Based on observation, interview, record review, job description review, and policy review, the governing body failed to ensure the facility was operated in a manner that ensured the safe management and overall well-being for all sixty-two residents. Findings include: 1. The following deficiencies were repeated deficiencies from the previous recertification survey on 10/5/17: F658 and F880. The following deficiencies were newly cited for the current survey: F657, F660, F684, F686, F690, F745, F835, F842, F867, and F881.
F837 citations in South Dakota
Administration Deficiencies
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Dakota cites F837 more often than its own record predicts
6.17 times the share F837 takes of citations nationally.
Of every deficiency written in South Dakota in 2025, this is the portion that was F837.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F837 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 observations, interviews, record reviews, and policy reviews, the governing body failed to ensure the facility was operated in a manner that ensured the safe management and overall well-being of 45 residents in the facility.Findings include:1. Observations, interviews, record reviews, and policy reviews throughout the survey on 4/21/26 through 4/23/26 and 4/27/26 through 4/29/26 revealed administrator 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 as it pertained to resident dignity, informed decision for psychotropic medications, resident self-administration of medications, resident… …
The short window
Recent years
| Year | Share of South Dakota citations | vs expected |
|---|---|---|
| 2023 | 0.36% | 4.90× |
| 2025 | 0.34% | 6.17× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else South Dakota surveyors cite →
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