A. Based on observation, interview, record review, and policy review, the provider failed to ensure resident safety by not assessing the side rails/grab bars and mattresses on the resident's beds for entrapment (trapped between the rail, mattress, or bedframe spaces) for four of six sampled residents (17, 21, 25, and 26) with loose side rails/grab bars on their beds, five of six sampled residents (6, 14, 17, 21, and 25) with an unsecured mattress on their bed, and one of six sampled residents (17) with a side rail/grab bar that was not indicated for use on the bed. Those failures put those residents at risk for entrapment, injury, or harm.Immediate Jeopardy (IJ) at F689, with a scope and severity of K, began on 5/28/26 at 10:05 a.m. upon observation of resident 14's bed. …
F689 citations in South Dakota
Accidents and supervision · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Dakota cites F689 more often than its own record predicts
1.88 times the share F689 takes of citations nationally.
Of every deficiency written in South Dakota in 2025, this is the portion that was F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F689 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.
A. Based on observation, interview, and record review, the provider failed to ensure an environment free from accident hazards for seventeen of seventeen sampled residents (3, 22, 23, 24,29, 43, 48, 70, 74, 78, 83, 84, 86, 92, 102, 106, and 110) who resided within a memory care unit (an area where specialized care is provided in a structured, safe and supportive environment to meet the unique needs of residents with significant memory and cognitive decline, that is secured to minimize unsafe wandering) and had access to the memory care unit exit door key.Findings include:1. Observation on 7/28/26 at 11:57 a.m. in the memory care unit kitchenette revealed resident 86 and her visitor were standing by the refrigerator, which was located by the exit door of the memory care unit. …
Based on observation, interview, record review, and policy review, the provider failed to ensure a safe environment and supervision for one of one sampled resident (15), identified at risk for falling and with a fall prevention intervention that directed staff to not leave him in his wheelchair alone in his room, who fell from his wheelchair and sustained bruising and a laceration (a deep cut) above his left eyebrow when he was left in his room and his wheelchair alone by nursing staff. Findings include: 1. Observation and interview on 8/18/26 at 9:55 a.m. with resident 15 in his room revealed he was sitting in a recliner with his wheelchair folded up and tucked behind the bedroom door. …
The short window
Recent years
| Year | Share of South Dakota citations | vs expected |
|---|---|---|
| 2023 | 2.90% | 0.59× |
| 2024 | 8.52% | 1.58× |
| 2025 | 10.40% | 1.88× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else South Dakota surveyors cite →
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