Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at United Living Community during CMS and state inspections, most recent first.
Dirty Dish Room Floor and Windowsill: The kitchen dish room floor beneath the rubber mats was caked with a brown and black substance, and the windowsill was dusty with food crumbs, dead flies, mosquitoes, and debris. Staff said they mopped around the mats instead of moving them, could not recall when the floor underneath was last cleaned, and the DM acknowledged the floor was stained while the monthly checklist showed the mats had not been documented as cleaned for months.
Medications and topical products were found unsecured in resident rooms and in unlocked medication cabinets for several residents, including inhalers, eye drops, creams, ointments, and nasal spray. An LPN said she did not know the medication storage policy, while other staff and the DON stated resident meds were expected to be locked and inaccessible at all times. One resident also had a locked cabinet with the key left hanging beside it, and another resident had family-brought meds in plain view on the bedside table.
Menu substitutions and pureed diet portions were not followed during observed meals. Residents on a pureed diet were not offered a nutritionally similar substitute when potato salad was unavailable, and one aide served only a partial portion of pureed vegetables because she believed the resident had a small appetite. Staff also served a meal that did not match the posted menu or the menu extension binder, with missing dinner rolls and a dessert/menu item mismatch, while substitutions were not documented for review.
A resident recovering from back surgery experienced prolonged call light delays and an incontinence episode after waiting for staff assistance, which left him embarrassed and led him to sleep in a recliner for a few nights. He also reported that when he asked a CNA for help walking, she said she could not assist because she was the only staff member on the unit. Records showed extended call light response times, dependence on staff for toileting and transfers, and conflicting documentation about continence status.
Bedside Medications Kept Without Orders or Self-Administration Assessments: Two residents had medications stored at the bedside without the required physician orders or documented self-administration assessments. One cognitively intact resident kept Vick's VapoRub on her overbed desk and used it on her own, while another resident kept Systane eye drops, saline nasal spray, and Vaseline on his table, including items brought in by his wife. Staff and the DON were unaware of the medications in the rooms, and the facility policy required an order and assessment before residents could keep medications in their rooms.
A resident ordered a gluten-free diet for celiac disease and ulcerative colitis was served a regular lunch instead of the planned gluten-free meal. The dietary aide knew the diet order but served country fried steak, mashed potatoes with country gravy, and vegetables when the gluten-free alternatives were not sent, and she did not ask the resident, nurse, or RP if the regular meal was acceptable. Kitchen staff also knew about the diet order, but one cook said she forgot to prepare the gluten-free items, and labels in the kitchen showed the served entrée and gravy contained wheat.
A facility failed to maintain documentation showing that four residents were properly screened, offered, or recorded as declining pneumococcal vaccination. One resident had a vaccine entry that did not specify the exact product, while three others had no record of receipt, offer, or refusal; none of the records contained a documented allergy or signed refusal. The RN IP confirmed the documentation gaps and stated the facility relied on admission education, provider visits, and the state immunization registry to track vaccines.
CNA Failed to Follow Transfer Care Plan: A CNA neglected a resident’s documented transfer instructions by attempting a stand pivot transfer instead of using the ordered stand lift with two staff assistance. The resident, who had an incomplete BIMS and required guided assistance for transfers, was lowered to the floor when her knees buckled during the transfer. Interviews with the CNA, another CNA, a dietary aide, an LPN, the DON, and the RN confirmed the resident’s care plan and family sheet were not followed.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents, resulting in an unsafe environment for residents.
A resident did not receive the specialized rehabilitative services required for their care, as the facility failed to provide or arrange for these necessary interventions according to the resident's assessed needs.
A deficiency was identified when a resident's spouse hit another resident on the head and moved a second resident to his room, indicating involuntary seclusion. The facility failed to protect residents from abuse and did not immediately notify law enforcement. The spouse had a history of verbal aggression, yet continued to visit regularly without adequate intervention.
A facility failed to notify required entities of abuse allegations involving a resident's spouse, who was reported to have physically and verbally abused two residents. Despite the facility's policy requiring immediate reporting to law enforcement and state agencies, the administrator did not contact them, following advice from an advisor and ombudsman. The facility's abuse policy was not adhered to, as evidenced by the lack of notification and documentation of similar past incidents.
A facility failed to thoroughly investigate allegations of abuse involving two residents. Despite initial reports and assessments, the investigation lacked comprehensive interviews with staff and residents, and there was no documentation of increased monitoring of the involved resident's spouse. The facility's actions did not comply with its abuse policy, highlighting deficiencies in handling the situation.
The facility failed to provide bed-hold notices to residents or their representatives during hospital transfers for four residents. Staff interviews revealed a lack of awareness and responsibility for completing written notifications, despite the facility's policy requiring such actions.
The facility failed to update care plans for residents using VirtuSense VSTAlert motion detection systems and side rails. Observations revealed that these devices were not documented in the care plans of three residents, and consent for their use was not obtained. The Director of Nursing and the administrator acknowledged these oversights, and the facility lacked a specific policy for the VST monitoring system.
The facility failed to ensure proper food labeling, storage, and hygiene practices. Observations revealed unlabeled and undated food items in the kitchen and kitchenette, and inappropriate glove use and hand hygiene by staff. Interviews with dietary staff highlighted a lack of adherence to protocols, despite clear expectations and policies.
Staff at the facility failed to adhere to hand hygiene and glove use protocols during resident care. An LPN and CNA did not wash hands between glove changes during a dressing change, and an RN did not sanitize hands before handling nebulizer equipment. These actions were contrary to the facility's infection control policies.
A resident was not accurately assessed for the safe self-administration of nebulized medication. She was left alone during treatments without proper education on using the nebulizer. The facility lacked an order for self-administration, and her care plan did not include it. Nurses were unaware of the facility's policy on self-administration, and the resident's ability to self-administer was not assessed.
Dirty Dish Room Floor and Windowsill
Penalty
Summary
The provider failed to maintain the kitchen floor and windowsill in the dish room in a clean and sanitary manner in one of one main kitchen areas. During observation on 12/2/25, the floor underneath the rubber mats in the dish room was caked with a brown and black substance, while the rest of the kitchen floor appeared clean. The dish room windowsill was visibly dusty and had scattered food crumbs, dead flies, mosquitoes, and a large white fluffy seed on its surface. During interview, cook U stated the dish room rubber mats were usually cleaned monthly in warmer months by taking them outside to pressure wash them, but that could not be done because it was below freezing, and she could not remember the last time the mats had been moved to clean the floor underneath. Cook J later observed the same condition and said she mopped around the rubber mats rather than moving them. The dietary manager acknowledged the floors were stained and said the maintenance department had a machine that was supposed to clean the floors monthly, but it was broken. She also stated the monthly cleaning checklists included cleaning the rubber mats, but review of those checklists showed the mats had not been documented as cleaned since June 2025. She was not aware of the dirty windowsill and confirmed the kitchen cleaning checklists did not include windowsills.
Medications Left Unsecured in Resident Rooms and Cabinets
Penalty
Summary
The facility failed to ensure resident medications were securely stored for six of 24 sampled residents on the South Ridge unit. Observations showed medications and topical products left in plain view in resident rooms, including Vick's VapoRub on an overbed desk in one resident's room and Systane eye drops, Vaseline, and saline nasal spray on another resident's bedside table. One resident confirmed his wife had brought in the eye drops and saline nasal spray, and he believed the facility probably did not know they were there for his use. Additional observations found multiple unlocked medication cabinets and drawers outside resident rooms, including cabinets containing inhalers, eye drops, nasal spray, creams, ointments, and other medications for residents 71, 63, 64, and 73. One resident's wall cabinet was locked, but the key was hanging on a screw beside it and the cabinet could be opened with that key. Staff interviews showed some nurses were unaware of the medication storage policy, while others stated medication cabinets and drawers were expected to be locked and inaccessible at all times. The DON stated all medications should have been locked up and that medications brought from home should have had a provider order and pharmacy label.
Menu Substitutions and Pureed Diet Portions Not Followed
Penalty
Summary
The provider failed to follow the planned menu for residents on a pureed diet and for all diet types during observed meals. On 12/2/25 in the memory care unit dining room, the posted lunch menu listed pulled pork sandwiches, potato salad, V8 juice, and pistachio dessert. Dietary aide S did not serve pureed potato salad to residents on a pureed diet because the kitchen had not sent any pureed potato salad, and those residents were not offered an alternative to the potato salad. They were served only the pureed sandwich, V8 juice, and pureed dessert. Later that same day in the [NAME] View dining room, the posted menu was the same, but dietary aide T did not serve the potato salad and instead offered either a fruit cup or pasta salad to residents. Residents on a pureed diet were not offered an alternative to the potato salad. The dietary manager stated the kitchen ran out of potato salad because the food supplier did not deliver enough, and the cook stated the pasta salad was used as a substitute. The cook also stated she did not puree the potato salad for residents on a pureed diet because she wanted to save as much potato salad as possible for regular diets, and she confirmed those residents did not receive an alternative food option during the noon meal. On 12/4/25 in the South Ridge dining room, the posted lunch menu and the menu extension binder did not match. The binder indicated lunch should include country fried steak, mashed potatoes, country gravy, California blend vegetables, cake, and a dinner roll with margarine, while the posted menu listed tropical fruit instead of cake and did not include dinner rolls. No dinner rolls were available or served, and cake was served rather than the tropical fruit posted on the wall. For the resident on a pureed diet, dietary aide K served only a quarter cup of pureed vegetables instead of the half cup listed in the binder, stating she knew the resident did not have a big appetite. Staff also confirmed they were unaware dinner rolls were supposed to be served, and the dietary manager stated substitutions were expected to be approved and documented, but no substitution log was available.
Delayed Call Light Response and Failure to Honor Resident Dignity
Penalty
Summary
The facility failed to maintain one resident’s dignity and respect when he experienced delayed responses to call lights and an incontinence episode. The resident, admitted for rehab after back surgery, reported that on the morning after admission he waited more than 20 minutes for staff to answer his call light and lost control of his bladder in bed. He said he felt embarrassed after wetting the bed and later began sleeping in a recliner for a few nights because he believed it would be easier for staff to help him get to the bathroom, although he normally slept in a bed. The resident also reported that he could tell when he needed to urinate and that he had to get up more frequently at night. He stated that therapy was encouraging him to walk more, but he could not do anything without nursing assistance and always needed someone to walk with him. On the day before the interview, he asked a nursing aide to help him walk, and the aide told him she could not because she was the only staff member on the unit at that time. The aide confirmed she was the only CNA on the unit during part of that shift and that she told him she could not help because she was alone and had other duties. Record review showed the resident’s call light log had two prolonged response times on the morning after admission, with one alarm taking about 23 minutes to clear and another taking about 41 minutes. His care plan identified that he was dependent on staff for toilet use, required substantial to maximal assistance for transfers, and needed prompt response to all requests for assistance. The admission record also showed conflicting documentation about continence status, with one note stating he was continent of bladder and another indicating he was ambulatory/incontinent. The facility’s resident rights policy stated residents would be informed of their rights, including dignity and respect.
Bedside Medications Kept Without Orders or Self-Administration Assessments
Penalty
Summary
The facility failed to ensure that two residents who had medications at their bedside were assessed for the ability to safely self-administer those medications and had the required physician orders. One resident had a jar of Vick's VapoRub on her overbed desk and stated she used it on her chest and under her nose when she was sick. Her EMR showed no physician order for the Vick's VapoRub and no evidence of a self-administration assessment. She had a BIMS score of 15 and diagnoses including weakness and rheumatoid arthritis. Another resident had Systane eye drops, saline nasal spray, and Vaseline on his overbed table, with his initials written on the eye drop bottle and no pharmacy labels on the items. He stated his wife brought the nasal spray and eye drops into the facility shortly after admission and that he kept them on his bedside table for easy access. His EMR showed no physician orders for the eye drops or nasal spray, an order for Vaseline applied to a skin biopsy site, and no evidence of a self-administration assessment. His BIMS score was 13, and his care plan did not include information about medication self-administration. The case manager, RN, and DON stated they were not aware of the medications in either resident's room. They confirmed there was no physician order for the Vick's VapoRub and that the resident had not been assessed to use it by herself. They also confirmed the second resident had not been assessed for self-administration of the saline nasal spray, Systane eye drops, or Vaseline, and the DON stated that if family brought medications from home, the nurse would request an order, request a pharmacy label, and assess the resident before allowing the medication to be stored in the room. The facility policy stated residents may not keep medications in their room without an order allowing self-administration and that a physician's order and assessment are required.
Gluten-Free Diet Not Followed at Meal Service
Penalty
Summary
The facility failed to serve appropriate gluten-free foods to a resident who was ordered a gluten-free diet on admission and who had celiac disease and ulcerative colitis. During lunch observation, the menu extension binder showed the gluten-free meal should have included a plain hamburger, gluten-free mashed potatoes and gravy, vegetables, a gluten-free dessert, and a gluten-free bun, but the dietary aide served the resident the regular menu of country fried steak, mashed potatoes with country gravy, and cooked vegetables, along with two gluten-free Krispie treats. The resident ate the country fried steak, mashed potatoes, and country gravy. The dietary aide stated she knew the resident was supposed to receive a gluten-free diet, but the kitchen did not send the gluten-free alternatives for that meal. She said the resident had sometimes eaten gluten-containing foods before and that she did not ask the resident, the nurse, or the resident's representative if it was okay to serve the regular gluten-containing lunch. Kitchen staff confirmed they knew the resident was on a gluten-free diet, but one cook said she did not make any gluten-free menu items that day because she "totally spaced" it. Observation in the kitchen showed the country fried steak and country gravy labels included wheat, and gluten-free gravy mix was available in storage. The dietary manager said she expected staff to follow the planned menu for each diet.
Pneumococcal Vaccination Documentation and Offer Process Failure
Penalty
Summary
The provider failed to ensure four sampled residents maintained their right to be immunized against pneumococcal disease in accordance with national standards of practice. Record review showed one resident had a pneumococcal vaccine documented on 1/8/20, but the record did not identify the exact vaccine given and did not contain a documented allergy or a signed refusal. Three other residents had no documentation that they received a pneumococcal vaccine or that they were offered and declined the vaccine, and none of those records contained a documented allergy or signed refusal. One resident had a pneumococcal vaccine recorded as dose 1 on 5/5/2008 and Prevnar 13 on 8/28/2017, but there was still no signed refusal documented in the record. During interview, the RN infection preventionist stated that new residents and families received a “Why note” about offered vaccinations, that immunization monitoring was tied to provider appointments and the South Dakota immunization website, and that if residents were not up to date the information was relayed to the medical provider. She also stated the facility had identified prior incorrect documentation of pneumococcal vaccines, confirmed the residents’ vaccination records were a concern, and confirmed there should be documentation in the EMR if a resident declined the vaccine. The facility policy stated all new residents would be screened and offered influenza, pneumococcal disease, and COVID-19 vaccines unless contraindicated, already immunized, or declined after education or shared decision-making.
CNA Failed to Follow Transfer Care Plan
Penalty
Summary
The facility failed to protect a resident from neglect when a CNA performed a stand pivot transfer instead of following the resident’s care plan and family sheet, which required a stand lift with two staff assistance for all transfers. The resident had a BIMS score of 99, indicating an incomplete or failed interview, and her care plan also directed staff not to leave her unattended during transfers or while in the bathroom. On the evening of the incident, the resident was transferred from a stationary chair in the dining room area without the required lift belt or the ordered transfer method, and her knees buckled as the CNA attempted to move her back to her wheelchair, causing her to be lowered to the floor. The resident was not injured. Interviews showed that the CNA did not ask for assistance before attempting the transfer and acknowledged that she thought the resident required a two-person stand lift. Another staff member reported that the CNA had not asked for help and that the resident was found on the floor with the CNA standing next to her. A dietary aide who was present stated she saw the CNA already pulling and lifting the resident from the chair and then helped lower the resident to the floor. The LPN who responded stated staff should have known how to transfer residents from the family sheets or care plans, and the case manager confirmed that family sheets were updated weekly and used to tell staff how residents were to be transferred. The provider’s policy defined neglect as the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, including failures that could result from one staff member’s disregard for resident care, comfort, or safety. The DON and RN confirmed that the CNA did not follow the resident’s care plan or family sheet, and the CNA received a written warning after the incident. The report also noted that the CNA had completed care plan education and mechanical lift competency at hire, and that staff were educated on falls policy and procedures, but the incident still occurred when the resident was transferred contrary to the documented instructions.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain a Hazard-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the occurrence of accidents. The deficiency centers on the lack of appropriate measures to identify and eliminate hazards, as well as insufficient oversight to safeguard residents from potential harm.
Failure to Provide Required Specialized Rehabilitative Services
Penalty
Summary
A resident did not receive specialized rehabilitative services as required for their care. The facility failed to provide or obtain these services, which are necessary to meet the resident's assessed needs. This deficiency was identified during the survey based on the lack of evidence that the required rehabilitative interventions were implemented for the resident.
Failure to Protect Residents from Abuse by Visitor
Penalty
Summary
The deficiency involves the failure of the facility to protect residents from abuse, specifically involving two residents and the spouse of another resident. The incident occurred when a resident's spouse was observed wheeling one resident down the hall and subsequently hitting him on the head. This action was witnessed by a certified nurse aide (CNA), who reported the incident to a registered nurse (RN). The RN assessed the resident and found no physical injuries, but the resident later confirmed that he was hit, although not very hard. The facility administrator was notified, but law enforcement and the South Dakota Department of Human Services were not immediately informed. Further investigation revealed that the same resident's spouse had previously moved another resident to his room and told him he could come out when he could act like a grown man, indicating involuntary seclusion. Interviews with staff and other residents indicated that the spouse had a history of verbal aggression and inappropriate interactions with residents, including calling one resident derogatory names. Despite these incidents, the spouse continued to visit the facility regularly and assist her spouse with daily routines. The facility's response to the incident was inadequate, as there was no immediate removal of the resident's spouse from the facility, and no comprehensive investigation was conducted to interview all involved parties. The facility's policy on abuse prevention and reporting was not fully adhered to, as evidenced by the lack of immediate notification to law enforcement and the absence of documented interventions to prevent further incidents. The facility's failure to protect residents from abuse and involuntary seclusion by a visitor constitutes a significant deficiency in ensuring resident safety and upholding their rights.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to notify the required entities of an allegation of physical abuse by a resident's spouse towards another resident, and an allegation of verbal abuse and involuntary seclusion by the same spouse towards a second resident. The incident was reported by a registered nurse who observed the spouse hitting a resident over the head. The resident did not show fear and claimed the hit was not hard. The facility administrator was notified, but local law enforcement and the South Dakota Department of Human Services were not informed, as the administrator was advised by both her advisor and the regional ombudsman not to contact the police because the resident did not want to press charges. Further investigation revealed that the facility's administrator was unaware that contacting the ombudsman did not fulfill mandatory reporting requirements. The ombudsman confirmed that the provider was obligated to contact law enforcement. Additionally, a dietary aide reported a similar incident involving the same resident's spouse, which had occurred earlier but was not formally documented or investigated. The aide also noted that the spouse had a history of aggressive behavior towards staff and other residents. The facility's abuse policy required immediate reporting of suspected abuse to the administrator, state agency, and law enforcement if a crime was suspected. However, the facility did not adhere to these guidelines, as evidenced by the lack of notification to law enforcement and the state agency. The policy also mandated that all alleged violations be reported within two hours if they involved resident abuse or resulted in serious bodily injury, which was not followed in this case.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of physical and verbal abuse, as well as involuntary seclusion, involving two residents. The incident was reported by a registered nurse who observed a certified nurse aide witnessing a resident's spouse hitting another resident. Despite the initial assessment showing no physical injuries, the resident claimed to have been hit. The facility's investigation documentation was insufficient, lacking interviews with other staff and residents, and failing to document further investigation into the allegations. Interviews with various staff members revealed that the facility did not conduct a comprehensive investigation. Only the registered nurse and the certified nurse aide who initially reported the incident were interviewed. Other staff members, including those present during the incident, were not formally interviewed. Additionally, there was no documentation of increased surveillance or monitoring of the resident's spouse, who had a history of inappropriate behavior towards other residents. The facility's abuse policy requires thorough investigation and documentation of all alleged violations, but this was not adhered to in this case. The administrator confirmed that only the involved residents were interviewed, and there was no written agreement with the resident's spouse to prevent further incidents. The lack of documentation and comprehensive investigation indicates a failure to comply with the facility's abuse policy and state regulations.
Failure to Provide Bed-Hold Notices During Hospital Transfers
Penalty
Summary
The provider failed to provide bed-hold notices to residents or their responsible parties at the time of transfer to a hospital, as well as ombudsman notification, for four sampled residents. Resident 6 was transferred to the hospital at the request of her family representative due to her inability to stand, but there was no written notification regarding the bed-hold policy or ombudsman notification. Similarly, Resident 4 was taken to the hospital after a fall and reported back pain, but there was no documentation that he or his responsible party received information about the bed-hold policy. Resident 25 was transferred to the hospital due to a critical blood glucose level, with her husband’s permission, yet there was no documentation of bed-hold policy notification. Resident 27 was transferred to the ER for evaluation, and later to the hospital, but again, there was no documentation of bed-hold policy notification. Interviews with facility staff revealed a lack of awareness and responsibility regarding the bed-hold notification process. The social service designee was unaware of the requirement to complete a written form at the time of transfer, and the administrator expected verbal notification by the nurse and follow-up by the social worker, but acknowledged that a written bed-hold form was not being completed. The facility's undated Holding Bed Space policy stated that information concerning the bed-hold policy should be provided upon admission and during transfers, with a copy mailed to the resident or representative in emergency transfers, but this was not adhered to in practice.
Deficiency in Care Plan Documentation for Monitoring Systems
Penalty
Summary
The provider failed to ensure that resident care plans were revised to reflect the current needs of three residents who had VirtuSense VSTAlert motion detection systems installed in their rooms. For Resident 6, the VST motion sensor was observed in the room, but there was no documentation of its use in the care plan, nor was there consent documentation for its use. Similarly, Resident 50 had a VST motion sensor and a side rail on her bed, but these were not documented in her care plan. The Director of Nursing acknowledged that the VST monitor was ordered by a Hospice physician but was not added to the medication administration record or care plan, and the side rail documentation was incomplete. Resident 54 also had a VST motion sensor in her room, but there was no documentation of its use in her care plan. An incident was noted where the VST alarm was not working, yet this was not addressed in the care plan. The administrator confirmed that a physician's order and consent should have been obtained and documented for the use of the VST monitoring system. Additionally, the facility lacked a specific policy regarding the VST monitoring system, and the existing policy on side rails required that their use be addressed in the resident care plan.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The provider failed to ensure that food items were appropriately labeled, stored, handled, prepared, and served in a safe and sanitary manner. Observations revealed that the commercial refrigerator contained several food items that were not labeled, dated, or discarded by the use-by date, including pickles, barbecue sauce, ranch dressing, broccoli broth, sliced onion, flour tortilla, deli pepper jack cheese, palmetto cheese spread, and apple pies. Additionally, the commercial freezer had opened frozen meat items and other food products that were not labeled or dated. Similar issues were found in the 500-hall kitchenette, where items like French Toast, pancake syrup, and dry cereal were not labeled or dated. The report also highlighted inappropriate glove use and hand hygiene practices by staff members. Cook G was observed placing raw chicken on a pan, seasoning it without washing hands, and then touching ready-to-eat garlic bread with the same gloves. Dietary aide F was seen moving between different areas and handling various food items and surfaces without changing gloves or washing hands. Similarly, UAP H served meals and handled food items without changing gloves or washing hands between tasks. Interviews with dietary staff revealed a lack of adherence to proper food handling and hygiene protocols. The dietary manager and registered dietitian expressed expectations for food labeling, glove use, and hand hygiene that were not met. The facility's policies on food storage, employee hygiene, and glove use were reviewed, indicating that employees must wash hands frequently and that gloves do not substitute for proper handwashing. However, these practices were not consistently followed, leading to the deficiencies observed.
Failure in Hand Hygiene and Glove Use During Resident Care
Penalty
Summary
The provider failed to ensure proper hand hygiene and glove use by staff during medical procedures, as observed in two separate incidents. In the first incident, a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) did not perform hand hygiene before or after glove use during a dressing change for a resident. The LPN removed soiled dressings and changed gloves multiple times without washing hands or using hand sanitizer, even though hand sanitizer was available in the room. Similarly, the CNA assisted with repositioning the resident and changing bedding and clothing, also failing to wash hands between glove changes. In the second incident, a Registered Nurse (RN) did not perform hand hygiene before or after glove use while providing a nebulizer treatment to another resident. The RN admitted to not sanitizing hands before handling the nebulizer equipment, which was against the facility's policy. The facility's policies clearly state the importance of hand hygiene in preventing healthcare-associated infections and outline specific situations where hand washing or sanitizing is required, which were not followed in these cases.
Failure to Assess Resident for Safe Self-Administration of Nebulized Medication
Penalty
Summary
The provider failed to ensure that a resident was accurately assessed for the safe self-administration of nebulized medication. Resident 115, who was receiving medication through a nebulizer, reported that she was left alone during treatments and had not been educated on using the nebulizer machine. She expressed a desire to self-administer her nebulizer treatment but was unable to operate the machine independently. During an observation, a registered nurse administered the nebulizer treatment and left the resident alone, setting a timer to return after ten minutes. The nurse was unaware of any order for the resident to self-administer the treatment and was not familiar with the facility's policy on self-administration. A review of the resident's electronic medical record revealed orders for Budesonide and Ipratropium but no order for self-administration. There was also no assessment to determine the resident's ability to self-administer the treatment safely, and her care plan did not include self-administration. Another registered nurse confirmed that there was no order for self-administration and that the resident had not been educated on using the nebulizer. The facility's policy stated that if it is deemed safe for a resident to self-administer medications, it should be documented in the medical record and care plan, with periodic reassessment based on changes in the resident's status.
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What surveyors actually found near you
We read the 14 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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Illustrative
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Nursing homes near Brookings
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Neighborhoods At Brookview | 2 mi | ★★★★★ | 2 | 0 |
| Riverview Healthcare Center | 20.9 mi | ★★★★★ | 11 | 1 |
| Flandreau Santee Sioux Tribe Care Center | 21.1 mi | ★★★★★ | 1 | 0 |
| Estelline Nursing And Care Center | 22.9 mi | ★★★★★ | 0 | 0 |
| Hendricks Community Hospital | 23.4 mi | ★★★★★ | 0 | 0 |
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