Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society Miller during CMS and state inspections, most recent first.
The facility failed to ensure proper sanitation levels in the kitchen, as staff were unable to verify the chemical sanitation level required for dishwashing due to expired test strips. The dishwasher's chemical sanitation was not functioning, and staff were unaware of procedures to follow in such cases. This deficiency increased the risk of foodborne illnesses for residents.
A blind resident experienced neglect in a LTC facility, including delayed incontinence care, flies on his food, and unmet personal hygiene needs before a funeral. The resident's daughter confirmed these issues, highlighting a failure to uphold the facility's abuse and neglect policy.
A resident with dementia and mobility issues was left on a bedpan overnight, resulting in pressure injuries. Despite being dependent on staff for care, the resident was not on a repositioning program. Staff interviews revealed a lack of comprehensive training on bedpan use, contributing to the deficiency.
The facility lacked an infection prevention and control program. The interim DON had not updated policies, conducted infection surveillance, or established antibiotic stewardship. The administrator confirmed the absence of an active program, and the quality assurance specialist noted the resignation of the former infection preventionist, leaving the facility without a qualified individual.
The facility failed to appoint a qualified infection preventionist (IP) for its infection control program. The interim DON was informed she would be the IP, but her certification had expired, and she was not planning to renew it. The administrator confirmed the absence of a qualified IP, and the previous DON, who was the IP, had resigned, leaving the facility without a qualified infection preventionist.
The facility's QAPI program was found lacking in effectiveness and comprehensiveness, with no current performance improvement plan in place. Issues such as incomplete resident baths, abuse concerns, and outdated dietary test strips were not addressed through the QAPI committee. Additionally, the grievance process was poorly monitored, and customer satisfaction feedback was not reviewed. The QAPI coordinator was unaware of facility-reported incidents, and communication issues were noted within the facility.
The facility failed to maintain effective pest control, with surveyors observing live and dead insects, including flies and crickets, in various areas. Residents experienced flies on personal items and in food, highlighting inadequate pest management. Staff interviews revealed monthly pest control visits and some control measures, but the dining room lacked fly control, and staff were unaware of the issue there.
The facility failed to follow the bathing preferences of three residents, leading to missed baths and unmet care plan requirements. Staffing changes and scheduling issues contributed to the deficiency, with residents not receiving baths on their preferred days or frequency. Interviews and record reviews revealed discrepancies between documented preferences and actual care provided.
The facility failed to update and follow care plans for several residents, leading to unmet care needs. A resident's care plan did not address his use of a neuropathy device, suicidal ideations, or unsafe driving. Another resident's bathing preferences were not met, and her bed was improperly positioned. A third resident did not receive necessary incontinence care. The facility's policy required comprehensive care plans, but these were not accurately maintained.
A resident exhibited suicidal ideation and unsafe driving practices, yet the facility failed to notify the physician. The resident, who had a car at the facility, was observed driving unsafely and made a threat of self-harm, which he later dismissed as a joke. Additionally, the resident engaged in inappropriate behavior with a female. Despite these incidents, the facility did not inform the physician, violating their Notification of Change policy.
A facility failed to notify the State Long-Term Care Ombudsman of a resident's hospital transfers. The resident was transferred twice, with the POA notified but no documentation of bed hold information provided. The ombudsman did not receive notifications, and the facility's policy required such notices to be sent.
A resident was transferred to the hospital twice without receiving bed-hold notices, as required by the facility's policy. Despite notifying the resident's POA of the transfers, there was no documentation of bed-hold information being provided. Interviews with staff confirmed the absence of these notices, highlighting a failure to adhere to the facility's bed-hold policy.
A resident used an infra-red device for neuropathy pain without a current physician order or safety assessment. The device, observed in the resident's room, was not included in the care plan, and there was no documentation of its use. Interviews revealed a lack of awareness and proper storage of the device, and the facility did not provide a policy on electronic medical equipment.
Failure to Ensure Proper Sanitation Levels in Kitchen
Penalty
Summary
The provider failed to ensure that staff were able to verify the chemical sanitation level required to sanitize the dishes used for preparation and serving residents' food. This deficiency was identified through observations, interviews, and record reviews. The survey revealed that the dishwasher's chemical sanitation was not functioning, and staff were not aware of any process to follow when this occurred. Additionally, staff could not accurately verify the chemical sanitation level of the dishwasher due to the use of expired test strips. During the survey, it was observed that the sanitizing testing strips located by the three-compartment sink had expired. Interviews with dietary staff confirmed that these expired strips were being used to test the sanitizing solution, which was not at the correct parts per million (PPM) for effective sanitization. The Nutrition and Food Services Supervisor confirmed that the test strips were outdated and that there were no other test strips available for use. Furthermore, the dishwasher sanitizer was tested and found to be insufficient, with a reading of 10 ppm instead of the required 50 ppm. The deficiency was further compounded by the lack of awareness among staff regarding the expiration of test strips and the proper procedures to follow when the dishwasher was not functioning correctly. The provider's policies and procedures for sanitizing food contact surfaces and warewashing were not effectively implemented, as evidenced by the expired test strips and the inadequate sanitizing solution levels. This failure increased the potential risk of foodborne illnesses for the entire resident population who received meals prepared in the kitchen and served to the residents.
Removal Plan
- Provide dishwasher manufacturer manual and disinfectant information to support instructions are being followed and appropriate sanitation is occurring.
- Use disposable paper plates, cups, and silverware until dishwasher is running appropriately.
- Place new non-expired strips in for the 3 comp sink.
- Remove all expired strips in kitchen.
- Wash all dishes in the 3-comp sink until dishwasher is fixed to verify levels.
- Implement the use of a Monitoring Use of Ecolab disinfectant Test Strips form for staff to sign off on expiration date of a cartridge when replaced and label in the cartridge holder on the wall.
- Complete education with all dietary staff on proper procedure for non-working dishwasher and education on non-expired test strips with return demonstration.
- Educate all staff via PCC Communications that kitchen staff must ensure all chemical test strips are not expired for the dishwasher and the 3 comp sink.
- Add to the TELS Service Provider a task for Director of Environmental Services to monitor weekly if a cartridge is near expiration and needs replacement.
- Contact EcoLab to fix dishwasher. In the meantime, try a new bucket of Ultra San Ecolab 5 gallon liquid sanitizer in the dishwasher and retest.
Neglect of Resident's Basic Care Needs
Penalty
Summary
The provider failed to ensure the well-being of a blind resident, identified as resident 15, by not protecting him from neglect and ensuring his basic care needs were met. The resident reported having to wait up to three hours for staff to respond to his care requests, including incontinence care, which was supposed to be provided every two hours. He also experienced issues with flies on his food and in his drink during a meal with visitors, who reportedly killed 12 flies at the table. The interim director of nursing acknowledged the problem with flies and the lack of timely incontinence care but was unsure if these issues were addressed in the resident's care plan. The resident also faced neglect in personal hygiene care. He was scheduled to have a bath once a week, but on the day before attending a funeral, he requested a bath twice and was not accommodated due to a lack of hot water in the tub room. He was not offered alternative bathing options or assistance with shaving, resulting in him attending the funeral unbathed and unshaven. The resident expressed dissatisfaction with the care provided, stating it was the worst place he had been in his life. The resident's daughter confirmed her father's reports of neglect, stating that he had called her for help when his call light was not answered for over an hour, leading to a bowel incontinence episode. She observed that he had not been bathed or cleaned, and his bedding was dirty. The business office manager confirmed receiving a call from the resident's daughter but did not report the incident or verify if the resident had been assisted. The facility's abuse and neglect policy emphasized the right of residents to be free from neglect, but the incidents reported indicate a failure to uphold this standard.
Resident Left on Bedpan Overnight, Leading to Pressure Injuries
Penalty
Summary
The deficiency involves a resident who developed facility-acquired pressure injuries after being left on a bedpan for an extended period. The resident, who is bedridden and dependent on staff for care due to a back injury and dementia, was left on a bedpan from the evening of one day until the morning of the next day. This incident was confirmed by multiple staff interviews, including a registered nurse and a certified medication aide, who noted that the resident had been on the bedpan throughout the night, resulting in red marks on his buttocks. The resident's care routine involved the use of a mesh sling for repositioning and a mechanical lift due to his size and mobility issues. Despite these measures, the resident was not on a turning or repositioning program, which is critical for preventing pressure ulcers. Observations and interviews revealed that the resident had existing wounds that were improving, but the prolonged time on the bedpan led to additional skin issues, including redness and potential bruising from the bedpan. Interviews with staff, including the interim director of nursing, revealed a lack of comprehensive education and training regarding bedpan use and repositioning. Although some staff were informed about the incident, there was no documented education or attendance records to ensure all staff were aware of the proper procedures. The resident's medical history, including stage 4 pressure ulcers and other conditions, highlights the critical need for diligent care and monitoring to prevent further deterioration of his skin condition.
Inadequate Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program. During an interview, the interim director of nursing admitted that she had not taken any significant actions regarding the infection control program in the month she had been in her position, aside from creating two binders. She acknowledged the absence of updated policies and procedures, a lack of infection surveillance, and no process for antibiotic stewardship, with no one monitoring antibiotic use or orders. The administrator confirmed the absence of an active infection prevention and control program. Additionally, the quality assurance specialist revealed that the former director of nursing, who had been the infection preventionist, resigned at the beginning of August 2024, leaving the facility without a qualified infection preventionist.
Lack of Qualified Infection Preventionist in Facility
Penalty
Summary
The nursing home failed to designate a qualified infection preventionist (IP) to oversee its infection prevention and control program. During an interview, the interim Director of Nursing (DON) revealed that she was informed she would assume the role of IP, but her certification had expired, and she was not planning to renew it due to her interim status. The facility administrator confirmed the absence of a qualified IP. Additionally, a quality assurance specialist noted that the previous DON, who had been the IP, resigned at the beginning of the month, leaving the facility without a qualified infection preventionist.
Deficiencies in QAPI Program and Incident Management
Penalty
Summary
The provider failed to maintain an effective, ongoing, and comprehensive Quality Assurance and Performance Improvement (QAPI) program. The QAPI coordinator, who had been in the role for three years, acknowledged that the committee met monthly and had previously completed a performance improvement plan (PIP) for pressure ulcer prevention and treatment. However, there was no current PIP in place. The coordinator was aware of issues such as resident baths not being completed as scheduled and abuse concerns involving specific male residents, but these issues had not been addressed through the QAPI committee. Additionally, the dietary department's outdated chemical sanitation test strips were not identified through the QAPI process, and communication issues within the facility were noted, with the last all-staff meeting held several months prior. The QAPI coordinator was not aware of any facility-reported incidents through the state department of health's online reporting system and only tracked adverse events through the provider's electronic medical record system. There was an adverse event involving a resident left on a bedpan for an extended period, which was communicated to the nursing staff but not addressed through the QAPI committee. Furthermore, the grievance process was not effectively monitored, with some concern forms going missing or not being addressed, and customer satisfaction survey feedback was not reviewed through the QAPI committee. The provider's policies outlined the importance of addressing grievances promptly and ensuring a comprehensive QAPI program. However, the QAPI committee failed to track and trend performance, systematically analyze and prioritize quality deficiencies, and develop action plans to correct identified issues. The administrator's job description emphasized the responsibility for ensuring a QAPI program is in place, but the deficiencies in the program's implementation and oversight were evident in the findings.
Ineffective Pest Control Measures
Penalty
Summary
The facility failed to ensure effective pest control measures, as evidenced by multiple observations of live and dead insects within the premises. On several occasions, surveyors observed live beetles, flies, and dead crickets in various areas, including the conference room, dining room, hallways, and resident rooms. Notably, a resident was found with live flies on his blanket, and another resident, who is blind, was informed by friends about flies in his food and drink during a meal. These observations indicate a significant issue with pest control, particularly concerning flies, which were found in areas where residents eat and reside. Interviews with facility staff revealed that a professional pest control company visits monthly, and certain areas have automatic spray systems and devices to catch flies. However, the dining room lacked any fly control measures, and staff were unaware of the fly issue in that area. The facility's proximity to a bird seed plant and city sewer lagoon was mentioned as a potential contributing factor to the pest problem. Despite efforts such as distributing fly swatters and frequent exterminator visits, the interim director of nursing acknowledged the persistent issue with flies, especially during times when doors are open throughout the day.
Failure to Follow Resident Bathing Preferences
Penalty
Summary
The provider failed to adhere to the bathing preferences of three residents, as identified through a resident council meeting, observations, interviews, and record reviews. Residents expressed concerns about not receiving baths on their scheduled days, which had been discussed during care plan meetings. One resident, who preferred three baths a week, only received one bath per week after admission and missed scheduled baths for two consecutive weeks. Another resident, who was satisfied with one bath a week, did not receive a requested bath before attending a funeral, despite asking staff twice. The third resident, who required assistance with bathing, missed a scheduled bath due to equipment issues and was uncertain about her bathing frequency. The facility's records revealed discrepancies between the residents' documented bathing preferences and the actual bathing schedule. The first resident's care plan was not updated to reflect her preference for three baths a week, and there was no documentation of a bath for 12 days. The second resident's records indicated a preference for two or more baths per week, but he did not receive a bath as requested before the funeral. The third resident's care plan noted a preference for one or two baths a week, but she went 15 days without a documented bath. Interviews with staff highlighted issues with the bathing schedule due to staffing changes. The regular bath aide had reduced hours, and the administrative assistant was responsible for scheduling available staff to cover baths. The interim director of nursing acknowledged the bathing issues and had begun tracking residents' bathing to ensure compliance with their preferences. The administrative assistant confirmed that bathing was not being completed according to resident preferences, as the full-time bath aide had recently left, and scheduling was challenging.
Care Plan Deficiencies in Resident Management
Penalty
Summary
The facility failed to ensure that care plans for four out of five sampled residents were followed, updated, and revised promptly to reflect their current status and care needs. Resident 27's care plan did not include his use of an electronic neuropathy machine, his suicidal ideations, inappropriate sexual behavior towards staff, or his possession and use of a car, which he was deemed unsafe to drive. Despite being aware of these issues, the facility did not complete an assessment of his cognitive abilities related to driving, and his care plan was not updated to address these concerns. Resident 1 expressed dissatisfaction with her bathing schedule, as she was receiving only one bath per week, contrary to her preference for three baths a week, which she had received in assisted living. Her care plan was revised to include two weekly whirlpool baths, but this did not align with her stated preference. Similarly, Resident 18's care plan indicated a preference for one or two whirlpool baths a week, but she reported missing a bath due to equipment issues and was unsure of her bathing frequency. Additionally, her care plan did not specify the appropriate height for her bed, which was observed to be in the highest position, contrary to safety protocols. Resident 15 reported not receiving incontinence care as needed, despite his care plan indicating he should be checked and changed every two to three hours. The facility's interim director of nursing was unsure if his incontinence care needs were included in his care plan. The facility's policy required comprehensive, person-centered care plans to be developed and updated to meet residents' needs, but the interdisciplinary team failed to ensure these plans were accurate and reflective of the residents' current care requirements.
Failure to Notify Physician of Resident's Suicidal Ideation and Unsafe Driving
Penalty
Summary
The provider failed to notify the physician of a resident's suicidal ideation and unsafe driving practices. The resident, identified as Resident 27, had a car parked at the facility and was observed driving it despite concerns about his safety. The interim director of nursing and a registered nurse acknowledged that they did not believe the resident was safe to drive and had notified the police, who informed them they could not revoke his driver's license. However, no assessment of the resident's cognitive abilities related to driving was conducted, and the physician was not informed of these concerns. Additionally, the resident's medical records indicated several incidents that warranted physician notification. On one occasion, the resident threatened self-harm with a sharp object, which he later claimed was a joke. There were also reports of the resident nearly being involved in a car accident and driving recklessly. Furthermore, the resident engaged in inappropriate behavior by squeezing a female's buttock. Despite these significant changes in the resident's mental and psychosocial status, there was no documentation to show that the physician had been informed, which is a requirement according to the facility's Notification of Change policy.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide a copy of the transfer notice to the Office of the State Long-Term Care Ombudsman for a resident who was transferred to the hospital. The resident, identified as resident 21, was transferred to the hospital on two occasions, once on May 15, 2024, and again on June 18, 2024. In both instances, the resident's power of attorney (POA) was notified of the transfers, but there was no documentation indicating that bed hold information was provided to either the resident or her POA. Interviews with the facility's local ombudsman and the facility administrator revealed that the facility typically filled out a report online about hospitalizations and had one month to notify the ombudsman of such transfers. However, the ombudsman confirmed that they had not received notifications for either of the resident's hospital transfers. The facility's social services coordinator was responsible for submitting these reports, but the administrator was unaware that every hospital transfer needed to be reported to the ombudsman. The facility's policy indicated that copies of notices for emergency transfers must be sent to the ombudsman, but this was not done in the case of resident 21.
Failure to Provide Bed-Hold Notices During Hospital Transfers
Penalty
Summary
The provider failed to provide bed-hold notices to a resident and their representative during two hospital transfers. The resident, identified as resident 21, was transferred to the hospital on two occasions, once on 5/15/24 and again on 6/18/24. In both instances, while the resident's power of attorney (POA) was notified of the transfers, there was no documentation indicating that bed-hold information was provided to either the resident or the POA. Interviews with the resident, a registered nurse, the business office manager, and the administrator confirmed the absence of bed-hold notices for these hospital stays. The facility's bed-hold policy, dated 12/7/23, requires that written information regarding the bed-hold and reserve bed payment policy be provided to the resident or their representative at the time of admission, transfer, or therapeutic leave. The policy also outlines the responsibilities of the charge nurse and social worker in ensuring notification procedures are completed. However, in the case of resident 21, these procedures were not followed, as evidenced by the lack of documentation and confirmation from staff interviews.
Failure to Ensure Safety and Proper Documentation for Infra-red Device Use
Penalty
Summary
The provider failed to ensure that a resident using an infra-red device for neuropathy pain had a current physician order and had been assessed for the safety of its use. The resident, who had diagnoses including dementia, chronic atrial fibrillation, chronic kidney disease, and heart failure, did not have a diagnosis for neuropathy. Despite this, he used an electronic neuropathy machine daily for pain in his feet. The device was observed in his room, placed on a folding chair, and had uncleanable surfaces with carpet and electrical tape attached to it. There was no current physician order for the device's use, and it was not included in the resident's care plan. Interviews with the interim director of nursing and a registered nurse revealed that the resident did not have a diagnosis of neuropathy and that the nurse was unaware of the device until the morning of the interview. There was no safety assessment conducted for the device's use, and it was confirmed that the device should have been stored in the medication room and documented in the treatment administration record. Despite these findings, the device was still observed in the resident's room later that day. The facility did not provide a policy regarding electronic medical equipment when requested.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Miller
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highmore Health | 22.5 mi | — | 1 | 0 |
| Eastern Star Home Of South Dakota, Inc | 33.2 mi | — | 0 | 0 |
| Avantara Redfield | 33.5 mi | — | 9 | 0 |
| Faulkton Senior Living | 36.1 mi | — | 3 | 0 |
| Weskota Manor Inc | 36.7 mi | — | 3 | 0 |
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