United Living Community

F-F610, finding 16.

14. Interview on 6/25/24 at 4:53 p.m. with director of social services G regarding the above incident revealed:

*Regarding the relationship between residents 1 and 2, she said, they periodically [NAME], staff usually intervene, and they are easy to redirect.

*She said that there had never been physical aggression between them.

*When asked if there had ever been a discussion about moving them to separate units, she revealed that resident 2 was recently moved to a room in a different hallway from resident 1.

-She said that this has been helpful because they do not always see each other when they come out of their rooms.

-Regarding moving one of them to a different unit, she said, you hate to uproot.

*She said that resident 3's spouse is a consistent person in the building, visiting multiple times a day.

*She was not aware of any previous physical aggression from resident 3's spouse. I've never seen that side of her.

15. Interview on 6/25/24 at 5:24 p.m. with administrator A regarding the above incident revealed:

*When asked if there were any other known incidents between resident 3's spouse and resident 1, she was not aware of a previous incident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 *She reviewed resident progress notes and was not able to find any information about any other incidents between resident 3's spouse and resident 1. Level of Harm - Actual harm 16. Continued interview on 6/26/24 with administrator A regarding the above incident revealed: Residents Affected - Few *The first step in the facility's investigation process when there was a complaint of potential abuse of a resident was to ensure resident safety.

-RN D performed her assessment of resident 1 and notified administrator A.

-RN D then had CNA C give a handwritten statement of what he had witnessed.

-She asked RN D where resident 3's spouse was and was told that she was in the room with resident 3 helping him get ready for bed.

-RN D completed the FRI that evening.

-She said that she entered the facility at 8:00 a.m. the next morning and talked to resident 3's spouse, RN D, and the ombudsman.

-She said that she asked the ombudsman if law enforcement needed to be notified, and the ombudsman did not tell her that it was required.

-She said that resident 1 was asked if he wanted to call law enforcement regarding the incident and he did not.

-When asked if there were any interviews of involved staff or residents and she said she had not. She felt that resident 3's spouse gave enough information about the incident, that there was no need to interview any other residents or staff.

*She said that there had been increased education to staff regarding incident reporting.

17. Phone interview on 6/26/24 at 9:48 a.m. with RN D regarding the above incident revealed:

*She was unaware of any other incidents in which resident 3's spouse was verbally aggressive with other residents.

*She said that she did hear from RN L that resident 3's spouse had spoken to resident 3 in an unpleasant manner before.

18. Interview on 6/26/24 at 9:56 a.m. with RN M regarding the above incident revealed:

*She was the case manager for the nursing home.

*She revealed that resident 3's spouse was at the facility often.

*She said that she was present for resident 3's senior psychological appointment in which resident 3's spouse voiced concerns that resident 3's roommate always has his TV volume very loud.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 -During the appointment, resident 3's spouse reported that [they] would turn down the volume and turn off

the TV when the volume bothered resident 3. Level of Harm - Actual harm -She said that it was verbally reinforced that resident 3's roommate has rights and that resident 3's spouse Residents Affected - Few must not control the TV belonging to resident 3's roommate.

-[They] were not happy about this.

*Resident 3's spouse said that if the volume is bothering resident 3, [they] would turn the TV off.

19. Interview on 6/26/24 at 10:21 a.m. with DHR I regarding the above incident revealed:

*She stated that she was present for the meeting between administrator A and resident 3's spouse on 6/16, 24.

-She said that she was there to take notes on the conversation and was not an active participant.

*Regarding the demeanor of resident 3's spouse, she said that resident 3's spouse did not want to be there.

*She said that resident 3's spouse wanted to record the conversation and was given the opportunity to do so but did not record the conversation.

*She said that resident 3's spouse then wanted to take written notes regarding the conversation and was given the opportunity to do so but did not take notes.

*During the conversation, resident 3's spouse said that resident 1 had hit her.

*When asked if resident 3's spouse had hit resident 1, she did not answer the questions and just shook her head.

*Administrator A then told resident 3's spouse that she was not to move or touch other residents and not to talk to resident 1 going forward.

*Resident 3's spouse then agreed to these terms as a verbal agreement. The agreement was not put in writing.

46453

20. Review of resident 1's electronic medical record revealed:

*He was admitted on [DATE REDACTED].

*His medical diagnoses included: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, vascular dementia, moderate, with agitation, major depressive disorder, unspecified anxiety disorder.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 *His most recent Brief Interview for Mental Status (BIMS) score from 3/15/24 was a 13, which indicated he was cognitively intact. Level of Harm - Actual harm *An incident note from 6/15/24 at 7:02 p.m. read: Residents Affected - Few -Staff reported to nursing during shift change that they had witnessed a visitor hit resident in the head when pushing him down the hall to his room.

-This resident and another male resident had been verbally arguing with each other and the visitor had separated them and took resident down the hall to his room.

-Per the staff member, the visitor did not know he was behind them when she was rolling resident to his room.

-This writer did an interview with resident, and it is unclear other than the witnessed event as to what happened.

-Writer asked resident what happened between him and the other male resident to start the conversation.

-Resident initially would not answer, once writer explained to him it was ok to talk about that writer was trying to figure out the situation for them to both be safe.

-Resident stated he and the other 'guy' were cussing at each other.

-He denies each other having physical contact.

-It is not uncommon for the two residents to argue at each other; however, staff do monitor as they do have a history with each other.

-This writer did ask if the visitor had taken him to his room and he stated yes.

-Writer asked resident if the visitor had hit him and he originally stated, 'She tried to,' I asked resident what

he did and he stated, 'I blocked her.'

-Later in the conversation resident did state the [visitor] hit him and when asked how hard [the visitor] hit him

he stated, 'not very hard.'

-Writer asked resident where the [visitor] hit him at, and he pointed to the left side of his temple.

-An assessment was completed head to toe and no redness is noted, no bruising is noted, and no raised area is noted.

-Writer assured resident that we are here to ensure he is safe and that we would monitor and keep all safe in

the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 -Resident when asked if he would like to press charges on the [visitor], he made the comment 'I want to make them pay, they took all my money I had saved up.' Level of Harm - Actual harm -Writer attempted to notify [resident's] daughter to notify her of the situation, however, when calling a Residents Affected - Few recording comes across 'the person you are calling cannot take calls at this time, the number you have dialed is not answering, please try later.'

-Administrator was notified of the situation and will be here tomorrow while the visitor is in the facility to take care of the situation.

*A follow-up health status note entered on 6/16/24 at 1:10 a.m. read:

-Resident has been monitored frequently this shift for any s/s [signs or symptoms] of distress related to recent incident early in the shift. Resident has been resting in bed with eyes closed. Has not shown any distress this part of the shift.

*A follow-up health status note entered on 6/16/24 at 12:15 p.m. read:

-Resident denies having any pain. Transfers per usual. Alert and out for meals. No bruising noted. Denies having any pain.

*A social work note entered on 6/18/24 at 3:49 p.m. read:

-[This] writer met with resident to follow up on recent incident involving another resident's family member hitting him on the head.

-Writer and resident visited about this incident.

-Resident initially did not recall the incident, however, was able to briefly state that he remembers 'that [person] that pushed me back to my room.'

-Writer asked resident if he is fearful of this person and he said 'no.'

-This writer asked resident if he feels safe at [facility] and he stated 'yes.'

-Will continue to check in with resident.

*There were no other follow-up notes regarding the incident between resident 1 and resident 3's spouse.

21. Review of CNA C's handwritten statement revealed:

*[Resident 1] and [resident 2] altercation led to [resident 3's spouse] wheeling [resident 1] back to his room.

*While doing so, [resident 1] was holding up his right hand possibly trying to [grab] her.

*In response, [resident 3's spouse] hit [resident 1] over the head with her right hand.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 *It was hard enough to be clearly heard 20 feet back and led to a vocalization of pain from [resident 1].

Level of Harm - Actual harm *[Resident 3's spouse] appeared to be angry about [resident 1] and [resident 2's] altercation.

Residents Affected - Few 22. Review of staff schedules from the evening of 6/15/24 on the South Ridge unit revealed the following employees were on-site:

*CNA C from 2:15 p.m. to 10:45 p.m.

*CNA E from 2:15 p.m. to 9:00 p.m.

*LPN K from 6:00 a.m. to 6:30 p.m.

*RN D from 6:00 p.m. to 6:30 a.m.

*Dietary aide F from 4:30 p.m. to 7:30 p.m.

23. Review of resident 2's electronic medical record revealed:

*He was admitted on [DATE REDACTED].

*His medical diagnoses included: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified anxiety disorder, major depressive disorder, vascular dementia.

*His most recent BIMS score from 4/10/24 was 13, which indicated he was cognitively intact.

*A social work progress note entered on 6/18/24 at 2:16 p.m. read:

-[This] writer met with resident to follow up on incident of him being wheeled into his room by other resident's family member.

-Resident was able to recall this incident, but did not feel threatened by the family member and stated he does not feel fearful of her.

-This writer asked resident if he feels safe at [facility] and he stated 'yes.'

*There was no indication that the resident's wife, his responsible party, was notified of the incident.

24. Review of resident 3's admission documentation revealed that his spouse signed the acknowledgement that they received a copy of the Residents' Rights document on 5/31/23.

25. Review of the provider's March 2017 Acknowledgement of Resident Rights and Responsibilities policy revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 *Policy Statement: Each resident (or resident representative) will be provided and must acknowledge receipt of a written copy of resident rights and all rules, regulations, and policies governing the resident's conduct Level of Harm - Actual harm and responsibilities during his/her stay in the facility.

Residents Affected - Few *Policy Interpretation and Implementation:

-1. Prior to or upon admission, a representative of the admitting office will give the resident, or the resident's representative, a written copy of resident rights and responsibilities, including facility rules, regulations, and policies governing the resident's conduct and responsibilities during his/her stay in the facility.

-2. A representative from the business office or from social services will review the rights and responsibilities with the resident or the resident's representative. This review will occur as soon as possible within the first week of the individual's admission to the facility.

-3. The resident, or the resident's substitute decision maker or representative, will be required to sign a statement acknowledging his/her receipt of a written copy of resident rights and responsibilities and that an oral review of such rights and responsibilities was conducted.

-4. For individuals who have been formally declared incompetent or who cannot make decisions in accordance with this state's current laws, regulations, and guidelines, the resident's representative will be informed of the resident's rights and the representative will be entitled to act on the resident's behalf.

-5. A representative of the administration or business office will inform residents orally and in writing of changes in federal or state regulations relative to resident rights or when changes in facility policy affects the rights or responsibilities of residents. Notices will be provided within 14 days of such change(s) taking effect.

-6. Signed and dated copies of the resident's acknowledgement of rights and responsibilities and any subsequent revisions are maintained in the resident's medical record.

26. Review of an email communication sent by RN M following resident 3's psychological appointment on 3/28/24 revealed:

*RN M provided education to resident 3's spouse on resident rights.

-Resident 3 and his spouse had been expressing feelings of frustration because they had been continually turning down resident 3's roommate's television because it was too loud.

-RN M wrote, Please remind her that this is a violation of [roommate's] rights.

27. Review of a Formal Grievance submitted by resident 3's spouse on 5/15/24 revealed:

*Resident 3's spouse submitted a formal grievance to discuss the care that resident 3 was receiving.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 *Resident 3's spouse named a specific CNA in their grievance, stating that [I find] bruises on [resident 3] when [I come] to see [resident 3] in the morning. Level of Harm - Actual harm -Resident 3's spouse did not provide any specific situations, nor could she recall any. Residents Affected - Few *Education was provided to [resident 3's spouse] regarding how [facility] investigates suspicious bruising and

the importance of reporting these concerns when they happen so they can be properly investigated . Information provided regarding [facility's] zero tolerance for retaliation, specifically regarding incident reporting.

*Education regarding policy on when/how police are called was given to [resident 3's spouse], specifically that [facility] would not call Police before attempting to contact [resident 3's spouse], with the only exception being imminent danger to staff or [resident 3].

*[Resident 3's spouse] expressed verbal understanding .

*Education regarding Resident Rights provided at this time.

*Action Plan:

-1. Monthly Care Conferences will be held with [resident 3's spouse], [director of social services G] and [DON B] to address any concerns and follow up on the Grievance action plan. These meetings will begin the week of June 17th, 2024, at [resident 3's spouse's] request.

- .4. Education regarding Resident Rights will be given to [facility] staff at the next all staff meeting on May 28th, 2024.

28. Review of the provider's undated Nursing Home Resident's Rights document revealed:

*Residents of nursing homes have rights that are guaranteed by the federal Nursing Home Reform Law. The law requires nursing homes to promote and protect the rights of each resident and stresses individual dignity and self-determination. Many States also include residents' rights in state law or regulation.

*Right to a Dignified Existence

-Be treated with consideration, respect, and dignity, recognizing each resident's individuality.

-Freedom from abuse, neglect, exploitation, and misappropriation of property .

- .Quality of life in maintained or improved.

-Exercise rights without interference, coercion, discrimination, or reprisal.

-A homelike environment .

-Equal access to quality care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 29. Review of the provider's February 2024 Abuse policy revealed:

Level of Harm - Actual harm *Policy Statement: Each resident has the right to be free from abuse, neglect . This includes but is not limited to freedom from corporal punishment, involuntary seclusion . Residents must not be subject to abuse by Residents Affected - Few anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals.

*Policy Explanation and Compliance Guidelines:

-1. The Abuse coordinator in the facility is the Director of Nursing, Administrator, or facility appointed designee. Report allegations or suspected abuse, neglect, or exploitation immediately to: Administrator, Other Officials in accordance with State Law, State Survey and Certification agency through established procedures.

-2. 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.

-- .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish.

--It includes verbal abuse .physical abuse, and mental abuse .

--'Willful' means the individual deliberately, not that the individual must have intended to inflict injury or harm.

-3. 'Verbal Abuse' means the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.

- .5. 'Physical Abuse' includes, but not limited to hitting, slapping, punching and kicking. It also includes controlling behavior through corporal punishment.

-6. 'Mental Abuse' includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation .

- .8. 'Involuntary Seclusion' refers to the separation of a resident from other residents or from his/her room or confinement to his/her room against the resident's will or the will of the resident's legal representative .

- .11. 'Mistreatment' means inappropriate treatment or exploitation of a resident.

*The facility must:

-1. Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 - .5. Prevention of Abuse, Neglect, and Exploitation - The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents: Level of Harm - Actual harm -- .d. Provide education on what constitutes abuse, neglect and misappropriation of property. Residents Affected - Few --e. React to all allegations or questions of abuse by residents, family members, employees or visitors.

--f. Take appropriate actions when abuse, neglect or exploitation is suspected.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm 46453

Residents Affected - Few Based 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). Findings include:

1. Review of the SD DOH FRI submitted on 6/15/24 at 7:35 p.m. revealed:

*Registered nurse (RN) D reported that certified nurse aide (CNA) C witnessed resident 3's spouse wheeling resident 1 down the hall.

*Resident 1 was holding his hand up as if he may have been attempting to grab resident 3's spouse.

*In response to resident 1's action, resident 3's spouse hit [resident 1] over the head with her right hand.

*RN D immediately assessed resident 1 and when asked if resident 3's spouse hit him, his response was that resident 3's spouse tried to hit him, and I blocked her.

*RN D's physical assessment did not reveal any redness, bruising, or raised areas on resident 1's head.

*Resident 1 then stated that resident 3's spouse did hit him on his temple, but not very hard.

*During interview with resident, he did not show any fear of the situation.

*RN D notified facility administrator. Administrator will be in the facility to discuss the situation with [resident 3's spouse].

*The report indicated that local law enforcement and the South Dakota Department of Human Services (DHS) were not notified.

-Under the section Why or why not? for law enforcement notification, the report indicated, Administrator will be in facility in am [a.m.]

-Under the section Why or why not? for DHS notification, the report indicated, Notified Ombudsman via email.

2. Interview on 6/24/24 at 5:32 p.m. with administrator A regarding the FRI revealed:

*She had contacted both her advisor and the regional ombudsman and asked if they should contact the police.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 -Both her advisor and the ombudsman had said to not contact the police because resident 1 did not want to press charges. Level of Harm - Minimal harm or potential for actual harm *She confirmed that no one had contacted law enforcement or DHS about the incident.

Residents Affected - Few 3. Interview on 6/24/24 at 6:15 p.m. with the SD DOH long term care nurse advisor about the above incident revealed she confirmed the provider was obligated to contact law enforcement.

4. Interview on 6/24/24 at 6:39 p.m. with resident 3's spouse about the above incident revealed:

*A verbal agreement was made between the administrator and resident 3's spouse to not speak with resident 1, and to not touch any resident except resident 3.

*Resident 3's spouse declined any further interview with the survey team.

*Two police officers arrived at that time to gather statements.

5. Interview on 6/25/24 at 12:41 p.m. with dietary aide F about the above incident revealed:

*She confirmed she was working on the evening of 6/15/24.

*No one had interviewed her about the incident to obtain her formal account.

*She had not seen the events on 6/15/24 unfold but had seen a similar situation between resident 1 and resident 3's wife before.

-It happened within the previous week of 6/15/24. It may have happened on 6/13/24, but she could not remember.

-Resident 2 was sitting in his normal spot in the dining room.

-Resident 1 wheeled himself into the dining room.

-They started bickering at each other.

-She could not understand what they were arguing about.

-Resident 3's spouse grabbed resident 1's wheelchair to take him out of the dining room.

-She overheard resident 3's spouse call resident 1 incompetent and asshole.

-Dietary aide F reported what she overheard to both the CNA and the nurse on duty at that time.

-She could not remember the names of the CNA or the nurse.

*Dietary aide F indicated that resident 3's spouse was known to fly off the handle with staff, and sometimes other residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 6. Interview on 6/25/24 at 2:42 p.m. with the regional ombudsman revealed that calling the ombudsman did not fulfill the mandatory reporting requirements, as the ombudsman was not a mandatory reporter. Level of Harm - Minimal harm or potential for actual harm 7. Interview on 6/25/24 at 5:24 p.m. with administrator A regarding the above incident revealed:

Residents Affected - Few *She was not aware of dietary aide F's account as explained in finding 5.

*She was not aware that the ombudsman was not part of the required reporting network.

*She stated again that the ombudsman recommended to not contact the police as resident 1 did not want to press charges against resident 3's spouse.

8. Review of the provider's investigation documentation revealed:

*Administrator A, director of human resources I, and resident 3's spouse met at the facility on 6/16/24 at around 11:00 a.m.

*Resident 3's spouse admitted to bringing resident 2 back to his room and told him he had to stay there 'until

he could learn to be a grown man.'

9. Review of resident 2's electronic medical record revealed there was no documentation to support the resident's wife or his primary care provider had been notified about the incident between resident 2 and resident 3's spouse as explained in finding 8.

10. Review of the provider's February 2024 Abuse policy revealed:

*Policy Explanation and Compliance Guidelines:

*1. The Abuse coordinator in the facility is the Director of Nursing, Administrator, or facility appointed designee. Report allegations or suspected abuse, neglect, or exploitation immediately to: Administrator, Other Officials in accordance with State Law, State Survey and Certification agency through established procedures.

* .9. Response and Reporting of Abuse, Neglect and Exploitation - Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should:

- .d. Notify the attending physician, resident's family/legal representative and Medical Director

- .f. Contact the State Agency and the local Ombudsman office to report the alleged abuse.

-g. If a crime, or suspicion of a crime has occurred, notify the local law enforcement agency.

*10. The facility must annually notify covered individuals' obligation to comply with the following reporting requirements:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 -a. Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any responsible [reasonable] suspicion of a crime against Level of Harm - Minimal harm or any individual who is a resident of or is receiving care from the facility. potential for actual harm -b. Each covered, individual shall report immediately, but not later than 2 hours after forming the suspicion, if Residents Affected - Few the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury.

* .13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must:

-a. Ensure that all alleged violations .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve resident abuse or result in serious bodily injury .to the administrator of the facility and to other official (including the State Survey Agency and adult protected services where state law provides for jurisdiction in long-term care facilities) in accordance with State law.

*The Administrator should follow up with government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final, as required by state agencies.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or 46453 potential for actual harm Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), investigation review, Residents Affected - Few 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). Findings include:

1. Review of the SD DOH FRI submitted on 6/15/24 at 7:35 p.m. revealed:

*Registered nurse (RN) D reported that certified nurse aide (CNA) C witnessed resident 3's spouse wheeling resident 1 down the hall.

*Resident 1 was holding his hand up as if he may have been attempting to grab resident 3's spouse.

*In response to resident 1's action, resident 3's spouse hit [resident 1] over the head with her right hand.

*RN D immediately assessed resident 1 and when asked if resident 3's spouse hit him, his response was that resident 3's spouse tried to hit him, and I blocked her.

*RN D's physical assessment did not reveal any redness, bruising, or raised areas on resident 1's head.

*Resident 1 then stated that resident 3's spouse did hit him on his temple, but not very hard.

*During interview with resident, he did not show any fear of the situation.

*RN D notified facility administrator. Administrator will be in the facility to discuss the situation with [resident 3's spouse].

2. Review of the provider's investigation documentation regarding the above incident revealed:

*There was a handwritten statement from CNA C.

*There was a typed summary of the conversation administrator A had with resident 3's spouse from the morning of 6/16/24.

-The summary revealed that resident 3's spouse admitted to bringing resident 2 back to his room and told him he had to stay there 'until he could learn to be a grown man.'

-There was no documentation to support that the provider investigated this allegation further.

*There was no documentation to support that other staff had been interviewed about the incident.

*There was no documentation to support that residents had been interviewed, other than residents 1 and 2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 3. Interview on 6/24/24 at 5:32 p.m. with administrator A regarding the above incident revealed:

Level of Harm - Minimal harm or *The incident happened on Saturday 6/15/24 around 6:30 p.m. potential for actual harm *She was informed of the incident on 6/15/24 and instructed RN D to complete a state report and obtain a Residents Affected - Few written statement from CNA C.

*Director of human resources (DHR) I and administrator A came to the facility on Sunday 6/16/24 and met with resident 3's spouse at around 11:00 a.m. to discuss the incident.

-They made a verbal agreement with resident 3's spouse to not move or touch other residents.

-During that conversation, resident 3's spouse admitted to moving resident 2 to his room and told him, You can come out when you can act like a grown man.

-Resident 3's spouse did not admit to hitting resident 1.

*Resident 1 was interviewed several times on the evening of 6/15/24.

-He was not a good historian.

-One time he said that resident 3's spouse hit him, and another time he said that I blocked it.

-He was not consistent with answering if he was hurt or not.

*Resident 3's spouse had a pattern when she visited. She came around 11:00 a.m., stayed through the lunch hour, left for a couple of hours in the afternoon, came back to the facility around 4:00 p.m., and stayed until resident 3 went to bed.

-This pattern was an everyday occurrence.

*Administrator A met with the manager's team on the morning of 6/17/24 to inform them of the situation.

-She instructed the managers to make more of a presence throughout the facility during the times that resident 3's spouse was known to be in the building.

-She confirmed there was no documentation to support the increased surveillance of resident 3's spouse.

*Administrator A confirmed she had not informed staff of that specific incident or to keep a closer eye on resident 3's spouse. Rather, she explained that staff were reeducated on monitoring call lights more closely.

-There was no documentation to support that.

*The regional ombudsman was scheduled to present on resident rights at the provider's all-staff meeting on 6/25/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 4. Interview on 6/24/24 at 6:25 p.m. with CNA E regarding the above incident revealed:

Level of Harm - Minimal harm or *He confirmed he was working on the evening of 6/15/24. potential for actual harm *He did not witness the incident. Residents Affected - Few *There was a meeting about the incident at the nurse's station including CNA E, CNA C, and RN D.

*He was not interviewed as part of a formal investigation into that incident.

*He had not been re-educated or briefed about the incident or to keep an eye out for family members or visitors interacting with a resident who was not their person.

5. Interview on 6/24/24 at 6:39 p.m. with resident 3's spouse about the above incident revealed:

*A verbal agreement was made between the administrator and resident 3's spouse to not speak with resident 1, and to not touch any resident except resident 3.

*Resident 3's spouse declined any further interview with the survey team.

6. Interview on 6/25/24 at 10:20 a.m. with resident 1 regarding the above incident revealed he:

*Denied having any issues with other residents, staff, or visitors.

*Was unable to remember the incident.

*Confirmed he felt safe in the facility and had not concerns regarding his safety.

7. Interview on 6/25/24 at 10:51 a.m. with resident 4 regarding safety revealed he:

*Confirmed he felt safe in the facility.

*Got along with the other residents.

*Denied seeing any arguments between other residents and/or their visitors.

8. Interview on 6/25/24 at 11:00 a.m. with resident 5 regarding safety revealed she:

*Had no concerns about her safety.

*Denied seeing any altercations with other residents, family, or visitors.

9. Interview on 6/25/24 at 11:09 a.m. with resident 6 regarding safety revealed he:

*Stuck to his room most of the time because people yell a lot.

*Gave nondescript answers to questions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 *Did not confirm nor deny worries of safety concerns.

Level of Harm - Minimal harm or 10. Interview on 6/25/24 at 12:41 p.m. with dietary aide F about the above incident revealed: potential for actual harm *She confirmed she was working on the evening of 6/15/24. Residents Affected - Few *No one had interviewed her about the incident to obtain her formal statement.

*She was in the South Ridge kitchenette doing dishes when CNA C came to her looking stressed and informed her of what happened.

*She had not seen the events on 6/15/24 unfold but had seen a similar situation between resident 1 and resident 3's wife before.

-It happened within the previous week on 6/15/24. It may have happened on 6/13/24, but she could not remember.

-Resident 2 was sitting in his normal spot in the dining room.

-Resident 1 wheeled himself into the dining room.

-They started bickering at each other.

-She could not understand what they were arguing about.

-Resident 3's spouse grabbed resident 1's wheelchair to take him out of the dining room.

-She overheard resident 3's spouse call resident 1 incompetent and asshole.

-Dietary aide F reported what she overheard to both the CNA and the nurse on duty at that time.

-She could not remember the names of the CNA or the nurse.

*Dietary aide F indicated that resident 3's spouse was known to fly off the handle with staff, and sometimes other residents.

11. Interview on 6/25/24 at 1:10 p.m. with RN D regarding the above incident revealed:

*As part of the investigation, she assessed resident 1 immediately.

*She had CNA C write down his statement before his shift was over.

*She reported the incident to the SD DOH.

12. Interview on 6/25/24 at 1:30 p.m. with administrator A revealed:

*She confirmed resident 3's spouse has had inappropriate verbal altercations with residents before.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 -We talked about going to get a staff member if someone is bothering [them].

Level of Harm - Minimal harm or *They have had conversations previously with resident 3's spouse about resident rights. potential for actual harm -She did not have documentation to support all their conversations with resident 3's spouse about her Residents Affected - Few behavior.

*She confirmed there was no visitor sign-in sheet.

*She confirmed there was no documentation to support her and the management team's increased presence throughout the building to monitor resident 3's spouse.

13. Interview on 6/25/24 at 3:24 p.m. with CNA C regarding the above incident revealed:

*After supper on the evening of 6/15/24, he was in the nurse's station to receive shift-to-shift report.

*After report, he walked out into the hallway.

-Resident 2's door was already closed, so he assumed resident 2 already went back to his room for the night.

-He walked past the main hallway and witnessed resident 3's spouse wheeling resident 1 towards his room.

-He saw resident 1 reaching upwards at resident 3's spouse with his right hand.

-Resident 3's spouse whacked resident 1 across the head with their right hand.

-He went directly to the nurse's station and reported what he saw to RN D and licensed practical nurse (LPN) L.

-LPN K left after that because it was the end of her shift.

*He confirmed that no one assessed resident 2. I didn't even think to check on him.

*He confirmed no one asked resident 3's spouse to leave. They left at their usual time of 7:30 p.m.

*He confirmed he gave a written statement to RN D, but no one else had interviewed him about the incident.

14. Interview on 6/25/24 at 2:52 p.m. with resident 3 regarding safety revealed he:

*Had no concerns with other residents or staff.

*Verbalized no complaints.

15. Interview on 6/25/24 at 4:06 p.m. with resident 2 regarding safety revealed he:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 *Confirmed that the staff treat him well and that he felt safe within the facility.

Level of Harm - Minimal harm or *Could not remember any specific incident where a visitor said any unkind things to him. potential for actual harm *Indicated there was one resident [resident 1] that annoyed him, but other than that he felt safe. Residents Affected - Few 16. Interview on 6/25/24 at 4:18 p.m. with LPN K regarding the above incident revealed:

*She confirmed she was working on 6/15/24, but she was on a different unit at the time of the incident.

*The incident happened after 6:00 p.m.

*She went to the South Ridge unit to give report to RN D for the night.

*CNA C came into the nurse's station and informed them of what happened.

*She recalled another time about a year ago where resident 3's spouse snapped at another resident.

-That resident had dementia and talked non-stop.

-She could not recall any more details regarding that incident.

*No one had formally interviewed her as part of an investigation regarding the 6/15/24 incident.

*She voiced no concerns regarding resident safety when resident 3's spouse was present.

17. Interview on 6/25/24 at 4:53 p.m. with director of social services G about the above incident revealed:

*As part of the investigation into this incident, she interviewed only residents 1 and 2 regarding their feelings of safety.

*No other residents were interviewed.

18. Interview on 6/25/24 at 5:24 p.m. with administrator A regarding the incident revealed:

*She confirmed she was not aware of the previous situation with resident 1 and resident 3's spouse when dietary aide F overheard the spouse calling resident 1 incompetent and asshole.

Continued interview on 6/26/24 at 9:15 a.m. with administrator A revealed:

*She confirmed she did not talk to other staff again as part of the investigation. The only staff interviews conducted were with RN D and CNA C.

-I felt I didn't need to do that because [resident 3's spouse] admitted to everything.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 *She confirmed they had a verbal agreement with resident 3's spouse to not touch other residents and to not speak with resident 1. Level of Harm - Minimal harm or potential for actual harm -There was no written or signed agreement.

Residents Affected - Few *To further prevent something like that from happening again, she and the management team were making more of a presence on the floor when resident 3's spouse was there.

-She confirmed again that they were making visual observations and not making any written accounts.

Continued interview on 6/26/24 at 10:57 a.m. with administrator A revealed:

*She confirmed the only residents interviewed as part of the investigation were residents 1 and 2.

*Residents were asked about feelings of safety with their normal quarterly assessments.

*When asked why they did not interview any other residents regarding feelings of safety or if anyone else had noticed strange interactions with visitors, she said, You guys already asked other residents and they said they feel safe.

19. Review of the provider's February 2024 Abuse policy revealed:

*Policy Statement: Each resident has the right to be free from abuse, neglect . This includes but is not limited to freedom from corporal punishment, involuntary seclusion . Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals.

*Policy Explanation and Compliance Guidelines:

-1. The Abuse coordinator in the facility is the Director of Nursing, Administrator, or facility appointed designee. Report allegations or suspected abuse, neglect, or exploitation immediately to: Administrator, Other Officials in accordance with State Law, State Survey and Certification agency through established procedures.

*The facility must:

- .5. Prevention of Abuse, Neglect, and Exploitation - The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents:

-- .e. React to all allegations or questions of abuse by residents, family members, employees or visitors.

--f. Take appropriate actions when abuse, neglect or exploitation is suspected.

- .6. Identification of Abuse, Neglect, and Exploitation - The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following possible indicators:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 --a. Resident, staff, or family report of abuse

Level of Harm - Minimal harm or -- .e. Verbal abuse of a resident overheard. potential for actual harm --f. Physical abuse of a resident observed. Residents Affected - Few - .7. Investigation of Alleged Abuse, Neglect and Exploitation. - When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted.

--Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include:

---a. Interview the involved resident, if possible, and document all responses. If a resident is cognitively impaired, interview the resident several times to compare responses.

---b. If there is no discernible response from the resident, or if the resident's response is incongruent with that of a reasonable person, interview the resident's family, responsible parties, or other individuals involved in

the resident's life to gather how he/she believes the resident would react to the incident.

---c. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in

the area, and visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement.

---d. Document the entire investigation chronologically.

- .9. Response and Reporting of Abuse, Neglect and Exploitation - Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should:

-- .c. Initiate an investigation immediately.

-- .e. Obtain witness statements, following appropriate policies. Suspend the accused employee pending completion of the investigation. Remove the employee from resident care areas immediately.

-- .i. Document actions taken in steps above in the medical record.

- .13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must:

-- .b. Have evidence that all alleged violations are thoroughly investigated.

-- .d. Report the results of all investigation to the administrator or his or her designated representative and to

the other official in accordance with State law, including to the State Survey Agency, within 5 working days of

the incident, and if the alleged violation is verified appropriate corrective action must be taken.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 29 435079 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435079 B. Wing 06/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

United Living Community 405 First Ave Brookings, SD 57006

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 *The policy did not indicate what actions should have been taken if the alleged abuse involved a family member or visitor. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 29 435079