Good Samaritan Society De Smet

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

baseline care plan was completed within 48 hours of her admission to the facility. 3. Interview on 10/23/25 at 9:09 a.m. with medical doctor (MD) E who participated by phone revealed:*He was resident 1's orthopedic surgeon for several surgeries involving resident 1's left knee and was familiar with her medical history.*Resident 1 was admitted to the hospital on [DATE REDACTED] from the nursing home (provider) with fractures above and below the rod that had been surgically placed. The resident also had a Stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to her buttocks/coccyx and associated moisture-related skin damage to her perineum (the area between the genitals and anus) that was not present when he discharged resident 1 from the hospital on [DATE REDACTED]. 4. Interview on 10/23/25 at 1:03 p.m. with administrator A and director of nursing (DON) B revealed:*DON B stated she typically completed resident baseline care plans within 48 to 72 hours after a resident admitted to the facility.*DON B was not at

the facility from 10/9/25 through 10/12/25 and did not complete resident 1's baseline care plan.-She planned to complete that care plan documentation when she returned to work on 10/13/25.*Administrator A expected that baseline care plans would be developed and completed within 48 hours of a resident's admission to the facility by DON B.-No other nurses were trained on how to complete the residents' baseline care plans.-Administrator A expected DON B to complete resident 1's care plan when she returned to work on 10/13/25, but resident 1 discharged to the hospital on [DATE REDACTED].*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. Without a written baseline care plan, she expected nursing staff members to pass along important information in their nursing report (staff verbal communication of residents' status) at the beginning and end of each shift.*Administrator A and DON B were unaware that resident 1 had developed

a pressure ulcer after she admitted to the facility. 5. Review of the provider's updated 12/2/24 Care Plan policy revealed:*Baseline care plan- Includes instructions needed to provide effective and person-centered care to the resident that meet professional standards of quality care.*A baseline care plan will be developed upon admission according to federal and state regulations. The location [facility] must provide the resident and resident representative with a written summary of the baseline care plan.*The resident/family or legal representative will have the opportunity to participate in the planning of his or her care to the extent practicable.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society DE Smet

411 Calumet Avenue NW DE Smet, SD 57231

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

updated 7/7/25 Staffing and Scheduling Resource Packet revealed:*.You want to make sure you have the necessary staff to fulfill the needs of the customers you serve.*Managing schedules requires attentiveness and responsiveness of census fluctuations.*The resource packet did not address the provider's current staffing levels or census. Review of the provider's 8/5/25 Facility Assessment revealed:*The facility assessment was used to determine what resources are necessary to care for its residents competently

during both day-to-day operations and emergencies.*The question How do you staff on all shifts, including nights and weekends, to meet acquity [acuity] & [and] needs of residents? was answered, We staff by a per diem basis. We listen to feedback from our staff when they feel they could use more support, and what times of the day they could use support. We also listen to feedback from residents and families. Part of our assessment of whether or not we are meeting residents' needs and have appropriate staffing is by reviewing our quality measures and outcomes.*There was no documentation of the current staffing levels.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society DE Smet

411 Calumet Avenue NW DE Smet, SD 57231

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident 1's stay.*DON B stated she completed all of the residents' care plans, but she did not complete a care plan for resident 1, and there were no documented interventions to prevent resident 1 from developing

a pressure ulcer.-She had planned to complete that documentation when she returned to work on 10/13/25, but resident 1 had been discharged to the hospital on [DATE REDACTED].*DON B expected that resident 1 would have been provided frequent repositioning, thorough cleaning of her perineum area, pain medications as needed, and the physician ordered Triad wound cream to prevent skin breakdown.*Administrator A and DON B were unaware that resident 1 developed a pressure ulcer after she admitted to the facility on [DATE REDACTED] and prior to her hospital readmission on [DATE REDACTED].*They 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. 12. Review of the provider's updated 7/7/25 Pressure Ulcer/Wound Care Resource Packet revealed:*The provider's wound care programs, pressure guidelines and protocols have been developed and implemented to provide quality services to our residents.*Programs may include. A comprehensive management program to prevent [the] development of pressure ulcers or other skin conditions (Braden, following interventions identified on care plan, nutritional intervention, specialty surfaces.).*Promotion of healing, pain management and prevention of complications is extremely important, as well as accurate assessment and documentation.* Wound Data Collection UDA [user defined assessment] completed by a licensed nurse and is required for documenting daily monitoring, is required at least weekly when skin integrity is impaired.*.The facility must ensure 1. A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable.

Event ID:

Facility ID:

If continuation sheet