Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at United Living Community during CMS and state inspections, most recent first.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents, resulting in an unsafe environment for residents.
A resident did not receive the specialized rehabilitative services required for their care, as the facility failed to provide or arrange for these necessary interventions according to the resident's assessed needs.
A deficiency was identified when a resident's spouse hit another resident on the head and moved a second resident to his room, indicating involuntary seclusion. The facility failed to protect residents from abuse and did not immediately notify law enforcement. The spouse had a history of verbal aggression, yet continued to visit regularly without adequate intervention.
A facility failed to notify required entities of abuse allegations involving a resident's spouse, who was reported to have physically and verbally abused two residents. Despite the facility's policy requiring immediate reporting to law enforcement and state agencies, the administrator did not contact them, following advice from an advisor and ombudsman. The facility's abuse policy was not adhered to, as evidenced by the lack of notification and documentation of similar past incidents.
A facility failed to thoroughly investigate allegations of abuse involving two residents. Despite initial reports and assessments, the investigation lacked comprehensive interviews with staff and residents, and there was no documentation of increased monitoring of the involved resident's spouse. The facility's actions did not comply with its abuse policy, highlighting deficiencies in handling the situation.
The facility failed to provide bed-hold notices to residents or their representatives during hospital transfers for four residents. Staff interviews revealed a lack of awareness and responsibility for completing written notifications, despite the facility's policy requiring such actions.
The facility failed to update care plans for residents using VirtuSense VSTAlert motion detection systems and side rails. Observations revealed that these devices were not documented in the care plans of three residents, and consent for their use was not obtained. The Director of Nursing and the administrator acknowledged these oversights, and the facility lacked a specific policy for the VST monitoring system.
The facility failed to ensure proper food labeling, storage, and hygiene practices. Observations revealed unlabeled and undated food items in the kitchen and kitchenette, and inappropriate glove use and hand hygiene by staff. Interviews with dietary staff highlighted a lack of adherence to protocols, despite clear expectations and policies.
Staff at the facility failed to adhere to hand hygiene and glove use protocols during resident care. An LPN and CNA did not wash hands between glove changes during a dressing change, and an RN did not sanitize hands before handling nebulizer equipment. These actions were contrary to the facility's infection control policies.
A resident was not accurately assessed for the safe self-administration of nebulized medication. She was left alone during treatments without proper education on using the nebulizer. The facility lacked an order for self-administration, and her care plan did not include it. Nurses were unaware of the facility's policy on self-administration, and the resident's ability to self-administer was not assessed.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain a Hazard-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the occurrence of accidents. The deficiency centers on the lack of appropriate measures to identify and eliminate hazards, as well as insufficient oversight to safeguard residents from potential harm.
Failure to Provide Required Specialized Rehabilitative Services
Penalty
Summary
A resident did not receive specialized rehabilitative services as required for their care. The facility failed to provide or obtain these services, which are necessary to meet the resident's assessed needs. This deficiency was identified during the survey based on the lack of evidence that the required rehabilitative interventions were implemented for the resident.
Failure to Protect Residents from Abuse by Visitor
Penalty
Summary
The deficiency involves the failure of the facility to protect residents from abuse, specifically involving two residents and the spouse of another resident. The incident occurred when a resident's spouse was observed wheeling one resident down the hall and subsequently hitting him on the head. This action was witnessed by a certified nurse aide (CNA), who reported the incident to a registered nurse (RN). The RN assessed the resident and found no physical injuries, but the resident later confirmed that he was hit, although not very hard. The facility administrator was notified, but law enforcement and the South Dakota Department of Human Services were not immediately informed. Further investigation revealed that the same resident's spouse had previously moved another resident to his room and told him he could come out when he could act like a grown man, indicating involuntary seclusion. Interviews with staff and other residents indicated that the spouse had a history of verbal aggression and inappropriate interactions with residents, including calling one resident derogatory names. Despite these incidents, the spouse continued to visit the facility regularly and assist her spouse with daily routines. The facility's response to the incident was inadequate, as there was no immediate removal of the resident's spouse from the facility, and no comprehensive investigation was conducted to interview all involved parties. The facility's policy on abuse prevention and reporting was not fully adhered to, as evidenced by the lack of immediate notification to law enforcement and the absence of documented interventions to prevent further incidents. The facility's failure to protect residents from abuse and involuntary seclusion by a visitor constitutes a significant deficiency in ensuring resident safety and upholding their rights.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to notify the required entities of an allegation of physical abuse by a resident's spouse towards another resident, and an allegation of verbal abuse and involuntary seclusion by the same spouse towards a second resident. The incident was reported by a registered nurse who observed the spouse hitting a resident over the head. The resident did not show fear and claimed the hit was not hard. The facility administrator was notified, but local law enforcement and the South Dakota Department of Human Services were not informed, as the administrator was advised by both her advisor and the regional ombudsman not to contact the police because the resident did not want to press charges. Further investigation revealed that the facility's administrator was unaware that contacting the ombudsman did not fulfill mandatory reporting requirements. The ombudsman confirmed that the provider was obligated to contact law enforcement. Additionally, a dietary aide reported a similar incident involving the same resident's spouse, which had occurred earlier but was not formally documented or investigated. The aide also noted that the spouse had a history of aggressive behavior towards staff and other residents. The facility's abuse policy required immediate reporting of suspected abuse to the administrator, state agency, and law enforcement if a crime was suspected. However, the facility did not adhere to these guidelines, as evidenced by the lack of notification to law enforcement and the state agency. The policy also mandated that all alleged violations be reported within two hours if they involved resident abuse or resulted in serious bodily injury, which was not followed in this case.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of physical and verbal abuse, as well as involuntary seclusion, involving two residents. The incident was reported by a registered nurse who observed a certified nurse aide witnessing a resident's spouse hitting another resident. Despite the initial assessment showing no physical injuries, the resident claimed to have been hit. The facility's investigation documentation was insufficient, lacking interviews with other staff and residents, and failing to document further investigation into the allegations. Interviews with various staff members revealed that the facility did not conduct a comprehensive investigation. Only the registered nurse and the certified nurse aide who initially reported the incident were interviewed. Other staff members, including those present during the incident, were not formally interviewed. Additionally, there was no documentation of increased surveillance or monitoring of the resident's spouse, who had a history of inappropriate behavior towards other residents. The facility's abuse policy requires thorough investigation and documentation of all alleged violations, but this was not adhered to in this case. The administrator confirmed that only the involved residents were interviewed, and there was no written agreement with the resident's spouse to prevent further incidents. The lack of documentation and comprehensive investigation indicates a failure to comply with the facility's abuse policy and state regulations.
Failure to Provide Bed-Hold Notices During Hospital Transfers
Penalty
Summary
The provider failed to provide bed-hold notices to residents or their responsible parties at the time of transfer to a hospital, as well as ombudsman notification, for four sampled residents. Resident 6 was transferred to the hospital at the request of her family representative due to her inability to stand, but there was no written notification regarding the bed-hold policy or ombudsman notification. Similarly, Resident 4 was taken to the hospital after a fall and reported back pain, but there was no documentation that he or his responsible party received information about the bed-hold policy. Resident 25 was transferred to the hospital due to a critical blood glucose level, with her husband’s permission, yet there was no documentation of bed-hold policy notification. Resident 27 was transferred to the ER for evaluation, and later to the hospital, but again, there was no documentation of bed-hold policy notification. Interviews with facility staff revealed a lack of awareness and responsibility regarding the bed-hold notification process. The social service designee was unaware of the requirement to complete a written form at the time of transfer, and the administrator expected verbal notification by the nurse and follow-up by the social worker, but acknowledged that a written bed-hold form was not being completed. The facility's undated Holding Bed Space policy stated that information concerning the bed-hold policy should be provided upon admission and during transfers, with a copy mailed to the resident or representative in emergency transfers, but this was not adhered to in practice.
Deficiency in Care Plan Documentation for Monitoring Systems
Penalty
Summary
The provider failed to ensure that resident care plans were revised to reflect the current needs of three residents who had VirtuSense VSTAlert motion detection systems installed in their rooms. For Resident 6, the VST motion sensor was observed in the room, but there was no documentation of its use in the care plan, nor was there consent documentation for its use. Similarly, Resident 50 had a VST motion sensor and a side rail on her bed, but these were not documented in her care plan. The Director of Nursing acknowledged that the VST monitor was ordered by a Hospice physician but was not added to the medication administration record or care plan, and the side rail documentation was incomplete. Resident 54 also had a VST motion sensor in her room, but there was no documentation of its use in her care plan. An incident was noted where the VST alarm was not working, yet this was not addressed in the care plan. The administrator confirmed that a physician's order and consent should have been obtained and documented for the use of the VST monitoring system. Additionally, the facility lacked a specific policy regarding the VST monitoring system, and the existing policy on side rails required that their use be addressed in the resident care plan.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The provider failed to ensure that food items were appropriately labeled, stored, handled, prepared, and served in a safe and sanitary manner. Observations revealed that the commercial refrigerator contained several food items that were not labeled, dated, or discarded by the use-by date, including pickles, barbecue sauce, ranch dressing, broccoli broth, sliced onion, flour tortilla, deli pepper jack cheese, palmetto cheese spread, and apple pies. Additionally, the commercial freezer had opened frozen meat items and other food products that were not labeled or dated. Similar issues were found in the 500-hall kitchenette, where items like French Toast, pancake syrup, and dry cereal were not labeled or dated. The report also highlighted inappropriate glove use and hand hygiene practices by staff members. Cook G was observed placing raw chicken on a pan, seasoning it without washing hands, and then touching ready-to-eat garlic bread with the same gloves. Dietary aide F was seen moving between different areas and handling various food items and surfaces without changing gloves or washing hands. Similarly, UAP H served meals and handled food items without changing gloves or washing hands between tasks. Interviews with dietary staff revealed a lack of adherence to proper food handling and hygiene protocols. The dietary manager and registered dietitian expressed expectations for food labeling, glove use, and hand hygiene that were not met. The facility's policies on food storage, employee hygiene, and glove use were reviewed, indicating that employees must wash hands frequently and that gloves do not substitute for proper handwashing. However, these practices were not consistently followed, leading to the deficiencies observed.
Failure in Hand Hygiene and Glove Use During Resident Care
Penalty
Summary
The provider failed to ensure proper hand hygiene and glove use by staff during medical procedures, as observed in two separate incidents. In the first incident, a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) did not perform hand hygiene before or after glove use during a dressing change for a resident. The LPN removed soiled dressings and changed gloves multiple times without washing hands or using hand sanitizer, even though hand sanitizer was available in the room. Similarly, the CNA assisted with repositioning the resident and changing bedding and clothing, also failing to wash hands between glove changes. In the second incident, a Registered Nurse (RN) did not perform hand hygiene before or after glove use while providing a nebulizer treatment to another resident. The RN admitted to not sanitizing hands before handling the nebulizer equipment, which was against the facility's policy. The facility's policies clearly state the importance of hand hygiene in preventing healthcare-associated infections and outline specific situations where hand washing or sanitizing is required, which were not followed in these cases.
Failure to Assess Resident for Safe Self-Administration of Nebulized Medication
Penalty
Summary
The provider failed to ensure that a resident was accurately assessed for the safe self-administration of nebulized medication. Resident 115, who was receiving medication through a nebulizer, reported that she was left alone during treatments and had not been educated on using the nebulizer machine. She expressed a desire to self-administer her nebulizer treatment but was unable to operate the machine independently. During an observation, a registered nurse administered the nebulizer treatment and left the resident alone, setting a timer to return after ten minutes. The nurse was unaware of any order for the resident to self-administer the treatment and was not familiar with the facility's policy on self-administration. A review of the resident's electronic medical record revealed orders for Budesonide and Ipratropium but no order for self-administration. There was also no assessment to determine the resident's ability to self-administer the treatment safely, and her care plan did not include self-administration. Another registered nurse confirmed that there was no order for self-administration and that the resident had not been educated on using the nebulizer. The facility's policy stated that if it is deemed safe for a resident to self-administer medications, it should be documented in the medical record and care plan, with periodic reassessment based on changes in the resident's status.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brookings
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Neighborhoods At Brookview | 2 mi | — | 2 | 0 |
| Riverview Healthcare Center | 20.9 mi | — | 11 | 1 |
| Flandreau Santee Sioux Tribe Care Center | 21.1 mi | — | 1 | 0 |
| Estelline Nursing And Care Center | 22.9 mi | — | 0 | 0 |
| Hendricks Community Hospital | 23.4 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.