Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society Scotland during CMS and state inspections, most recent first.
Unlocked medication and treatment carts and expired vaccines were found during observations and interviews. A CMA left the med cart unlocked and unattended while administering meds, an RN left the treatment cart unlocked and unattended during resident care, and expired Fluzone influenza vaccine syringes were stored in the med refrigerator. The DON stated staff were expected to lock carts when not in line of sight, and the facility policy required meds to be stored in locked compartments and expired meds to be routinely checked and disposed of per state/pharmacy regulations.
Restorative therapy was not completed consistently for two residents whose care plans called for regular rehab-based interventions to maintain mobility, transfers, and independence. One resident said she exercised on her own because restorative services were often missed when the restorative aide was pulled to the floor, and another said exercise depended on staff availability. EMR review showed both residents’ ordered ROM, walking, Nu Step, weights, and Omnicycle programs were documented far less often than scheduled, and the DON and administrator acknowledged the inconsistency.
Failure to Monitor Nutrition, Hydration, and Weight Status: A resident with multiple diagnoses, including intellectual disabilities and schizophrenia, was observed with an empty water cup and indicated he wanted water, yet staff did not ensure water was available. Physician orders required daily weights and food/fluid intake documentation, but the resident had notable weight fluctuations without documentation of a re-weigh, and intake records were limited. Staff interviews showed inconsistent understanding of who monitored weights and hydration, while the DON stated she expected more documentation and a re-weigh when the weights varied.
The facility failed to complete baseline care plans and provide written summaries to residents or their representatives within 48 hours of admission. Four residents did not receive timely or complete care plans, with missing components such as dietary orders and therapy services. Staff interviews revealed that staffing challenges contributed to the delay, and the facility did not adhere to its policy requiring prompt development and distribution of care plans.
Two residents experienced medication administration errors due to facility staff's failure to follow physician orders. One resident missed doses of Tamiflu and spironolactone was incorrectly resumed, while another resident missed increased doses of Cymbalta and did not receive Clozaril as documented. Miscommunication and misinterpretation of orders contributed to these errors.
A resident with severe cognitive impairment was verbally abused by a CNA, who demanded she 'shut her mouth and drink her coffee.' The incident was witnessed by a cook, reported to an RN the next day, but not addressed until three days later. The facility's abuse reporting protocol was not followed, leading to a delay in addressing the incident.
A resident's alleged abuse incident was not reported to the SD DOH within the required timeframe. The incident involved a CNA's inappropriate verbal exchange with a resident, witnessed by a cook who reported it to an RN. The report was delayed due to the administrator being on vacation and the report not being found until days later, contrary to the facility's policy requiring immediate reporting.
Unlocked Medication and Treatment Carts and Expired Vaccines Found in Storage
Penalty
Summary
Medication and treatment carts were left unlocked and unattended during resident care, and expired medications were found stored in the medication refrigerator. During observation in the dining room, CMA E was seen administering medications while leaving the medication cart unlocked and unattended, with her back to the cart on three occasions. When asked, she stated that if she was in the same room, the cart did not have to be locked, although she did lock it each time she left it unattended. In the medication room, a box of 10 Fluzone High Dose influenza vaccine syringes was observed with an expiration date of June 2026, and RN J agreed the vaccines were expired and should not have remained in the refrigerator. RN/clinical care coordinator C stated she knew the expired vaccines were there and was trying to determine how to return them to the vendor. In addition, RN D was observed leaving the treatment cart unlocked and unattended while providing care, and she stated the cart should have been locked when unattended. The DON stated staff were expected to lock medication and treatment carts when they were not in line of sight, and the facility policy required medications to be stored in locked compartments and expired medications to be routinely checked and disposed of according to state/pharmacy regulations.
Restorative Therapy Not Completed Consistently
Penalty
Summary
The provider failed to provide restorative therapy services according to residents’ care plans for two sampled residents who reported the services were not being completed regularly. One resident stated she was doing exercises on her own because restorative therapies were not being offered consistently, and that she wanted to maintain her strength and independence. She reported that the restorative aide was often pulled from the schedule to work on the floor when another staff member called in sick, which resulted in restorative therapy not being offered on those days. Her EMR showed care plan interventions for transfers, ambulation, walking, Nu Step use, and upper and lower extremity exercises scheduled multiple times per week, but documentation showed these interventions were completed only a few times during June and the first half of July. A second resident reported that exercise was inconsistent and depended on staff availability, and that mobility was important to her because she had difficulty breathing and used a manual wheelchair to get to and from the dining room. Her care plan included daily active range of motion and passive range of motion using leg weights and an Omnicycle six days per week, but documentation showed these restorative interventions were completed only four times each in June and seven times each during the first half of July. The DON stated that restorative services had not been completed regularly because staff were reassigned to basic care duties when staffing shortages occurred, and the administrator acknowledged there was an issue with restorative therapy being completed consistently.
Failure to Monitor Nutrition, Hydration, and Weight Status
Penalty
Summary
The provider failed to ensure staff monitored a resident’s nutrition, hydration, and weight status as ordered by the physician. The resident had multiple pelvic fractures, unspecified intellectual disabilities, schizophrenia, and an encounter for autism screening. He was unable to complete the BIMS assessment. Physician orders dated 7/8/26 directed staff to weigh him daily for the first 14 days after admission and to record food and fluid intake three times per day. However, during observation on 7/14/26, the resident was sitting in bed with an empty water cup and indicated he wanted water. During observation on 7/16/26, he could be heard yelling in the hallway for help to the bathroom, and his water cup remained empty throughout the observation period. The resident’s documented weights showed fluctuations from 145 pounds on 7/9/26 to 155 pounds on 7/10/26, 154 pounds on 7/11/26, and 144.5 pounds on 7/12/26, with no documentation that he was re-weighed after those changes. Intake documentation was also limited, with only partial meal percentages recorded on some days and minimal fluid intake documented on 7/14/26 and 7/15/26. Staff interviews showed differing understanding of who monitored weights and when water was provided, while the DON stated she expected the resident to have been re-weighed when his weights varied that much and expected more documentation regarding the weight changes. The facility’s policies required re-weighing when weight varied by more than 3% and routine monitoring of nutritional status and hydration.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to complete a baseline care plan and provide a written summary to the resident or their representative within 48 hours of admission for four recently admitted residents. Resident 8's electronic medical record showed no progress notes related to a baseline care plan, and the resident was unaware of any care plan discussions. Similarly, resident 133 did not receive a summary of his care plan, and his comprehensive care plan was not completed until much later. Resident 183 and his wife could not recall any care plan discussions within the first two days of admission, and the baseline care plan did not address all required areas. Resident 184's baseline care plan was incomplete, missing essential components such as dietary orders, therapy services, and social services. The care plan was not provided to the resident or her representative within the required timeframe. Interviews with staff, including the MDS coordinator and the Director of Nursing, revealed that the baseline care plans were not completed within the 48-hour requirement due to staffing challenges and other priorities. The facility's policy required a baseline care plan to be developed upon admission and provided to the resident or representative. However, the facility did not meet these requirements, as confirmed by interviews with the MDS coordinator and the administrator. The lack of timely and complete baseline care plans indicates a failure to adhere to federal and state regulations, impacting the quality of care provided to the residents.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to administer medications as ordered by physicians for two residents, leading to medication errors. Resident 11, who was cognitively intact and diagnosed with congestive heart failure and chronic respiratory failure, experienced errors with her medication regimen. The facility staff incorrectly transcribed her Tamiflu order, resulting in the resident missing six doses. Additionally, there was a misunderstanding regarding the continuation of her spironolactone, leading to unnecessary administration without a physician's order. Resident 3, who had severe cognitive impairment and was diagnosed with severe vascular dementia and bipolar disorder, also experienced medication errors. The resident's Cymbalta dosage was increased, but the facility continued administering the previous lower dose, resulting in 13 missed doses of the increased prescription. Furthermore, the resident's Clozaril was not administered as it had not been filled by the pharmacy, yet it was incorrectly documented as given. The errors were compounded by miscommunication and misinterpretation of physician orders by the facility staff. The certified medication aide (CMA) involved in the administration of Clozaril did not receive proper handover information and failed to follow the five rights of medication administration. The facility's processes for medication reconciliation and administration were not adequately followed, leading to these deficiencies.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The deficiency involved a failure to protect a resident from verbal abuse by a certified nursing assistant (CNA) in a long-term care facility. The incident occurred when the CNA raised his voice at a resident with severe cognitive impairment, demanding that she 'shut her mouth and drink her coffee.' This exchange was witnessed by a cook, who reported the incident to a registered nurse (RN) the following morning. However, the report was not immediately acted upon, as it was not found until three days later. The resident involved in the incident had a history of severe cognitive impairment, anxiety, and other health issues, including dementia and a cognitive communication deficit. Her care plan included interventions for her cognitive and psychosocial well-being deficits, such as monitoring changes in cognitive function and providing a calm environment. Despite these interventions, the resident was subjected to verbal abuse, which was not promptly reported or documented in her medical records. The facility's policy required immediate reporting of abuse allegations, but this protocol was not followed. The cook who witnessed the incident did not report it immediately, and the RN who received the report did not ensure it was promptly addressed. The delay in reporting and addressing the incident highlights a breakdown in the facility's abuse reporting and response procedures, which are critical for protecting residents from harm.
Delayed Reporting of Alleged Abuse Incident
Penalty
Summary
The provider failed to report an incident of alleged abuse within the required timeframe to the South Dakota Department of Health (SD DOH) for a resident. The incident involved a verbal exchange between a certified nursing assistant (CNA) and a resident, which was observed by a cook. The cook reported the incident to a registered nurse (RN) the following morning, who instructed the cook to write a report and place it under the administrator's door. However, the report was not discovered until three days later, delaying the notification to the SD DOH. The incident occurred when the resident attempted to take a Styrofoam cup of coffee to her room, and the CNA verbally refused her request in an inappropriate manner. The cook, who witnessed the exchange, initially did not report the incident immediately but later informed the nutrition and food services supervisor (NFSS) and the RN. Despite being instructed to report the incident, the cook's report was not acted upon promptly, leading to a delay in addressing the alleged abuse. The facility's policy requires immediate reporting of abuse allegations to the administrator or designated authority in their absence, and a two-hour timeline for reporting to the DOH. The administrator, who was on vacation at the time, confirmed that the incident reporting was not completed in a timely manner. The policy also mandates that the charge nurse or licensed nurse assess the situation and ensure any potential for further abuse is eliminated, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Scotland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Menno-olivet Care Center | 9.1 mi | ★★★★★ | 1 | 0 |
| Good Samaritan Society Tyndall | 13.2 mi | ★★★★★ | 9 | 0 |
| Oakview Terrace | 19.5 mi | ★★★★★ | 0 | 0 |
| Avera Bormann Manor | 21.9 mi | ★★★★★ | 4 | 0 |
| Sd Human Services Center - Geriatric Program | 23 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.