United Living Community

Inspectors wroteBased on observation, interview, and record review, 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.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure resident medications were securely stored for six of twenty-four sampled residents (8, 63, 64, 71, 72, and 73) in the South Ridge unit.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to follow the planned menu for the pureed diet, which had the potential to affect all residents who were prescribed the pureed diet, for two of two meals observed, and failed to follow the planned menu for all diet types for one of two meals observed which had the potential to affect all residents.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure that one of eighteen sampled resident's (72) right to a sense of dignity and respect was maintained related to wearing incontinence products and experiencing an incontinence episode, and that preferences were followed related to staff assistance with walking.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (8 and 72) who had medications at their bedside were assessed for the ability to safely self-administer medications and had a physician's order to self-administer medications according to the provider's policy.

Inspectors wroteBased on South Dakota Department of Health (SD DOH), facility reported incident (FRI), interviews, and policy review, the provider failed to protect the resident's right to be free from neglect by certified nursing assistant (CNA) C who pivot transferred resident (28) causing her to have a fall without injuries. The resident was care planned for use of a stand lift with two staff assistance for all transfers.

Inspectors wroteBased on observation, interview, and record review, the provider failed to serve appropriate gluten-free foods to one of one sampled resident (70) who was on a gluten-free diet for one of two meals observed.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure four of four sampled residents' (1, 4, 28, and 30) right to immunize against pneumococcal disease was maintained and followed in accordance with national standards of practice. Failure to offer vaccination placed residents at increased risk for pneumococcal disease.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, interview, and record review, the provider failed to protect one of one sampled resident's (1) right to be free from potential neglect by two of three certified nursing assistants (CNAs) (E and J) who had neglected to assist resident 1 off the toilet in a reasonable amount of time, and did not inform the oncoming shift that the resident was still on the toilet, which resulted in the resident sitting on the toilet for at least two hours.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) complaint intake review, interview, observation, record review, and policy review, the provider failed to communicate with staff and implement fall prevention interventions, which potentially contributed to at least six falls (four of which resulted in injuries) from 2/1/25 to 7/6/25 for one of two sampled residents (1).

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) complaint intake review, record review, interview, and policy review, the provider failed to adequately monitor for neurological changes and follow the provider's falls protocol for two of three sampled residents (1 and 2) after they had fallen.

Inspectors wroteBased on record review and interview, the provider failed to implement and effectively manage a nursing restorative therapy program for one of one sampled resident (1).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to protect one of two sampled resident (1) from physical and verbal abuse, and one of two sampled resident (2) from verbal abuse and involuntary seclusion by resident 3's spouse.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, and policy review, the provider failed to notify the required entities of an allegation of physical abuse by resident 3's spouse towards one of two sampled residents (1), and an allegation of verbal abuse and involuntary seclusion by resident 3's spouse towards one of two sampled residents (2).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), investigation review, interview, and policy review, the provider failed to thoroughly investigate an allegation of physical abuse and verbal abuse experienced by one of two sampled residents (1), and involuntary seclusion and verbal abuse experienced by one of two sampled residents (2).

Inspectors wrote4. Review of resident 27's EMR revealed: *A health status progress note (PN) on 3/21/24 at 11:52 a.m. indicated the resident .transferred to the ER [emergency room] for further evaluation. Resident left [facility name] at 1130 via ambulance. *A PN on 3/21/24 at 1152 a.m. indicated her son was notified of the resident's transfer to the ER. *A PN on 3/22/24 at 4:04 p.m. indicated she had returned to the facility. *A PN on 4/7/24 at 12:30 p.m. indicated her son . agree to transport patient to the hospital for evaluation. *A PN on 4/10/24 at 1:44 p.m. indicated she had returned to the facility. *There were no documentation the resident or her responsible party had received information about the bed-hold policy. 5. Interview on 5/23/24 at 10:22 a.m. with social service designee (SSD) C revealed: *The bed-hold information was located in the welcome book. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure resident care plans were revised to reflect the current needs for three of twenty-one sampled residents as follows: *Three of three sampled residents (6, 50, and 54) who had VirtuSense VSTAlert motion detection systems installed in their rooms. *One of one sampled resident (50) who had a side rail on her bed.

Inspectors wroteBased on observation, interview, and policy review the provider failed to ensure food items were appropriately labeled, stored, handled, prepared, and served in a safe and sanitary manner in one of one kitchen and one of four kitchenettes for the following: *One of one commercial refrigerator that contained food items that were not labeled, dated, or discarded by the use-by date, *One of one commercial freezer that contained food items that were not labeled or dated. *One of one kitchen and one of four kitchenettes that contained dry food items that were not labeled or dated. *Appropriate glove use and hand hygiene by cook G while preparing food. *Appropriate glove use and hand hygiene by dietary aide F and by unlicensed assistive personnel (UAP) H while handling food.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure: *Licensed practical nurse (LPN) O and certified nursing assistant (CNA) P had performed hand hygiene and glove use according to the provider's policy during a dressing change for sampled resident (164). *Registered nurse (RN) K had performed hand hygiene and glove use according to the provider's policy during a nebulizer treatment with resident (115).

Inspectors wroteBased on interview, observation, record review and policy review, the provider failed to ensure one of one sampled resident (115) was accurately assessed for appropriate and safe self-administration of a nebulized (converted from liquid to mist) medication.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to maintain the following kitchen equipment in a clean and sanitary manner: -One of one grease trap drawer under the flattop grill. -One of one catch tray under the gas stove. -One of two ovens which was under the gas stove. -The floor in the walk-in freezer. -Four of four dishwashers. -The cupboard space under one of one sink in the Robin's View kitchenette.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to preserve the nutritive value of pureed foods by thinning the food items with plain water.