Good Samaritan Society St Martin Village: Injury Unreported - SD
They came back a few days later and found her hand covered in purple and black bruising, fingers to palm, extending up her forearm. The top of her hand was bruised the same way. The swelling was severe enough that photographs the family took that day showed it clearly. Nobody at the facility had called them. Nobody had told them anything had happened.
Nobody had.
A complaint filed with the South Dakota Department of Health on July 16, 2025, set off an investigation that ended with a federal inspection on September 4, 2025. What inspectors found was not a mystery about how the resident got hurt. What they found was a facility that knew about the injury, documented it, wrapped it, and still failed to make a single required call — not to the family, not to the state.
The injury had a name in the medical record. A physician visit note from July 11 described a large hematoma on the top of the resident's left hand and bruising of her left forearm. A licensed practical nurse named LPN E entered a progress note the same day documenting that the medical provider and a nurse had wrapped the resident's left forearm. The cause, the physician's note said, was unknown. No definitive explanation had been found.
That July 11 note was the first time the injury appeared anywhere in the resident's chart. The family's photographs and their account of what they saw placed the injury's discovery several days before that. The record offered no documentation of how or when staff first noticed the bruising, no incident report, no investigation.
What the record did contain was a progress note entered by the facility's infection preventionist and clinical care leader, identified in the inspection report as IP/CCL B, on July 1 — ten days before the physician visit. In that note, IP/CCL B documented that she had returned a call from the resident's daughter and explained that the bruising on the resident's arm was most likely caused by a blood draw performed on July 7.
The blood draw had been taken from the resident's right arm.
IP/CCL B confirmed this to inspectors during an interview on the morning of September 4. She confirmed that the bruising was on the resident's left hand and arm. She confirmed that the lab draw on July 7 was from the right arm. She confirmed, in other words, that the explanation she had given to the resident's daughter was wrong. The injury had no confirmed cause when she made that call, and it still had no confirmed cause.
She also confirmed that it was LPN E's responsibility to have notified the resident's family when the injury was first discovered. Because the cause was unknown, LPN E was also expected to have notified a nurse supervisor or the facility's administrator, identified in the report as administrator A. Injuries of unknown origin were supposed to be documented, investigated, and reported to the South Dakota Department of Health. None of that happened.
Administrator A confirmed the same thing to inspectors later that morning. Staff had not followed the facility's own procedure for notifying families. Staff had not followed the procedure for notifying the state. The administrator did not dispute either point.
The facility's own abuse and neglect policy, revised as recently as April 7, 2025, spelled out what was supposed to happen. Designated agencies, including the South Dakota Department of Health, were to be notified in accordance with state law. The physician and family were to be informed of the situation. If there was a suspected injury of unknown origin, they were to be told that an investigation was in progress. That notification was supposed to be recorded.
None of it was recorded because none of it was done.
What makes the timeline difficult to read without stopping is the gap between what staff knew and what they communicated. The family discovered severe bruising and swelling during a visit and had to take their own photographs to document what they were seeing. They made calls. IP/CCL B returned one of those calls and offered an explanation that turned out to be anatomically impossible — the wrong arm, the wrong draw, the wrong answer. The physician visited on July 11, found a large hematoma and unexplained bruising, wrapped the injury with a nurse, and still no report went to the state. Still no call went to the family explaining that no cause had been found and that an investigation was underway, because no investigation was underway.
The inspection cited the deficiency at a level of minimal harm or potential for actual harm, the lowest tier of the federal harm scale. The resident affected was one person. The violations were classified as affecting few residents.
What the harm scale doesn't capture is what it means to visit someone you care for, find her hand black and purple and swollen, and then wait for an explanation that never comes — or comes wrong. The family filed a complaint with the state after finding the bruising. They were the ones who triggered the investigation. They were the ones who took the photographs that documented what the facility had not documented. They were the ones who made the calls.
The facility had a policy that required staff to do all of this. The policy had been updated four months before the injury was discovered. The administrator confirmed it wasn't followed. The clinical care leader confirmed it wasn't followed. The nurse who first should have made the calls never made them.
A woman's hand turned purple and black and nobody could say why, and the people responsible for finding out and telling her family chose, or failed, to do neither.
Her family found out because they showed up.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 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.
They came back a few days later and found her hand covered in purple and black bruising, fingers to palm, extending up her forearm.
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.