Good Samaritan De Smet: Pressure Ulcer Failures - SD
The resident was readmitted to the hospital with injuries that weren't present when she was discharged from the hospital initially. Her orthopedic surgeon confirmed the pressure ulcer to her buttocks and moisture-related skin damage to her perineum developed after her nursing home admission.
Federal inspectors found the facility violated care planning requirements during their October 23 investigation.
The resident's baseline care plan was never completed during her stay. Director of nursing B typically finished these plans within 48 to 72 hours of admission, but she was absent from October 9 through October 12. She planned to complete the documentation when she returned October 13.
The resident was hospitalized before that happened.
Administrator A expected baseline care plans within 48 hours of admission. But only the director of nursing knew how to create them. No other nurses received training on the process.
"DON B stated that nursing staff used the baseline care plan to know how to care for a resident until the comprehensive care plan was completed," inspectors wrote. Without written instructions, she expected staff to rely on verbal reports between shifts.
The facility's own policy required baseline care plans upon admission to provide "effective and person-centered care" that meets professional standards. The policy mandated providing residents and families with written summaries of these plans.
Neither the administrator nor director of nursing knew the resident had developed a pressure ulcer after admission.
Medical doctor E, the resident's orthopedic surgeon, participated in the inspection by phone. He had performed several surgeries on the resident's left knee and was familiar with her medical history.
The resident was admitted to the hospital from the nursing home with fractures above and below the rod that had been surgically placed. She also had a Stage II pressure ulcer to her buttocks and associated moisture-related skin damage to her perineum.
These injuries were not present when he discharged the resident from the hospital initially.
Stage II pressure ulcers involve partial-thickness skin loss, appearing as open wounds or blisters. They indicate inadequate pressure relief and positioning care.
The facility's updated care plan policy from December 2024 outlined specific requirements. Baseline care plans must include instructions for effective, person-centered care meeting professional standards. Residents and representatives must receive written summaries and have opportunities to participate in care planning.
But the system broke down when the only trained staff member was absent. The administrator expected the director of nursing to complete the resident's care plan upon her return, but the resident's condition deteriorated first.
Federal regulations require nursing homes to develop baseline care plans immediately upon admission. These plans guide staff care until comprehensive assessments and care plans are completed.
The inspection revealed a single point of failure in the facility's care planning system. With no backup trained staff, residents admitted during the director's absence received no written care guidance.
Staff relied instead on verbal shift reports to communicate the resident's needs. This informal system failed to prevent the development of pressure ulcers and associated complications.
The resident's orthopedic surgeon confirmed the timeline. The injuries that required hospitalization developed during the nursing home stay, not before admission.
The facility received a minimal harm citation affecting few residents. But for this resident, the consequences were significant. She returned to the hospital with new fractures and wounds that developed under the facility's care.
The inspection found Good Samaritan Society De Smet failed to ensure adequate care planning systems remained functional during staff absences. The resident paid the price with preventable injuries that required additional 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 20, 2026 · Our methodology
GOOD SAMARITAN SOCIETY DE SMET in DE SMET, SD was cited for violations during a health inspection on October 23, 2025.
The resident was readmitted to the hospital with injuries that weren't present when she was discharged from the hospital initially.
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.