Avera Sister James Care Center
2111 West 11th Street, Yankton, SD 57078 · Non profit - Corporation · 194 certified beds · (605) 668-8900 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
- it has 1 actual-harm citation
- the CMS record shows $8,492 in federal fines (most recent 2026-02-05)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
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
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
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.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.8% | 21.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.1% | 5.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.7% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.7% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.5% | 5.7% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.4% | 5.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 16.9% | 19.4% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 20.0% | 17.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.7% | 4.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.9% | 25.4% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.4% | 24.6% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 2.0% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 78.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.2% | 19.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 10.4% | 12.0% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.58 | 1.52 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 0.69 | 1.75 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
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.
53.1% 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 200 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 67.0% 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 179 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 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 53.1%CMS range 47.4–59.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.2%CMS range 7.3–13.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 67.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 63.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 59.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.8%CMS range 2.9–9.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 194 beds and averages 189.0 residents a day — about 97% occupied, or roughly 5 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 4.10 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.17 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.77 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 3.68 hrs/resident/day on weekends vs 4.27 on weekdays — 14% thinner on weekends. RN hours go from 1.32 to 0.79 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 31% is below 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.
9 citations, most serious first — scroll within the box to see all.
- Actual harm · G2026-02-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure the staff used assistive safety devices for one of one resident (1) who fell, suffered a broken nose, and required emergency room treatment, while ambulating to a meal when one of one certified medication aide (E) failed to use a gait belt (a waist strap gripped as support for safe mobility and transfers) while assisting resident 1 with ambulating (walking).Findings include: 1. Review of the 1/28/26 SD DOH FRI regarding resident 1 revealed:*He was ambulating to the dining room.*He tripped over his feet and fell forward hitting his head on a table and landed on the floor.*CMA E was walking with the resident, but did not use a gait belt.*He was sent to the emergency room for evaluation.*He had a nasal bone fracture (broken nose) and multiple skin tears on his face and arms. 2. Observation and interview on 2/4/26 at 9:10 a.m. with resident 1 in…
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.
- Potential for harm · E2026-05-14 · tag F0641 — patternEnsure each resident receives an accurate assessment.
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 record review, interview and Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual review, the provider failed to ensure four of six sampled residents' (3, 34, 107, and 151) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop and individualized care plan to manage the resident's care needs) assessments were accurately coded for the areas of diagnosis, Pre-admission Screening and Resident Review (PASRR) or dialysis. Findings include:1. Review of resident 34's EMR revealed he was admitted to the facility on [DATE]. His 2/24/26 BIMS assessment score was 15 which indicated his cognition was intact. He had a diagnosis of Chronic Bipolar Affective Disorder (a mental health condition that causes extreme, cyclical shifts in mood, energy and activity levels) dated 2/2/15. Resident 34 had a 11/20/23 Maximus notice of PASRR Level 1 screen outcome that indicated if a resident was currently in a…
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.
- Potential for harm · E2026-05-14 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the provider failed to follow food safety standards to ensure that equipment in food service and preparation areas was maintained in a sanitary condition for two of six pantry dishwashers, one of five wall-mounted fans, and one of fifteen handwashing sinks. This deficient practice had the potential to affect the safety of food served to residents. Findings include:1. Observation on 5/14/26 at 7:58 a.m. in the Country neighborhood pantry revealed that there was a thick layer of biofilm (a sticky film with germs) and food particle buildup on the inner surface of the dishwasher doors, which could result in dishes not being properly cleaned and sanitized, which could place residents at risk for foodborne illness.Across the room from the dishwasher, a fan was mounted to the wall. A layer of visible dust buildup was on the fan blades and the fan cage. The fan was blowing air across the room to where the hot-holding steam tables used to serve residents' food 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.
- Potential for harm · D2026-05-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, interview, and policy review the provider failed to ensure infection control practices were followed for one of two sampled residents (22) who used a nebulizer (a device that converts liquid medication into an inhalable mist) machine that was not cleaned after each use by the nursing staff and according to the provider's policy.Findings include:1. Observation on 5/12/26 at 10:35 a.m. of resident 22 in his room revealed, he placed his handheld nebulizer tube in the holder on the nebulizer machine after completing his treatment tubing was dated 4/2/26.2. Observation on 5/12/26 at 1:45 p.m. in resident 22's room revealed the handheld nebulizer tube was in the holder on the nebulizer machine, the nebulizer tube is dated 4/2/26 and had a small amount of clear liquid remaining in the chamber.3. Observation on 5/13/26 at 9:48 a.m. in resident 22's room revealed his handheld nebulizer tube was in the holder on the nebulizer machine with a clear liquid half-filled the medication chamber.4. Observation on 5/13/26 at 11:17 a.m. of resident 22's room…
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.
- Potential for harm · E2025-01-08 · tag F0926 — failed to keep the home smoke-free / fire-safe — patternHave policies on smoking.
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 implement their tobaco free campus policy for three of three sampled residents (66, 115, and 144) who smoked on the provider's property. Findings include: 1. Observation on 1/7/24 at 8:29 a.m. of resident 144 revealed: *She was seated in a wheelchair with a coat on. *She used the side exit door on the Chalkstone Drive neighborhood to go out to smoke. *The exit door had been propped open and a staff member stood there and monitored her while she smoked a cigarette. 2. Observation and interview on 1/7/25 at 9:56 a.m. with resident 66 in his room revealed: *He smoked and kept his smoking supplies in his room. *The staff would let him out when he wanted to go smoke. 3. Observation on 1/8/25 at 1:01 p.m. of resident 115 revealed: *She had been outside smoking on the facility property. *She discarded her cigarette in the landscaping in the facility parking lot. 4. Interview on 1/8/25 at 8:42 a.m. with registered nurse (RN)…
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.
- Potential for harm · D2025-01-08 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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' (80 and 330) had been assessed to determine their ability to have safely self-administered those medications and a physician's order to self-administer those medications. *One of one sampled resident (330) who stored a self-administered medication at his bedside had a physician's order to have stored that medication at his bedside. Findings included: 1. Observation and interview on 1/7/25 at 9:32 a.m. with resident 330 revealed: *Resident 330 was seated on the edge of the bed with a face oxygen mask on. *He was on 6 liters of oxygen. *Stated he had a bloody nose that morning. -Stated his nose would often get dry from the oxygen, and would bleed. *There was a prescription nasal spray on the bedside table. *Resident 330 stated he used that nasal spray every morning for his dry nose. Review of resident 330's electronic medical records (EMR) revealed: *He was admitted to the facility 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.
- Potential for harm · E2024-01-24 · tag F0676 — failed to keep up residents' daily-living abilities — patternEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a complaint, record review, observation, and interview, the provider failed to ensure six of eight sampled residents (1, 2, 3, 4, 5, and 6) had received regular scheduled bathing. Findings include: 1. Review of the South Dakota online report received on 1/10/24 revealed: *The complainant reported that on Sunday 1/7/24, the overnight shift was short-staffed and they had a concern about the residents safety. *The complainant was concerned that the day shift had also been short-staffed and often residents were not getting their scheduled baths, stating residents are going 8 or 9 days without a bath. *The provider had been short-staffed on and off for a while. *The complainant had addressed her concerns regarding staffing and bathing with the director of nursing but stated nothing has changed. *At the time of the report, the complainant had not thought any resident had a negative outcome from being short-staffed. 2. Observation and interview on 1/23/24 at 4:00 p.m. with resident 1 revealed: *He was sitting in his electric wheelchair at the end of the hall. *His hair was matted…
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.
- Potential for harm · D2023-09-14 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and policy review, the provider failed to ensure two of two sampled residents (17 and 71) on the 200 Cabin unit had received a proper notification of bed hold notice option upon their transfer out of the facility. Findings include: 1. Review of resident 17's electronic medical record (EMR) revealed: *She had a fall on 7/4/23 and was transferred to the emergency room. *Resident 17 was hospitalized for a left hip fracture on 7/4/23 and was discharged from the hospital on 7/7/23. *Her emergency contact had been notified on 7/4/23 of the fall and the need for an emergency room evaluation. *There had not been any documentation found regarding notification of the resident's bed hold. 2. Review of resident 71's EMR revealed: *He required an emergency room evaluation on 5/30/23. *Resident 71 was hospitalized for pneumonia on 5/30/23 and was discharged from the hospital on 6/2/23. *There was no documentation in the EMR that the resident's emergency contact had been notified of the necessity for an emergency room visit or bed hold notification. 3. Interview…
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.
- Potential for harm · D2023-09-14 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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
Based on observation, interview, record review, and policy review, the provider failed to ensure three of ten sampled residents (68, 77 and 155) were assessed for ability the to safely self-administer medications that had been prepared by one of one registered nurse (RN) BB and one of one licensed practical nurse (LPN) E prior to allowing those residents to self-administer medications. Findings include: 1. Observation and interview on 9/13/23 at 1:36 p.m. with RN BB preparing medication for administration for resident 68 reveled: *RN BB prepared gabapentin 300 milligrams (mg) oral capsule in a medication cup and placed it on the resident 68's bedside table. *RN BB stated that resident had a physician's order to self-administer her oral medication. *She had not stayed and observed the resident take their medication. Review of resident 68's electronic medical record (EMR) revealed: *There was no assessment completed for self-administration of that medication. *There was no physician's order to self-administer her medication. 2. Observation and interview on 9/14/23 at 7:00 a.m. with…
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.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,492 in federal fines across 1 penalty.
- $8,492 — penalty dated 2026-02-05
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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.7 | +1.3 vs chain |
| Health inspection | 4 of 5 | 3.5 | +0.5 vs chain |
| Staffing | 5 of 5 | 4.3 | +0.7 vs chain |
| Quality measures | 4 of 5 | 3.1 | +0.9 vs chain |
The other 12 homes this chain runs (chain average 3.7★, per CMS)
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
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| AVERA HEALTH | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2001 |
| DEMUTH, JONATHON | Individual | CORPORATE DIRECTOR | — | since 07/01/2025 |
| HUNHOFF, BERNIE | Individual | CORPORATE DIRECTOR | — | since 07/01/2019 |
| HURLEY, JOHN | Individual | CORPORATE DIRECTOR | — | since 07/01/2020 |
| KOLECKA, DEBRA | Individual | CORPORATE DIRECTOR | — | since 07/01/2017 |
| LEON, AMY | Individual | CORPORATE DIRECTOR | — | since 07/01/2019 |
| MINER, AMY | Individual | CORPORATE DIRECTOR | — | since 07/01/2025 |
| MOELLER, ARTHUR | Individual | CORPORATE DIRECTOR | — | since 07/01/2024 |
| REZAC, BARBARA | Individual | CORPORATE DIRECTOR | — | since 07/01/2025 |
| SCHINDLER, STEVE | Individual | CORPORATE DIRECTOR | — | since 07/01/2024 |
| SCHMEICHEL, STEVE | Individual | CORPORATE DIRECTOR | — | since 07/01/2024 |
| STEWARD, BRIAN | Individual | CORPORATE DIRECTOR | — | since 07/01/2018 |
| STROM, RICHARD | Individual | CORPORATE DIRECTOR | — | since 07/01/2017 |
| WELBIG, LUCILLE | Individual | CORPORATE DIRECTOR | — | since 07/01/2002 |
| HANSON, VICTORIA | Individual | CORPORATE OFFICER | — | since 05/03/2025 |
| LAUTT, JULIE | Individual | CORPORATE OFFICER | — | since 03/01/2020 |
| DOVER, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/23/2023 |
| ERICKSON, ANTHONY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/16/2026 |
| HOLSTEIN, MARTHA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2025 |
CMS files one row per role, so the 21 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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the South Dakota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 435070. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.