Good Samaritan De Smet: Care Failures Harmed Resident - SD
Administrator A and Director of Nursing B learned about the pressure sore only when federal inspectors arrived to investigate a complaint....
Latest reports, citations, and penalties from CMS data
Administrator A and Director of Nursing B learned about the pressure sore only when federal inspectors arrived to investigate a complaint....
Inspectors determined that Leakesville Rehabilitation and Nursing Center did not meet this standard....
R2 sat in the dining room eating pot roast, mashed potatoes and a dinner roll for lunch on December 21....
Federal inspectors documented the complaint during a December 2025 visit....
The November 8 incident at Handmaker Home for the Aging resulted in a substantiated abuse finding after the facility's five-day investigation....
The cart contained insulin, Narcan, lidocaine patches, and topical antiseptics....
The grandson brought it to the administrator's attention on June 14, 2025....
The committee logged no grievances in June....
The resident had been telling people he ran into a laundry cart....
Federal inspectors cited the facility on December 23, 2025, for failing to report the incident to law enforcement....
The confrontation unfolded in a hallway when Resident #3 walked past with a walker near another resident's room....
The first call came at 9:34 PM....
This distinction is significant....
The facility's own policy requires medications to be given within one hour of their scheduled time....
LPN 5 told inspectors on December 31 that she managed insulin for two residents on her hallway, both wearing FreeStyle electronic glucose monitors....
The resident, identified as R9 in inspection records, has severe cognitive impairment with a score of zero out of 15 on cognitive testing....
Federal inspectors found the unlabeled Humalog insulin pen on December 16 during a medication cart review at Complete Care at Springbrook....
Staff member C has been under contract with the facility since January 22, 2022, according to staffing records reviewed by inspectors....
The facility's own policy was specific....
The records tell the story in clinical shorthand....