Citations in South Dakota
Statistics, citations and compliance trends for long-term care facilities in South Dakota.
Statistics for South Dakota (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in South Dakota
Failure to Use Gait Belt During Assisted Ambulation: A CNA assisted a resident with a walker to the bathroom without using a gait belt, and the resident lost balance and fell, sustaining an elbow abrasion and a fractured femur requiring surgery. The resident had COPD, dementia, repeated falls, and a history of TBI, and her care plan called for one staff member to assist with toileting and transfers using a gait belt, wheelchair, or sit-to-stand lift as needed. Interviews showed staff relied on the care plan or Kardex for assistance needs, while the facility policy stated gait belts should be used with assisted ambulation unless medically contraindicated.
A CNA/QMA accepted a resident’s offer to cash scratch tickets in exchange for part of the winnings and also took a discharged resident’s Mounjaro injection for personal use. The resident with intact cognition confirmed the money arrangement, and an RN administered the unlabeled injection after the CNA/QMA asked her to do so. The facility’s policies prohibited staff from accepting resident money or gifts and defined diversion of a resident’s medication for personal use as financial abuse.
Staff failed to respond promptly to resident call lights, and multiple residents reported long waits for help, including one resident whose call light was left on for over an hour and another who sometimes urinated before assistance arrived. Call light reports showed repeated delays for several residents, with many responses over 20 minutes and some over 60 minutes or longer. Interviews with residents and staff showed inconsistent response expectations, limited radio use, and situations where staff in one room were unaware that other residents needed assistance.
Medications were left unsecured on medication carts and one cart was observed unlocked and unattended. An RN left an opened antibiotic for a resident on top of a cart, another RN left Polyethylene Glycol and Fluticasone nasal spray on top of a cart while administering meds, and a CMA was observed with an unlocked cart whose drawers were easily opened. The DON stated medications should be locked in the cart and refrigerated meds returned to the refrigerator after use.
An RN failed to maintain a resident's dignity and respect when she told him to "stop talking" after he asked about the timing and contents of his meds. The resident had moderately impaired cognition and multiple mental health diagnoses, and his care plan directed staff to use supportive communication, allow time to respond, and explain all procedures, treatments, and medications. Interviews with the CNA, RN, DON, and administrator confirmed that telling a resident to stop talking was not considered dignified care.
An LPN assisted four residents with supper without performing hand hygiene between resident contacts, touching residents and their items while feeding and handing out utensils. In the kitchen, a cook with a beard was observed preparing raw chicken and other food without a hairnet covering his beard, despite staff stating that beard coverings were expected anytime food was being prepared.
Failure to Use Gait Belt During Assisted Ambulation
Penalty
Summary
The nursing home failed to ensure that a gait belt was used when a CNA assisted a resident with ambulation to the bathroom, and the resident fell and sustained a broken femur. The incident report stated that the resident was walking with a front-wheeled walker and receiving contact guard assistance from CNA AA, but no gait belt was used. During the walk to the bathroom, the resident lost her balance, fell, and suffered an elbow abrasion and a femur fracture that required surgery. The resident had been admitted with diagnoses including COPD, dementia, and repeated falls, with a history of traumatic brain injury. Her BIMS score was 13, indicating intact cognition, and her fall assessments reflected varying levels of risk, including a moderate risk score on 6/1/26 and a low risk score on 6/23/26. Her care plan stated that for toileting and transferring she required one staff member to assist in a pivot transfer using a gait belt, wheelchair, or sit-to-stand lift as needed. Interviews showed differing understanding among staff about when a gait belt was required. The CNA stated she used the resident's walker because she knew the resident used one, but did not know whether a gait belt was needed. The DON, RN/clinical nurse leader, therapy staff, and other CNAs all described reliance on the care plan or Kardex to determine assistance needs, while the provider's gait-transfer belt policy stated gait belts should be used with assisted ambulation unless medically contraindicated. The resident and family member reported that the resident used a walker for short trips to the bathroom and that the staff did not always use a gait belt when assisting her.
Misappropriation of Resident Property and Medication
Penalty
Summary
The facility failed to protect residents from misappropriation of property when a CNA/QMA accepted a resident’s offer to cash lottery scratch tickets in exchange for half of the winnings and also took a discharged resident’s Mounjaro injection for personal use. The abuse and neglect policy defined financial abuse to include diversion of a resident’s medication for personal use or gain, and the gift policy prohibited employees from accepting cash or other gifts from residents. The employee handbook also stated that accepting gifts, tips, or gratuities from residents was strictly prohibited. One resident, who had a BIMS score of 15 and intact cognition, told the facility’s social worker that she had offered the CNA/QMA half of her scratch ticket winnings if the CNA/QMA would cash them at a gas station. The resident later recalled winning $50 and offering $25 to the CNA/QMA. During observation and interview, the resident confirmed that she had made this arrangement with the CNA/QMA and kept a $25 voucher on her bedside table showing the facility had reimbursed her. There were no notes in the resident’s EMR about the incident. A discharged resident had a physician’s order for Mounjaro 10 mg weekly injections. The CNA/QMA admitted taking that resident’s Mounjaro medication and asked an RN to administer the injection for her. The RN stated the syringe was unlabeled and that she would not have given the injection if she had known it came from a discharged resident’s medication supply. The facility’s medication disposal policy stated that unused medications left after discharge were to be evaluated for return to the pharmacy or destroyed by authorized staff with required witnesses.
Delayed Response to Resident Call Lights
Penalty
Summary
The provider failed to ensure staff responded promptly to residents’ call lights for 12 of 31 sampled residents who reported extended wait times for assistance. Multiple residents stated that call lights were not answered in a timely manner, and call light response reports documented repeated delays, including numerous responses over 20 minutes, over 30 minutes, over 40 minutes, over 50 minutes, over 60 minutes, and in some cases over 90 minutes or more. The facility’s call light policy stated that the purpose was to ensure residents always have a method of calling for assistance and to promptly answer resident call lights. Resident 13 reported that call lights were not answered in a timely manner, and the response report for that resident showed 20 responses over 20 minutes, with several much longer, including one over 90 minutes. Resident 59 said he sometimes waited at least 30 minutes and occasionally called the facility phone number to get help; his report showed 10 responses over 20 minutes and one response of 150 minutes. Resident 164 said she had waited up to 20 minutes and sometimes urinated before help arrived; her report showed two responses over 20 minutes. Resident 21 reported a call light left on for over an hour and later found shut off without anyone asking what she needed; her report showed one response of 127 minutes. Other residents described similar delays and the reports reflected the same pattern. Resident 27 had 92 responses over 20 minutes and 29 over 60 minutes. Resident 85, who had a tracheostomy and needed extensive assistance, reported long waits and her report showed three responses over 20 minutes. Resident 14, who had chronic pain, quadriplegia, and required two staff for repositioning and transfers, reported waiting hours at times; her report showed 23 responses over 20 minutes and one response of 112 minutes. Resident 73, who was legally blind and needed assistance with most care, reported waiting 45 minutes; his report showed four responses over 20 minutes. Resident 119, who required extensive assistance with toileting and used a total lift, reported his call light was on for a long period and his report showed 18 responses over 20 minutes and 6 over 30 minutes. During observations and interviews, staff described expected response times ranging from two to ten minutes, while the DON stated she expected call lights to be answered within 20 minutes. Staff also reported that radios were not consistently available or used, and some staff in resident rooms were not aware when other residents’ call lights were activated.
Unsecured medications left on carts and an unlocked medication cart observed
Penalty
Summary
Medications were not securely stored in three observed medication carts. On 6/30/26, an opened bottle of liquid Amoxicillin-Pot Clavulanate oral suspension for resident 181 was left on top of a medication cart in the 700 hallway outside resident 75's room with no staff present. During the time it remained there, CMA X, an activities assistant, and two unidentified visitors walked past the cart. Clinical care leader S later removed the antibiotic and stated RN V had been assigned to that cart and had left the medication there; RN V acknowledged she had forgotten to return the antibiotic to the refrigerator after leaving the cart. Resident 181 had a physician's order for Amoxicillin-Pot Clavulanate oral suspension via NG tube for acute cystitis without hematuria. On 7/1/26, RN FF was observed preparing medications for residents 47 and 150 and left a bottle of Polyethylene Glycol and a bottle of Fluticasone nasal spray on top of the medication cart while she walked into the dining room to administer medications. RN FF stated she left the Fluticasone nasal spray there so she would not forget to give it to resident 89, who was eating, and said the Polyethylene Glycol bottle was not supposed to be left unsecured. On 7/2/26, RN/clinical nurse leader I and CMA Z were observed with an unlocked medication cart in the 200 hallway with no nurse or medication aide attending it, and the drawers were easily opened. CMA Z stated she thought she had locked the cart. The DON stated medications were expected to be locked in the cart and not left unattended, and refrigerated medications were expected to be returned to the refrigerator after use.
RN Told Resident to Stop Talking During Medication Question
Penalty
Summary
The provider failed to protect a resident's right to dignity and respect when an RN told the resident to "stop talking" during a conversation about his medications. During observation on 7/1/26 at 8:44 a.m., the resident was sitting in his wheelchair in the hallway and asked the RN what time he should be getting his medications and what he would receive. The RN responded that the medications were at 8:00 a.m. but she was behind, then told the resident, "I'm behind, and this isn't the time, so stop talking." The resident remained in the hallway and waited until the RN administered his morning medications at 8:50 a.m. Resident 145 was admitted to the facility on [DATE] and had a BIMS score of 12 on 6/3/26, indicating moderately impaired cognition. His diagnoses included dependent personality disorder, anxiety disorder, obsessive-compulsive disorder, malignant neoplasm of the brain, and schizoaffective disorder, bipolar type. His care plan directed staff to use communication techniques that enhanced interactions, allow adequate time for him to respond, repeat as necessary, not rush him, request feedback clarification, face him when speaking, make eye contact, and explain all procedures, treatments, and medications. Interviews with a CNA, the RN, the DON, and the administrator all identified dignity as treating residents with respect, listening to concerns, and not telling a resident to stop talking.
Hand Hygiene and Beard Restraint Food Safety Failures
Penalty
Summary
The provider failed to follow standard food safety practices when an LPN assisted four residents with the evening meal in the 400-hall dining room without performing hand hygiene between resident contacts. During the observation, the LPN placed a spoon in one resident’s hand, touched his leg and shoulder, added pudding to his plate, handed another resident silverware and bowls, fed a spoonful of food to a third resident, and assisted a fourth resident with supper while touching the resident’s clothing protector, wheelchair, thumb, fork, and cranberry juice glass. RN QQ stated that hand hygiene was expected to be completed in between helping residents eat their food, and the infection preventionist also stated that staff were expected to perform hand hygiene in between assisting residents to eat in the dining room. The provider also failed to ensure that a cook with a beard wore a hairnet over his beard while preparing food in the main kitchen. The cook was observed preparing raw chicken and later preparing food at a food preparation table without a hairnet covering his beard, and he acknowledged that he was not wearing one and should have been. The systems chef stated that staff with beards were expected to have them covered with a hairnet anytime they were preparing food. The facility’s Employee Hygiene and Dress Code policy stated that hairnets or hair restraints and beard nets or beard restraints are used when cooking, preparing, assembling food or ingredients, including dish room and storage areas, and a kitchen entry sign stated that hair restraints are required at all times in the kitchen.
Find your facility
Search by name to see its inspection history, citations and penalties — and how to prepare for the next survey.
Get alerted when Immediate Jeopardy citations hit in South Dakota — free
You're all set
Compliance trends in South Dakota
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.
