F684 in South Dakota. Pick another state for the same tag.
Against expectation — 2025
South Dakota cites F684 less often than its own record predicts
Versus expected share0.82×
0.82 times the national share — cited less often here than elsewhere.
Share of South Dakota citations3.52%
Of every deficiency written in South Dakota in 2025, this is the portion that was F684.
South Dakota3.52%
National4.30%
Share of all citations that were F684.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F684 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.
J · Immediate jeopardy, isolatedNovember 19, 2025
Based on South Dakota Department of Health (SD DOH) complaint intake report review, record review, interview, and policy review, the provider failed to ensure staff provided quality care related to skin injury prevention and skin management processes including completing skin evaluations, accurate communication, accurate documentation, and implementing interventions and treatment orders for one of one sampled resident (1) who developed skin injuries to his left lower leg, left foot, and right lower leg and was hospitalized related to those wounds. Those failures put all residents at potential risk for serious injury or harm. …
Based on interview, observation, record review, and policy review the provider failed to ensure the quality of care for one of one sampled resident (2) who had a physician's order to be straight catheterized (placing a flexible tube into the bladder to drain urine, then removing the tube) twice a day when that order was discontinued in the provider's electronic medical record (EMR) system by one of one registered nurse (RN) (D) on 7/9/26, which resulted in the resident not having his urine drained by straight catheterization for sixteen days. That failure potentially contributed to the resident's hospitalization for evaluation and treatment of diagnosed urosepsis (infection in the bloodstream from a urinary tract infection [UTI]). Findings include:1. Interview on 8/4/26 at 11:49 a.m. …
E · No harm, potential for more than minimal, patternAugust 28, 2026
Based on South Dakota Department of Health ( SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to maintain effective pain management for one of one resident (20) who was prescribed a Butrans (buprenorphine) transdermal patch (controlled narcotic skin patch that slowly releases an opioid medicine to treat severe pain), which was received from the pharmacy and unaccounted for, resulting in a replacement patch being ordered and subsequently administered late to resident 20. Findings include:1. Review of the provider's 6/13/26 SD DOH FRI revealed that on 6/12/26, resident 20's ordered Butrans transdermal patch was unaccounted for. …
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