United Living Community Visitor Abuse Failure - SD
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.
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
UNITED LIVING COMMUNITY in BROOKINGS, SD was cited for abuse-related violations during a health inspection on June 26, 2024.
The incident involved the spouse of one resident physically hitting another resident who was reaching up toward her while being transported in his wheelchair.
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.