BROOKINGS, SD - United Living Community failed to properly investigate allegations of physical and verbal abuse by a visitor toward vulnerable residents and neglected to notify law enforcement as required by state regulations, according to inspection findings from June 2024.
Visitor Strikes Resident During Altercation
On June 15, 2024, a certified nursing aide witnessed a visitor strike a resident in the head while wheeling him back to his room following a verbal dispute between two residents. The incident involved the spouse of one resident physically hitting another resident who was reaching up toward her while being transported in his wheelchair.
According to the facility's incident report, the visitor "hit [resident 1] over the head with her right hand" hard enough to be "clearly heard 20 feet back and led to a vocalization of pain" from the resident. The nursing aide who witnessed the event reported that the visitor "appeared to be angry" about the altercation between the two residents.
When nursing staff immediately assessed the affected resident, he initially stated that the visitor "tried to" hit him and "I blocked her," but later confirmed that the visitor "did hit him" on his temple, though "not very hard." A physical examination revealed no visible injuries such as redness, bruising, or swelling.
The resident who was struck had medical diagnoses including stroke-related paralysis on his left side, vascular dementia with agitation, and major depressive disorder. His cognitive assessment score indicated he was mentally intact, though staff noted he was "not a good historian" and gave inconsistent accounts of whether he was hurt.
Verbal Abuse and Involuntary Confinement Incident
During the facility's investigation, the visitor admitted to additional misconduct involving a second resident. The visitor acknowledged bringing the second resident back to his room and telling him he had to stay there "until he could learn to be a grown man" - constituting involuntary seclusion under nursing home regulations.
A dietary aide reported witnessing an earlier incident where the same visitor grabbed the first resident's wheelchair to remove him from the dining room and called him "incompetent" and an "asshole." This incident occurred approximately two days before the physical assault but was not formally investigated by facility administrators.
The dietary aide described the visitor as someone who was "known to fly off the handle with staff, and sometimes other residents," indicating a pattern of aggressive behavior that facility leadership had not adequately addressed.
Medical and Safety Implications
Physical assault of nursing home residents poses serious medical risks, particularly for individuals with existing neurological conditions. The affected resident's medical history of stroke and resulting left-side paralysis made him especially vulnerable to injury from any physical contact. Head trauma in elderly individuals can lead to complications including brain bleeding, cognitive decline, and increased fall risk.
Involuntary seclusion violates fundamental resident rights and can cause psychological distress, particularly for individuals with dementia or depression. Confining residents to their rooms against their will can lead to increased agitation, social isolation, and deterioration of mental health. Federal regulations specifically prohibit such practices because they compromise resident dignity and autonomy.
The verbal abuse documented in these incidents creates a hostile environment that can affect not only the targeted residents but also other residents who witness such behavior. This type of psychological mistreatment can increase anxiety, depression, and feelings of vulnerability among the resident population.
Investigation Failures and Missed Protocols
The facility's investigation proved fundamentally inadequate according to regulatory standards. Administrator A confirmed that no comprehensive witness interviews were conducted beyond obtaining a brief written statement from the nursing aide who witnessed the assault.
Despite multiple staff members being on duty during the incident, including a second nursing aide, a licensed practical nurse, and a dietary aide, none were formally interviewed as part of the investigation. The administrator stated she "felt I didn't need to do that because [resident 3's spouse] admitted to everything," demonstrating a misunderstanding of proper investigation protocols.
The facility also failed to interview other residents who might have witnessed the incidents or could provide information about the visitor's pattern of behavior. When questioned about this omission, the administrator incorrectly stated that surveyors had already interviewed residents about safety concerns, conflating routine safety assessments with incident-specific investigations.
Proper investigation protocols require comprehensive witness interviews, documentation of all statements, and thorough review of any previous incidents involving the same individuals. The facility's own abuse policy specified that investigations should include interviews with "all witnesses separately" including "roommates, residents in adjoining rooms, staff members in the area, and visitors in the area."
Reporting Violations and Legal Requirements
The facility failed to notify law enforcement of the physical assault as required by state law. Administrator A confirmed that neither local police nor the Department of Human Services were contacted about the incident, despite regulations mandating such reports within 24 hours for non-serious injuries.
The administrator stated she consulted with her advisor and the regional ombudsman, both of whom allegedly advised against contacting police because the affected resident did not want to press charges. However, this reasoning demonstrates a fundamental misunderstanding of mandatory reporting requirements, which exist regardless of the victim's wishes to pursue charges.
A state health department advisor confirmed during the inspection that the facility was obligated to contact law enforcement regardless of the resident's preference. The ombudsman is not considered a mandatory reporter under state regulations, and contacting the ombudsman does not fulfill the facility's legal reporting obligations.
These reporting failures left the incident unaddressed by appropriate authorities and potentially exposed other residents to continued risk from the visitor's aggressive behavior.
Pattern of Rights Violations
Documentation revealed a history of the visitor violating resident rights that facility management had inadequately addressed. In March 2024, the visitor had been educated about resident rights after repeatedly controlling another resident's television volume, which nursing staff identified as a rights violation.
In May 2024, the visitor filed a formal grievance claiming to find unexplained bruises on her spouse, though she could provide no specific details. During this process, facility staff again provided education about resident rights, indicating ongoing issues with the visitor's understanding of appropriate behavior.
The facility had previously established that the visitor followed a predictable daily schedule, arriving around 11:00 a.m., staying through lunch, leaving briefly in the afternoon, and returning around 4:00 p.m. until bedtime. Despite this regular presence and documented behavioral concerns, administrators failed to implement adequate monitoring or intervention strategies.
Additional Issues Identified
The inspection revealed several other deficiencies in the facility's operations. No visitor sign-in system was in place to track who was in the building at any given time. The facility lacked written documentation of increased surveillance measures that administrators claimed to have implemented following the incidents.
Staff members reported they had not received specific education or alerts about monitoring visitor interactions with residents who were not their family members. The facility's abuse policy did not clearly address procedures for handling alleged abuse by family members or visitors, creating confusion about appropriate response protocols.
The facility also failed to notify the responsible parties for the second resident who experienced verbal abuse and involuntary seclusion, leaving his family unaware of the incident and unable to take protective measures.
Following the survey, local police officers arrived at the facility to gather statements about the incidents, indicating that proper law enforcement notification eventually occurred through the inspection process rather than facility reporting.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for United Living Community from 2024-06-26 including all violations, facility responses, and corrective action plans.
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