Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Sister James Care Center during CMS and state inspections, most recent first.
MDS assessments were inaccurately coded for several residents. One resident with Chronic Bipolar Affective Disorder had a PASRR Level I outcome indicating the condition should be documented, but A1500 was coded no and A1510 was not completed. Another resident with bipolar II, depression, and anxiety was not properly referred for PASRR review and was also coded no at A1500. A third resident receiving regular dialysis had no dialysis documented on the admission MDS, and a fourth resident with a Level II PASRR and mental health diagnosis was also coded no at A1500.
Unsanitary conditions were observed in two neighborhood pantries when dishwashers had thick biofilm and food particle buildup on the inner doors, one handwashing sink had grayish buildup, and a wall-mounted fan had visible dust buildup while blowing air toward the food service area. Staff stated the dishwasher and sinks were supposed to be cleaned daily, but the buildup was not known to the FSW-FA, CDM, or DSS, and there were no checklists showing when cleaning tasks were last completed.
Nebulizer equipment was not cleaned after use for a resident receiving scheduled and PRN inhaled treatments. Observations showed the nebulizer chamber repeatedly left with clear liquid remaining, and the tubing was dated weeks earlier. Staff interviews confirmed the LPN did not rinse the nebulizer after treatments, and the RN supervisor stated the chamber should be rinsed and air-dried after each use per policy.
Staff failed to follow a high fall-risk resident’s care plan and facility policy requiring use of a gait belt during assisted ambulation. The cognitively intact resident, with CHF, weakness, hyponatremia, and multiple documented high fall-risk assessments, was care planned and discharged from therapy for one-person contact guard assist with a walker and gait belt, including during a walk-to-dine program. While being walked to the dining room by a CMA who knew the resident required one-person assist, no gait belt was used; the resident walked too fast, his walker moved too far ahead, he tripped over his feet, fell forward into a table, and sustained a nasal bone fracture and multiple skin tears, requiring ER evaluation.
The facility failed to enforce its tobacco-free campus policy, allowing three residents to smoke on the property. Observations showed residents smoking outside exit doors and keeping smoking supplies in their rooms. Staff interviews confirmed noncompliance with the policy, despite residents being assessed as safe to smoke independently. The facility's policy prohibited smoking on campus, but residents were still permitted to smoke outside.
Two residents were allowed to self-administer medications without proper assessments or physician's orders. One resident used a nasal spray for a dry nose caused by oxygen use, while another used a nebulizer for breathing treatments. The facility's policy requiring assessments and orders was not followed.
MDS Assessments Were Inaccurately Coded for PASRR, Diagnosis, and Dialysis
Penalty
Summary
The facility failed to ensure accurate MDS coding for diagnosis, PASRR, and dialysis information for four sampled residents. The report states that resident 34 had a diagnosis of Chronic Bipolar Affective Disorder and a Maximus PASRR Level I screen outcome indicating the facility should document the PASRR condition in Medicaid nursing facility paperwork, but the 2/24/26 annual MDS coded A1500 as no, which prevented A1510 from being completed with the resident’s diagnosis. The SSD later confirmed she completed the section A coding and agreed A1500 should have been marked yes based on the PASRR outcome. Resident 107 was admitted with diagnoses including bipolar II, depression, and anxiety, and the record showed a psychiatric provider note documenting bipolar II since 1/14/13. The hospital completed the Level I PASRR before admission but did not indicate bipolar II and the resident was not referred for a Level II PASRR review. The SSD stated she should have reviewed the diagnoses at admission, identified bipolar II, completed a new Level I PASRR, and referred the resident for Level II review, but the admission MDS still coded A1500 as no. Resident 151 returned from dialysis treatments on a regular schedule of Tuesdays, Thursdays, and Saturdays, yet the 5/1/26 admission MDS did not indicate dialysis. The RN supervisor acknowledged dialysis was being received and should have been documented on the MDS. Resident 3 had paranoid delusional disorder, a 4/3/25 Level I PASRR screen, and a Level II PASRR review indicating a mental health diagnosis, but the comprehensive 3/11/26 MDS still coded A1500 as no for a mental health diagnosis. The SSD stated she was responsible for completing A1500 for residents in the Cabin neighborhood and that resident 3’s MDS should have been coded yes.
Unsanitary Dishwasher, Sink, and Fan Conditions in Pantry Areas
Penalty
Summary
Food service equipment and areas were not maintained in a sanitary condition in two neighborhood pantries. On 5/14/26 at 7:58 a.m. in the Country neighborhood pantry, a thick layer of biofilm and food particle buildup was observed on the inner surface of the dishwasher doors. A wall-mounted fan in the same area had visible dust buildup on the fan blades and cage and was blowing air across the room toward the hot-holding steam tables used to serve residents' food. On 5/14/26 at 11:39 a.m. in the Chalkstone neighborhood pantry, an unidentified grayish buildup was observed in one handwashing sink, and the dishwasher again had a thick layer of biofilm and food particle buildup on the inner surface of the dishwasher doors. During interview, the food service worker-feeding assistant and the certified dietary manager stated that staff were supposed to clean the sinks and dishwasher daily. The food service worker-feeding assistant described cleaning the dishwasher by turning it off, draining the water, spraying the inside parts and wash arms with plain water, and removing the catch screens to spray them off in the sink. Neither the food service worker-feeding assistant nor the certified dietary manager was aware of the buildup on the dishwasher doors in the Chalkstone pantry. The director of support services stated that the staff had standard kitchen and neighborhood pantry cleaning task lists, but there were no checklists to show when those tasks were last completed, and he was not aware of the buildup on the dishwasher doors in both observed pantries.
Nebulizer Equipment Not Cleaned After Use
Penalty
Summary
Infection control practices were not followed for a resident who used a nebulizer for respiratory treatments. The resident had orders for Albuterol PRN, Albuterol/Ipratropium PRN, and Albuterol/Ipratropium BID by nebulizer, and he was also ordered to self-administer treatments after staff set-up assistance. He was cognitively intact with a BIMS score of 14. Observations over several days showed the handheld nebulizer tube remained in the holder on the nebulizer machine with clear liquid still present in the medication chamber, including a chamber that was half-filled with clear liquid on multiple occasions. The tubing was dated 4/2/26, and the resident stated it had been more than a week since staff changed the nebulizer tube. The resident's nebulizer tubing was ordered to be changed weekly on Wednesdays at 7:00 p.m., and staff interviews confirmed the tubing should be dated when changed. The LPN stated it was the nurse's responsibility to rinse the nebulizer tube and attachments after use and acknowledged she did not rinse the resident's nebulizer tube and attachments on 5/12/26 or 5/14/26 when she completed set-up of the nebulizer medications. The RN supervisor stated the nebulizer tube and attachments were to be changed daily, the oxygen tubing weekly, and that the medication chamber should be rinsed after each use and left to air-dry. She also confirmed there was no MAR task reminding nurses to return and rinse the nebulizer after treatment. The provider's Respiratory Equipment Care policy required the nebulizer to be emptied, rinsed with sterile or distilled water after every treatment, and stored to air dry, with the nebulizer replaced weekly.
Failure to Use Required Gait Belt During Assisted Ambulation Resulting in Fall With Injury
Penalty
Summary
Staff failed to follow an identified fall-risk resident’s care plan and facility policy requiring use of a gait belt during assisted ambulation, resulting in a fall with injury. The resident, who was cognitively intact with a BIMS score of 15, had diagnoses including CHF, weakness, and hyponatremia, and had been assessed multiple times as being at high risk for falls. His care plan and therapy discharge instructions specified that he required one-person assist with ambulation using a walker and a gait belt, and he was on a walk-to-dine program in which staff were to walk with him to and from meals. The care plan interventions included use of a walker with a gait belt and one assist, wheelchair with foot pedals for distance, and cues to slow down when ambulating. On the day of the incident, the resident was ambulating to the dining room with a certified medication aide who knew he required one-person assist with ambulation but did not apply a gait belt. As they walked, the resident began walking too fast, his walker moved too far in front of him, and despite the aide cueing him to slow down, he tripped over his own feet, fell forward into a table, hit his head, and landed on the floor. He sustained a nasal bone fracture and multiple skin tears on his face and arms and required evaluation in the emergency room. Subsequent observations showed multiple cuts and bruises on his face and arms, and interviews with staff and therapy confirmed that a gait belt should have been used whenever he was assisted with walking, in accordance with his care plan and the facility’s gait belt and falls/accident policies.
Failure to Enforce Tobacco-Free Campus Policy
Penalty
Summary
The provider failed to implement their tobacco-free campus policy for three residents who smoked on the property. Observations revealed that Resident 144 was seen smoking outside the side exit door, which had been propped open, while a staff member monitored her. Resident 66 was found to keep smoking supplies in his room and was allowed by staff to smoke outside when he wished. Resident 115 was observed smoking on the facility property and discarding her cigarette in the landscaping. Interviews with staff confirmed that residents were smoking on campus despite the tobacco-free policy, and that the Director of Nursing (DON) was planning to inform residents of a smoking ban. The residents involved were cognitively intact, as indicated by their Brief Interview of Mental Status (BIMS) scores of 15. They had various medical conditions, including bipolar disorder, chronic kidney disease, and diabetes. Smoking assessments had been completed for these residents, determining them safe to smoke independently. The facility's policy, as outlined in their welcome booklet and Tobacco-Free Campus Policy, clearly stated that smoking was not permitted on the campus by anyone, and tobacco waste should not be left on the property. Despite this, the facility allowed residents to smoke outside exit doors, and smoking supplies were kept in residents' rooms or at the nurses' station.
Failure to Assess and Obtain Orders for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents, identified as 80 and 330, were assessed for their ability to safely self-administer medications and did not obtain the necessary physician's orders for self-administration. Resident 330 was observed with a prescription nasal spray at his bedside, which he used daily for a dry nose caused by oxygen use. Despite a request for a physician's order for the nasal spray, there was no documented assessment or order for the resident to self-administer the medication or to keep it at his bedside. The RN supervisor was unaware of the resident's self-administration and acknowledged the lack of a completed assessment. Similarly, resident 80 was observed using a nebulizer machine for breathing treatments without a physician's order for self-administration. The resident's electronic medical records indicated scheduled nebulizer treatments, but there was no documentation of an assessment or order for self-administration. An RN confirmed that it was her practice to allow the resident to self-administer the treatment, but she was unaware if an assessment had been completed. The facility's policy requires an interdisciplinary team assessment and a physician's order for self-administration, which were not followed in these cases.
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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 Yankton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sd Human Services Center - Geriatric Program | 2.8 mi | ★★★★★ | 0 | 0 |
| Wakonda Heritage Manor | 18.6 mi | ★★★★★ | 5 | 0 |
| Sunset Manor Avera Health | 19.6 mi | ★★★★★ | 12 | 0 |
| Accura Healthcare Of Hartington | 19.7 mi | ★★★★★ | 5 | 0 |
| Good Samaritan Society - Bloomfield | 22.4 mi | ★★★★★ | 8 | 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.