Good Samaritan Society Sioux Falls Village

F-F689, finding 2.

19. Interview on 4/16/25 at 10:43 a.m. with certified nursing assistant (CNA) PP regarding grab bars and side rails on residents' beds revealed:

*She had not seen or heard about any issues related to grab bars.

*She did not feel resident 103's significant movement of her grab bar was an issue because a resident could have used it to pull themselves up in bed.

20. Interview on 4/16/25 at 11:55 p.m. with administrator B revealed:

*Monitoring of the beds was completed monthly with a check mark task by the maintenance staff.

*Not all the monitoring was documented in the TELS computerized system.

*He was trying to locate more documentation of the beds having been monitored.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0700 21. Interview on 4/16/25 at 12:06 p.m. with administrator A revealed:

Level of Harm - Immediate *A facility-wide assessment of the beds was completed on 2/6/25 and all repairs were completed by jeopardy to resident health or maintenance on 2/10/25. safety *The checklists in the computerized system were not specific to each bed. Residents Affected - Few 22. Interview on 4/16/25 at 12:38 p.m. with administrator B revealed:

*Most resident beds that were not in the rehab wing of the building were Hill-Rom beds.

*Some of the Hill-Rom beds had pre-installed side rails while others had not.

*The Hill-Rom beds that did not have pre-installed grab bars had to have the side rails/grab bars ordered separately by the facility.

*Some of the grab bars ordered came from a contracted vendor.

*Administrator B did not know if the grab bars ordered from the contracted vendor were manufacturer approved and safe for use for those beds.

23. Interview on 4/16/25 at 3:03 p.m. with registered nurse (RN)/Minimum Data Set (MDS) nurses D and E revealed:

*The process for the application of a side rail and grab bars for resident's beds included:

-On admission the entrapment evaluation was to be completed, the family would sign a consent and a physician's order for the grab bars would be obtained.

-If staff or the resident felt the resident would benefit from a grab bar, the nurse manager would be notified.

-If the resident was receiving therapy services, the therapists would be consulted regarding the benefit of the resident getting a grab bar on their bed.

-If it was determined the grab bar would be beneficial for the resident, a maintenance work request was to be entered into the electronic maintenance management system (TELS), and the maintenance staff would install the grab bars on the resident's bed.

*An entrapment evaluation was to be completed on admission.

*The Physical Device and/or Restraint Evaluation and Review was to be completed quarterly, annually, and with a significant change by the MDS nurse.

*When the MDS nurse completed the resident's Physical Device and/or Restraint Evaluation and Review assessment they would interview a staff nurse to determine if the resident was using the grab bars.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0700 *When asked about education provided as indicated on the Physical Device and/or Restraint Evaluation

Review they stated staff were provided education regarding the use of the grab bars or the resident was Level of Harm - Immediate educated, if the resident was able to understand the education. jeopardy to resident health or safety *If a staff member noticed a loose grab bar a maintenance work order should have been entered for that to be repaired. Residents Affected - Few *Maintenance was responsible for the installation, maintenance, and removal of the grab bars/side rails to ensure resident's safety.

24. Interview on 4/16/25 at 3:41 p.m. with DON R revealed:

*The entrapment assessment was completed on the resident's Physical Device and/or Restraint Evaluation and Review.

*The MDS nurse would have indicated in the comment box of the Physical Device and/or Restraint Evaluation and Review if they felt the grab bar was an entrapment risk.

*There was no formal process for assessing entrapment risks.

25. Interview on 4/16/25 at 4:05 p.m. with administrator B and DON R revealed:

*There was no formal process to assess entrapment risk.

*Measurements of bed zones was not a portion of the assessment process when grab bars were installed.

*Therapy had not assessed all residents' beds or the residents' ability for use related to grab bars to ensure their safety.

26. Review of the provider's resident admission packet revealed:

*There was a prefilled consent form for Grab bars on bed.

*The consent indicated that prior to the instillation of grab bars the facility must have attempted to use alternatives.

*If the alternative interventions attempted were not effective the resident would be assessed for the use of grab bars.

-The determination includes a review of risk, including entrapment. The location must ensure the bed is appropriate for the resident and that bed rails [grab bars] are properly installed and maintained.

27. Interview on 4/23/25 at 3:19 p.m. with Social Service Supervisor J regarding resident admissions revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0700 *The social services staff completed the admission paperwork with the family or the resident upon the resident's admission. Level of Harm - Immediate jeopardy to resident health or *The consent for the grab bar was in the admission paperwork and was to be presented to all families as an safety option available to help residents reposition themselves in bed.

Residents Affected - Few *The social service staff were to explain to the families the risk of entrapment as well as the other risks identified on the consent form.

*The consent form would be readdressed if there was a change in the resident's bed or if there was a request from staff, family, or the resident for a grab bar and there was no consent already on file.

*The consent having been completed on admission did not allow for alternative interventions to be attempted prior to determine if there was a need for the grab bar.

28. Interview on 4/23/25 at 4:17 p.m. with DON R revealed:

*She agreed with the grab bar consent being completed on admission, there was a potential that no alternatives would have been attempted prior to the application of the grab bar on the resident's bed.

*She indicated that often the alternatives would be initiated simultaneously with the application of the grab bar.

29. Review of the January 2010 USER MANUAL for the Resident LTC [long term care] Bed from Hill-Rom revealed:

*Use only Hill-Rom parts and accessories.

*Do not make modifications to the bed without authorization from Hill-Rom.

*Evaluate patients for entrapment risk according to facility protocol, and monitor patients appropriately. Make sure all siderails are fully latched when in the raised position. Failure to do either of these could cause serious injury or death.

Review of the July 2018 The Transfer Handle For Spring Style Hospital Beds manufacturer's information revealed:

*The Transfer Handle [grab bar] is designed to accommodate a range of different manufacturers. If the device does not easily attach to the bed per the instructions or interferes with the sub-frame, or the mattress does not firmly make contact with the Transfer Handle-DO NOT USE.

*These guidelines were developed by the FDA [Food and Drug Administration] for Bed Rails to help prevent entrapment. It is important information to be aware of.

30. Review of the provider's 2/2/24 Bed Safety and Side Rail Entrapment Resource Packet revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0700 *A resident's bed should be a place of comfort and relaxation, a safe place. When the bed system does not fit correctly and the resident becomes trapped or injured, the resident's bed is no longer a safe place. Level of Harm - Immediate jeopardy to resident health or *Grab bars or assist bars provide a sturdy and secure handhold to assist residents in repositioning and safety getting in and out of bed.

Residents Affected - Few *Conditions such as agitation, delirium, pain, confusion, incontinence, or uncontrolled body movements can cause the resident to be more active in bed or attempt to get out of bed. The proper sizing of the mattress,

the fit and integrity of the bed rail or other design elements such as wide spaces between the bars in the rail can also increase the risk for resident entrapment, injury and in some instances death.

*The purpose of the Bed Safety-Including Bed Rails/Side Rails/Assist Bars P&P [policy and procedure] is to: promote bed safety with the appropriate use of bed rails when used for medical necessity to reduce the risk of entrapment as well as the least restrictive alternative to side rails.

*It is important to remember that not all rails and mattresses fit all bed frames.

*Inspect the bed system for:

-Proper installation of side rails or assistive devices such as grab bars.

-Rails or assistive devices designed for the bed frame manufacturer.

-Rails or assistive devices that meet the design elements of bed safety standards to avoid entrapment injuries or death.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm 51816

Residents Affected - Some Based on observation, interview, record review, and policy review, the provider failed to ensure sufficient nursing staff for one of one secured unit to safely meet residents' needs, well-being, and the security of 17 of 17 residents (39, 86, 95, 96, 100, 102, 110, 114, 115, 122, 127, 131, 133, 135, 140, 148, and 453). Staff reported concerns with medication errors related to interruptions, difficulty keeping wandering residents within the unit, and difficulty completing all care tasks for residents due to the staffing of the unit. These failures placed those residents at risk for unmet care needs and potentially negative outcomes.

Findings include:

1. During the entrance conference on 4/14/25 at 2:45 p.m. with administrator A, she stated the evening meal was served at 5:30.

2. Initial observation on 4/14/25, beginning at 5:34 p.m., of the dining room of the 100 hall, which is the secured unit, revealed:

*Many of the residents had already finished eating and were walking around the adjacent day room and hallway.

*Some residents had finished eating and were still seated at tables in the dining room.

*Some residents required assistance to eat their meals.

*Two unidentified staff members were working in the unit and were:

-Assisting residents with their meals.

-Transferring residents from their dining room chairs to wheelchairs and to recliners in an adjacent room.

-Clearing the tables after the residents had finished their meals.

-There were 17 residents in the unit.

3. Interview on 4/14/25 at 5:57 p.m. with certified medication aide (CMA) O revealed:

*The dinner meal was served at 5:00 p.m. in the secured unit, not at 5:30 p.m. like the rest of the facility.

*The unit was staffed with one CMA and one certified nursing assistant (CNA) from 6:00 a.m. until 10:00 p.m. , and one CNA from 10:00 p.m. until 6:00 a.m.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0725 *At mealtimes, the CMA and CNA were responsible for getting residents into the dining room and seated for meals, serving the meal, assisting residents to eat their meals, clearing the tables, and helping residents who Level of Harm - Minimal harm or required assistance with transferring and cares after the meal. potential for actual harm *In addition to passing medications, the CMA was responsible for getting residents up in the morning and to Residents Affected - Some bed at night, getting weights before breakfast, giving residents showers and filling out a Bath Skin Form, providing personal care as needed, and intervening and redirecting with resident behaviors.

*If staff on the secured unit needed assistance, they would use their radio to call the nurse on the 300 hall or

a nurse manager.

-The nurse on the 300 hall was also responsible for the residents on the secured unit.

4. Observation on 4/15/25 at 11:24 a.m. in the day room of the secured unit revealed:

*A group of residents was participating in an activity with an activity assistant.

*Many of the doors to residents' rooms were closed.

5. Observation on 4/15/25 at 11:42 a.m. of the dining room in the secured unit revealed:

*All the residents' doors were closed except for two.

*The activity assistant and an additional staff member assisted CMA O and the CNA with getting residents to

the dining room for lunch and with serving the meal.

*During the meal, dietitian CC and licensed practical nurse (LPN) H also came to the dining room and stayed

on the unit for approximately eight minutes.

-They talked to the staff that was already in the dining room, but did not assist with any resident care.

6. Interview on 4/15/25 at 3:49 p.m. with CMA O about the number of staff that were present during the lunch meal earlier that day revealed there were more staff present, and that it was not the normal staffing ratio for

the secured unit.

7. Observation on 4/22/25 at 3:49 p.m. in the day room revealed:

*Two residents were outside in the courtyard.

*They were knocking and pulling on the door, attempting to reenter the day room, and were not able to get in by themselves.

*Another resident who was in the day room was able to open the door and let them into the building.

*There was no staff member outside in the courtyard, in the day room, or within sight while the surveyor was observing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0725 8. Interview on 4/23/25 at 3:14 p.m. with CMA O revealed:

Level of Harm - Minimal harm or *She felt she was interrupted multiple times per shift during medication passes because of resident potential for actual harm behaviors that required intervention.

Residents Affected - Some *She thought the frequent interruptions to staff responsible for medication administration contributed to some of the medication errors that had been happening in that unit because it was challenging for them to maintain their focus on administering medication.

*She did not think the staffing was adequate in that unit because she was unable to meet all the residents' needs, and that other areas of the facility had different staffing ratios of staff per residents.

-She had been asked by management to increase the amount of charting and documentation regarding the residents in the unit, but did not feel she had enough time to complete more charting because she was too busy doing tasks and providing resident care.

-She stated on one occasion, she had been in the shower room assisting a resident with a shower, and the CNA went into a resident's room to help another resident. When she walked out of the shower room, she found a resident lying on the floor who had fallen and needed assistance.

*A staff member from the 300 hall was supposed to come to the secured unit to cover the CMA and CNA for breaks, but that did not usually happen.

*When the CMA or CNA in the secured unit took a break, there was only one nursing staff member in the unit to care for those residents.

9. A staffing policy had been requested, and the surveyor was given the provider's 6/5/24 Staffing and Scheduling Resource Packet.

-This packet contained scheduling guidelines and principles, as well as a formula to calculate the labor per diem (the daily cost of caring for a resident).

10. Interview and record review on 4/24/25 at 8:26 a.m. with staffing coordinator Q revealed:

*She had been completing the staff scheduling for approximately four years.

*She scheduled the staff for all of the long-term care and rehab units.

*She had not seen and was not aware of the provider's 6/5/24 Staffing and Scheduling Resource Packet, and did not use that to guide staffing.

*She scheduled staff as she had been trained to by a previous director of nursing (DON).

*The 400 wing was staffed with one nurse and two CNAs for the 400 North hall, and one nurse and two CNAs for the 400 South hall.

*The 300 hall was staffed with one nurse, one CMA, and two CNAs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0725 *The 100 hall (the secured unit) was staffed with one CMA and one CNA. The nurse for the 300 hall would also cover nursing needs for the 100 hall. Level of Harm - Minimal harm or potential for actual harm *She agreed that there were fewer staff for the 100 hall.

Residents Affected - Some 11. Interview on 4/24/25 at 8:43 a.m. with registered nurse (RN)/clinical care leader (CCL) I for the secured unit revealed:

*Regarding the staffing ratio in the secured unit, she felt the staffing ratio was common throughout the building.

*She felt staffing on the secured unit was adequate.

*She felt that the frequent interruptions during the medication pass were not as impactful once the staff got into a routine.

*She stated leadership was looking at a time study for the secured unit because they had heard it was getting a little busier.

-She did not offer further details of what was busier.

*Regarding a medication error where a medication had been documented as unavailable for four days by a CMA in the secured unit, she agreed that their policy had not been followed, and the CMA should have notified the nurse that the medication was not in the med cart.

12. Interview on 4/24/25 at 9:53 a.m. with CMA C about working on the secured unit revealed:

*She had been a CMA for over ten years.

*Her first medication error happened in that unit.

*She described it as overwhelming because of interruptions with medication passes and said the staff were expected to do a lot in the secured unit.

*She said she was sometimes asked to do nursing functions like neurological assessments after a resident's fall, and skin assessments.

*They would sometimes see a nurse on the unit for only five minutes a day; sometimes they would not see a nurse all day.

*Staff from the secured unit had tried to discuss their concerns about inadequate staffing with management, but there had been no follow-through on improvement attempts.

*She stated that they were supposed to start being relieved for breaks by a staff member from the 300 hall, but that had only happened about three times.

*There were two residents the staff were supposed to try and keep separated because they fight, but stated

she felt that was almost impossible if you're the only one [working] back here.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0725 *She loved working with the residents who resided in the secured unit, but felt they needed more support from staff. Level of Harm - Minimal harm or potential for actual harm 13. Review of medication error reports for the secured unit from 2/13/25 through 4/19/25 revealed:

Residents Affected - Some *There had been six medication error reports from that period.

*Only one medication error report was for a single administration error.

*Resident 135 had only received 25 milligrams (mg) of his ordered dose of 50mg of Seroquel (an antipsychotic medication) for seven days, from 2/5/25 through 2/12/25.

*Resident 86 had received 50 mg of Seroquel instead of his ordered dose of 25 mg for seven days, from 2/5/25 through 2/12/25.

-The medication error report indicated that staff had noticed he had been more lethargic during the day, but wakes easily.

*Resident 133 had not received her Seroquel at bedtime for four days.

-The medication was charted as not available on 3/12/25 through 3/15/25.

*Resident 114 had received 60 mg of furosemide (a diuretic or water pill) on Saturday, 4/12/25, and Sunday, 4/13/25, when the order was for Mondays, Wednesdays, and Fridays only.

*Resident 110 received 45 mg of mirtazapine (an antidepressant) instead of her ordered dose of 15 mg from 3/20/25 through 4/15/25.

-An order was received on 3/20/25 to decrease the dose of mirtazapine from 30 mg to 15 mg related to weight gain.

-An order for the 15 mg dose was entered, but the order for the 30 mg dose was not discontinued.

-A 4/3/25 progress note for medication regimen review by the consultant pharmacist noted that both doses are active on the MAR [medication administration record], sent communication to DC [discontinue] 30MG [30 mg] dose.

-The order was corrected on 4/16/25, 27 days after the order was received.

*Resident 127 had received 50 mg of her total ordered dose of 75 mg of sertraline (an antidepressant) on 4/18/25.

*Those six medication error reports accounted for 48 medication administration errors from 2/13/25 through 4/19/25.

14. Interview on 4/24/25 at 10:22 a.m. with DON R revealed:

*She had no concerns about staff being able to safely care for residents on the secured unit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0725 *Regarding the unit staffing ratios and medication errors potentially related to the frequent interruptions with

the medication pass, elopements, and resident behaviors in the secured unit, she stated they had those Level of Harm - Minimal harm or same types of issues everywhere in the facility. potential for actual harm *They had added a CMA to the 300 hall so that the nurse for the 300 hall could be more available to the Residents Affected - Some secured unit.

*She stated, And the activity aide is back there.

-She acknowledged that the activity aide could not provide personal care for the residents, but they could assist residents with some redirection.

*She expected skin assessments to be completed by a nurse and documented by a nurse.

15. Review of the provider's 4/8/25 Medication: Administration Including Scheduling and Medication Aides policy revealed:

*Purpose

-To administer medications correctly and in a timely manner.

*Policy

-Medication administration

--Pre-setting medications is not an acceptable practice. Once the medication pass has begun, interruptions should be avoided. Unless emergent, no one should interrupt the nurse/med aid during the medication pass.

-Medication Errors

--A SAFE Event Report will be completed for all medication errors. If a medication is not available for 24 hours, the provider must be notified that the medication is not available and must give direction for how to proceed.

*Procedure

-Review the MAR [medication administration record] for medications due.

-Follow the Six Rights: Right medication, right dose, right resident, right route, right time and right documentation.

-Perform three checks: Read the label on the medication container and compare with the MAR when removing the container from the supply drawer, when placing the medication in an administration cup/syringe and just before administering the medication .

16. Review of the provider's 2/7/25 facility assessment revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0725 *Regarding the number of staff utilized for residents who have behavioral health needs:

Level of Harm - Minimal harm or -They did not identify the number of staff utilized to provide care for residents with behavioral health needs. potential for actual harm *Regarding appropriate staffing on all shifts: Residents Affected - Some -They Identify needs daily using census and resident acuity to staff accordingly to help where needed.

-They did not indicate the number of staff that would be appropriate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 49958 potential for actual harm Based on record review, interview, and policy review, the provider failed to ensure two of four sampled Residents Affected - Some certified nursing assistant (CNA)/certified medication aides (CMA) (U and KK) who worked in one of one secured memory care unit had an annual performance review completed. Findings include:

1. Review of CNA/CMA KK's personnel records revealed:

*She was hired on 11/16/21.

*Her last annual performance review was conducted on 5/31/23.

-Her annual performance review was more than 10 months overdue.

2. Review of CNA/CMA U's personnel records revealed:

*She was hired on 12/28/22.

*Her last annual performance review was conducted on 5/31/23.

-Her annual performance review was more than 10 months overdue.

3. Interview on 4/24/25 at 11:11 a.m. with administrator A regarding the completion of the annual performance evaluations for CNAs revealed:

*She confirmed that CNA/CMA U and CNA/CMA KK's last performance reviews had been completed on 5/31/23.

*The provider's human resources department staff tracked the completion of the annual performance reviews.

*She was unaware that CNA/CMA U and CNA/CMA KK had not had the required annual performance reviews completed.

4. Review of the provider's revised 6/11/24 Performance Management policy revealed:

*The performance management process should be dedicated time for employees and their leaders, to connect. These connections are intended to be frequent meetings throughout the calendar year and personalized based on the work and individual.

*Based on the performance expectations of the position, performance management conversations may serve as a reference point when determining career growth, developmental needs .

*Leaders should schedule one-on-one meetings with each of their employees to check-in, provide timely meaningful feedback, discuss performance, share performance ratings, and focus on career growth and development consistently throughout the year.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0730 *Once per year, depending on role requirements, Employees and leaders will have the opportunity to seek feedback from others they work with . Level of Harm - Minimal harm or potential for actual harm Refer to

F-F700 was given verbally and in writing on 4/16/25 at 4:21 p.m. to administrator A regarding:

*The provider failed to ensure bedrails were securely attached, mattresses were able to be elevated when

the side rail(s)/grab bar(s) were moved, and there were gaps greater than five inches between the end of the mattress and the headboard. These identified concerns were related to the bedrail installation, maintenance, and bed zone safety and entrapment assessments.

-Observations made throughout the survey and throughout the entire building on 4/16/25 revealed the following:

*In residents 18, 47, 67, 97, 108, and 126s' rooms the side rails/grab bars were not securely attached to the bedframe, that created a risk for entrapment and the potential for injury.

*In residents 5, 18, 47, 72, 83, 89, 97, 99, and 112s' rooms the side rails/grab bars were not securely attached to the bed frame, and the mattress on those beds were able to be elevated when the side rails/grab bars were moved, that created a risk for entrapment zone and the potential for injury

*In residents 5, 22, 73, 83, 89, 106, and 137s' rooms there were gaps greater than five inches between the end of the mattress and the headboard, that created a risk for potential entrapment and injury.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0700 *In residents 86, 100, 122, 133, and 148s' rooms there were a bed rail particle board frames in place under

the mattresses. There were no bed rails attached. There were two exposed metal installation holes, where Level of Harm - Immediate the bed rails would attach, that created a risk for potential injury. jeopardy to resident health or safety *Resident 356 was using side rails and did not have a Physical Device and/or Restraint Evaluation and

Review assessment completed. Residents Affected - Few *Other residents who had side rails had not been accurately or fully assessed for the use of side rails

*The style of bed rail used with the Hill-Rom spring bed frames was not compatible according to the manufacturer's instructions.

*Resident 103's bed rail was broken and not secured to the spring bed frame. When weight was applied to

the bed rail as if a resident were to use it for mobility and stability, the bed rail buckled backwards potentially creating a fall hazard. The particleboard grab bar frame was broken in one corner creating potential for injury.

*The above concerns had the potential to cause serious harm, injury, impairment or death for residents.

*A plan for the removal of the immediacy was requested at that time.

IMMEDIATE JEOPARDY REMOVAL PLAN

On 4/16/25 at 8:39 p.m. the provider submitted the following immediate jeopardy removal plan for review:

*A comprehensive assist bar audit has been completed for the 26 of 159 residents. The 26 residents have been corrected on 4/16/2025 as follows:

-Assist bars were removed from the beds of residents 5,18, 47, 67,72, 83, 86, 89, 97, 99, 100, 103, 112, 122, 126, 133, and 148.

-The bed footboard was removed from resident 453's bed and the family was notified.

-Resident 108's bed was replaced as the resident wished to keep the assist bars.

-The footplate to hold the mattress in place to prevent gaps of greater than four inches in resident 5, 22, 73, 83, 99, 106, and 137s' rooms were put into place.

-A physical device evaluation was completed on 4/7/2025 and updated on 4/16/25 for resident 356.

--The residents who had their assist bars removed, resident was educated-family was called and educated for residents with a BIMs score of under 13 or those who could not comprehend education.

*Identification of others:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0700 -An audit of all grab bars and mattresses in the facility was completed as of 4/16/2025 in order to identify residents at risk for similar deficient practice. Resident was educated if assist bar needed to be removed Level of Harm - Immediate from their bed-family was called and educated for residents with BIMs score of under 13 or those who could jeopardy to resident health or not comprehend education. During the audit, bed rails that were identified as noncompliant were replaced or safety removed. Care plan and physical device assessment updated as appropriate.

Residents Affected - Few *Process/Systemic Changes to Prevent Recurrence:

-1. The facility is currently in compliance with the 'Bed Safety and Side Rail Entrapment Resource Packet' which is an internal [corporate] policy.

-2. Physical Device Assessments listed in the policy titles 'Restraints Policy' will be completed on April 16th, 2025.

-3. During the daily nurse clinical meeting, the team will review and evaluate all new residents to ensure that

a comprehensive physical device assessment has been completed in accordance with the Restraint Policy.

-4. The Maintenance Supervisor or designee will complete a preventative maintenance task 'Bed Inspection, Testing and Maintenance' [corporate] audit monthly. Maintenance staff were educated task audit on 4/16/25.

*Education and Training:

-An On-Shift message was sent to all employees' personal phones educating on entrapment and potential entrapment hazards on April 16 at 5:28 p.m.

-Education will be provided by a Clinical Learning and Development Specialist or Designee to all staff by April 16, 2025 or prior to their next shift. All staff members not currently on the schedule will receive education prior to their next shift. This training will cover entrapment risk, immediate interventions to address entrapment, and the appropriate personnel to notify if a resident is identified as being at risk.

*Monitoring:

-Comprehensive audits will be conducted by Quality RN or Designee on resident assist bars weekly x4 [times four] weeks, then biweekly x2 [times two] for two months. Findings will be presented to the Quality Assurance Performance Improvement Committee for review.

-Audits will be conducted by Maintenance Supervisor or designee on mattress gaps to ensure compliance weekly. The schedule includes x4 for Four weeks, then bi-weekly x2 for two months. Findings will be presented at the QAPI for review.

*Completion Date:

-Please consider this IJ removal plan as the facility action to address the immediate concerns of noncompliance. This plan will be implemented and completed on April 16, 2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0700 The IJ removal plan was accepted on 4/16/25 at 10:18 p.m.

Level of Harm - Immediate The immediate jeopardy was removed on 4/16/25 at 11:15 p.m. after the survey team verified on site on jeopardy to resident health or 4/17/25 at 8:45 a.m. that the provider had implemented their removal plan through observation, document safety review, and staff interviews. After the removal of the immediate jeopardy, the scope and severity of the non-compliance remained an E. Current census was 159 residents. Residents Affected - Few 2. Observation on 4/14/25 at 3:17 p.m. of resident 103's room revealed she had a white metal grab bar on

the left side of her bed.

Observation on 4/16/25 at 9:57 a.m. of resident 103's grab bars on her bed:

*When the left grab bar was pulled away from the bed, it lifted the mattress and separated from the mattress approximately 45 degrees.

*Under the mattress the grab bar was attached to a piece of particleboard with a corner broken off.

*There were four securement locations, two near the frame of the bed and two over the bed springs.

*Neither the grab bars nor the particleboard was secured to the bed frame or the bed springs.

Interview on 4/16/25 at 10:11 a.m. with registered nurse (RN) T regarding resident 103 revealed:

*She did not use her grab bar.

*She was super stiff and difficult to roll in bed and required staff assistance with bed mobility.

Review of resident 103's 2/23/25 Physical Device and/or Restraint Evaluation and Review revealed:

*The consent for the grab bar was indicated as being given by the resident's physician.

*The assessment had a comment that indicated Resident is able to use grab bar appropriately.

*The Alternatives that have been attempted did not have any documented alternatives.

*There was no documentation of education provided related to the grab bars.

3. Observation on 4/14/25 at 3:33 p.m. of resident 99's room revealed there were white metal grab bars on both sides of her bed.

Observation and interview on 4/16/25 at 10:26 a.m. with resident 99 in her room revealed:

*The grab bars on both sides of the bed lifted the mattress when pulled on.

*Resident 99 stated she used the grab bars for repositioning herself when in bed.

Review of resident 99's 3/3/25 Physical Device and/or Restraint Evaluation and Review revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0700 *The Alternatives that have been attempted did not have any documented alternatives.

Level of Harm - Immediate *There was no documentation of education provided related to the grab bars. jeopardy to resident health or safety 4. Observation on 4/14/25 at 3:37 p.m. of resident 89's room revealed she had white metal grab bars on both sides of her bed. Residents Affected - Few

Observation on 4/16/25 at 10:20 a.m. of resident 89's bed revealed:

*The right grab bar moved freely when pulled on.

-It was not secured to the springs of the bed.

*The left grab bar was loose when it was pulled on.

Review of resident 89's 2/27/25 Physical Device and/or Restraint Evaluation and Review revealed:

*The consent for the grab bar was indicated as being given by the resident's physician.

*The Alternatives that have been attempted did not have any documented alternatives.

*There was no documentation of education provided related to the grab bars.

5. Observation on 4/14/25 at 3:42 p.m. of resident 112's room revealed she had a white metal grab bars on

the right side of her bed.

Observation on 4/16/25 at 11:00 a.m. of resident 112's grab bar revealed it was loose and lifted the mattress when it was pulled on.

Review of resident 112's 2/11/25 Physical Device and/or Restraint Evaluation and Review revealed:

*The consent for the grab bar was indicated as being given by the resident's physician.

*The Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcome, etc. ) had not been addressed.

*The Alternatives that have been attempted did not have any documented alternatives.

*There was no documentation of education provided related to the grab bars.

6. Observation and interview on 4/16/25 at 9:58 a.m. with resident 19 in her room revealed:

*She had a white metal grab bar on the left side of her bed.

*The grab bar was loose and pulled the mattress up from the bed when pulled on.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0700 *Resident 19 stated that the mattress pulls up even when she is sitting on the edge of the bed and pulls on

the grab bar. Level of Harm - Immediate jeopardy to resident health or Review of resident 19's 1/21/25 Physical Device and/or Restraint Evaluation and Review revealed: safety *The consent for the grab bar was indicated as being given by the resident's physician. Residents Affected - Few *The Alternatives that have been attempted did not have any documented alternatives.

7. Observation and interview on 4/16/25 at 10:06 a.m. with resident 47 in her room revealed:

*She had a white metal grab bar on the left side of her bed.

*There was movement of the grab bar from side to side and up and down when testing it.

*Resident 47 was unsure if she used her grab bar in bed or for transfers.

Review of resident 47's 3/20/25 Physical Device and/or Restraint Evaluation and Review revealed:

*The consent for the grab bar was indicated as being given by the resident's physician.

*The Alternatives that have been attempted did not have any documented alternatives.

*There was no documentation of education provided related to the grab bars.

8. Observation and interview on 4/16/25 at 10:09 a.m. with resident 97 in her room revealed:

*She had bilateral white metal grab bars on her bed.

*When the grab bars were pulled in the mattress was lifted from the bed frame.

*Resident 97 stated she used her grab bars while she was in bed, and she felt they were loose when she pulled on them.

Review of resident 97's 3/4/25 Physical Device and/or Restraint Evaluation and Review revealed:

*The Alternatives that have been attempted did not have any documented alternatives.

*Documented education related to the grab bars was given to staff.

9. Observation on 4/16/25 at 10:15 a.m. of resident 126's bed revealed:

*She had a white metal grab bar on the left side of her bed.

*The grab bar was not secured to the bed frame.

Review of resident 126's 1/28/25 Physical Device and/or Restraint Evaluation and Review revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0700 *The consent for the grab bar was indicated as being given by the resident's physician.

Level of Harm - Immediate *The Alternatives that have been attempted did not have any documented alternatives. jeopardy to resident health or safety *There was no documentation of education provided related to the grab bars.

Residents Affected - Few 10. Observation and interview on 4/16/25 at 10:18 a.m. with resident 18 in his room revealed:

*He had a white metal grab bar on the left side of his bed.

*The grab bar lifted the mattress when it was pulled on.

*Resident 18 stated he used the grab bar for repositioning while he was in bed.

Review of resident 18's 3/12/25 Physical Device and/or Restraint Evaluation and Review revealed:

*The Alternatives that have been attempted did not have any documented alternatives.

*There was no documentation of education provided related to the grab bars.

11. Observation and interview on 4/16/25 at 10:22 a.m. with resident 108 in his room revealed:

*He is lying in bed, leaning with most of his body weight on his left grab bar.

*He stated he used the grab bar for repositioning in bed and he had noticed that it did get loose at times.

Review of resident 108's 4/10/25 Physical Device and/or Restraint Evaluation and Review revealed:

*The consent for the grab bar was indicated as being given by the resident's physician.

*The Alternatives that have been attempted did not have any documented alternatives.

*There was no documentation of education provided related to the grab bars.

12. Observation on 4/16/25 at 10:53 a.m. of resident 67's bed revealed:

*He had a white metal grab bar on the right side of his bed.

*The grab bar moved slightly when shaken.

*The grab bar lifted the mattress when it was pulled on.

Review of resident 67's 3/3/25 Physical Device and/or Restraint Evaluation and Review revealed:

*The Alternatives that have been attempted did not have any documented alternatives.

*The education documented was given to staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0700 13. Observation on 4/16/25 at 10:56 a.m. of resident 5's bed revealed:

Level of Harm - Immediate *He had white metal side rails on both sides of his bed. jeopardy to resident health or safety *The right grab bar was loose when it was pulled on.

Residents Affected - Few Review of resident 5's 3/17/25 Physical Device and/or Restraint Evaluation and Review revealed:

*The consent for the grab bar was indicated as being given by the resident's physician.

*The Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcome, etc. ) had not been addressed.

*The Alternatives that have been attempted did not have any documented alternatives.

*There was no documentation of education provided related to the grab bars.

14. Observation and interview on 4/16/25 at 11:10 a.m. with resident 137 in her room revealed:

*She had a white metal grab bar on the left side of her bed.

*The grab bar was able to be moved in all directions when pulled on.

*Resident 137 stated she used her grab bar to get out of bed.

*She was aware her grab bar was loose and indicated she would have tightened it if she had a screwdriver.

Review of resident 137's 4/7/25 Physical Device and/or Restraint Evaluation and Review revealed:

*The Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcome, etc. ) had not been addressed.

*The Alternatives that have been attempted did not have any documented alternatives.

*There was no documentation of education provided related to the grab bars.

15. Observation on 4/16/25 at 11:17 a.m. of resident 83's bed revealed:

*She had a white metal grab bar on the left side of her bed.

*The grab bar was loose when it was pulled on.

Review of resident 83's 3/17/25 Physical Device and/or Restraint Evaluation and Review revealed:

*The consent for the grab bar was indicated as being given by the resident's physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0700 *The Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcome, etc. Level of Harm - Immediate ) had not been addressed. jeopardy to resident health or safety *The Alternatives that have been attempted did not have any documented alternatives.

Residents Affected - Few *There was no documentation of education provided related to the grab bars.

16. Observation and interview on 4/16/25 at 11:20 a.m. with resident 72 in her room revealed:

*She had a white metal grab bar on the right side of her bed.

*The grab bar lifted the mattress when it was pulled on.

*Resident 72 stated she knew the grab bar was loose but had not thought to ask for someone to tighten it.

Review of resident 72's 3/22/25 Physical Device and/or Restraint Evaluation and Review revealed:

*The consent for the grab bar was indicated as being given by the resident's physician.

*The Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcome, etc. ) had not been addressed.

*The Alternatives that have been attempted did not have any documented alternatives.

*There was no documentation of education provided related to the grab bars.

17. Observation and interview on 4/16/25 at 11:28 a.m. with resident 356 in her room revealed:

*Her bed had bilateral tall, white, metal bed rails.

*She was currently in bed and was not feeling well.

*She used the bed rails to reposition herself when she wanted to sit on the edge of the bed.

*She used the right side more than the left.

*A wooden platform was visible under the mattress and it appeared to be how the bed rail was attached to

the bed.

-We were unable to view the attachment as the resident was in bed.

Observation and interview on 4/17/25 at 8:22 a.m. with resident 356 in her room revealed:

*She indicated she used the right bed rail more than the left.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0700 *The right bed rail was loose and moved a couple of inches towards the top of the bed and a couple of inches towards the bottom of the bed. Level of Harm - Immediate jeopardy to resident health or -It was attached to a wooden platform that was attached to the bed. safety *The left bed rail was significantly loose and could be lifted several inches off the bed. Residents Affected - Few -It appeared to be anchored in only one of three available places.

Review of resident 356's 4/7/25 Physical Device and/or Restraint Evaluation and Review revealed:

*The consent for the grab bar was indicated as being given by the resident's physician.

*The Potential resident safety risks have been evaluated for this device/restraint (e.g., potential entrapment, accident hazard, potential negative outcome, physical restraint, potential negative psychosocial outcome, etc. ) had not been addressed.

*The Alternatives that have been attempted did not have any documented alternatives.

*There was no documentation of education provided related to the grab bars.

Observation on 4/17/25 at 8:33 a.m. with administrator A of resident 356's bed rails revealed.

*Administrator A confirmed that the right bed rail was loose and that the left bed rail could be lifted off the bed.

*Administrator A stated that the bed rails would be repaired immediately and confirmed that resident 356 would not be allowed to use the bed until it was fixed to ensure her safety.

18. Observations, interviews, and record reviews during the survey identified residents (5, 17, 22, 73, 83, 103, 106, 123, 137, and 453) had concerns with potential entrapment areas on their beds related to the mattresses and the headboard or footboards. Refer to

F-F725 Finding 8, 11, 12, 13, 14, and 15.

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51472 potential for actual harm Based on observation, interview, record review, and policy review, the provider failed to follow proper Residents Affected - Some infection control practices to ensure

*Supplies were not stored under sinks in four of four soiled utility rooms.

*Resident care and cleaning supplies were monitored for outdates and disposed of in two of four soiled utility rooms (400 South hall, and 300 hall) and one of four resident shower rooms (100 hall).

*Splash guards were properly installed on three of four hoppers (specialized sink for disposing of bodily fluids) in the soiled utility rooms.

*One of one biohazard container was covered as directed in the provider's policy to safely contain biohazardous material during storage and transport to prevent leakage, spilling, and potential exposure.

*Personal care products (combs, brushes, finger-nail clippers, and personal hygiene supplies) were not shared between residents in four of four shower rooms (100, 200, 300, and 400 hall).

*Clean linen was covered while stored and transported as directed in the provider's policy to protect it from potential contamination.

*Soiled linen was covered in one of four resident shower rooms (400) to prevent cross-contamination, and

the spread of infection as directed in the provider's policy.

*Multiple chairs were free of dust, dirt, and food particles in accordance with the provider's policy in the dining room in the 400 hall and in the common areas in the 100 and 400 halls.

Findings include:

1. Observation on [DATE REDACTED] at 3:50 p.m. of the 400 hall lobby area revealed:

*A purple dining room chair with a white unknown substance located on the middle front of the seat cushion.

*A white and gray chair with an unknown dried yellow stain in the middle of the seat cushion.

*A light green colored chair with an unknown yellow stain on the front of the seat cushion.

2. Observation on [DATE REDACTED] at 3:55 p.m. of the 100 hall day room revealed:

*A brown suede recliner with a wet area on the seat, a greasy stain on the headrest, and a brownish-red substance on the arm of the chair.

*An empty wheelchair with a solid unidentified brownish yellow crusty substance on the seat.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0880 3. Observation on [DATE REDACTED] at 5:39 p.m. of the 400 hall dining room revealed:

Level of Harm - Minimal harm or *There were multiple dining room chairs with dried unidentified discolorations to the fabric on the backs and potential for actual harm seats of the chairs.

Residents Affected - Some *Residents were seated in those chairs for the meal.

4. Observation and interview on [DATE REDACTED] at 2:51 p.m. in the 200 hall shower room with certified nursing assistant (CNA) W revealed:

*On a shelf in the wooden cabinet were two hairbrushes, one black comb, one opened stick deodorant, one opened tube of toothpaste, one partially used tube of skin protectant cream, and a pair of scissors without resident identifiers listed on them.

*In the shower was a partial bottle of shampoo.

*CNA W stated she was unsure why the partially used containers and brushes were in the cabinet. She indicated she would have used supplies from each resident's room or gotten new supplies from the supply room if needed.

*She indicated she would not be able to identify which resident the above personal care items belonged to because there were no resident identifiers on the items.

*On the back of the toilet were two containers of personal hygiene wipes.

-One of the wipe containers was opened and partially used.

*CNA W indicated the containers of wipes were used for multiple residents.

5. Observation and interview on [DATE REDACTED] at 3:02 p.m. in the 400 hall shower room with CNA K revealed:

*There was a bag of soiled linen that was uncovered.

*In the wooden cupboard were two razors, partial bottles of body wash, partial bottles of lotion, partial tubes of zinc oxide (medicated) cream, and a nail clipper that did not contain resident identifiers.

*CNA K stated if the personal hygiene supplies were for a specific resident, they should have been labeled with resident identifiers.

*She indicated she would not have used fingernail clippers or razors on a resident if it did not belong to that resident.

*She did use the facility-supplied body washes and shampoos between residents and did not wipe the bottles or have a process in place to prevent potential cross-contamination between residents.

*She agreed the nail clipper appeared to have been used and was not clean.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0880 *She stated if a fingernail clipper was used between multiple residents, it would need to be cleaned with an alcohol wipe, but she would have obtained a new fingernail clipper from the storage room for each resident. Level of Harm - Minimal harm or potential for actual harm 6. Observation and interview on [DATE REDACTED] at 3:09 p.m. in the 400 South hall soiled utility room with CNA K revealed: Residents Affected - Some *There was a plastic splash guard on the floor next to the hopper.

*CNA K stated the guard used to be mounted on the hopper to protect staff from splashing substances onto themselves or outside of the hopper when they were rinsing soiled linen.

*Above the hopper, there was a sign that said, Please wear gown, gloves, and goggles when using the hopper spray.

-No gowns and gloves were available in the room. Goggles were present, but they were soiled with a thick layer of dust.

*Paint was peeling from the wall and ceiling, making it an uncleanable surface.

*The following items were stored under the sink:

-A plastic bag that contained a pair of utility gloves.

-A gray basin with dried brown and white sediment on the bottom.

-A white bucket that had a dried, white, crusty substance in it.

-A clear [NAME] jar with dust and a brown coating on it.

-Two U shaped metal strips approximately 18 inches long.

-A pink bedpan.

-A gray basin with a dead spider in it.

-A two-compartment black container that contained a toilet brush with holder, a black wireless battery, a skin prep pad that had expired [DATE REDACTED], two white metal assist bars, a gray commode or toilet lid, and a green folder that contained a Safety Data Sheet (SDS) for Good Sense RTU Odor Counteractant.

*On top of a cabinet, there was an Emergency Response kit with no expiration date seen.

7. Observation and interview on [DATE REDACTED] at 3:19 p.m. in the 400 North hall soiled utility room with environmental services (EVS) technician RR revealed:

*A trash bin that did not have a cover to prevent the potential spread of infection, debris, and odor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0880 *The plastic splash guard for the hopper was not attached properly.

Level of Harm - Minimal harm or *There was a large red bin that was overfilled with used, locked sharps containers. potential for actual harm

It was so full that the lid could not be closed and sealed properly to contain the medical waste. Residents Affected - Some *On a shelf above the sink, there was a suction machine with a cover labeled Return to Central Supply.

*The wall had visible clusters of gray dust on it.

*The following items were stored under the sink:

-A white towel with flecks of unidentified brown, solid material.

-A tan colored plastic container that had approximately a half-inch of standing water in it, and the bottom of

the container was covered with brown sediment.

-A gray circular piece of plastic.

8. Observation on [DATE REDACTED] at 3:31 p.m. in the 300 hall shower room revealed:

*A partial bottle of body wash and a gray basin with a white, crusty substance on the bottom of it on the shower chair.

*A Roho cushion (a pressure-relieving cushion) and a wet Roho cushion cover were on a shelf, which in this environment could increase the risk of contamination and potential spread of infection.

*In the cabinet were partial bottles of shaving cream, lotion, baby powder, foam cleanser, shampoo, body wash, a black wrist brace, a nail clipper, and a partially used container of washcloth wipes, which were all unlabeled.

*There was dust and debris along the outer edges of the floor of the room.

9. Observation on [DATE REDACTED] at 3:32 p.m. of the 300 hall soiled utility room revealed:

*There were flakes of brown residue at the bottom of the basin of the hopper, which could indicate the presence of dirt, organic matter, or other contaminants.

*The splash guard on the hopper was covered with a layer of dust.

*The following items were stored under the sink:

-A bottle of drug destroyer.

-A container of peroxide multi-surface cleaner wipes that were dry.

-A white plastic bucket.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0880 -A white plastic square container with a brown residue covering the bottom that contained a tube of Carmex,

a sliver squeegee, a toilet brush holder, and a yellow plunger. Level of Harm - Minimal harm or potential for actual harm -A Facts on MRSA 2009 information paper.

Residents Affected - Some -An opened box of surgical masks and goggles with a white, crusty substance on it.

-An opened box of masks with visors.

-A white bucket that contained an ice cream bucket with green sediment in the bottom of it, and a nebulizer machine.

-A wheelchair foot pedal.

-A toilet brush and holder.

-Two short white metal siderails.

-A basin covered with a white and yellowish-brown substance with clear liquid in the bottom of it that contains

a bottle of Oxivir disinfectant concentrate that expired [DATE REDACTED], along with peroxide multi-surface cleaner wipes.

10. Observation on [DATE REDACTED] at 3:44 p.m. of the 100 hall soiled utility room revealed:

*A water bottle was on the floor.

*A box of bags was on the counter with a coffee cup on top of it.

*A wheelchair cushion cover was on the floor.

*Six damp floor mop pads were draped over the sink, which could transfer bacteria to the sink surface, potentially contaminating other items used in the soiled utility room and staff clothing.

*The following items were stored under the sink:

-A bottle of Pine-Sol.

-A clear glass vase.

-A black bag that had a toilet seat and cover in it.

-Two green plastic containers with two compartments that contained a toilet scrub brush, a bag of utility gloves, seven glass vases, three plungers, a container of wet task wipes, a spray can of matte finish acrylic sealer, and a dustpan.

-Those items stored under the sink increase the risk of cross-contamination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0880 11. Observation and interview on [DATE REDACTED] at 4:04 p.m. of the 100 hall shower room with CMA O revealed:

Level of Harm - Minimal harm or Clean, folded linen was stored uncovered on the top shelf of a cart near the shower, exposing it to potential potential for actual harm contamination from moisture, splashes, and airborne particles.

Residents Affected - Some *There was an unlabeled partial bottle of body lotion on the shower ledge.

*The cabinet on the wall contained:

-An unlabeled electric razor full of gray hair stubble.

-An unlabeled partially used package of disposable washcloths.

-Ketoconazole 2% (antifungal) shampoo with no resident identifier that had been spilled onto the cabinet shelf.

-An unlabeled bottle of Selsun Blue shampoo that expired in [DATE REDACTED].

-Partially used and unlabeled containers of deodorant, rinse-free foam cleanser, baby powder, body wash, shampoo, conditioner, lotion, barrier creams, and skin protectants.

-A fingernail clipper that had a crusty buildup on it.

-A spoon.

-Two combs with gray hairs and a white crust on them.

-A gray hair tie with gray hair attached to it.

-A blue bin containing two gray hair brushes with copious amounts of gray hair in them, a pair of resident socks, 13 black combs with white dried material and long gray hair on them, a tube of Chapstick, a partial roll of clear tape, a foot/callous file with white sediment on it, two hair picks with white sediment and gray hair, and an abundant amount of unsecured elastic hair ties.

-A clear tub containing a black brush that was full of gray hair and white sediment, a black comb with white sediment, an almost empty bottle of Aveeno baby lotion that expired in [DATE REDACTED], three opened stick deodorants, one roll-on deodorant, and a nail clipper.

*CMA O agreed that the personal care items were not labeled with resident identifiers and stated that some personal care items were shared between residents.

12. Interview on [DATE REDACTED] at 7:44 a.m. with director of nursing (DON) R and assistant director of nursing (ADON)/infection preventionist (IP) G revealed:

*It was their expectation that resident care equipment, such as nail clippers, electric razors, barrier creams, hairbrushes, personal hygiene wipes, creams, and cleansers, was not to be shared between residents because that could lead to the spread of infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0880 -They indicated these items should have been disposable or designated for a specific resident to limit the potential spread of infection. Level of Harm - Minimal harm or potential for actual harm *Clean linens should have been covered during transportation and storage in the shower rooms to reduce

the potential for contamination. Residents Affected - Some *The red biohazard buckets in the soiled utility rooms should be covered.

*Nurse managers were responsible to be sure expiration dates were checked on their respective halls.

*Chairs in the common areas and in the dining room were cleaned by housekeeping and maintenance would assist as needed.

*Agreed PPE should be accessible to staff who used the hoppers in the soiled utility room to prevent contamination from splash when they washed out soiled linen.

13. Observation and interview on [DATE REDACTED] at 8:30 a.m. in the laundry room with lead laundry technician L revealed:

*A linen cart used to transport clean linens had a cover with a rip so large on one side that linens could not be covered. The opposite side of the cover was torn and frayed, making it an uncleanable surface.

*Laundry must be covered during transportation. She agreed the cover did not provide adequate protection for clean linens.

*Clean laundry should have been covered in public areas, such as a shower room, due to the risk of contamination.

14. Interview on [DATE REDACTED] at 8:41 a.m. with registered nurse (RN)/clinical care leader (CCL) M revealed:

*She was not aware there was a suction machine stored in the soiled utility room.

*It should not have been stored in the soiled utility room because it was considered a clean item in a soiled environment.

*Residents that required a suction machine had one in their room and if additional suctions machines were needed there were ones on the crash cart or up front.

15. Interview on [DATE REDACTED] at 8:46 a.m. with administrator A revealed the provider did not have a policy for shared personal care equipment cleaning or a policy regarding supply expiration dates.

16. Interview on [DATE REDACTED] at 10:02 a.m. with lead environmental technician V revealed:

*The soiled utility rooms were not on the environmental service staff's cleaning schedule and did not get cleaned routinely.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0880 *Shower rooms were cleaned three times per week.

Level of Harm - Minimal harm or *Chairs in the common areas and dining rooms used to be cleaned by a man who no longer worked there. potential for actual harm 17. Interview on [DATE REDACTED] at 10:33 a.m. with CNA P revealed: Residents Affected - Some *No items were to be stored under sinks.

*Each resident was to have their own personal care items such as hygiene supplies, fingernail clippers, and electric razors.

*After each use an electric razor was to have the hair emptied, the head of the razor rinsed, and then wiped down with an alcohol wipe.

*Clean and dirty linen was to be covered when it was in the hallway and the shower rooms.

18. Interview on [DATE REDACTED] at 9:58 a.m. with RN/CCL M regarding expiration dates revealed:

*The nurses on the floor were responsible for checking for expiration dates on the medication carts.

*She would assist the nurses if they did not have time.

*There was no schedule in place to check supplies other than medications for their expiration dates.

*She expected housekeeping staff to check for outdates on chemicals in the soiled utility rooms.

*Any staff could and should have looked for outdated supplies and should have disposed of them appropriately.

19. Interview on [DATE REDACTED] at 10:29 a.m. with administrator A revealed:

*She expected staff to follow the manufacturer's expiration dates and dispose of the item when it was outdated.

*Cleaning of the dining room chairs and chairs in the common areas were the responsibility of maintenance staff.

-There was no schedule to indicate when the chairs were to be cleaned.

-If there was soiled chair identified she would have expected maintenance staff to attend to the chair that day.

20. Review of the provider's [DATE REDACTED] Infection Prevention and Control Program policy revealed:

*Purpose:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0880 -To establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable Level of Harm - Minimal harm or diseases and infections. potential for actual harm *Definitions: Residents Affected - Some -Infection Prevention and Control Program- A program that prevents, identifies, reports, investigates, and controls infections and communicable diseases for all residents, staff, and visitors, following nationally accepted standards and guidelines.

*Policy:

-The infection Prevention and Control Program is a facility-wide effort involving all disciplines and individuals and is an integral part of the Quality Assurance and Performance Improvement Program.

-The components of an Infection Prevention and Control Program include, but are not limited to: Program Oversight, Policies and Procedures, Surveillance, Data Analysis, Antibiotic Stewardship, Outbreak Management, Prevention of Infection, Immunizations, and Employee Health and Safety.

*Program Components

-The skilled nursing facility has designated at least one individual as the Infection Preventionist, who is responsible for the facility's Infection and Control Program.

-The facility has developed and implemented written policies and procedures for the provision of infection prevention and control.

-Process surveillance (ex, hand hygiene compliance program) and outcome surveillance (ex, monthly infection rates) are used as measures of the Infection Prevention and Control Program effectiveness.

Review of the provider's [DATE REDACTED] Surveillance, AL, Rehab/Skilled, Home Health, Hospice policy revealed:

*Surveillance is an activity that a healthcare institution employs to find, analyze, control and prevent nosocomial [healthcare-associated] infections.

*Process surveillance reviews practices directly related to resident/patient care in order to identify whether practices comply with established prevention and control policies and procedures.

Review of the provider's [DATE REDACTED] Housekeeping, Resource Packet revealed:

*Policy/Procedure:

-Environmental cleaning plays an important role in an infection control program. While most infections result from person-to-person transmission, the spread of infections from contaminated surfaces is significant and supports the need for good procedures and practices related to cleaning and disinfecting of surfaces.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0880 -All staff members play a role and should be aware of the general principles of environmental cleaning and safety. Level of Harm - Minimal harm or potential for actual harm -Adequate safety levels can be achieved for most non-critical [examples include computers, walls, tabletops, and medical equipment surfaces like blood pressure cuffs and lift equipment] and low touch areas by Residents Affected - Some keeping the surfaces visibly clean using water and a detergent or a low-level disinfectant.

*Barber/Beauty Shops

-A clean, closed, and locked container will be provided for all creams, lotions, soaps, solutions, cosmetics, powders, and other products used in direct contact with residents.

*Bio-Hazardous-Infectious Material Collection and Disposal

-For these reasons, regardless of the knowledge of diagnosis, all bio-hazardous material should be considered, collected, and handled as potentially infectious substances and should be properly separated, stored, and disposed.

-All [provider] locations will comply with applicable federal, state, and local regulations pertaining to the collection, handling, storage, and disposal of bio-hazardous material and will, at a minimum, follow procedures to reasonably limit the potential for cross-contamination.

*Common Area Cleaning

-Keep all common areas clean, neat and free of litter.

-Clean (disinfect if needed or required by regulations) chairs in dining rooms weekly or as needed.

-Clean surfaces as often as necessary to keep furniture and equipment free of accumulations of dust, dirt, food particles, etc.

-Spot clean walls, door and partitions as needed to remove visible material. Use a soft, clean cloth with disinfectant cleaner solution and wipe dry.

-All mops and rags will be handled wearing the proper PPE [personal protective equipment] for the product being used. All used/soiled mops and rags will be stored in an appropriate storage container in accordance with [provider] or local cleaning procedures .

*Monitoring and Quality Assurance

-Visual assessments of housekeeping and custodial outcomes should be monitored on a regular basis. This monitoring is the responsibility of all staff members working in the building.

51816

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51472 potential for actual harm Based on observations, interviews, record reviews, and policy reviews, the provider failed to ensure that one Residents Affected - Few of the sampled residents (103), whose care plan included a fall prevention intervention of a soft touch call light within her reach to notify staff when she needed assistance, was accessible to her while in her room. Findings include:

1. Observation on 4/14/25 at 3:17 p.m. of resident 103's room revealed:

*Resident 103 was lying in her bed.

*There was a flat soft touch call light attached to the floor to ceiling room divider curtain about halfway up the curtain.

*Due to the location of the call light related to resident 103's location she would not be able to access the call light to call for assistance.

Observation on 4/15/25 at 9:26 a.m. of resident 103 in her room revealed:

*She had been assisted to bed by staff with the use of a sit-to stand mechanical lift (used to assist from a seated to a standing position).

*She had not responded to staff when she was spoken to.

*Her soft touch call light was clipped to the room divider curtain about halfway up the floor-to-ceiling curtain.

Observation on 4/16/25 at 9:32 a.m. of resident 103 in her room revealed:

*She is sitting in her wheelchair facing her bed with her eyes closed.

*Her soft touch press call light was clipped to the room divider curtain about halfway up the floor to ceiling curtain.

2. Interview on 4/16/25 at 3:03 p.m. with registered nurse (RN)/Minimum Data Set (MDS) nurses D and E revealed:

*The flat soft touch call lights were given to a resident that was unable to push the button on a standard call light.

*They were not aware of any residents that had been care planned as unable to use their call light.

3. Interview on 4/17/25 at 11:37 a.m. with certified nursing assistant (CNA) X regarding resident 103 revealed:

*The resident was unable to use her call light due to her cognition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0919 *Staff placed the call light close to her in case she could access it, but she did not, so staff checked on her frequently to ensure her needs were met. Level of Harm - Minimal harm or potential for actual harm 4. Interview on 4/23/25 at 10:33 a.m. with CNA P regarding call light placement fore residents revealed call lights were to be in reach of a resident while the resident was in their room whether the resident was able to Residents Affected - Few use the call light or not.

5. Interview on 4/23/25 at 10:45 a.m. with licensed practical nurse (LPN) H regarding call lights revealed:

*It was her expectation for call lights to be within reach of the residents while they were in their room.

*Soft touch call lights were used for the residents that were unable to press a standard call light to call for assistance by placing it beside the resident while in bed, in a recliner, or in a wheelchair, to alert staff the resident was getting up.

*The call light clipped to the divider curtain in resident 103's room was not accessible to the resident while

she was in her wheelchair or bed and would not alert staff if the resident were to attempt to get out of her bed or wheelchair.

6. Interview on 4/24/25 at 8:13 a.m. with director of nursing (DON) R regarding call lights revealed:

*It was her expectation call lights be placed within reach of the residents while they were in their room.

*Soft touch call lights were also used as a fall intervention by placing the call light alongside the resident to alert staff when the resident moved.

7. Interview on 4/24/25 at 10:29 a.m. with administrator A revealed it was her expectation that staff follow facility policies and procedures related to call lights.

8. Review of resident 103's electronic medical record (EMR) revealed:

*She was admitted on [DATE REDACTED].

*Her 2/25/25 Brief Interview for Mental Status assessment score was 0, which indicated she was severely cognitively impaired.

*She had a diagnosis of dementia with other behavioral disturbance.

*Her 4/15/25 care plan revealed:

-She had a focus area of The resident has had an actual fall with No Injury R/T [related to] self transferring, impulsive initiated on 2/20/23 with an intervention of Soft touch call light initiated on 3/7/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0919 -She had a focus area of The resident is at risk for fall R/T dementia without behavioral disturbances, anxiety initiated on 12/14/22 with an intervention of I need my soft touch call light and personal items within reach Level of Harm - Minimal harm or and my floor clear of clutter initiated on 12/14/22. potential for actual harm

Review of the provider's 7/29/24 Call Light policy revealed: Residents Affected - Few *PURPOSE

-To ensure resident always has a method of calling for assistance.

*When leaving the room, place [the] call light within easy reach of [the] resident.

*For residents [who are] unable to use [the] call light, care plan appropriate interventions and provide an adaptive call light if applicable.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 49958

Residents Affected - Few Based on record review, interview, and policy review, the provider failed to ensure one of four certified nursing assistant (CNA)/certified medication aide (CMA) (KK) reviewed , who worked in the secure memory care unit (MCU), had completed the required annual in-service training. Findings include:

1. Review of CNA/CMA KK's personnel records revealed:

*She was hired on 11/16/21.

*CNA/CMA KK had documented medication errors from working in the MCU on 3/12/25, 3/13/25, 3/14/25, and 3/15/25.

-She received Coaching/Counseling on 3/17/25.

-She completed a Plan of Correction training on 6/1/24.

*Her last annual performance review was conducted on 5/31/23.

-Her annual performance review was more than 10 months overdue.

*She had received 4.89 training hours of in-service education since 1/1/24.

- Of those training hours 1.96 training hours were completed between 1/1/24 and 11/16/24 and 2.93 hours were completed between 11/16/24 and 2/27/25.

*There was no documentation that indicated that the above training included dementia management training or resident abuse prevention training.

*There was no documentation that indicated that the above training addressed areas of weakness as determined in her nurse aide performance reviews.

*There was no documentation that indicated that the above training addressed the care of cognitively impaired residents.

2. Interview on 4/24/25 at 11:11 a.m. with administrator A revealed:

*She confirmed that CNA/UMA KK's last performance reviews had been completed on 5/31/23.

*She confirmed that CNA/CMA KK had not completed all her annual training as required.

*Clinical Learning and Development Specialist (CLDS) MM tracked the completion of annual training of employees and sent reports to director of nursing (DON) R when staff had not completed their scheduled training.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0947 *She expected staff to complete their annual required training.

Level of Harm - Minimal harm or 3. Interview on 4/24/25 at 11:18 a.m. with CLDS MM revealed: potential for actual harm *She tracked the completion of employee annual training and sent reports to administrator A and DON R Residents Affected - Few when staff had not completed their required annual training.

*She confirmed CNA/CMA KK had not completed her required annual training and that she had notified administrator A and DON R.

*She expected administrator A or DON R to follow up with staff when overdue training needed to be completed.

4. Interview on 4/24/25 at 11:24 a.m. with DON R regarding CNA/CMA KK's annual training revealed:

*An email notification had been sent regarding CNA/CMA KK's incomplete annual training while she was on leave from work.

-There had been an interim DON at that time.

*She stated, It got missed.

*CNA/CMA KK worked PRN [as needed] and her last shift worked had been on 4/21/25.

*She had notified CNA/CMA KK that she had training she needed to complete.

*She expected that CNA/CMA KK would complete that training as soon as she could.

5. Review of CNA/CMA KK's Past Due training report revealed:

*There were 17 required trainings with a Due Date between 4/30/23 and 10/31/24 that were marked as Registered/Past Due.

*Those trainings included:

-Protecting Resident Rights in Nursing Facilities,

-Behavioral Health, and

-Communicating Effectively.

6. Review of the provider's revised 9/17/24 Competency and Mandatory Education Requirement policy revealed:

*The provider .is responsible to provide processes for ongoing education and competency achievement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of 80 435045 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435045 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society Sioux Falls Village 3901 S Marion Rd Sioux Falls, SD 57106

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 0947 *Employees are responsible to attain and maintain competency and complete mandatory education required within their specific job description. Level of Harm - Minimal harm or potential for actual harm *The provider . requires organizational mandatory education. Additional mandatory education may be required at the department/clinic or the specific job level. Residents Affected - Few *Every department/clinic is expected to ensure ongoing competencies and mandatory education requirements that apply to their employees are completed within the designated frames and documented.

*Competency achievements and mandatory education are required to be documented and are reviewed as part of the performance appraisal process.

Review of the provider's revised 6/11/24 Performance Management policy revealed:

*The performance management process should be dedicated time for employees and their leaders, to connect. These connections are intended to be frequent meetings throughout the calendar year and personalized based on the work and individual.

*Based on the performance expectations of the position, performance management conversations may serve as a reference point when determining career growth, developmental needs .

*Leaders should schedule one-on-one meetings with each of their employees to check-in, provide timely meaningful feedback, discuss performance, share performance ratings, and focus on career growth and development consistently throughout the year.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of 80 435045