Good Samaritan De Smet: Care Plan Failures - SD
The facility admitted the resident on a date in early October but never completed her required baseline care plan before she was hospitalized with complications. Only one nurse at the 48-bed facility knew how to write the plans, and she was on vacation.
Resident 1 arrived at Good Samaritan after orthopedic surgery for her left knee. Within days, she developed fractures above and below a surgically placed rod and a pressure ulcer on her buttocks that wasn't present when she left the hospital.
Her orthopedic surgeon, identified as MD E, told inspectors the resident also had moisture-related skin damage to her perineum that developed after her nursing home admission. He had performed several knee surgeries on the resident and was familiar with her medical history.
Director of nursing B told inspectors she "typically completed resident baseline care plans within 48 to 72 hours after a resident admitted to the facility." But she was away from October 9 through October 12 and never completed the resident's plan.
Nobody else could do it.
Administrator A told inspectors that "no other nurses were trained on how to complete the residents' baseline care plans." The administrator expected the director of nursing to finish the resident's care plan when she returned to work on October 13.
The resident was hospitalized before that happened.
Federal regulations require nursing homes to develop baseline care plans within 48 hours of admission. These plans provide "instructions needed to provide effective and person-centered care to the resident that meet professional standards of quality care," according to the facility's own policy updated in December 2024.
Without the written plan, nursing staff had to rely on verbal reports passed between shifts to know how to care for the resident. The director of nursing told inspectors she "expected nursing staff members to pass along important information in their nursing report at the beginning and end of each shift."
Both the administrator and director of nursing told inspectors they were unaware the resident had developed a pressure ulcer after admission.
The facility's policy states that baseline care plans must be developed "upon admission according to federal and state regulations." The policy also requires providing residents and their representatives with written summaries of these plans and opportunities to participate in care planning "to the extent practicable."
Pressure ulcers typically develop when residents remain in one position too long without proper repositioning and skin care. Stage II ulcers involve partial-thickness skin loss and appear as open wounds or blisters.
The resident's orthopedic surgeon confirmed the pressure ulcer and skin damage were not present when he discharged her from the hospital before her nursing home admission. The complications developed during her stay at Good Samaritan Society De Smet.
The inspection, conducted October 23 following a complaint, found the facility violated federal requirements for developing comprehensive care plans. Inspectors classified the violation as causing minimal harm or potential for actual harm to a few residents.
Good Samaritan Society De Smet, located on Calumet Avenue, has operated in the small South Dakota town for decades. The facility must submit a plan of correction to state regulators detailing how it will prevent similar care planning failures.
The resident's case illustrates how administrative gaps can directly affect patient outcomes. Her orthopedic surgeon had successfully treated her knee problems through multiple surgeries, but the nursing home's failure to establish proper care protocols contributed to new complications requiring another hospitalization.
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 22, 2026 · Our methodology
GOOD SAMARITAN SOCIETY DE SMET in DE SMET, SD was cited for violations during a health inspection on October 23, 2025.
Only one nurse at the 48-bed facility knew how to write the plans, and she was on vacation.
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.