Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure that the physician was promptly notified of a change in condition for review and recommendations to ensure prompt assessment and treatment for one of one sampled resident (1) identified to be vomiting and with increased weakness, by one of one registered nurse (RN) E. This failure resulted in resident 1 being transferred to the emergency room (ER) for evaluation and subsequent hospitalization. The provider also failed to notify the resident's first emergency contact of the resident's change in condition. Findings include:1. …
F580 citations in South Dakota
Notifying of changes · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Dakota cites F580 less often than its own record predicts
0.11 times the national share — cited less often here than elsewhere.
Of every deficiency written in South Dakota in 2025, this is the portion that was F580.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F580 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.
Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure the physician was notified that prescribed medication had not been given to one of one sampled resident (2). Findings include: 1. Review of the provider's 5/13/25 SD DOH FRI revealed: *Resident 2 had inappropriate contact with resident 3. *As part of the investigation the facility staff reviewed resident 2's medication and was found that his monthly Depo-Provera [medication that may control sexually inappropriate behaviors] injections had not been administered for April 2025, and the medication was unavailable for his May 2025 dose. 2. …
The short window
Recent years
| Year | Share of South Dakota citations | vs expected |
|---|---|---|
| 2024 | 0.22% | 0.15× |
| 2025 | 0.17% | 0.11× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else South Dakota surveyors cite →
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