Based on observation, interview, record review, policy review, South Dakota Department of Health (SD DOH) on-line incident report, and job description review, the provider failed to follow their Skin Integrity policy for: *Accuracy of weekly skin assessments and/or wound documentation for eighteen of twenty-three sampled residents (1, 2, 3, 4, 9, 10, 11, 13, 14, 15, 16, 17, 18, 19, 21, 22, 24, and 25). *physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *Notification to physician, resident and/or family representative of skin and wound issues in a timely manner for seven of twenty-three sampled residents (2, 3, 4, 13, 14, 15, and 23). *A turning and repositioning program for ten of twenty-three sampled residents (2, 3, 4, 10, 11, 15, 22, 23, 24, and 25) to off load pressure areas. …
F686 citations in South Dakota
Pressure ulcers · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Dakota cites F686 more often than its own record predicts
1.45 times the share F686 takes of citations nationally.
Of every deficiency written in South Dakota in 2025, this is the portion that was F686.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F686 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 implement pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) prevention interventions for one of one sampled resident (26) who developed a pressure ulcer to his left heel after he admitted to the facility on [DATE].Findings include: 1. Observation and Interview on 9/1/26 at 1:43 p.m. with resident 26 in his room revealed he had a boot on his left foot, and he stated he had his left foot amputated. 2. Observation and Interview on 9/2/26 at 3:30 p.m. with resident 26 in his room revealed he had a wound on the bottom of his left heel. The wound was black in color, and the skin was not open. Resident 26 denied pain in that area unless the area was pushed on. …
Based on observation, interview, record review, and policy review, the provider failed to assess, document, and notify the resident's physician of two facility-acquired pressure ulcers (skin and/or underlying tissue injury from prolonged pressure) for one of one sampled resident (12) who developed a pressure ulcer on her right heel and left buttock, and to complete wound assessment documentation weekly for her right inner buttock pressure ulcer by one of one director of nursing (DON)/wound nurse B and for nursing staff to monitor her right and left inner buttocks daily. Findings include:1. Observation and interview on 4/28/26 at 2:39 p.m. …
The short window
Recent years
| Year | Share of South Dakota citations | vs expected |
|---|---|---|
| 2023 | 4.71% | 2.30× |
| 2024 | 2.02% | 0.97× |
| 2025 | 2.85% | 1.45× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else South Dakota surveyors cite →
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