Based on observation, interview, record review, and policy review, the provider failed to ensure a medication error rate of less than 5 percent. The facility failed to prevent a medication error involving two inhalers (a small, handheld medical device that delivers medication directly into your lungs when you breathe) for one of one observed resident (55) when contracted travel licensed practical nurse (LPN) T and certified medication aide (CMA) V left the inhalers on a dining room table for the resident to self-administer. Resident 55 did not have a physician's order to self-administer either inhaler. This practice resulted in a medication error rate of 6.25 percent. Findings include: 1. Observation and interview on 8/27/26 at 7:50 a.m. …
F759 citations in South Dakota
Medication error rate · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Dakota cites F759 less often than its own record predicts
0.78 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 F759.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F759 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 |
|---|---|---|
| 2024 | 0.67% | 0.63× |
| 2025 | 0.84% | 0.78× |
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