the front door keypad code earlier in the day and exited the building at 5:04 p.m., remaining outside the facility unsupervised for about 18.5 hours until he returned in a private vehicle the following day. The report further documents that the front door keypad code had been in place for several years and was not changed immediately after the elopement. The keypad was located near the front door with a laminated paper above it displaying the code written backwards, which could be read and used by anyone with intact cognition. Observations showed a visitor reading the laminated sign and entering the code to exit. Staff interviews confirmed that some residents, including the eloping resident, knew and used the door code to go outside. The resident whose room was closest to the front door stated he had watched people use the keypad, learned the code, tested it earlier in the day, and then chose a time when staff were busy to leave the building. The code remained unchanged from the time of his elopement until several days later. In addition, the facility did not consistently assess newly admitted residents for elopement risk as required by its elopement policy. The policy stated that all residents would be assessed for elopement risk during the pre-admission and/or admission process using a user-defined assessment (UDA) in the electronic medical record system, with results used to individualize care plans. After a software update to the Point Click Care (PCC) system in December 2025, the elopement assessment no longer opened automatically, and the nurse responsible for admission assessments reported that she only completed elopement assessments if residents expressed a desire to leave or had certain clinical risk factors. The admission checklist was also no longer used. Record review showed that three newly admitted residents during the review period had no documented admission elopement screening assessments in their EMRs, and leadership acknowledged that not all residents were being screened on admission as required by policy.
Failure to Timely Report Fall Incident and Verbal Abuse Allegations to SD DOH
Penalty
Summary
The deficiency involves the facility’s failure to report certain incidents and allegations to the South Dakota Department of Health (SD DOH) within required time frames. For one resident who required a sit-to-stand mechanical lift with two-person assistance per the care plan, a CNA performed the transfer alone. During the transfer, the resident slipped from the sling, slid to the floor onto his bottom, and rolled onto his right side. An LPN immediately assessed the resident and found no injury, but the incident, which occurred on 11/28/25 at 11:30 a.m., was not reported to the SD DOH until 12/1/25, exceeding the 24-hour reporting requirement for such events. The facility also failed to timely report allegations of verbal abuse involving another resident. After a CNA left her shift early and raised quality of care concerns, the administrator and DON interviewed residents and staff. One resident reported that a CNA told her not to sing and to “shut up” and “sit up or I am not going to help you.” Two additional residents reported that the same CNA made rude and inappropriate comments, including “You would not have these issues if you went out to the dining room” and “Don’t be cocky.” Although the CNA denied making rude or inappropriate comments, these allegations of verbal abuse were not reported to the SD DOH until six days after the DON was notified, well beyond the required two-hour reporting window for abuse allegations. A third deficiency involved another resident and additional allegations of verbal abuse. Following the same initial staff report of quality of care concerns, the facility investigated and learned that a CNA reported the resident had used the call light several times during the night for leg pain and repositioning needs. The CNA stated she did not use profanity toward residents while providing care but acknowledged using profanity at times when talking with other staff members about a resident, as an expression of how she felt. The DON later confirmed that reports of resident abuse and neglect were required to be reported to the SD DOH within two hours, and all other reportable events within 24 hours, and acknowledged that the verbal abuse allegations related to these residents, as well as the earlier fall incident, were not reported within the required time frames. The facility’s own abuse and neglect policy required immediate reporting, but not later than two hours, for allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of property, or serious bodily injury, and within 24 hours for other allegations without serious bodily injury.
Failure to Implement Fall Prevention Interventions as Care Planned
Penalty
Summary
A deficiency occurred when staff failed to implement fall prevention interventions as described in the care plan for a resident with a history of repeated falls, muscle weakness, dementia, and use of anticoagulants. The resident was found on the floor next to his bed with a laceration near his right eye, requiring emergency department treatment and sutures. The facility's investigation revealed that the silent TABs alarm, intended to alert staff when the resident attempted to stand, was left in the resident's recliner instead of being placed on the bed, as required by the care plan. The certified nursing assistant who assisted the resident to bed forgot to move the alarm, resulting in the alarm not being in place at the time of the fall. Further review of the resident's medical record and care plan showed that the resident was care planned to have a silent TABs alarm in both his bed and recliner at all times, with instructions to ensure the alarm was used, plugged in, and functioning when the resident was in either location. However, multiple progress notes documented that the alarm was not consistently placed under the resident at bedtime and was often found in the recliner while the resident was in bed. Staff interviews confirmed that only one alarm was being used and transferred between the bed and chair, rather than having two alarms as specified. Some staff were unaware of the care plan requirements, and others reported that attempts to use two alarms resulted in malfunctions, leading to the removal of the second alarm without alternative interventions being consistently implemented. Observations confirmed that the resident's room did not have two alarms as required, and the STOP, Wait for assistance sign, which was supposed to be in place as an additional intervention, was not visible. Interviews with nursing and administrative staff revealed a lack of awareness regarding the specific fall prevention interventions required for the resident, and documentation of these interventions was inconsistent. The facility's fall prevention policy emphasized the need to identify risk factors and implement interventions before a fall occurs, but these procedures were not followed in this case.
Failure to Communicate Hydration Restrictions Leads to Care Plan Deviation
Penalty
Summary
Staff failed to follow the care plan regarding hydration needs for a resident with a history of stroke, hemiplegia, and dysphagia. The resident was observed receiving medications with pudding and water through a straw, despite care plan instructions specifying mildly thickened liquids with meals, thin liquids in the room only after oral care, and no use of straws as per speech therapy recommendations. The certified medication aide administering the medication was unfamiliar with the resident's specific needs, and the water mug in the resident's room contained a straw, contrary to the care plan. Interviews with dietary and nursing staff revealed that the restriction on straw use was documented in the care plan but was not transferred to the Kardex, the tool used by front-line caregivers to access residents' care needs. Both the CNA and RN confirmed reliance on the Kardex for such information, and the DON was unaware of the no-straw requirement. The facility's policy required care plans to reflect current care needs and ensure appropriate care and services, but the failure to update the Kardex led to staff not being informed of the resident's hydration restrictions.
Failure to Remove Previous Buprenorphine Patch Leads to Double Application
Penalty
Summary
The deficiency involved a failure to properly manage the administration of Buprenorphine transdermal patches for a resident, leading to the application of two patches simultaneously. The resident, who had a history of neurogenic bladder and urinary tract infections, was found with two Buprenorphine patches on his skin when evaluated at a hospital for altered mental status. The resident had an order to apply one patch every seven days, but due to a delay in delivery, a second patch was applied without removing the first one. The incident occurred because the nurse who applied the second patch was unaware that the previous patch had not been removed. The facility's process for managing transdermal patches was not followed correctly, as evidenced by the lack of signatures on the narcotic patch placement form and the failure to verify the removal of the previous patch. Interviews with staff revealed that there was confusion about the availability and delivery of the medication, and the process for checking and removing old patches was not consistently followed. The director of nursing service acknowledged the incident and reported it to the South Dakota Department of Health. Despite the resident's history of UTIs, the hospital suspected that the altered mental status was due to the double application of Buprenorphine patches. The facility had not provided new education to all staff regarding the process for applying and removing transdermal patches, and there was no updated policy since the incident, indicating a gap in ensuring compliance with medication administration procedures.
Deficiency in Resident Transfer Safety and Supervision
Penalty
Summary
The report identifies a deficiency in the safety and supervision of a resident who required assistance during transfers with a sit-to-stand mechanical lift. The resident, who had a history of stroke resulting in weakness in the left leg and arm, was involved in an incident where he was dropped in the shower room, leading to a head injury and a hospital visit. Despite the care plan indicating the need for two staff members to assist with the lift, observations revealed that only one staff member was often present during transfers, which compromised the resident's safety. Interviews with staff members, including CNAs and LPNs, highlighted a lack of awareness and adherence to the care plan. One CNA admitted to transferring the resident alone, believing he required only one assist, while another staff member was unaware of the resident's discomfort and fear of using the lift. The resident expressed concerns about the lift's safety, indicating that it caused discomfort and fear during transfers. Despite these concerns, the lift continued to be used without proper reevaluation or adjustment to the resident's needs. The facility's failure to ensure proper documentation and communication of the resident's transfer needs contributed to the deficiency. The Kardex, which contained updated care instructions, was not consistently checked by staff, leading to improper transfer methods. Additionally, the facility's fall prevention policy was not effectively implemented, as evidenced by the lack of timely updates to the care plan and inadequate staff training on the use of mechanical lifts. This oversight resulted in the resident's fall and subsequent injuries, highlighting a significant lapse in the facility's duty to provide a safe environment for its residents.
Deficiencies in Food Storage and Sanitation
Penalty
Summary
The provider failed to ensure proper storage, labeling, and cleanliness of food items in the kitchen and kitchenette areas. Observations revealed multiple instances of unlabeled and undated food items, including cookies, butter, peanut butter, and various items in the walk-in refrigerator and freezer. Additionally, spoiled food items such as celery and salad were found, and some items were past their discard dates. The kitchen environment was unsanitary, with hardened substances on a metal cart, crumbs and substances on equipment like the Magic Bullet, and a lack of soap in the hand-washing sink. The serving area outside the kitchen also exhibited deficiencies, with food crumbs and debris between equipment, and unlabeled and undated food items such as cookies and blueberries. The refrigerator in this area contained expired and spoiled items, including thickened water and a salad labeled for a resident. The kitchenette in the 500-wing had similar issues, with unlabeled and undated food items, and expired thickened juices. The review of cleaning logs showed incomplete cleaning tasks, with many tasks left uncompleted over several weeks. The director of dining services acknowledged the issues, including the lack of awareness about the empty soap dispenser and the incomplete cleaning logs. The provider's policies on date marking and cleaning schedules were not adhered to, contributing to the deficiencies observed.
Failure to Update Care Plan After Catheter Removal
Penalty
Summary
The provider failed to update the care plan for a resident after the removal of her catheter. The resident, who was moderately cognitively impaired, confirmed during an observation and interview that she no longer had a catheter. However, her care plan still indicated the need for Enhanced Barrier Precautions due to an indwelling Foley catheter, which had been initiated months earlier. The resident's electronic medical record showed that the catheter was discontinued, and subsequent assessments confirmed its absence, yet the care plan was not updated to reflect this change. Interviews with facility staff, including a registered nurse and a certified nurse assistant, revealed that the care plan had not been revised to remove the catheter information. The RN responsible for updating care plans acknowledged that the care plan should have been updated and indicated that the nurse manager should have communicated the change. The facility's policy emphasizes the importance of care plans in coordinating services based on individual needs, but this was not adhered to in this instance.
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Nursing homes near Sioux Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Norton | 0.6 mi | — | 21 | 0 |
| Bethany Home Sioux Falls | 0.9 mi | — | 3 | 0 |
| Good Samaritan Society Sioux Falls Village | 2.4 mi | — | 0 | 0 |
| Good Samaritan Society Sioux Falls Center | 2.8 mi | — | 4 | 0 |
| Dow Rummel Village | 2.9 mi | — | 6 | 0 |
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