01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-12-17 | 8 | 2025-12-17 | 2 |
| Cycle 2 | 2024-05-16 | 3 | 2024-05-16 | 2 |
| Cycle 3 | 2023-03-23 | 7 | 2023-03-23 | 3 |
CMS CCN 4350422026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Avera Mother Joseph Manor Retirement Community
1002 North Jay Street · Aberdeen, SD 57401 · Brown County
Certified beds81CMS provider file
Recent citation rows25current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
25 rows in the current release
3 rows carry G–L scope/severity codes; 0 carry J–L. 4 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-12-17 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-01-242025-12-17 · HEALTHF0585Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-01-242025-12-17 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2026-01-162025-12-17 · HEALTHF0725Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Correction field: Deficient, Provider has date of correction · 2026-01-242025-12-17 · HEALTHF0732Severity F · widespread; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has date of correction · 2025-12-262025-12-17 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-01-302025-12-17 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-01-302025-12-17 · FIREK0241Severity C · widespread; potential for minimal harm
Egress Deficiencies
Have correct number of accessible exits for each story.
Correction field: No revisit needed · 2025-12-262025-12-17 · FIREK0374Severity C · widespread; potential for minimal harm
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Correction field: No revisit needed · 2025-12-262025-08-01 · HEALTHF0678Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Correction field: Deficient, Provider has date of correction · 2025-09-18 · complaint2025-06-04 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Past Non-Compliance · 2025-05-27 · complaint2024-08-28 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Past Non-Compliance · 2024-07-31 · complaint2024-05-16 · HEALTHF0755Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2024-06-192024-05-16 · FIREK0241Severity C · widespread; potential for minimal harm
Egress Deficiencies
Have correct number of accessible exits for each story.
Correction field: Deficient, Provider has no plan of correction2024-05-16 · FIREK0374Severity C · widespread; potential for minimal harm
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Correction field: Deficient, Provider has no plan of correction2023-08-02 · HEALTHF0583Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Correction field: Deficient, Provider has date of correction · 2023-09-18 · complaint2023-03-23 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2023-04-212023-03-23 · HEALTHF0684Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2023-04-212023-03-23 · HEALTHF0686Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2023-04-212023-03-23 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2023-04-212023-03-23 · HEALTHF0849Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Correction field: Deficient, Provider has date of correction · 2023-04-212023-03-23 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2023-04-212023-03-23 · FIREK0241Severity C · widespread; potential for minimal harm
Egress Deficiencies
Have correct number of accessible exits for each story.
Correction field: Fire Safety Evaluation Survey · 2023-05-112023-03-23 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2023-04-2003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-08-28 | Fine | $8,824 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- AVERA HEALTHOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 01/01/1998
- BIERNE, KATHLEENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2018
- FAUTH, KRISTENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2022
- FOUBERG, ERINIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2025
- FRANKS, SHANEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2024
- GOLZ, HEIDIIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2018
- HEINZ, BLAKEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2024
- HERMAN, MICHAELIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2022
- JENSEN, PAULAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2023
- KERKVLIET, MARIETTAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2018
- KNAPP, MICHAELIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/01/2011
- MCNEIL, DAVIDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2025
- PANOWICZ, KATHLEENIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2014
- WOBST, GARRETIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2018
- BJERKNES, DANIELIndividual · CORPORATE OFFICERNOT APPLICABLE · since 08/15/2022
- DOVER, JAMESIndividual · CORPORATE OFFICERNOT APPLICABLE · since 10/23/2023
- HENRICKSON, PAULAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/26/2024
- LAUTT, JULIEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2020
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.06per resident day
RN hours0.96per resident day
Weekend nurse hours3.35per resident day
Staff turnover55.7%CMS reported field