Good Samaritan St Martin: Family Discovers Bruises - SD
The resident's family had visited during the July 4th weekend and noticed no signs of injury on her left hand or arm. When they returned a few days later, they found extreme bruising and swelling that had developed without explanation.
Digital photographs taken by the family during that visit showed the underside of the resident's hand had purple and black bruising across her fingers and palm that extended upward to her forearm. The entire top of her left hand was similarly bruised.
Nobody had told them their family member was injured.
State health department inspectors discovered the facility's failure to follow reporting requirements during a September complaint investigation. The Good Samaritan Society facility failed to notify the resident's family of the injury and failed to report the incident to state authorities, despite policies requiring both actions when injuries have unknown causes.
The infection preventionist and clinical care leader confirmed during inspector interviews that she had initially told the resident's daughter the bruising was "most likely caused by a recent lab draw on 7/7/25." But she later acknowledged the blood draw was taken from the resident's right arm, not the injured left arm.
The facility's medical provider documented the injury during a July 11th visit, noting there was "no definitive cause that was found" for the resident's left hand and arm injury. A nurse's progress note from that same day described wrapping the resident's left forearm, which was "bruised and has a large hematoma on the top of her left hand."
Licensed practical nurse E was responsible for notifying the resident's family about the left hand and arm injury, according to the infection preventionist. Because the cause was unknown, the nurse should also have notified a supervisor or the administrator.
None of that happened.
The facility administrator confirmed during the September inspection that staff had not followed procedures for notifying families about resident injuries. They also failed to report the incident to the South Dakota Department of Health, as required when injuries have unknown origins.
The facility's own abuse and neglect policy, revised in April, clearly outlined the requirements staff ignored. The policy states that designated agencies "will be notified in accordance with state law, including the State Survey and Certification Agency." It also requires staff to "notify the physician and family regarding the facts of the situation" and inform them "that an investigation is in progress" when there is "an injury of unknown origin."
The policy specifically requires that such notifications be recorded in the resident's file.
The resident's case illustrates a broader pattern of communication failures that can leave families unaware of injuries occurring in nursing homes. Federal regulations require facilities to immediately notify residents' representatives of any injuries, changes in condition, or incidents that could affect their health or safety.
The infection preventionist's initial explanation to the family — blaming a blood draw from the wrong arm — suggests staff may have been unprepared to discuss the injury's actual cause. Her subsequent acknowledgment that the lab draw couldn't have caused the bruising raises questions about whether staff conducted any investigation before offering that explanation.
The timing of the injury's discovery also raises concerns about daily monitoring procedures. The resident's family noticed no injury during their July 4th weekend visit, but found extensive bruising covering her hand and forearm just days later. The severity of the bruising, described as purple and black across her fingers, palm, and extending up her forearm, suggests the injury would have been visible to staff providing daily care.
The facility's failure to investigate the injury's cause violated both their internal policies and state reporting requirements. South Dakota regulations require nursing homes to report injuries of unknown origin to state health authorities, who can then determine whether additional investigation or oversight is necessary.
The administrator's admission that staff failed to follow proper procedures indicates the violations weren't the result of unclear policies or training gaps, but rather a failure to implement existing protocols designed to protect residents and keep families informed.
The inspection found the facility's violations created minimal harm or potential for actual harm, affecting few residents. However, the case demonstrates how procedural failures can leave families uninformed about significant changes in their loved ones' condition and prevent state authorities from investigating potentially serious incidents.
The resident's family discovered the injury through their own observation during a routine visit, not through any communication from facility staff. Their decision to photograph the bruising and report their concerns to state authorities ultimately led to the inspection that revealed the facility's policy violations.
The case occurred at a time when nursing home oversight has intensified following concerns about resident safety and family communication during and after the COVID-19 pandemic. Federal and state regulators have emphasized the importance of transparent communication with families and prompt reporting of incidents that could indicate neglect or abuse.
Good Samaritan Society - St Martin Village's failure to investigate and report the resident's injury represents a breakdown in the safety systems designed to protect vulnerable residents and ensure their families remain informed about their care and condition.
The resident's extensive bruising, covering her entire left hand and extending up her forearm, remains unexplained. The facility never conducted the investigation required by their own policies, leaving questions about how such severe injuries can occur without staff knowledge or documentation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society - St Martin Village from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
GOOD SAMARITAN SOCIETY - ST MARTIN VILLAGE in RAPID CITY, SD was cited for violations during a health inspection on September 4, 2025.
The resident's family had visited during the July 4th weekend and noticed no signs of injury on her left hand or arm.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.