F0609

D

Failure to Timely Report Fall Incident and Verbal Abuse Allegations to SD DOH

Sioux Falls, South Dakota Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report certain incidents and allegations to the South Dakota Department of Health (SD DOH) within required time frames. For one resident who required a sit-to-stand mechanical lift with two-person assistance per the care plan, a CNA performed the transfer alone. During the transfer, the resident slipped from the sling, slid to the floor onto his bottom, and rolled onto his right side. An LPN immediately assessed the resident and found no injury, but the incident, which occurred on 11/28/25 at 11:30 a.m., was not reported to the SD DOH until 12/1/25, exceeding the 24-hour reporting requirement for such events.

The facility also failed to timely report allegations of verbal abuse involving another resident. After a CNA left her shift early and raised quality of care concerns, the administrator and DON interviewed residents and staff. One resident reported that a CNA told her not to sing and to “shut up” and “sit up or I am not going to help you.” Two additional residents reported that the same CNA made rude and inappropriate comments, including “You would not have these issues if you went out to the dining room” and “Don’t be cocky.” Although the CNA denied making rude or inappropriate comments, these allegations of verbal abuse were not reported to the SD DOH until six days after the DON was notified, well beyond the required two-hour reporting window for abuse allegations.

A third deficiency involved another resident and additional allegations of verbal abuse. Following the same initial staff report of quality of care concerns, the facility investigated and learned that a CNA reported the resident had used the call light several times during the night for leg pain and repositioning needs. The CNA stated she did not use profanity toward residents while providing care but acknowledged using profanity at times when talking with other staff members about a resident, as an expression of how she felt. The DON later confirmed that reports of resident abuse and neglect were required to be reported to the SD DOH within two hours, and all other reportable events within 24 hours, and acknowledged that the verbal abuse allegations related to these residents, as well as the earlier fall incident, were not reported within the required time frames. The facility’s own abuse and neglect policy required immediate reporting, but not later than two hours, for allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of property, or serious bodily injury, and within 24 hours for other allegations without serious bodily injury.