Based on observation, record review, interview, and policy review, the provider failed to ensure an effective quality assurance and performance improvement (QAPI) program had been implemented to identify and address concerns related to residents' care within the facility. Findings include: 1. Interview on 10/17/19 at 2:59 p.m. with the administrator regarding their QAPI program revealed: *She was the QAPI coordinator. *They would like to do monthly meetings but had been meeting quarterly. -They were due for their next quarterly meeting in October. *They currently had a medical director. -They were in the process of finding a new medical director. *Their last QAPI meeting was in (MONTH) or July. …
F867 citations in South Dakota
QAPI improvement activities · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
South Dakota cites F867 less often than its own record predicts
0.51 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 F867.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What South Dakota surveyors wrote
F867 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 South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), record review, and interview, the provider failed to ensure an effective, comprehensive quality assurance and performance improvement (QAPI) program was implemented to track and measure performance; systematically analyze underlying causes of a systemic quality deficiency; develop and implement corrective actions or performance improvement activities; and evaluate the effectiveness of the corrective actions, and to revise those actions as needed.Findings include:1. Review of a 3/20/26 SD DOH FRI revealed that the incident investigation substantiated neglect occurred when the facility failed to provide resident 56 incontinence care. 2. …
The short window
Recent years
| Year | Share of South Dakota citations | vs expected |
|---|---|---|
| 2024 | 0.22% | 0.50× |
| 2025 | 0.17% | 0.51× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else South Dakota surveyors cite →
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