Based on South Dakota Department of Health (SD DOH) complaint intake review, record review, interview, and policy review, the provider failed to:Ensure there was a physician's order for one of one closed record sampled resident's (1) urinary catheter.Ensure there was a documented clinical indication for urinary catheter use by one of one closed record sampled resident (1) that included a physician's order for catheter removal when it was no longer clinically indicated.Identify and implement measures to mitigate of one of one closed record sampled resident (1) with a urinary catheter from developing a urinary tract infection.Findings include: Review of the 6/24/25 SD DOH complaint intake revealed:On 6/18/25, the provider discharged resident 1. …
F690 citations in South Dakota
Incontinence and catheter care · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Dakota cites F690 less often than its own record predicts
0.12 times the national share — cited less often here than elsewhere.
Of every deficiency written in South Dakota in 2025, this is the portion that was F690.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F690 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, record review, interview, and policy review, the provider failed to ensure interventions to lessen the occurrence of urinary tract infections (UTI) were implemented for one of one resident (14) who had a UTI. Findings include: 1. Observation on 10/2/24 between 11:30 a.m. and 12:15 p.m. of resident 14 in the dining room revealed: *A plastic cup of ice water and another cup of juice were served to the resident with her meal. -She ate and drank independently. *Both cups remained mostly full at the end of the meal. -Staff provided no verbal cueing or encouragement to the resident to drink those fluids during the meal service. Review of resident 14's electronic medical record (EMR) revealed: *She was admitted to the facility on [DATE]. …
The short window
Recent years
| Year | Share of South Dakota citations | vs expected |
|---|---|---|
| 2023 | 0.72% | 0.45× |
| 2024 | 0.45% | 0.30× |
| 2025 | 0.17% | 0.12× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else South Dakota surveyors cite →
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