Based on South Dakota Department of Health (SD DOH) complaint intake review, interview, document review, and policy review, the provider failed to thoroughly investigate 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 F610 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. The removal plan was approved soon after 4:30 p.m. …
F610 citations in South Dakota
Investigating alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Dakota cites F610 more often than its own record predicts
1.11 times the share F610 takes of citations nationally.
Of every deficiency written in South Dakota in 2025, this is the portion that was F610.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F610 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 the South Dakota Department of Health (SD DOH) complaint report review, interview, document review, record review, and policy review, the provider failed to ensure two of two sampled residents' with expressed feelings of emotional distress (57 and 78) allegations of sexual abuse reported to social services designee (F) regarding having been touched in their private areas without the residents' consent by one of one certified nursing assistant (CNA) (D) and an unidentified staff member were thoroughly investigated to prevent further emotional distress, further staff-to-resident sexual abuse or to mitigate the risk of sexual abuse. Findings include:1. …
Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to investigate a staff-reported incident of potential resident abuse regarding one of one previous contracted travel certified nursing assistant (CNA) (BB) who allegedly pulled one of one residents' (56) wheelchair backward into the bathroom with resident (56) sitting in it, causing the resident's leg to get caught under the wheelchair wheel, which caused her to have pain.Findings include: 1. Review of the provider's 6/9/26 SD DOH FRI revealed alleged abuse between previous contracted travel CNA BB and resident 56 occurred on 6/8/26 at 8:30 p.m. …
The short window
Recent years
| Year | Share of South Dakota citations | vs expected |
|---|---|---|
| 2023 | 1.45% | 1.13× |
| 2024 | 1.79% | 1.25× |
| 2025 | 1.68% | 1.11× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else South Dakota surveyors cite →
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