United Living Community

In the surveyor’s words

From the most serious findings on record at United Living Community, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 10, 2025

  Based 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).Findings include: 1. Review of the SD DOH complaint intake received on 4/7/25 revealed:*An anonymous community member called to express their concerns about resident falls at the facility.*They specifically mentioned resident 1's falls which had resulted in issues.-They did not explain what those issues were. 2. […]

• Actual harm, isolatedF600Jun 26, 2024

  Based 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. 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. […]

• No harm, potential for more than minimal, widespreadF812Dec 4, 2025

  Based 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.Findings include: 1. Observation on 12/2/25 from 8:17 a.m. to 8:41 a.m. during the initial kitchen tour in the main kitchen revealed the floor underneath the rubber mats in the dish room was caked with a brown and black substance. The rest of the tile floor in the kitchen was gray in color and appeared to be clean. The rubber mats in the dish room were the standard slip-resistant black rubber mats with drainage holes in it.The windowsill in the dish room was visibly dusty, with scattered food crumbs, dead flies, and mosquitoes. […]

• No harm, potential for more than minimal, patternF761Dec 4, 2025

  Based 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.Findings include:1. Observation on 12/2/25 at 10:10 a.m. in resident 8's room revealed there was a jar of Vick's VapoRub sitting on top of her overbed desk. It was in plain view from the doorway.2. Observation on 12/3/25 at 9:18 a.m. in resident 72's room revealed there was a bottle of Systane eyedrops, a tube of Vaseline, and a bottle of saline nasal spray sitting on his bedside table. They were in plain view from the doorway.Interview on 12/4/25 at 8:14 a.m. […]

• No harm, potential for more than minimal, patternF803Dec 4, 2025

  Based 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.Findings include: 1. Observation on 12/2/25 at 10:59 a.m. in the memory care unit dining room revealed the posted menu listed pulled pork sandwiches, potato salad, V8 juice (a brand of tomato juice), and pistachio dessert. Dietary aide (DA) S did not serve pureed potato salad to the residents on a pureed diet, as the kitchen did not send any pureed potato salad. […]