Based on review of the South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to ensure suicide risks evaluation had been completed for one of one sampled resident (1) by two of two nurses (E and G) who had documented the resident's comments of not wanting to live anymore to address his observed and expressed changes in his mental health. Findings include: 1. Review of the SD DOH FRI regarding resident 1 revealed: *On 5/9/25 licensed practical nurse (LPN) E had walked by resident 1's room and noticed blood on the floor in his room. *Resident 1 had a push pin in his hand and had cut himself in the antecubital (the area of the arm at the elbow crease) areas of both of his arms. …
F741 citations in South Dakota
Quality of Life and Care Deficiencies
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Dakota cites F741 more often than its own record predicts
3.50 times the share F741 takes of citations nationally.
Of every deficiency written in South Dakota in 2025, this is the portion that was F741.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F741 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.
The short window
Recent years
| Year | Share of South Dakota citations | vs expected |
|---|---|---|
| 2023 | 0.36% | 7.36× |
| 2025 | 0.17% | 3.50× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else South Dakota surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction