Avera Mother Joseph Manor Retirement Community

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

48.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 64 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 49.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 77 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 56% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 81 beds and averages 77.5 residents a day — about 96% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.06 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.96 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.65 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.35 hrs/resident/day on weekends vs 4.34 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 1.10 to 0.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

18 citations, most serious first. The 13 most serious are shown; the remaining 5 are one tap away and print in full.

• Actual harm · G2024-08-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who fell from his wheelchair while being pushed by facility staff. Failure to use wheelchair pedals may have contributed to resident 1's fall. This citation is considered past noncompliance based on the corrective actions the provider implemented immediately after the incident. Findings include: 1. Review of the provider's 7/26/24 SD DOH FRI report revealed: *On 7/26/24, occupational therapy assistant (OTA) C was wheeling the resident back to his room. The resident was holding his feet off the floor; wheelchair pedals were not attached to wheelchair. During the transport, resident 1's feet dropped to the floor, causing him to fall forward out of the wheelchair. *He hit his head on the floor during the fall, causing a laceration and bleeding. *He was evaluated in the emergency department at the local hospital. *A chest X-ray revealed he had multiple left side…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · G2023-03-23 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to: *Ensure environmental precautions were in place to prevent harm to one of one sampled resident (37) who received a burn to her left ankle from a heat register in her room after her bed had been moved. *Implement timely and appropriate bowel management interventions for one of one sampled resident (128) who had been receiving hospice services. Findings include: 1. Observation on 3/21/23 at 8:09 a.m. and again at 10:08 a.m. of resident 37 revealed: *She was lying in bed under the blankets and appeared to be sleeping soundly. *The bed was in the lowest position and a fall mat was on the floor in front of the bed. *She had a full body pillow positioned beside her on the non-wall side. *A call button was clipped to the pillow at the head of her bed. *There was a wheelchair in the corner of her room with a Pommel cushion setting in it. *At 10:08 a.m., she was lying on top of her made bed, dressed and groomed under a throw…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-03-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure ongoing and timely skin assessments were conducted and documented by a licensed nurse prior to the development of pressure ulcers for two of two sampled residents (20, and 58). Findings include: 1. Observation and interview on 3/21/23 at 10:38 a.m. with resident 20 in his room revealed he: *Was sitting in a wheelchair on a pressure relieving cushion. There was a pressure relieving cushion in his recliner and a pressure reduction mattress on his bed. *Had a colostomy, was able to empty the colostomy bag independently and the nurse changed the appliance every five days. *Received a shower with staff assistance once a week. *Had a prosthetic for his right lower leg, was able to put it on independently but was not wearing it because he had swelling in his leg and it would not fit at that time. *Had a CROW [Charcot Restraint Orthotic Walker]boot that was used to accommodate and support and keep his left foot from rolling…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-12-17 · tag F0732 — widespread
  Post nurse staffing information every day.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, document review, and interview, the provider failed to ensure the posted nurse staffing information included the actual hours worked by registered nurses, licensed practical nurses, and certified nursing assistants per shift, and that the form was posted daily.Findings include:1. Observation on 10/2/25 at 10:00 a.m. of the provider's nursing services staff posting revealed the number of nursing staff working was listed, but not the number of hours they worked was not included.2. Interview on 10/2/25 at 11:12 a.m. with registered nurse (RN) health unit coordinator F revealed:*She was responsible for posting the nursing services staff form.*She was not aware of the requirement that the posting was to include the number of hours worked by nursing services staff, including the RN, LPN, and CNAs.*She posted the nursing services staff form daily when she worked, so it was not completed when she was gone, on weekends, or on holidays.3. A policy that addressed the nursing staff posting was requested, but according to administrator A, the facility did not have a policy…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-12-17 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, document review, interview, and policy review, the provider failed to:*Ensure appropriate hand hygiene was performed by six dietary staff (K, T, U, BB, and CC) to meet professional food cleanliness standards.*Maintain three of three dishwashers and three of three sanitation solution containers in a manner that met professional food service sanitation standards.Findings include:1. Interview on 9/29/25 at 4:32 p.m. with resident 67 revealed she:*Preferred to eat her meals in her room.*Stated her food was often cold when she received it in her room.*Told the kitchen staff that her food was often cold, but no one had followed up with her regarding that concern, and her food continued to be delivered to her cold.2. Review of the provider's 2025 monthly resident council meeting minutes revealed:*At the 2/19/25 resident council meeting an identified concern was that the Scalloped potatoes are never done*At the 6/18/25 resident council meeting an identified concerns was that the Food temps [temperatures] need to be hotter-The response to this concern was that a plate…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-17 · tag F0585 — failed to handle grievances — pattern
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and policy review, the provider failed to implement an effective grievance process to ensure residents' satisfaction with the resolution of voiced grievances for:*Two of two sampled residents (55 and 76) regarding long call light response times and noise at night.*One of one sampled resident (89) regarding long call light response times and receiving medications late.*One of one sampled resident (67) regarding cold food and menu choices.*One of one sampled resident (90) regarding lost hearing aides. Findings include: 1. Interview on 9/29/25 at 4:21 p.m. with resident 89 revealed: *Resident 89 stated that she felt that one nurse aide had treated her poorly. Resident 89 explained that she went to bed at approximately 8:30 p.m. one evening and, about three hours later, activated her call light to request assistance to use the bathroom. When the nurse aide responded, the aide stated, I just took you. Resident 89 insisted on being taken to the bathroom, and the aide assisted her but commented, I can't be coming in every five minutes. Resident 89 told another nurse aide…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-17 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, record review, call light report review, and policy review the provider failed to ensure prompt staff response to resident call lights for seven of seven residents (30, 34, 45, 55, 71, 73, and 76 ) who complained of slow responses to call lights.Findings include:1. Interview on 9/29/25 at 4:26 p.m. with resident 71's husband in the hallway revealed: *He turned on his wife's call light when she was incontinent and needed staffs assistance, and it took the staff over 45 minutes to help his wife. *His wife was dependent on the staff to have her incontinence brief changed as she was immobilized. Observation on 9/30/25 at 8:44 a.m. of resident 71 in her room revealed: *She was sitting in a wheelchair, chewing on her clothing protector, and did not verbally respond to questions. Review of resident 71's EMR revealed: *She was admitted [DATE]. *Her 8/15/25 BIMS score was 0, which indicated her cognition was severely impaired. *She had diagnoses of Alzheimer's disease (a progressive and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-17 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to protect the resident's rights and ensure a resident's advance directive code status (an individual's desire to be resuscitated with cardiopulmonary resuscitation (CPR), specific limited interventions, or not resuscitated (DNR) if their heart stopped) wishes were identified accurately on the physician's orders and the care plans for one of 32 sampled resident (55).Findings include:1. Observation on [DATE] at 2:53 p.m. outside of resident 55's room revealed she had a red dot on her name plate on her door.2. Interview and review of resident 55's electronic medical record (EMR) on [DATE] at 4:30 p.m., and on [DATE] at 4:43 p.m. with licensed practical nurse (LPN)/resident care supervisor J revealed:*Residents' code statuses (specifies the type of emergent treatment a person wishes to receive if their heart or breathing would stop) were ordered by their physician.*The residents did not sign code status forms.*If a resident's…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure the staff followed respiratory professional standards for:*The clean storage of nasal cannulas (flexible tubing with prongs that delivers oxygen through the nose) for three of three sampled residents (5, 50, and 90) who used them.*The cleaning and storage of nebulizer masks (a mask worn when using a nebulizer machine that converts liquid medication into an inhalable mist) for three of three observed sampled residents (5, 42, and 63) who used them.*The cleaning of Continuous Positive Airway Pressure (CPAP) machines (a device that uses air pressure to keep breathing airways open) for two of two observed sampled resident (5 and 90) who had CPAP machines in their rooms.Findings include: 1. Observation and interview on 9/29/25 at 4:05 p.m. with resident 63 revealed that she was seated in a recliner in her room. Her right hand was contracted, and she was unable to move the fingers of her left hand. A nebulizer machine was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-17 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to ensure standard infection prevention practices were followed by:*Two of two certified nursing assistants (CNA) ( R and Y) and 1 of 1 registered nurses (RN) (Z) removed their gloves prior to entering the hallway.*Two of two CNAs (R and Y) and one of one RN (Z) performed hand hygiene (handwashing) prior to the application and after the removal of gloves for one of one residents (51).*One of one CNA (R) who used a phone with soiled gloves while in one of one sampled resident's (51) room who was on enhanced barrier precautions (glove and gown use) after assisting that resident with personal hygiene. Findings include:1. Observation on 9/30/25 at 9:18 a.m. in the [NAME] hallway revealed: *CNA Y exited a resident room with a glove on his right hand. *That resident's room had personal protective equipment (such as gowns, gloves, face shield, and masks) (PPE), and a sign posted on the door which indicated a resident who resided in that room was on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-01 · tag F0678 — failed to provide CPR when needed — pattern
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, and interview, the provider failed to withhold cardiopulmonary resuscitation (CPR) for one of one resident (1) with a do not resuscitate/do not intubate (DNR/DNI) code status (specifies the type of emergent treatment a person wishes to receive if their heart or breathing would stop) who experienced a choking episode, choked, and had no pulse or respirations after her airway was cleared.Findings include:1. Review of the provider's 7/27/25 SD DOH FRI revealed:*On 7/27/25, resident 1 choked while eating her lunch.*The nurse was called over to the table where resident 1 had been eating and finger swept a large bite of meat out of resident 1's mouth and did several back blows.*Staff members assisted resident 1 to stand, and the nurse did abdominal thrusts for several minutes with no luck dislodging the food.*911 was called and the EMTs [emergency medical technicians] and police arrived within minutes and were…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-04 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure professional standards of nursing practice were followed by licensed practical nurse (LPN) H who had failed to document and communicate one of one sampled resident (1) newly observed wound to the physician to initiate timely evaluation and treatment. Failure to document and communicate the new wound delayed wound treatment and may have delayed the healing of that wound. This citation is considered past non-compliance based on the review of the corrective actions the provider implemented immediately after they became aware of the wound and the provider's internal investigation. Findings include: 1. Review of the provider's 5/23/25 SD DOH FRI revealed: *On 5/22/25 resident [name] had been seen at a clinic appointment. *An ulceration to the dorsal aspect (back) of her left foot had been diagnosed and identified. *Treatment orders had been sent with resident 1 after…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Past Non-Compliance
• Potential for harm · E2024-05-16 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the provider failed to ensure: *Two of two sampled residents (38 and 68) home narcotic medications had been reconciled and accounted for. *Three of five residents (8, 29, and 55) did not receive expired medications. Findings include: 1. Observation and interview on 05/15/24 at 10:31 a.m. with registered nurse (RN) C at the medication cart located on the Dakota unit while reviewing the controlled medication reconciliation process revealed: *The locked controlled medication drawer contained: -Two bottles of resident 68's medications in a biohazard bag. --One bottle contained 43 gabapentin 300 milligrams (mg) capsules. --The second bottle contained 50 oxycodone 5 mg tablets. --The sheet of paper was dated 4/17/24 and contained a handwritten note Send home with family. *RN C stated the medication had been removed from resident 68's room and placed in the medication cart. *There was no controlled substance record form to confirm the count of the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$8,824 in federal fines across 1 penalty.

• $8,824 — penalty dated 2024-08-28

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to AVERA HEALTH — 13 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 24 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in SD