F835 in South Dakota. Pick another state for the same tag.
Against expectation — 2025
South Dakota cites F835 more often than its own record predicts
Versus expected share2.28×
2.28 times the share F835 takes of citations nationally.
Share of South Dakota citations0.67%
Of every deficiency written in South Dakota in 2025, this is the portion that was F835.
South Dakota0.67%
National0.29%
Share of all citations that were F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F835 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.
L · Immediate jeopardy, widespreadDecember 14, 2020
Based on observation, interview, record review, and policy review, the provider failed to ensure during a world wide pandemic the facility was administered and operated in a manner to ensure the safety and overall wellbeing for all twenty-six residents in the facility. Findings include.
1. Interviews, observations, record reviews, and policy reviews throughout the course of the survey revealed the administrator and the director of nursing (DON) had not ensured the safe management and overall well-being of all residents in the outbreak of a pandemic (COVID-19).
2. On 12/9/20 at 5:45 p.m. …
Based on observation, interview, record review, policy review, and job description review, the provider failed to ensure the facility was operated and administered in a manner that ensured the safety and overall well-being for all fifty-four residents in the facility. Findings include:
1. Observations, interviews, record reviews, and policy reviews conducted throughout the course of the survey from 7/8/19 through 7/10/19 revealed the administrator and the director of nursing had not been an effective leadership team to ensure the safe management and overall well-being of the residents.
Interview and record review on 7/10/19 at 2:30 p.m. …
F · No harm, potential for more than minimal, widespreadJune 2, 2026
Based on observation, interview, record review, and policy review, the provider failed to ensure the facility was operated and administered by chief executive officer (CEO) A and director of nursing (DON) B in a manner that ensured quality of life and overall well-being for all 26 residents in the facility.Findings include:1. Observations, interviews, record reviews, and policy reviews throughout the survey from [DATE] through [DATE] and [DATE] through [DATE] revealed CEO A and DON B did not ensure the management, safety, quality of life, and overall well-being of all the residents who lived at the facility.Those were evidenced by a widespread system breakdown to ensure services provided met professional standards and the minimum requirements as it pertained to providing education to… …
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