Good Samaritan Society - St Martin Village

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on South Dakota Department of Health (SD DOH) complaint review, record review, interview, and policy review, the provider failed to follow their policy for reporting to the SD DOH and one of one sampled resident's (1) representative of the resident's injury of bruising to her left arm and hand with unknown cause (origin).Findings include:1 Review of a 7/16/25 SD DOH complaint intake revealed that during the weekend of 7/4/25, resident 1 was visited by her family. The resident's left hand and arm had shown no signs of injury at that time. The resident's family had returned a few days later to visit and noticed extreme bruising and swelling of her [the resident's] left hand and forearm. Digital photographs of resident 1's hand taken by the family during that visit showed the underside of the resident's hand had purple and black bruising of her fingers and palm that extended upwards to her forearm. The entire top of the resident's left hand was similarly bruised. The resident's family had not been notified that resident 1 had been injured.Interview on 9/4/25 at 9:00 a.m. and review of resident 1's electronic medical record (EMR) with infection preventionist (IP)/clinical care leader (CCL) B revealed the progress note she entered in resident 1's chart on 7/1/25 stated received and returned her [the resident's daughter] call to discuss the bruise noted on the resident's arm. Explained that according to PCC [EMR] notes, the mark was most likely caused by a recent lab draw

on 7/7/25. IP/CCL B confirmed resident 1's 7/7/25 blood draw was taken from the resident's right arm. She confirmed the cause of resident 1's left hand and arm injury was not the result of a lab draw.IP/CCL B confirmed that resident 1's left hand and arm injury was first documented in her medical provider's 7/11/25 Nursing Home Attending Physician Visit note, which indicated there was no definitive cause that was found for resident 1's left hand and arm injury. A 7/11/25 nurse progress note completed by licensed practical nurse (LPN) E after the above visit: indicated [Medical provider's name] visited. The medical provider and a nurse wrapped resident 1's L [left] forearm, which is bruised and has a large hematoma [a raised bruised area] on the top of [her] L hand.IP/CCL B stated it was LPN E's responsibility to have notified resident 1's family of the left hand and arm injury. Because the cause of that injury was unknown, LPN E should also have notified a nurse supervisor or administrator A. Injuries of unknown origins were expected to have been documented, investigated, and reported to the SD DOH, but that had not occurred. Interview on 9/4/25 at 10:15 a.m. with administrator A confirmed the staff had not followed the provider's procedure for notifying families, and the SD DOH regarding resident injuries of unknown cause.Review of the provider's revised 4/7/25 Abuse and Neglect policy revealed:Procedure: 4.c. Designated agencies will be notified in accordance with state law, including the State Survey and Certification Agency [SD DOH].4.g. Notify the physician and family regarding the facts of the situation. If there is alleged or suspected abuse/neglect or in

an injury of unknown origin, inform them that an investigation is in progress. That notification was expected to have been recorded.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - St Martin Village

4825 Jericho Way Rapid City, SD 57702

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

[pulmonary embolism].A 7/11/25 progress note completed by licensed practical nurse (LPN) E after the above medical provider's visit indicated [Medical provider] visited. We wrapped the L [left] forearm which is bruised and has a large hematoma [a raised bruised area] on the top of [her] L hand. There was no documentation to support that an investigation had been initiated to identify a cause for resident 1's injury, any factors that might have contributed to that injury occurring, or what actions had been implemented to decrease the likelihood of that injury reoccurring. Interview on 9/4/25 at 10:10 a.m. with LPN E revealed she stated, I don't recall knowing it [resident 1's left hand and arm injury] was there earlier that day [on 7/11/25

before the medical provider's visit]. LPN E stated the cause of that injury might have been related to the resident's 7/7/25 blood draw. LPN E had not known that a blood draw was taken from resident 1's right hand and not her left hand, so it could not have caused that injury.LPN E confirmed that after the left hand and arm bruise was identified on 7/11/25, she had not reported that injury of unknown cause to a nurse supervisor. As a result, an investigation was not initiated to identify the cause or possible cause for that injury. Without having identified a cause for resident 1's left arm and hand bruising, LPN E agreed that nothing different had been done to prevent a similar injury from recurring. Interview on 9/4/25 at 9:00 a.m. with infection preventionist (IP)/Clinical Care Leader (CCL) B revealed it was LPN E's responsibility to have notified a nurse supervisor or administrator A of resident 1's injury of unknown origin. Injuries of unknown origin were expected to have a thorough investigation completed and documented, but that had not occurred. Interview on 9/4/25 at 10:15 a.m. with administrator A confirmed that the staff had not followed

the provider's procedure for documenting and investigating resident injuries of unknown cause. Review of

the provider's revised 4/7/25 Abuse and Neglect policy revealed:Purpose: To ensure that all identified events of alleged or suspected abuse/neglect, including injuries of unknown origin, are promptly reported and investigated. To ensure a complete review by the investigation team to identify events, such as suspicious bruising of residents/clients, occurrences, patterns and trends that may constitute abuse to determine the direction of the investigation.

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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - St Martin Village

4825 Jericho Way Rapid City, SD 57702

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)

Federal health inspectors cited GOOD SAMARITAN SOCIETY - ST MARTIN VILLAGE in RAPID CITY, SD for a deficiency under regulatory tag F-F0684 during a complaint investigation conducted on 2025-09-04.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 3 deficiencies cited during this inspection of GOOD SAMARITAN SOCIETY - ST MARTIN VILLAGE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-19.