A. Based on observation, interview, record review, testing, resident group meeting interview, and policy review, the provider failed to maintain a comfortable room temperature for fifteen random residents (1, 7, 8, 10, 11, 12, 13, 15, 17, 21, 24, 25, 35, 36, and 37) Findings include: Surveyor: 1. Review of the resident council minutes on: *4/5/21 documentation for maintenance/housekeeping/laundry department A/C's [air conditioners] in rooms. *5/10/21 documentation for maintenance/housekeeping/laundry department No window AC's. *6/25/21 documentation for other No air conditioning - explained doors open, air comes thru [through] halls - if windows open, then doors need to be shut. *7/12/21 documentation for maintenance Discussed air conditioning protocol thru out [throughout] the building. …
F584 citations in South Dakota
Safe, clean, homelike environment · Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Dakota cites F584 less often than its own record predicts
0.64 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 F584.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F584 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 observation, interview, record review, and policy review, the provider failed to ensure a homelike environment was maintained for two of fourteen sampled residents (18 and 32) who did not have a bathroom door and four of fourteen sampled residents (10, 24, 35, and 44) whose walls in their rooms had exposed drywall and peeling paint. Findings include:1. Observation on 7/14/26 at 9:28 a.m. in resident 24's room revealed an approximately ten-inch area between her end table and stationary chair with peeling paint, more than five gouges in the drywall, and two three-to-four-inch areas where the drywall was exposed. 2. Observation and interview on 7/14/26 at 11:19 a.m. with residents 18 and 32 in their shared room revealed that they did not have a bathroom door. …
The short window
Recent years
| Year | Share of South Dakota citations | vs expected |
|---|---|---|
| 2023 | 1.81% | 0.81× |
| 2024 | 2.24% | 1.05× |
| 2025 | 1.34% | 0.64× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else South Dakota surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction