Cycle 1
Health 2024-12-12 · Fire 2024-12-12
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Mitchell, SD
Avera Brady Health And Rehab
5-star overall rating with 4-star inspections with 3 recent health deficiencies
500 S Ohlman, Mitchell, SD
(605) 996-7701
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
74
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Avera Health
Operator or chain grouping
Approved since
1991-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 4 overall / 3 health / 5 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.44
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.20
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
3.09
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
4.73
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
4.10
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.95
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.51
CMS adjusted RN staffing hours
Adjusted total hours
4.98
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
16%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,183
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9988
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.59
Baseline 16.66% · Performance 19.77% · Measure score 3.59 · Achievement 3.59 · Improvement 0
Healthcare-associated infections
5.81
Baseline 6.19% · Performance 6.10% · Measure score 5.81 · Achievement 5.81 · Improvement 0.22
Total nurse turnover
4.57
Baseline 31.71% · Performance 45.00% · Measure score 4.57 · Achievement 4.57 · Improvement 0
Adjusted total nurse staffing
4.27
Baseline 4.60 hours · Performance 4.29 hours · Measure score 4.27 · Achievement 4.27 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.57% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 100 · Observed rate 5% · Lower 95% interval 6.63% |
| Discharge to community | 47.28% |
50.57%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 86 · Observed rate 48.84% · Lower 95% interval 38.4% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.87% |
95.27%
2.6 pts better
|
Numerator 92 · Denominator 94 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 94 |
| Discharge self-care score | 54.76% |
53.69%
1.1 pts better
|
Numerator 46 · Denominator 84 |
| Discharge mobility score | 57.14% |
50.94%
6.2 pts better
|
Numerator 48 · Denominator 84 |
| Pressure ulcers or injuries, new or worsened | 2.13% |
2.29%
0.2 pts better
|
Numerator 2 · Denominator 94 · Adjusted rate 2.44% |
| Healthcare-associated infections requiring hospitalization | 6.1% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 0% · Lower 95% interval 3.15% |
| Staff COVID-19 vaccination coverage | 24.83% |
8.2%
16.6 pts better
|
Numerator 36 · Denominator 145 |
| Staff flu vaccination coverage | 87.19% |
42%
45.2 pts better
|
Numerator 177 · Denominator 203 |
| Discharge function score | 63.1% |
56.45%
6.6 pts better
|
Numerator 53 · Denominator 84 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 47 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 31.91% |
25.2%
6.7 pts better
|
Numerator 15 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.5 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.9
0.9 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.7 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
95.4%
3 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 98.3% · Q3 98.3% · Q4 98.4% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
96.9%
1.6 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
5.1%
0.2 pts better
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 1.7% · Q3 6.7% · Q4 6.6% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
4.6%
4.2 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
5.5%
0.3 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 1.9% · Q3 7.4% · Q4 5.3% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.4% |
17.8%
0.6 pts worse
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 18.5% · Q3 20.4% · Q4 17.5% · 4Q avg 18.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.2% |
25.1%
13.9 pts better
|
16.7%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 10.2% · Q3 12.5% · Q4 10.2% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.4% |
21.3%
9.9 pts better
|
16.3%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 3.3% · Q3 7.8% · Q4 11.2% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.2% |
21.6%
12.4 pts better
|
14.9%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 7.8% · Q3 0.0% · Q4 15.1% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.0% |
2.0%
1 pts worse
|
1.0%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 2.3% · Q3 2.8% · Q4 2.8% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
3.3%
0.8 pts better
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.4% · Q3 1.7% · Q4 3.3% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.4% |
25.8%
0.6 pts worse
|
19.8%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.1% · Q2 27.2% · Q3 24.1% · Q4 32.4% · 4Q avg 26.4% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
4.6%
0.1 pts worse
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 3.6% · Q3 3.1% · Q4 2.8% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
83.2%
16.3 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.4% |
11.7%
1.7 pts worse
|
12.0%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 10.9% · Expected 9.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.7%
1 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.8% |
78.2%
15.6 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.3% |
21.5%
2.2 pts better
|
23.9%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.3% · Observed 14.5% · Expected 18.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-17 · Fire 2023-08-17
2 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2022-06-24 · Fire 2022-06-24
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-08-17
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-09-08
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-12
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-01-08
E · Potential for more than minimal harm
2024-12-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-08
D · Potential for more than minimal harm
2024-12-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-08
D · Potential for more than minimal harm
2023-08-17
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-15
Penalties and ownership
What sits behind the stars
Ownership
Avera Health
5% Or Greater Direct Ownership Interest · Organization
Avera Health
Operational/Managerial Control · Organization
Bergeleen, Darlene
Corporate Director · Individual
Brookbank, Julie
Corporate Director · Individual
Claussen, Jessica
Corporate Director · Individual
Dierks, Trevor
Corporate Director · Individual
Dover, James
Corporate Officer · Individual
Hunhoff, Mark
Corporate Director · Individual
Koehler, Jean
Corporate Director · Individual
Larson, Tracey
Corporate Director · Individual
Lautt, Julie
Corporate Officer · Individual
Puetz, Mark
Corporate Director · Individual
Rockwell, Hilary
Operational/Managerial Control · Individual
Rockwell, Hilary
Corporate Officer · Individual
Sandhoff, Diane
Corporate Director · Individual
Stahle, Nicole
Corporate Director · Individual
Tegethoff, Jennifer
Corporate Director · Individual
Thompson, Ryan
Corporate Director · Individual
Tolsma, Jay
Corporate Director · Individual
Zomer, Brad
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Firesteel Healthcare Center
Mitchell, SD
1-star overall rating with 1-star inspections with $110,798 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Avera Bormann Manor
Parkston, SD
3-star overall rating with 3-star inspections with $34,749 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Good Samaritan Society Corsica
Corsica, SD
5-star overall rating with 5-star inspections with $8,190 in total fines with 2 recent health deficiencies
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