Good Samaritan Sioux Falls: Call Light Neglect - SD
Federal inspectors documented the violation during a September complaint investigation at the 401 West Second Street facility, finding staff failed to provide prompt assistance despite the resident's repeated attempts to summon help.
The incident involved Resident 4, who used his call light to request bathroom assistance. Staff did not respond for over an hour, leaving him waiting in distress.
When inspectors asked the administrator if an hour was too long for a resident to wait for help, he said "that would depend on what the resident's needs would be." The administrator's expectation for call light response was that it "would be answered in an appropriate time," which he said "would depend on the resident and the resident's needs."
This response contradicted what staff members told inspectors about proper call light procedures. A certified nursing assistant who had worked at the facility for three years said the expected response time was two minutes. The facility's own revised call light policy, dated July 8, 2025, stated its purpose was "to ensure residents always have a method of calling for assistance and to promptly answer resident's call light."
The director of nursing had a dramatically different standard. She told inspectors that staff answering a call light within 20 to 30 minutes "would be a prompt response and that was her expectation."
Resident 4's situation was complicated by behavioral challenges that staff described in detail to inspectors. The certified nursing assistant said she had observed him "screaming at other staff and throwing things in his room" and noted he had "periods when he would cry and bang on things." He sometimes refused care including toileting and bathing.
A certified medication aide described him as having "a hot temper and could go from being calm to hot in a short period of time." She said incontinence episodes "could set him off and he will get upset."
Despite these challenges, staff confirmed Resident 4 was capable of using his call light system. The director of nursing acknowledged he would sometimes refuse assistance with toileting, bathing, showering, repositioning, and wound care, but said he did attend care conferences.
The resident's care preferences had recently changed. According to the director of nursing, he preferred bed baths before February 7, 2025, "to allow for his smoking time preference." He switched to weekly showers on that date.
During the inspection, investigators found a stark disconnect between written policies and actual practice. The facility's abuse and neglect policy, revised April 7, 2025, stated that residents have "the right to be free from abuse, neglect, misappropriation of resident/client property and exploitation."
The policy specified this includes "freedom from corporal punishment and involuntary seclusion" and stated residents "must not be subjected to abuse by anyone, including but not limited to, location employees, other residents/clients, consultants or volunteers, employees of other agencies serving the individual, family members or legal guardians, friends or other individuals."
Yet when faced with a concrete example of a resident waiting over an hour for basic assistance, the facility's leadership defended the delay rather than acknowledging it as a violation of the resident's rights.
The certified nursing assistant who spoke with inspectors appeared to understand the gravity of the situation differently than her supervisors. When describing Resident 4's distress, she noted his frustration with staff who would "not answer his call light" and questioned "how can another person do that to another person."
This case highlights the gap between policy and practice that federal inspectors frequently encounter in nursing homes. While facilities maintain written standards promising prompt responses to resident needs, the actual implementation often falls far short of those commitments.
The inspection was conducted as a complaint investigation, suggesting someone reported concerns about care quality at the facility. Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents.
However, the administrator's casual dismissal of hour-long response times suggests the problem may extend beyond this single incident. His statement that appropriate response time depends on "what the resident's needs would be" could justify indefinite delays for any resident whose needs are deemed non-urgent by staff.
For Resident 4, the combination of behavioral challenges and staff indifference created a particularly vulnerable situation. His documented tendency to become upset when experiencing incontinence would be exacerbated by being forced to wait over an hour for bathroom assistance.
The facility's own policies recognized the importance of prompt call light responses, yet leadership failed to enforce these standards when it mattered most. The director of nursing's expectation that 20 to 30 minutes constitutes a "prompt response" contradicts both the written policy and basic standards of dignified care.
The certified nursing assistant's two-minute expectation aligns more closely with industry standards and the facility's stated commitment to prompt assistance. Her emotional response to the situation suggests front-line staff may understand the human impact of these delays better than their supervisors.
Good Samaritan Society Sioux Falls Center's handling of this incident raises questions about how the facility prioritizes resident needs and whether vulnerable residents receive the timely assistance they require for basic dignity and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society Sioux Falls Center from 2025-09-05 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 SIOUX FALLS CENTER in SIOUX FALLS, SD was cited for neglect violations during a health inspection on September 5, 2025.
The incident involved Resident 4, who used his call light to request bathroom assistance.
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.