Based on a South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to ensure residents were free of significant medication errors for one of one sampled resident (3) who received 2.5 milliliters (mL) of Morphine Sulfate (narcotic) by mouth instead of the ordered dose of 0.25 mL from a certified nursing assistant (CNA)/medication aide (MA) E and experienced decreased oxygen levels, lethargy (abnormal drowsiness or sluggishness that involves low energy, decreased alertness, reduced mental and physical activity), respiratory distress (trouble breathing), and required the use of Narcan (a medication that reverses the effects of opioids).Findings include:1. …
F760 citations in South Dakota
Significant medication errors · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Dakota cites F760 more often than its own record predicts
1.16 times the share F760 takes of citations nationally.
Of every deficiency written in South Dakota in 2025, this is the portion that was F760.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F760 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 record review, interview, and policy review, the provider failed to ensure one of one discharged resident (67) received her physician-prescribed antibiotic intravenously (IV) (within a vein) as ordered for her right knee infection.Findings include: 1. Review of resident 67's closed electronic medical record (EMR) revealed she admitted to the facility on [DATE]. She went to a clinic appointment on 6/22/26 and was admitted to the hospital from that appointment, as she refused to return to the provider's facility. …
The short window
Recent years
| Year | Share of South Dakota citations | vs expected |
|---|---|---|
| 2024 | 2.24% | 1.92× |
| 2025 | 1.51% | 1.16× |
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