Good Samaritan De Smet: Care Failures Harmed Resident - SD
The resident, identified only as Resident 1 in federal inspection records, was admitted to the facility and developed the preventable wound before being readmitted to the hospital. Administrator A and Director of Nursing B learned about the pressure sore only when federal inspectors arrived to investigate a complaint.
DON B admitted she never completed a care plan for Resident 1, despite facility protocols requiring comprehensive management programs to prevent pressure ulcers. She told inspectors she had planned to complete the documentation when she returned to work on October 13, but the resident had already been discharged to the hospital by then.
The nursing director expected staff would provide frequent repositioning, thorough cleaning of the resident's perineum area, pain medications as needed, and physician-ordered Triad wound cream to prevent skin breakdown. But no formal interventions were documented.
"She expected that the nurses on duty would have implemented interventions to prevent resident 1 from developing a pressure ulcer when DON B and RN/wound nurse C were not available at the facility," inspectors wrote.
The facility's own policies, updated in July, emphasize preventing pressure ulcers through comprehensive management programs. The protocols include Braden scale assessments, following interventions identified on care plans, nutritional intervention, and specialty surfaces.
According to the facility's wound care resource packet, "promotion of healing, pain management and prevention of complications is extremely important, as well as accurate assessment and documentation."
The policies require licensed nurses to complete wound data collection assessments for daily monitoring, with documentation required at least weekly when skin integrity is impaired. None of this happened for Resident 1.
Federal regulations mandate that residents who enter nursing homes without pressure sores should not develop them unless their clinical condition demonstrates the wounds were unavoidable. The inspection found actual harm to the resident, affecting few residents overall.
The case reveals a breakdown in basic nursing home oversight. While the facility maintained detailed written protocols for preventing pressure ulcers, those in charge failed to ensure the policies were followed for a vulnerable resident.
DON B's absence from the facility left critical care planning incomplete. The expectation that other nurses would automatically implement preventive measures without formal documentation or oversight proved inadequate.
Pressure ulcers, also known as bedsores, develop when sustained pressure reduces blood flow to skin and underlying tissue. They are largely preventable through proper positioning, skin care, and nutrition management. When they occur in nursing homes, they often indicate substandard care.
The facility's July resource packet acknowledged the importance of preventing pressure ulcers, stating that programs "have been developed and implemented to provide quality services to our residents." But implementation failed when it mattered most.
The inspection narrative doesn't detail the severity of Resident 1's pressure ulcer or her current condition following hospitalization. It also doesn't specify how long she was at the facility before developing the wound.
What's clear is that basic care coordination broke down. A resident entered the facility without pressure sores and developed one serious enough to require hospital treatment, while administrators remained unaware of the deteriorating condition.
The case underscores how nursing home policies mean little without consistent implementation and oversight. Written protocols for wound prevention become meaningless when staff fail to complete care plans or monitor vulnerable residents adequately.
Resident 1's hospitalization represents the human cost of this administrative failure. She entered the facility expecting care that would maintain her health and instead developed a painful, preventable wound that required emergency medical intervention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society De Smet from 2025-10-23 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 27, 2026 · Our methodology
GOOD SAMARITAN SOCIETY DE SMET in DE SMET, SD was cited for violations during a health inspection on October 23, 2025.
Administrator A and Director of Nursing B learned about the pressure sore only when federal inspectors arrived to investigate a complaint.
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.