United Living Community: Resident Left on Toilet - SD
The resident, identified in inspection records only as Resident 1, was assessed as severely cognitively impaired. The facility's own Staff Assessment for Mental Status documented that she rarely or never understood her surroundings and rarely or never made decisions about the tasks of daily living. She was, by the facility's own classification, among the most vulnerable people in its care.
She was left on the toilet anyway.
The incident triggered a complaint inspection completed August 14, 2025. Inspectors cited the facility under F0600, which covers abuse and neglect, at a level of minimal harm or potential for actual harm.
After the incident, the facility updated Resident 1's care plan. Staff were now required to check on her every five minutes while she was in the bathroom. That change was documented. What was not documented was any evidence that the facility had looked back at its other residents to determine whether anyone else had been left in a similar situation around the same time.
Inspectors asked. The facility could not produce it.
There was also no documentation that the facility had conducted ongoing audits to verify that staff understood the safety protocols and had absorbed whatever education followed the incident. A care plan update is a piece of paper. What inspectors were looking for was evidence that someone had actually checked, actually followed through, actually made sure the failure with Resident 1 had not been repeated with someone else down the hall.
That evidence did not exist.
The inspection report is brief, running only three pages, and the narrative provided to inspectors covers only the tail end of the investigation. What it captures is a facility that responded to a serious lapse in supervision by updating one resident's care plan and, apparently, stopping there.
For a resident assessed as severely impaired, the five-minute check interval written into her updated care plan represents a significant level of supervision. It also represents an acknowledgment that she cannot call for help, cannot signal distress in ways staff would reliably recognize, and cannot protect herself from the consequences of being forgotten. The care plan change, in other words, is the facility's own admission of how much she depends on staff to remember she is there.
The inspection found no documentation that staff had been audited to ensure they understood that responsibility going forward.
Complaint inspections at nursing homes are typically triggered by a report from a resident, family member, or staff member. The inspection report does not identify who filed the complaint or what specifically prompted it. What it does record is the deficiency inspectors confirmed when they arrived: a severely impaired woman had been left on a toilet for a prolonged period, and the facility's response, while producing a care plan revision, produced no documented effort to determine the scope of the problem or verify that staff had genuinely changed their behavior.
United Living Community is located in Brookings, in eastern South Dakota.
The woman whose care plan now requires a check every five minutes while she is in the bathroom did not ask to be left there. She rarely or never made decisions. She depended entirely on the people around her to make the right ones.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for United Living Community from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 19, 2026 · Our methodology
UNITED LIVING COMMUNITY in BROOKINGS, SD was cited for violations during a health inspection on August 14, 2025.
The resident, identified in inspection records only as Resident 1, was assessed as severely cognitively impaired.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.