Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to ensure a physician orders for a therapeutic pureed (blended food) diet was followed for one of one sampled resident (1) who had a diagnosis of dysphagia (difficulty swallowing) and received a snack from one of one certified nursing assistant (CNA) (D) that was not the right texture and then required life-saving measures through use of the Heimlich maneuver after the food became lodged in his throat. On 2/18/26 at 12:59 p.m., an Immediate Jeopardy was identified for a facility reported incident (FRI) related to the quality of care and treatment that occurred on 2/11/26 at 12:59 a.m. …
F803 citations in South Dakota
Menus · Nutrition and Dietary Deficiencies
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Dakota cites F803 more often than its own record predicts
1.08 times the share F803 takes of citations nationally.
Of every deficiency written in South Dakota in 2025, this is the portion that was F803.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F803 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 menu review, observation, and interview, the provider failed to ensure one of two dietary staff (cook J) followed the menu serving sizes for each diet offered which had the potential to affect all residents within the facility, and failed to substitute a nutritionally adequate replacement for the pureed garlic bread for three of three residents (6, 11, and 17) who required a pureed diet.Findings Include:1. Review of the provider's lunch menu for 8/16/26 showed that the planned meal included lasagna, a layered lettuce salad, garlic bread, chocolate vanilla swirl pudding, and milk. …
The short window
Recent years
| Year | Share of South Dakota citations | vs expected |
|---|---|---|
| 2023 | 0.72% | 0.97× |
| 2024 | 1.12% | 1.55× |
| 2025 | 0.67% | 1.08× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else South Dakota surveyors cite →
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