F658 in South Dakota. Pick another state for the same tag.
Against expectation — 2025
South Dakota cites F658 more often than its own record predicts
Versus expected share3.01×
3.01 times the share F658 takes of citations nationally.
Share of South Dakota citations5.37%
Of every deficiency written in South Dakota in 2025, this is the portion that was F658.
South Dakota5.37%
National1.78%
Share of all citations that were F658.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F658 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.
G · Actual harm, isolatedNovember 8, 2023
A. Based on observation, interview, and record review, the provider failed to clarify one of one sampled resident's (35) medication dosage from a physician's order which resulted in the resident receiving 8 times the intended prescribed dose of an antipsychotic medication for 14 days, which potentially contributed to his increased lethargy during that time.
Findings include:
1. Observation and interview on 11/6/23 at 2:19 p.m. with resident 35 revealed:
*He was hard of hearing and could not answer questions.
*He was sitting in a Broda chair.
*He appeared very thin, his eyes and temples were sunken, and was calling for his mother and father.
2. …
D · No harm, potential for more than minimal, isolatedAugust 20, 2026
Based on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, record review, interview, and policy review, the provider failed to ensure the staff followed professional standards regarding unwitnessed falls after one of one sampled resident (28) was found on her bedroom floor by certified nursing assistant (CNA) (I), had a bruise on her face, and the staff did not follow the provider's unwitnessed fall protocol. Findings include:1. Review of the provider's 6/21/26 FRI revealed that registered nurse (RN) H reported to director of nursing (DON) B on 6/20/26 at 6:27 p.m. that resident 28 had a bruise on her forehead. DON B initiated an investigation after resident 28 reported that she was not sure where the bruise on her forehead came from. …
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