Based on South Dakota Department of Health (SD DOH) complaint intake review, interview, document review, and policy review, the provider failed to notify the required entities of allegations of physical, mental, and verbal abuse by certified nursing assistant (CNA) J towards two of seven sampled residents (7 and 9). Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy at F609 was given verbally and in writing via email on 1/8/25 at 3:57 p.m. to director of nursing (DON) B and division director of clinical operations (DDCO) C relating to failure to report allegations of abuse. A plan for removal of the immediacy was requested. On 1/8/25 at 4:30 p.m., DDCO C emailed a written plan for the removal of the immediate jeopardy. …
F609 citations in South Dakota
Reporting alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Dakota cites F609 more often than its own record predicts
1.30 times the share F609 takes of citations nationally.
Of every deficiency written in South Dakota in 2025, this is the portion that was F609.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F609 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 a 10/7/24 complaint intake report review, interview, record review, and policy review. The provider failed to ensure a thorough investigation was completed to rule out if abuse and neglect occurred for one of one sampled resident (1) who had bruising and swelling of unknown origin on the left knee, right wrist, and penis and to report the incidents to the South Dakota Department of Health. Findings include. 1. Review of the 10/7/24 South Dakota Department of Health (SD DOH) complaint intake revealed: * On 8/21/24, staff notified the family that resident 1 had fallen in the bathroom and had a small skin tear. * On 9/22/24, staff notified the family that resident 1's knee is swollen, and it was unknown what had happened. …
Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to report a serious bodily injury from an unknown source to the SD DOH within two hours for one of one resident (38) when she was found with head trauma and deceased in her room by two of two certified nursing assistants (CNAs) (R and S).Findings include:1. Review of the provider's [DATE] SD DOH FRI received at 4:40 a.m. revealed that on [DATE] resident 38 was found unresponsive on her bedroom floor at 1:50 a.m. …
The short window
Recent years
| Year | Share of South Dakota citations | vs expected |
|---|---|---|
| 2023 | 3.62% | 1.83× |
| 2024 | 2.24% | 0.98× |
| 2025 | 3.19% | 1.30× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else South Dakota surveyors cite →
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