DE SMET, SD - Federal health inspectors determined that Good Samaritan Society De Smet failed to provide appropriate pressure ulcer care and prevent new pressure ulcers from developing, resulting in documented actual harm to at least one resident. The findings emerged from a complaint investigation completed on October 23, 2025, which yielded three total deficiency citations against the facility located in this small eastern South Dakota community.
Complaint Investigation Reveals Wound Care Deficiencies
The Centers for Medicare & Medicaid Services (CMS) conducted a complaint investigation at Good Samaritan Society De Smet, a long-term care facility operated under the Good Samaritan Society umbrella — one of the largest nonprofit senior care organizations in the United States. The investigation focused on concerns about the quality of care provided to residents, and inspectors substantiated problems related to the facility's handling of pressure ulcers.
The deficiency was cited under federal regulatory tag F0686, which falls within the broader category of Quality of Life and Care Deficiencies. This tag specifically addresses a facility's obligation to ensure that residents who are admitted without pressure ulcers do not develop them unless clinically unavoidable, and that residents who already have pressure ulcers receive the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from forming.
Inspectors assigned the violation a Scope/Severity Level G, which indicates an isolated instance of actual harm that did not rise to the level of immediate jeopardy. While the "isolated" designation means the deficiency was not found to be widespread throughout the facility, the "actual harm" classification is significant — it means that a resident experienced measurable negative health consequences as a direct result of the facility's failure to meet federal care standards.
Understanding Pressure Ulcers and Their Medical Significance
Pressure ulcers, also known as pressure injuries or bedsores, are localized areas of tissue damage that develop when sustained pressure reduces blood flow to the skin and underlying tissue. They most commonly occur over bony prominences such as the sacrum, heels, hips, and elbows in individuals who have limited mobility or are confined to a bed or wheelchair for extended periods.
These wounds are classified into four stages based on severity:
- Stage 1: Non-blanchable redness of intact skin, signaling that tissue damage has begun beneath the surface. - Stage 2: Partial-thickness skin loss involving the epidermis and possibly the dermis, presenting as a shallow open wound or blister. - Stage 3: Full-thickness skin loss extending into subcutaneous fat, though bone, tendon, and muscle are not exposed. - Stage 4: Full-thickness tissue loss with exposed bone, tendon, or muscle, representing the most severe form of pressure injury.
Additional classifications include "unstageable" ulcers, where the wound bed is obscured by dead tissue, and "deep tissue injury," where intact skin shows signs of damage to underlying soft tissue.
The medical consequences of inadequately managed pressure ulcers are well documented in clinical literature. Open wounds create pathways for bacterial infection, which can progress to cellulitis (infection of surrounding skin tissue), osteomyelitis (infection of underlying bone), or sepsis — a life-threatening systemic infection. In elderly nursing home residents, who frequently have compromised immune systems, diabetes, cardiovascular disease, or nutritional deficiencies, these complications can be fatal.
Pressure ulcers also cause significant pain and dramatically reduce quality of life. Residents with advanced pressure injuries may require surgical intervention, including debridement (removal of dead tissue) or skin grafting, and healing times can extend from weeks to many months depending on the severity and the patient's underlying health status.
Federal Standards for Pressure Ulcer Prevention and Treatment
Federal regulations governing nursing home care are explicit about expectations for pressure ulcer prevention and management. Under 42 CFR §483.25(b), facilities must ensure that each resident receives care and services to promote the highest practicable physical well-being, including proper skin integrity management.
The standard of care for pressure ulcer prevention in long-term care settings includes several key components:
Risk Assessment: Every resident should receive a comprehensive skin assessment upon admission and at regular intervals thereafter. Standardized tools such as the Braden Scale are used to evaluate risk factors including sensory perception, moisture exposure, activity level, mobility, nutrition, and friction or shear forces. Residents identified as high risk require immediate implementation of preventive interventions.
Repositioning Protocols: Residents who are immobile or have limited mobility must be repositioned at minimum every two hours when in bed and every hour when seated in a wheelchair. Repositioning schedules should be individualized based on the resident's skin tolerance, medical condition, and support surface in use. Each repositioning should be documented with the time, position, and any skin observations.
Support Surfaces: Appropriate pressure-redistribution mattresses, overlays, and wheelchair cushions should be provided based on the resident's risk level. High-risk residents and those with existing pressure ulcers typically require advanced support surfaces such as alternating pressure mattresses or low-air-loss mattresses.
Nutrition Management: Adequate nutrition is essential for skin integrity and wound healing. Residents at risk for or with existing pressure ulcers should receive nutritional assessments and interventions, including adequate protein intake, caloric supplementation, and hydration monitoring. Nutritional deficiency is one of the most common contributing factors to pressure ulcer development in the nursing home population.
Wound Care Protocols: For residents who develop pressure ulcers, evidence-based wound care must include regular assessment and measurement of the wound, appropriate wound cleansing, selection of proper dressings to maintain a moist healing environment, infection monitoring, and pain management. Wound care plans should be updated as the wound status changes, and any deterioration should prompt a reassessment of the overall care plan.
Documentation and Communication: All assessments, interventions, and outcomes must be thoroughly documented. Changes in wound status must be communicated promptly to the attending physician, the resident's family or representative, and all members of the care team.
The Scope of the Problem in Long-Term Care
Pressure ulcers remain one of the most common and preventable adverse events in nursing home settings across the United States. According to data from CMS, pressure ulcer deficiencies are among the most frequently cited violations during nursing home inspections nationwide. The Agency for Healthcare Research and Quality (AHRQ) has identified facility-acquired pressure ulcers as a key indicator of nursing home care quality.
Research published in peer-reviewed medical journals has consistently demonstrated that the vast majority of pressure ulcers in nursing homes are preventable when facilities implement and adhere to evidence-based prevention protocols. The development of a new pressure ulcer in a resident who was admitted without one is considered a sentinel event — a red flag that the facility's preventive care systems may have failed.
The costs associated with pressure ulcer treatment are substantial. Treatment of a single Stage 4 pressure ulcer can exceed $100,000 over the course of healing, and the total annual cost of pressure ulcer treatment in the United States is estimated in the billions. Beyond the financial burden on the healthcare system, the human toll on affected residents and their families is considerable.
Three Deficiencies Identified During Investigation
The pressure ulcer citation was one of three total deficiencies identified during the October 2025 complaint investigation at Good Samaritan Society De Smet. While the specific details of the other two citations were not included in the inspection summary reviewed for this report, the presence of multiple deficiencies during a single complaint investigation indicates that inspectors found more than one area where the facility fell short of federal standards.
The pressure ulcer deficiency carried the most significant severity classification of the findings, with its Level G designation confirming that actual harm occurred. This classification falls in the middle range of the CMS severity scale — more serious than deficiencies involving only the "potential" for harm (Levels A through F) but below the most critical "immediate jeopardy" classifications (Levels J through L) that indicate a resident's life or safety was in imminent danger.
Facility Response and Corrective Action
Following the inspection, Good Samaritan Society De Smet was classified as deficient with a provider-reported date of correction. The facility indicated that corrective action was completed by November 20, 2025, approximately four weeks after the inspection concluded.
Corrective action plans for pressure ulcer deficiencies typically include staff retraining on wound care assessment and prevention protocols, revision of care plans for affected residents, implementation of enhanced monitoring systems for skin integrity, and updates to facility policies and procedures governing wound care management.
The Good Samaritan Society, headquartered in Sioux Falls, South Dakota, operates dozens of senior care facilities across multiple states. As a large nonprofit organization affiliated with Sanford Health, the organization has access to system-wide clinical resources and quality improvement infrastructure. The citation at the De Smet location will remain part of the facility's public inspection record maintained by CMS and accessible through the Medicare Care Compare website.
What Families Should Know
Families with loved ones in long-term care facilities should be aware that federal inspection results, including deficiency citations and their severity levels, are public record. These reports can be accessed through the CMS Care Compare tool at medicare.gov, which provides inspection histories, staffing data, and quality ratings for every Medicare- and Medicaid-certified nursing home in the country.
Warning signs of pressure ulcer development that family members should watch for during visits include redness or discoloration of the skin over bony areas, complaints of pain or tenderness in specific locations, visible open wounds or blisters, and changes in the texture or temperature of the skin. Any concerns should be raised immediately with facility nursing staff and documented in writing.
Residents and their families have the right to review their care plans, request information about wound care protocols, and file complaints with their state survey agency if they believe care is inadequate. In South Dakota, complaints about nursing home care can be directed to the South Dakota Department of Health, which serves as the state survey agency responsible for conducting inspections on behalf of CMS.
The full inspection report for Good Samaritan Society De Smet is available through the CMS Care Compare database. Readers are encouraged to review the complete findings for additional details about the deficiencies cited during this investigation.
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.
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