Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avera Prince Of Peace during CMS and state inspections, most recent first.
A resident was discharged to another LTC facility without proper documentation that the transfer was necessary, and without providing required written notice or appeal information to the resident or their representative. The facility relied on a signed admission addendum as justification, but did not meet federal requirements for discharge documentation or notification.
A resident was discharged to another LTC facility without receiving the required 30-day written notice or information about appeal rights. The resident's representative was verbally informed of the discharge, but neither the resident, representative, nor the Ombudsman received written notification as mandated by facility policy.
Residents were not provided with information about the grievance process and experienced ongoing delays in call light responses, with staff sometimes failing to return or responding negatively. Concerns about housekeeping, such as catheter bins and bed linen changes, remained unresolved for several months despite being repeatedly raised in resident council meetings. The grievance process was not discussed at council meetings, and issues were not effectively resolved by management.
Surveyors found that staff repeatedly left computers displaying residents' medical information unattended and visible in hallways, resident rooms, and nurses' stations. Despite facility policy and staff expectations to lock or close screens when not present, multiple instances were observed where PHI was accessible to unauthorized individuals, resulting in breaches of confidentiality.
Multiple residents reported neglect due to prolonged call light response times, with some waiting over 10 minutes and experiencing pain, incontinence, and emotional distress. Residents described staff as rude, rough, or dismissive, and expressed fear or reluctance to request assistance. Complaints about staff behavior and delayed care were repeatedly raised in council meetings and individual interviews, with documentation showing unresolved issues and insufficient investigation or follow-up.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Staff did not consistently perform hand hygiene or use gloves properly while handling and serving food, including touching hair, face, and uniforms before serving meals, and failing to wear required hairnets. Food items were left uncovered and accessible, with residents touching food that was later served to others, in violation of facility policies.
Staff did not consistently use required PPE or perform hand hygiene during high-contact care activities for residents on enhanced barrier precautions, including those with indwelling devices, wounds, or infections. Multiple staff were observed providing care, handling soiled linens, and performing sterile procedures without following established infection control policies, leading to widespread noncompliance.
A resident was administered psychotropic medications without clear medical necessity or was given medications that restrained their ability to function, in violation of regulations requiring the prevention of unnecessary drug use.
A resident with PTSD and bipolar 2 disorder, who was receiving related medications, had a completed PASRR Level II assessment that was not accurately documented in the MDS assessment. Staff interviews revealed that the PASRR Level II information was not properly entered, with the RN coordinator confirming inaccuracies in both comprehensive and quarterly MDS assessments, despite facility policy requiring accurate and complete documentation.
Surveyors identified that the facility failed to keep its medication error rate below 5%, with two errors out of twenty-seven observed administrations. One resident received carbidopa/levodopa late, and another received an underdose of Guaifenesin/DM SF, both administered by CMAs. The DON acknowledged the error rate, and the facility's policy defines these as medication errors.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors who noted environmental risks and insufficient staff monitoring.
Failure to Ensure Proper Transfer/Discharge Procedures and Documentation
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the transfer and discharge of a resident to another LTC facility met federal requirements. The resident, who was admitted to the rehabilitation area with a care plan goal to return home but with the understanding that a higher level of care might be needed, was discharged to another LTC facility approximately 75 miles away. The discharge was initiated after the care team determined the resident had not made sufficient progress in therapy and would require long-term care, which the facility stated could not be provided in the rehab unit. However, there was no documentation that the transfer was necessary for the resident's welfare, that the facility could no longer meet the resident's needs, that the resident's health had improved sufficiently, that the health or safety of others was endangered, or that the resident had failed to pay for their stay. Interviews with the resident's daughter revealed that the family was informed of the discharge only a few days prior and felt they were not given adequate time or notice to make alternative arrangements. The daughter also reported not being provided with information on how to appeal the discharge decision. The social worker confirmed that no written discharge notice or appeal information was given to the resident, their representative, or the ombudsman. The facility staff believed that the signed admission agreement addendum, which indicated the resident's consent to cooperate with discharge planning, was sufficient to proceed with the discharge without further documentation or notice. Review of facility policies and federal regulations showed that the facility's own policies required specific conditions to be met and documented for a transfer or discharge, including providing advance notice and information on appeal rights. Despite this, the facility did not provide evidence that any of the regulatory criteria for discharge were met in this case, nor did they follow the required notification and appeal procedures. The deficiency was identified through observation, interviews, record review, and policy review during the survey.
Failure to Provide Required Written Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to provide a written notice of discharge to a resident, the resident's representative, and the Office of the State Long-Term Care Ombudsman at least 30 days prior to a planned transfer to another long-term care facility. The resident was admitted with a care plan goal to return home but was instead discharged to another facility approximately 75 miles away. Documentation in the electronic medical record did not show that the required written notice was given. The resident's daughter reported being verbally informed of the discharge six days prior but did not receive written notice or information about the right to appeal the decision. Interviews with the facility's social worker confirmed that no written discharge notice or appeal information was provided to the resident, the representative, or the Ombudsman. The social worker believed that the signed admission addendum allowed for discharge without the 30-day written notice and did not notify the Ombudsman until after the discharge occurred. Review of facility policies indicated that a 30-day written notice and information about appeal rights are required, but these procedures were not followed in this case.
Failure to Address Resident Grievances and Timely Response to Requests
Penalty
Summary
The facility failed to provide residents with information about the grievance process and did not ensure prompt or satisfactory resolution of concerns raised during resident council meetings. Multiple residents were unable to identify the facility grievance official, and the grievance process was not discussed at council meetings. Residents reported extended wait times for call light responses, with staff sometimes turning off call lights and not returning, or responding with negative attitudes and aggressive actions. Several residents expressed fear or humiliation when requesting assistance, and some experienced incontinence or pain due to delayed staff response. Concerns about housekeeping, such as catheter bins left in rooms and uncertainty about bed linen changes, were repeatedly raised but remained unresolved over several months. Review of resident council meeting minutes over several months showed that issues such as call light response times, catheter bins, and bed-making were consistently reported as unresolved. Management responses to these concerns were either delayed or insufficient, with some issues persisting for at least three months. The social services designee was unaware of the need to discuss the grievance process at council meetings and had not involved the area ombudsman. Grievances were handled by social services staff and forwarded to the ADON, but ongoing issues were simply referred to department heads without effective resolution.
Failure to Secure Electronic PHI Exposes Resident Information
Penalty
Summary
Surveyors observed multiple instances where residents' personal and medical information was left visible and unsecured on computer screens throughout several neighborhoods in the facility, including Bluegrass Way, Platinum Ridge, Boulder Creek, and Arrowhead Trail. Computers on rolling stands and at nurses' stations were found with screens open to sensitive resident information, such as medical records and medication lists, while unattended by staff. In several cases, the screens were positioned so that information could be viewed from the hallway, and it was not always clear which staff member was logged in at the time. These observations occurred both inside resident rooms and in common areas, with no staff present to monitor or secure the information. Interviews with staff, including an LPN, RN coordinator, and the DON, confirmed that the expectation was for computer screens to be closed or locked when not in use to protect resident privacy. The facility's policy on safeguarding protected health information (PHI) requires staff to log off or lock workstations when leaving the area and to position monitors to prevent unauthorized viewing. Despite these policies, staff failed to consistently secure electronic PHI, resulting in multiple breaches of confidentiality as observed by surveyors.
Failure to Protect Residents from Neglect and Delayed Response to Call Lights
Penalty
Summary
Residents experienced neglect related to delayed staff response to call lights, with multiple reports indicating that residents waited 10 minutes or longer, and in some cases up to 30 minutes or more, for assistance. Residents described being left in pain, feeling humiliated, and in some cases becoming incontinent while waiting for help. Several residents reported that staff would turn off call lights and either leave without assisting or promise to return but did not, and some staff responded with anger or rudeness when residents requested help, especially at night. These issues were consistently raised in resident council meetings and individual interviews, with residents expressing fear or reluctance to use their call lights due to negative staff reactions. Documentation from resident council meetings over several months showed that concerns about long call light response times and staff behavior remained unresolved. Residents repeatedly reported that staff were rough, rude, or dismissive, and that their complaints were not always addressed or investigated thoroughly. Specific incidents included residents being left in soiled clothing for extended periods, being spoken to harshly, and experiencing physical discomfort or injury due to delayed or rough care. Call light audits confirmed that several residents experienced frequent and prolonged waits for assistance, particularly during busy times such as mornings. The facility's complaint and grievance records revealed a pattern of similar concerns from both residents and staff, including reports of staff ignoring call lights, yelling at residents, and providing rough or disrespectful care. Investigations into these complaints often lacked clear identification of the staff involved and did not always include thorough documentation of follow-up or resolution. Staff interviews indicated that while education on resident rights and abuse was provided, there was no consistent process for monitoring or addressing ongoing concerns, and some staff attributed negative interactions to cultural differences rather than addressing the underlying issues of neglect and disrespect.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory standards for the labeling and secure storage of medications and biologicals. No further details about specific residents, staff, or incidents are provided in the report.
Failure to Follow Hand Hygiene and Food Safety Practices During Meal Service
Penalty
Summary
Staff failed to follow standard food safety practices during multiple observed meal services in two of three neighborhood dining rooms. Specifically, servers and certified medication aides (CMAs) did not consistently perform hand hygiene or use gloves appropriately while handling food and serving residents. Observations included staff touching their hair, face, uniforms, and other non-food surfaces, then handling food or serving utensils without washing their hands. Additionally, some staff did not wear required hairnets, and food items such as bread and pastries were left uncovered and accessible to both staff and residents, with instances of residents touching multiple food items before they were served to others. The facility's own policies required hand hygiene before clean procedures, after glove removal, and when handling ready-to-eat foods, as well as the use of hairnets in the kitchen. Despite these policies, staff were observed repeatedly failing to wash hands after removing gloves, after touching potentially contaminated surfaces, and before handling food. Interviews with staff confirmed a lack of awareness regarding proper hand hygiene and food handling protocols, contributing to the observed deficiencies.
Failure to Follow Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
Staff failed to follow standard infection prevention and control practices for all sampled residents on enhanced barrier precautions (EBP). Observations revealed that staff, including certified medication aides, LPNs, RNs, and housekeepers, did not consistently wear required personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. These activities included transferring residents, providing hygiene, changing linens, and device care for residents with indwelling devices, wounds, or infections. In several instances, PPE was not visible or accessible, and staff were observed performing care without donning appropriate protective gear, despite clear signage and policy requirements. Multiple staff members were observed not performing hand hygiene at critical moments, such as before and after resident contact, after glove removal, and before handling clean supplies or equipment. Staff were also seen using the same gloves for multiple tasks, touching clean supplies with contaminated gloves, and failing to clean equipment and personal items after use in EBP rooms. In some cases, staff expressed uncertainty about the reasons for EBP or the correct procedures for hand hygiene and PPE use, despite existing policies and posted instructions. Residents involved had significant risk factors, including indwelling urinary catheters, feeding tubes, wounds, and histories of multidrug-resistant organism (MDRO) infections or urinary tract infections. The facility's own policies required sterile technique for certain procedures, such as urinary catheter flushing, and mandated that soiled linens be bagged at the point of care. However, staff were observed using non-sterile containers for sterile solutions, transporting soiled linens without proper containment, and storing clean supplies inappropriately. Interviews with facility leadership confirmed expectations for compliance with infection control policies, but direct observations and staff interviews demonstrated widespread noncompliance.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear medical justification or were given medications that limited their functional abilities, contrary to regulatory requirements.
Inaccurate PASRR Level II Coding on MDS Assessment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's Preadmission Screening and Resident Review (PASRR) Level II assessment was accurately coded on the Minimum Data Set (MDS) assessment. The resident, who had diagnoses of post-traumatic stress disorder (PTSD) and bipolar 2 disorder and was receiving medications for these conditions, had a PASRR Level II assessment completed as required. However, interviews with facility staff revealed that the PASRR Level II information was not properly documented in the MDS assessments. The social worker designee stated that while she completed the PASRR Level II assessments for her assigned unit, she did not document them in the MDS, leaving this responsibility to the RN coordinator. The RN coordinator confirmed that the resident's most recent comprehensive and quarterly MDS assessments were inaccurately marked and did not reflect the required PASRR Level II information, despite the resident having a qualifying diagnosis. Further review of facility policies indicated that all staff completing any portion of the MDS must sign to attest to its accuracy, and the assessment coordinator is responsible for ensuring accurate and complete MDS data is transmitted to CMS. The director of nursing confirmed the expectation for accurate MDS documentation. The facility's PASRR policy also requires individualized screening and appropriate documentation for residents with mental illness or intellectual disabilities. The failure to accurately code the PASRR Level II assessment on the MDS resulted in incomplete and inaccurate resident assessment documentation.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by regulation. During observation of medication administration, two errors were identified out of twenty-seven opportunities, resulting in a 7.41% error rate. In one instance, a certified medication aide (CMA) administered carbidopa/levodopa to a resident at 7:55 a.m., despite the medication being ordered for 6:30 a.m. The CMA indicated that the night shift typically administered this medication, but on this occasion, it was delayed and given by the day shift. The medication was ordered to be given three times daily. In another instance, a different CMA administered an incorrect dose of Guaifenesin/DM SF to a resident. The ordered dose was 10 mL, but only approximately 8 mL was measured and given, despite the CMA verifying the amount and stating it was correct. The facility's medication administration policy requires medications to be given at the correct time and dose, and defines such failures as medication errors. The Director of Nursing acknowledged the medication error rate during the survey.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
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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.
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Nursing homes near Sioux Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Norton | 2.6 mi | — | 21 | 0 |
| Good Samaritan Society Luther Manor | 3.1 mi | ★★★★★ | 11 | 0 |
| Bethany Home Sioux Falls | 3.9 mi | ★★★★★ | 3 | 0 |
| Good Samaritan Society Sioux Falls Center | 4.3 mi | ★★★★★ | 19 | 0 |
| Dow Rummel Village | 5 mi | ★★★★★ | 6 | 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 July 2026) and official state health department websites.