Scotchman Living Center

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure the resident's had a prescription label on their medication bottle and that it matched the physician's order in the resident's electronic medical record (EMR) for one of one observed resident (22) who was administered magnesium glycinate that included a prescribed dose amount indicated on her medication bottle or in her EMR by licensed practical nurse (LPN) (E). 1. Observation and record review on 7/16/26 at 4:50 p.m. in the memory care unit dining room revealed LPN E administered two capsules of magnesium glycinate to resident 22. The prescription label on the magnesium glycinate bottle did not indicate the dosage amount to be administered to resident 22. Resident 22's electronic medication administration record (eMAR) did not indicate the magnesium glycinate's dosage to be administered. 2. [...]

Inspectors wroteBased on observation, interview, record review, American Society of Consultant Pharmacist Medications (ASCP) resource review, and policy review, the provider failed to ensure:*An extended-release medication was not crushed by one of one observed registered nurse (RN) (C) who then administered that medication to one of one sampled resident (31).*A laxative documented as administered to one of one sampled resident (31) by one of one observed RN (C) who did not observe that medication was taken. Those findings resulted in a medication error rate of 6.67%.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to follow infection control practices to ensure: *Three of five observed certified nurse aides (CNA) (E, H, and D) removed their personal protective equipment (PPE) (gowns and gloves ) and performed hand hygiene (HH) (handwashing with soap and water or a hand sanitizer) before exiting two of two sampled residents' rooms (3 and 21) who required transmission-based precautions (infection control measures such as the use of PPE and HH used to prevent the spread of infection (TBP).*Two of two observed CNAs (F and P) performed HH before putting on PPE and providing contact care for one of one sampled resident (31) who required TBP. [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who fell, suffered head trauma, and required emergency room (ER) treatment when one of one certified nursing assistant (CNA) (B) failed to use a gait belt as directed in the resident's care plan while assisting the resident to the bathroom. Failure to use the gait belt potentially contributed to resident 1's fall which resulted in an injury that required treatment at the ER. This citation is considered past non-compliance based on review of the corrective actions the provider implemented following the incident.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (21) who eloped (left the facility without staff knowledge) when a visitor exited the building. This citation is considered past-noncompliance based on review of the corrective actions the provider implemented following the incident.

Inspectors wroteBased on interview, observation, and document review, the provider failed to protect one of one sampled resident's (4) right to be free from neglect by one of one certified nursing assistant (CNA) N who had not followed the resident's care plan related to transferring (moving from one place to another) which resulted in an open wound on her leg. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on record review, observation, interview, and policy review, the provider failed to adequately treat pressure injuries for one of one sampled resident (11) by not following wound care nurse recommendations, and not notifying the resident's physician, resulting in a non-healing pressure injury.

Inspectors wroteBased on observation, interview, and document review, the provider failed to properly label foods and discard foods on or before the manufacturer's best-by date, and failed to maintain the following kitchen items in a clean and sanitary manner: *In the kitchenette: -The flattop grill. -The grease trap drawer beneath the flattop grill. -The juice dispenser. -The overhead ventilation hood panels. *In the main kitchen: -The ceiling and ceiling vents throughout the kitchen. -The grease trap drawer beneath the flattop grill. -The deep fat fryer and the spaces in between the fryer and the adjacent equipment.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure four of sixteen sampled residents (4, 8, 21, and 22) had their care plans updated, and revised promptly to reflect their current status and care needs.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to follow their Resident Weight policy and notify the registered dietitian (RD) and begin follow-up for one of one sampled resident (34) who experienced a significant weight loss.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to follow their policy related to oxygen administration for two of five sampled residents (4 and 12) who received oxygen therapy: *Resident 4's oxygen tubing was not dated. *Resident 12's oxygen tubing was not changed monthly per facility policy. *Resident 4's nasal cannula was observed on the floor during one of three observations. *Resident 4's foam filter on the back of the oxygen concentrator machine had a buildup of dust.

Inspectors wroteBased on review of the South Dakota Department of Health (SD DOH) complaint online report, interview, and policy review, the provider failed to protect one of one sampled resident (20) from mistreatment while receiving care from staff.