Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to ensure the resident representative had been notified of an elopement and change in the resident's status for one of one sampled resident (24) with cognitive impairment. The resident was identified as at risk for elopement and had eloped (left the facility grounds without staff knowledge) on 7/4/25.Findings include:1. Review of the provider's 7/24/25 SD DOH FRI regarding resident 24 revealed:*On 7/4/25 at 6:57 p.m., resident 24 was found to be at the apartment building across the street.*She [resident 24] had signed out of the facility earlier in the day, therefore the incident was not reported.*The resident had a 5/5/25 contract… …
F551 citations in South Dakota
Resident Rights Deficiencies
Give the resident's representative the ability to exercise the resident's rights.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Dakota cites F551 more often than its own record predicts
2.17 times the share F551 takes of citations nationally.
Of every deficiency written in South Dakota in 2025, this is the portion that was F551.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F551 findings written in South Dakota, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
What else South Dakota surveyors cite →
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