Based on observation, interview, record review, and policy review, the provider failed to ensure residents' care plans (a personalized plan addressing a resident's care needs, goals, and interventions) were reviewed and revised to reflect the current care needs for one of two sampled residents (3) who had a suprapubic catheter (a thin, flexible tube inserted directly into the urinary bladder through a small incision in the lower abdomen), and for one of two sampled residents (6) who had a wound on his buttocks. Findings include:1. Interview on 8/25/26 at 9:02 a.m. with resident 3 revealed he had a catheter coming from his stomach. He had the catheter for approximately four months because he had to urinate every hour of the day before he had the catheter put in.2. …
F657 citations in South Dakota
Care plan timing and revision · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Dakota cites F657 more often than its own record predicts
1.98 times the share F657 takes of citations nationally.
Of every deficiency written in South Dakota in 2025, this is the portion that was F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F657 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 resident care plans were updated to accurately reflect the residents' abilities to use call lights effectively for five of five observed sampled residents (5, 18, 20, 21, and 23) with impaired cognition who resided in the memory care unit (MCU). Findings include: 1. Observation and interview on 3/18/25 at 9:35 a.m. and again on 3/19/25 at 1:38 p.m. with resident 5 revealed: *Resident 5 sat on the edge of her bed and her call light was attached to the curtain in the center of the room between the two beds on the opposite side of the room from her bed on her roommate's side of the room on both days. …
The short window
Recent years
| Year | Share of South Dakota citations | vs expected |
|---|---|---|
| 2023 | 5.43% | 2.54× |
| 2024 | 5.16% | 2.70× |
| 2025 | 3.69% | 1.98× |
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