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F0600
E

Failure to Protect Residents from Verbal Abuse and Neglect by CNA/CMA

Brandon, South Dakota Survey Completed on 12-18-2025

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

The facility failed to protect multiple residents from verbal abuse and neglect by a certified nurse aide/certified medication aide (CNA/CMA). The incident involved the CNA/CMA withholding fluids from residents during meals as a form of punishment for making a mess or for concerns that they would not eat if given drinks. Additionally, the CNA/CMA denied a resident's repeated requests for coffee, yelled at residents, and attempted to force-feed residents by shoving large bites of food into their mouths while yelling at them to eat. These actions caused distress and agitation among the residents, particularly those with significant memory and cognitive decline residing in a secured memory care unit. The report details that the CNA/CMA also scolded a resident for wanting to change her clothes frequently, attributing it to creating extra work and laundry for staff. Staff interviews and record reviews confirmed that these behaviors were observed and reported by another CNA/CMA, and additional staff corroborated the allegations. The affected residents included those with cognitive impairments who were particularly vulnerable to such treatment, and the incidents occurred in a specialized memory care neighborhood designed to provide a structured and supportive environment. Prior to the incident being reported, there were no documented concerns or disciplinary actions related to the CNA/CMA's care or treatment of residents, aside from previous medication administration errors. The deficiency was substantiated through staff interviews and review of the facility's records, which confirmed that the residents were subjected to verbal abuse and neglect by the CNA/CMA during the provision of care.

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