Cycle 1
Health 2025-09-11 · Fire 2025-09-11
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Pierre, SD
Avera Maryhouse Long Term Care
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
717 East Dakota, Pierre, SD
(605) 224-3163
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
80
Certified beds
Average residents
56
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Avera Health
Operator or chain grouping
Approved since
1985-08-26
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.08
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
2.63
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
4.45
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
3.82
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.66
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.34
CMS adjusted RN staffing hours
Adjusted total hours
5.51
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,540
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.15
Composite VBP score used to determine payment impact.
Payment multiplier
1.0030
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.43
Baseline 19.39% · Performance 19.38% · Measure score 4.43 · Achievement 4.43 · Improvement 0
Healthcare-associated infections
4.7
Baseline 5.60% · Performance 6.43% · Measure score 4.7 · Achievement 4.7 · Improvement 0
Total nurse turnover
3.51
Baseline 42.31% · Performance 49.35% · Measure score 3.51 · Achievement 3.51 · Improvement 0
Adjusted total nurse staffing
7.03
Baseline 5.23 hours · Performance 5.08 hours · Measure score 7.03 · Achievement 7.03 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.84% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 105 · Observed rate 3.81% · Lower 95% interval 5.46% |
| Discharge to community | 64.29% |
50.57%
13.7 pts better
|
Better than the National Rate · Eligible stays 99 · Observed rate 66.67% · Lower 95% interval 56.5% |
| Medicare spending per beneficiary | 0.65 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 95.1% |
95.27%
0.2 pts worse
|
Numerator 97 · Denominator 102 |
| Falls with major injury | 1.96% |
0.77%
1.2 pts worse
|
Numerator 2 · Denominator 102 |
| Discharge self-care score | 47.67% |
53.69%
6 pts worse
|
Numerator 41 · Denominator 86 |
| Discharge mobility score | 38.37% |
50.94%
12.6 pts worse
|
Numerator 33 · Denominator 86 |
| Pressure ulcers or injuries, new or worsened | 1.96% |
2.29%
0.3 pts better
|
Numerator 2 · Denominator 102 · Adjusted rate 2.57% |
| Healthcare-associated infections requiring hospitalization | 6.43% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 3.57% · Lower 95% interval 3.3% |
| Staff COVID-19 vaccination coverage | 2.59% |
8.2%
5.6 pts worse
|
Numerator 3 · Denominator 116 |
| Staff flu vaccination coverage | 87.27% |
42%
45.3 pts better
|
Numerator 96 · Denominator 110 |
| Discharge function score | 66.28% |
56.45%
9.8 pts better
|
Numerator 57 · Denominator 86 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 65 · Denominator 65 |
| Resident COVID-19 vaccinations up to date | 37.68% |
25.2%
12.5 pts better
|
Numerator 26 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.9
0.4 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.4%
4.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
96.9%
1.1 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.6% |
5.1%
1.5 pts worse
|
3.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 8.5% · Q3 6.0% · Q4 6.0% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.6%
4.6 pts better
|
11.4%
11.4 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 who lose too much weight | 5.4% |
5.5%
0.1 pts better
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 5.0% · Q3 4.5% · Q4 4.8% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.5% |
17.8%
10.3 pts better
|
19.6%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 7.3% · Q3 8.5% · Q4 6.8% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.8% |
25.1%
9.3 pts better
|
16.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 11.4% · Q3 20.0% · Q4 15.8% · 4Q avg 15.8% · 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 | 14.9% |
21.3%
6.4 pts better
|
16.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 15.1% · Q3 20.7% · Q4 7.0% · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.9% |
21.6%
4.3 pts worse
|
14.9%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 28.9% · Q3 31.1% · Q4 16.7% · 4Q avg 25.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 7.2% |
2.0%
5.2 pts worse
|
1.0%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 7.3% · Q3 8.5% · Q4 4.6% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.2% |
3.3%
0.9 pts worse
|
1.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 4.3% · Q3 2.1% · Q4 4.3% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.2% |
25.8%
4.4 pts worse
|
19.8%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.1% · Q2 32.3% · Q3 25.4% · Q4 25.5% · 4Q avg 30.2% |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
4.6%
3.1 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 4.4% · Q3 12.2% · Q4 7.4% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
83.2%
16 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 98.5% · Q3 100.0% · Q4 100.0% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.0% |
11.7%
4.3 pts worse
|
12.0%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 14.5% · Expected 10.2% · 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 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.7% |
78.2%
11.5 pts better
|
79.7%
10 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.6% |
21.5%
5.9 pts better
|
23.9%
8.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 12.9% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-21 · Fire 2024-03-21
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-03-16 · Fire 2023-03-16
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
C · Minimal harm
2025-09-11
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2025-10-24
C · Minimal harm
2025-09-11
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-10-24
C · Minimal harm
2025-09-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-10-24
B · Minimal harm
2025-09-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-10-24
B · Minimal harm
2025-09-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-24
B · Minimal harm
2025-09-11
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-10-24
C · Minimal harm
2024-03-21
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Not marked corrected
C · Minimal harm
2024-03-21
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Not marked corrected
C · Minimal harm
2024-03-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-03
E · Potential for more than minimal harm
2023-03-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-04
C · Minimal harm
2023-03-16
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2023-05-04
C · Minimal harm
2023-03-16
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-05-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-10-24
D · Potential for more than minimal harm
2025-09-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-24
D · Potential for more than minimal harm
2025-07-02
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-15
E · Potential for more than minimal harm
2024-03-21
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 2024-05-06
D · Potential for more than minimal harm
2024-03-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-06
D · Potential for more than minimal harm
2023-03-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-04
D · Potential for more than minimal harm
2023-03-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-04
D · Potential for more than minimal harm
2023-03-16
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 2023-05-04
Penalties and ownership
What sits behind the stars
Ownership
Avera Health
5% Or Greater Direct Ownership Interest · Organization
Avera Health
Operational/Managerial Control · Organization
Krebs, Shantel
Operational/Managerial Control · Individual
Krebs, Shantel
Corporate Officer · Individual
Plumage, Darrell
Corporate Director · Individual
Raske, Talli
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Avantara Pierre
Pierre, SD
2-star overall rating with 2-star inspections with abuse icon flag with $22,048 in total fines with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Highmore Health
Highmore, SD
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Avera Oahe Manor
Gettysburg, SD
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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