Good Samaritan Society St Martin Village: Neuro Checks Skipped - SD
What followed at Good Samaritan Society St. Martin Village was a series of things that didn't happen.
The resident, identified in federal inspection records only as Resident 2, was a woman with a history that made a head injury particularly dangerous. She was blind. She had dementia. She had survived a stroke. She had rheumatoid arthritis, major depressive disorder, and anxiety. She had fallen seven times in the six months leading up to that morning in late July. And she had been taking aspirin, a blood thinner, continuously since 2021.
On July 22, 2025, after falling and striking her head, she needed neurological assessments. The facility's own policy required them, beginning immediately and continuing every 30 minutes, four times, then every eight hours for three days. Registered Nurse G performed a head-to-toe assessment and checked her vital signs. But according to the inspection report, RN G did not perform a neurological assessment at all.
Resident 2 was transferred to the emergency room. She was admitted to the hospital and treated for a subdural hemorrhage, a collection of blood between her brain and the inner layer of her skull.
When she came back, the neurological assessments still didn't happen.
The facility's own neurological evaluation policy explicitly addresses this situation. It states that if a resident goes to the hospital and returns, "documentation should resume using the existing schedule." The schedule that was never started.
Federal inspectors arrived September 4. Administrator A confirmed what the records showed. Nurses were expected to follow fall prevention policy and protocols, she said. Neurological exams should be completed for all residents who fell and hit their head. She agreed that no neurological exam had been completed for Resident 2 after she fell on July 22. She agreed.
The gap between what the policy required and what the nurses did wasn't a matter of interpretation. The facility's neurological evaluation policy covers three situations: a witnessed fall where the resident hit their head, an unwitnessed fall, and any event resulting in known or suspected head injury. This fall was witnessed. The injury was visible. The blood had coagulated on the floor before anyone moved her. Every condition that should have triggered the protocol was present.
Subdural hemorrhages are not always immediately catastrophic. They can expand. Symptoms can worsen hours or days after the initial injury. Neurological checks exist precisely because deterioration can be subtle and rapid, and because a resident who is talking and oriented at 7 a.m. may not be the same resident at noon. For someone on a blood thinner, the risk of continued or expanding bleeding is higher than for someone who is not.
Resident 2's fall history tells its own story. She fell on February 21 and was assessed as high risk. She fell on March 4 and March 20, and her risk score dropped to low both times. She fell again on May 21 and June 15, and was rated medium risk. Then she fell on July 22 and bled onto the floor of her room, and her risk was finally rated high again. Seven falls. The scores moved up and down. She kept falling.
Inspectors classified the violation as having the potential for actual harm. The inspection was a complaint survey, meaning someone had reported a concern before investigators arrived.
What the record does not contain is any explanation for why RN G skipped the neurological assessment, or why no one completed the checks after she returned from the hospital. The inspection report does not say whether anyone tracked her neurological status during her hospitalization, or what her condition was when she came back through the door.
It says she was found in a pool of blood. It says she told them she fell and hit her head. It says the checks were never done.
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: 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 25, 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.
What followed at Good Samaritan Society St.
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.