Based on record review, interview, and policy review the provider failed to ensure the Office of State Long-Term Ombudsman (an advocate of residents' overall quality of care and rights) was notified when a resident discharged from the facility, for one of two sampled residents (6).Findings include:1. Review of resident 6's electronic medical record (EMR) revealed she was discharged on 4/21/26 to another facility. Her primary care physician (PCP) was notified of the intent to discharge on [DATE] and the facility received a physician's order on 4/21/26 for resident 6 to be discharged to the assisted living with her current orders. There was no documentation that the Office of State Long-Term Care Ombudsman was notified of resident 6's transfer to another facility.2. …
F628 citations in South Dakota
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Dakota cites F628 less often than its own record predicts
0.72 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 F628.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F628 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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