SIOUX FALLS, SD - Federal inspectors documented widespread infection control breakdowns at Good Samaritan Society Sioux Falls Village during an April 2025 survey, finding contaminated equipment shared between residents, expired medical supplies, and unsanitary conditions throughout common areas and utility rooms that placed residents at risk for healthcare-associated infections.
Contaminated Personal Care Items Shared Between Residents
Inspectors discovered numerous instances where personal hygiene items and medical equipment were being shared between residents without proper cleaning protocols, directly violating infection control standards designed to prevent disease transmission in congregate care settings.
In the 100 hall shower room, staff had stored an electric razor filled with gray hair stubble without any resident identification label. The cabinet also contained two combs with gray hairs and white crust, along with a bin holding two hairbrushes with excessive amounts of gray hair, 13 black combs with dried material and long gray hair, a foot file with white sediment, and numerous unsecured hair accessories. When questioned, a certified medication aide acknowledged that some personal care items were being shared between residents.
Similar conditions existed in other shower facilities. The 400 hall shower room contained razors, partial bottles of body wash and lotion, tubes of medicated zinc oxide cream, and a nail clipper—all without resident identifiers. Staff member CNA K confirmed she would not use fingernail clippers or razors on residents if the items didn't belong to them, yet acknowledged she used facility-supplied body washes and shampoos between residents without wiping the bottles or implementing any process to prevent cross-contamination. She noted the nail clipper "appeared to have been used and was not clean."
The sharing of personal care items between residents creates significant infection transmission risks. Items like nail clippers, razors, and hairbrushes can harbor bloodborne pathogens including hepatitis B, hepatitis C, and other infectious agents. Even items like combs and brushes can transmit fungal infections, lice, and bacterial scalp conditions between residents. Medical protocols require that such items either be single-use disposable products or dedicated equipment assigned to individual residents with proper cleaning between uses.
In the 200 hall shower room, inspectors found containers of personal hygiene wipes that were being used for multiple residents. CNA W stated she would be unable to identify which resident the partially used personal care items belonged to because there were no resident identifiers on them.
Expired Medical Supplies and Contaminated Storage Areas
The inspection revealed systematic failures in monitoring expiration dates and maintaining sanitary storage conditions in utility rooms throughout the facility. These areas, which should maintain the highest infection control standards, showed evidence of neglect and improper storage practices.
In the 400 South hall soiled utility room, inspectors found a skin prep pad that had expired in September 2022—more than two years past its expiration date. The room's hopper (a specialized sink for disposing bodily fluids) had its plastic splash guard lying on the floor rather than properly mounted, and the posted instructions required staff to wear gowns, gloves, and goggles, yet no gowns or gloves were available. The goggles present were covered in a thick layer of dust. Paint peeled from walls and ceilings, creating surfaces that cannot be properly cleaned or disinfected.
Under the sink in this room, inspectors documented a concerning array of improperly stored items: a gray basin with dried brown and white sediment, a white bucket with dried crusty substance, utility gloves in a plastic bag, a bedpan, and various pieces of equipment—all stored in an area that should remain clear to prevent contamination. An Emergency Response kit had no visible expiration date.
The 300 hall soiled utility room contained even more expired materials stored under the sink. A bottle of Oxivir disinfectant concentrate had expired in October 2023, stored in a basin covered with yellowish-brown substance. Peroxide multi-surface cleaner wipes in the container had completely dried out, rendering them ineffective. The room also housed a nebulizer machine (used for respiratory treatments) stored inappropriately in a soiled utility environment alongside other contaminated items.
Expired medical supplies lose their effectiveness and can pose safety risks. Disinfectants and antiseptics degrade over time, losing their ability to kill pathogens effectively. Using expired skin prep pads before procedures could fail to adequately disinfect the skin, increasing infection risk during medical interventions. The presence of expired supplies indicates inadequate inventory management and quality control processes.
In the 100 hall shower room, inspectors found a bottle of Selsun Blue shampoo that had expired in September 2021—nearly four years past its expiration date. A bottle of Aveeno baby lotion stored in the cabinet had expired in October 2019, more than five years overdue for disposal.
The director of nursing acknowledged that nurse managers were responsible for checking expiration dates on their respective halls, but there was no schedule in place to systematically check supplies other than medications. The facility administrator confirmed the provider had no written policy regarding supply expiration dates.
Unsanitary Conditions in Resident Areas
Throughout common spaces where residents spent significant time, inspectors documented furniture contaminated with biological materials that posed infection risks and compromised resident dignity.
In the 400 hall lobby area, three chairs showed visible contamination: a purple dining chair with white unknown substance on the seat cushion, a white and gray chair with a dried yellow stain in the middle of the cushion, and a light green chair with a yellow stain on the front cushion.
The 100 hall day room revealed more concerning findings. A brown suede recliner had a wet area on the seat, a greasy stain on the headrest, and a brownish-red substance on the arm. An empty wheelchair contained a solid unidentified brownish-yellow crusty substance on the seat. These items remained in use by residents despite their contaminated condition.
During the dinner meal service at 5:39 p.m., inspectors observed the 400 hall dining room where "multiple dining room chairs had dried unidentified discolorations to the fabric on the backs and seats." Residents were seated in these contaminated chairs while eating their meals.
Contaminated seating surfaces present multiple health risks. Porous fabric materials can harbor bacteria, viruses, and fungi that survive for extended periods. When residents with compromised immune systems—common among nursing home populations—come into contact with these surfaces, they face increased risk of skin infections, urinary tract infections, and gastrointestinal illnesses. Food consumption while seated on contaminated surfaces compounds these risks through potential hand-to-mouth transmission.
The facility's lead environmental technician revealed that soiled utility rooms were not included on the environmental services cleaning schedule and "did not get cleaned routinely." Shower rooms received cleaning only three times weekly. Regarding the contaminated chairs in common areas and dining rooms, the technician stated these used to be cleaned by someone who no longer worked at the facility, indicating the responsibility had been neglected after that person's departure.
The administrator confirmed that maintenance staff held responsibility for cleaning dining room and common area chairs but acknowledged there was no schedule indicating when cleaning should occur. She stated that if a soiled chair was identified, she expected maintenance to attend to it that day—yet the widespread contamination observed during the survey demonstrated this expectation was not being met.
Inadequate Staff Training and Oversight
The inspection revealed that at least one certified nursing assistant/certified medication aide who worked in the secure memory care unit had not completed required annual in-service training, including dementia management and resident abuse prevention training.
CNA/CMA KK, hired in November 2021, had documented medication errors on four consecutive days in March 2025 while working in the memory care unit. Her last annual performance review had been completed in May 2023—more than 10 months overdue at the time of inspection. Between January 2024 and February 2025, she completed only 4.89 hours of in-service education, significantly below required levels. Records contained no documentation that this training addressed dementia care, abuse prevention, or care of cognitively impaired residents.
The facility's training tracking system showed 17 required courses with due dates between April 2023 and October 2024 marked as "Registered/Past Due," including critical topics such as "Protecting Resident Rights in Nursing Facilities," "Behavioral Health," and "Communicating Effectively."
When questioned, the director of nursing acknowledged that email notifications about incomplete training had been sent while she was on leave, stating simply, "It got missed." The Clinical Learning and Development Specialist confirmed she tracked training completion and notified leadership when staff fell behind, but expected the administrator or director of nursing to follow up—a process that clearly failed in this case.
Adequate staff training represents a foundational element of quality care. In memory care settings specifically, specialized training in dementia management is not merely regulatory compliance but essential for resident safety. Staff who lack current training in behavioral management techniques, communication strategies for cognitively impaired residents, and abuse recognition may inadvertently use approaches that escalate behavioral symptoms or fail to identify concerning situations.
Additional Issues Identified
Inspectors documented a resident with severe cognitive impairment whose care plan specified a soft-touch call light as a fall prevention intervention. However, on three separate observation dates, staff had clipped this call light to the room divider curtain approximately halfway up—completely out of reach whether the resident was in bed or her wheelchair. Staff acknowledged the resident was unable to use the call light due to her cognition, yet failed to place it appropriately to alert them when she moved.
In multiple soiled utility rooms, clean supplies and equipment were improperly stored under sinks alongside contaminated items, creating cross-contamination risks. The 400 North hall soiled utility room contained a large red bin overfilled with used sharps containers so full the lid could not close properly to contain the medical waste. A suction machine labeled "Return to Central Supply" was found stored in a soiled utility room—a clean item in a contaminated environment.
Clean linen was stored and transported without proper covering in several areas. In the 100 hall shower room, clean folded linen sat uncovered on a cart near the shower, exposed to moisture, splashes, and airborne particles. A laundry cart used to transport clean linens had a cover so badly torn it could not adequately protect the contents. The lead laundry technician acknowledged the cover did not provide adequate protection but the deficiency had not been corrected.
The facility's own infection prevention and control policy stated the program should "provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections," with the infection preventionist responsible for program oversight. The policy specified that "environmental cleaning plays an important role in an infection control program" and that "all staff members play a role and should be aware of the general principles of environmental cleaning and safety." The inspection findings demonstrated systematic failure to implement these stated standards across multiple departments and locations within the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society Sioux Falls Village from 2025-04-24 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.