Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avera Maryhouse Long Term Care during CMS and state inspections, most recent first.
A provider failed to complete self-administration medication assessments for two residents who had medications in their rooms and were taking them on their own. One resident with intact cognition kept PreserVision AREDS and Lutein in a bedside drawer without current physician orders or a self-administration assessment, and another resident with moderately impaired cognition had an order to self-administer fluticasone propionate nasal spray but no assessment and no care plan entry reflecting self-administration. Staff and the DON confirmed that an order, assessment, and care plan update were expected for residents who self-administer medications.
A resident with an indwelling catheter and NC oxygen had the catheter bag repeatedly observed on the floor and under a wheelchair, and NC tubing was also found on the floor. An RN wiped the NC prongs with an incontinent care wipe and reapplied the tubing to the resident's face, despite the tubing having last been changed 22 days earlier and being ordered for weekly changes. Staff interviews and policy review confirmed catheter bags should not touch the floor and oxygen tubing should be changed per MIFU.
A resident with moderate cognitive impairment sustained serious injuries, including subarachnoid hemorrhages and fractures, after falling from a whirlpool tub chairlift during a transfer by a CNA. The incident, which required immediate reporting to the SD DOH within two hours per facility policy, was not reported until nearly a day later. Staff interviews confirmed the delay and inconsistency in timely reporting of major injuries.
Failure to complete self-administration assessments and care plan updates
Penalty
Summary
The provider failed to ensure self-administration of medication assessments were completed for two residents who had medications in their rooms and were self-administering them. One resident had intact cognition with a BIMS score of 15 and was observed keeping PreserVision AREDS and Lutein in her bedside stand drawer, stating she took them occasionally and not every day; neither bottle had a label indicating use, and there was no current physician order for either supplement or a self-administration assessment in the EMR. Another resident had a BIMS score of 10 indicating moderately impaired cognition and had a physician order to self-administer fluticasone propionate nasal spray, which was observed sitting on his windowsill; he said he had not used it in a couple of weeks, but there was no self-administration assessment completed and his care plan did not indicate self-administration of medications. Interviews with nursing staff and the DON confirmed that a physician order, a self-administration assessment, and care plan updates were expected when a resident self-administered medication. Staff stated the resident's ability to safely self-administer should be assessed by nursing or the IDT and reflected in the care plan. The DON acknowledged that the resident with fluticasone did not have a self-administration assessment completed and was unaware that the other resident had PreserVision AREDS and Lutein in her room until informed during the survey.
Infection Control Lapses With Catheter Bag and NC Tubing
Penalty
Summary
Infection control practices were not followed for a resident with an indwelling urinary catheter and nasal cannula oxygen therapy. On 9/9/25, surveyors observed the resident's catheter bag lying on the floor next to the bed without a covering or barrier, then later observed the uncovered catheter bag under the resident's wheelchair in the dining room touching the floor. The resident was also observed with nasal cannula tubing and oxygen tubing lying on the floor in the room. On 9/10/25, an RN and LPN were observed in the resident's room and the nasal cannula tubing was again found on the floor, coiled under the bedside table wheel. The RN picked up the tubing, wiped the prongs with an incontinent care wipe, and reapplied it to the resident's face, stating this was her usual process for cleaning NC tubing found on the floor. The RN checked the EMR and found the tubing had last been changed 22 days earlier, although it was ordered to be changed every Monday at 2:30 p.m. The RN then returned with new NC tubing, and the LPN picked up the catheter bag from the floor and hung it on the bed frame. Staff interviews and policy review showed catheter bags should be hung below the bladder and not touch the ground, and oxygen tubing should be changed per manufacturer instructions.
Failure to Timely Report Resident Fall with Major Injury
Penalty
Summary
The facility failed to report a serious incident involving a resident who sustained major injuries from a fall within the required two-hour timeframe to the South Dakota Department of Health (SD DOH). The resident, who was moderately cognitively impaired with a BIMS score of 10, fell from a whirlpool tub chairlift while being transferred by a CNA. The safety belt had been loosened at the resident's request but not removed. Following the fall, the resident was found unconscious and bleeding from the forehead, and was subsequently sent to the emergency room where he was diagnosed with two subarachnoid hemorrhages, a closed nasal bone fracture, and lacerations to the forehead and right lower extremity. Despite the facility's policy requiring immediate reporting of incidents involving serious bodily injury within two hours, the initial Facility Reported Incident (FRI) was not submitted to the SD DOH until nearly 22 hours after the event. Interviews with staff, including the social worker, administrator, and DON, confirmed the delay in reporting and acknowledged that the facility was not consistent in meeting the required reporting timeframe for major injuries. The facility's policy and staff expectations were reviewed, highlighting the lapse in timely notification to the appropriate authorities.
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Illustrative
What surveyors actually found near you
We read the 12 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pierre
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Pierre | 0.1 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.