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F0600
G

Failure to Protect Residents from Abuse and Neglect by Staff

Flandreau, South Dakota Survey Completed on 09-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Multiple incidents occurred in which staff failed to protect residents from abuse and neglect. In one case, a certified nursing assistant (CNA) responded to a resident's request for pain medication in a rude and unpleasant manner, telling the resident she would receive her medication only when her name came up on the nurse's list. When the resident repeated her request, the CNA responded with an unpleasant tone, reiterated her previous statement, and slapped her fist on the door. The resident reported feeling distressed and anxious as a result of this interaction, and subsequently avoided using her call light and experienced increased anxiety when seeing the CNA. In another incident, a certified medication aide (CMA) refused to assist a resident with taking her medication. The resident, who had a history of schizoaffective disorder, trauma, bipolar disorder, and anxiety, requested help with her cup of water while taking her medications. The CMA was reportedly rude and did not want to help with small tasks. After the incident, medication pills and water were found on the floor of the resident's room, and the resident was observed crying and expressing emotional distress. The resident's care plan indicated she required assistance with nutritional needs if her hands were not working properly, but did not specify that staff must remain with her during medication administration. A third incident involved a CNA who, in a joking manner, told a resident he would fight him for a breakfast bar the resident had taken from a snack cart. The CNA's actions escalated, becoming aggressive as he approached the resident in a boxing stance, circled the resident's wheelchair, grabbed the resident's arm, and took the breakfast bar from his hand. The resident, who had severe cognitive impairment, cerebral palsy, and communication difficulties, was assessed and found to have no injuries, but the interaction was verified as inappropriate and aggressive by witnesses.

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