Cycle 1
Health 2025-12-17 · Fire 2025-12-17
9 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Aberdeen, SD
Avera Mother Joseph Manor Retirement Community
3-star overall rating with 2-star inspections with $20,612 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1002 North Jay Street, Aberdeen, SD
(605) 622-5850
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
81
Certified beds
Average residents
77
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Avera Health
Operator or chain grouping
Approved since
1990-05-11
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
0.92
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
2.57
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
4.02
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.08
CMS adjusted RN staffing hours
Adjusted total hours
4.70
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,006
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.35
Composite VBP score used to determine payment impact.
Payment multiplier
1.0069
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.24
Baseline 16.45% · Performance 19.00% · Measure score 5.24 · Achievement 5.24 · Improvement 0
Healthcare-associated infections
5.58
Baseline 6.23% · Performance 6.17% · Measure score 5.58 · Achievement 5.58 · Improvement 0.03
Total nurse turnover
5.73
Baseline 30.30% · Performance 40.28% · Measure score 5.73 · Achievement 5.73 · Improvement 0
Adjusted total nurse staffing
4.39
Baseline 4.32 hours · Performance 4.33 hours · Measure score 4.39 · Achievement 4.39 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.37% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 87 · Observed rate 5.75% · Lower 95% interval 5.85% |
| Discharge to community | 48.16% |
50.57%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 42.19% · Lower 95% interval 34.69% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 89.04% |
95.27%
6.2 pts worse
|
Numerator 65 · Denominator 73 |
| Falls with major injury | 4.11% |
0.77%
3.3 pts worse
|
Numerator 3 · Denominator 73 |
| Discharge self-care score | 51.79% |
53.69%
1.9 pts worse
|
Numerator 29 · Denominator 56 |
| Discharge mobility score | 48.21% |
50.94%
2.7 pts worse
|
Numerator 27 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 8.22% |
2.29%
5.9 pts worse
|
Numerator 6 · Denominator 73 · Adjusted rate 7.8% |
| Healthcare-associated infections requiring hospitalization | 6.17% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 3.28% · Lower 95% interval 3.02% |
| Staff COVID-19 vaccination coverage | 3.62% |
8.2%
4.6 pts worse
|
Numerator 5 · Denominator 138 |
| Staff flu vaccination coverage | 80.85% |
42%
38.8 pts better
|
Numerator 152 · Denominator 188 |
| Discharge function score | 55.36% |
56.45%
1.1 pts worse
|
Numerator 31 · Denominator 56 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.3% |
96.28%
About the same
|
Numerator 26 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 48.57% |
25.2%
23.4 pts better
|
Numerator 17 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.5
0.9 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.3 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.9
About the same
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
95.4%
4.2 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.5% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
96.9%
1.8 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.5% |
5.1%
3.4 pts worse
|
3.3%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 8.3% · Q3 9.0% · Q4 8.3% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
4.6%
2.3 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.0% · Q3 1.7% · Q4 1.4% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
5.5%
0.8 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 5.3% · Q3 6.8% · Q4 1.6% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.4% |
17.8%
1.4 pts better
|
19.6%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 16.7% · Q3 18.3% · Q4 18.5% · 4Q avg 16.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.4% |
25.1%
2.7 pts better
|
16.7%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 22.7% · Q3 23.3% · Q4 22.0% · 4Q avg 22.4% · 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 | 23.5% |
21.3%
2.2 pts worse
|
16.3%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 19.7% · Q3 18.6% · Q4 24.0% · 4Q avg 23.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.2% |
21.6%
3.6 pts worse
|
14.9%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 32.0% · Q3 14.9% · Q4 22.8% · 4Q avg 25.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
2.0%
0.2 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2% · 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 7.0% · Q2 0.0% · Q3 3.0% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.5% |
25.8%
0.3 pts better
|
19.8%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q2 28.4% · Q3 19.1% · Q4 19.9% · 4Q avg 25.5% |
| Percentage of long-stay residents with pressure ulcers | 7.2% |
4.6%
2.6 pts worse
|
5.1%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 9.6% · Q3 6.5% · Q4 7.9% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
83.2%
15.5 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 96.2% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
11.7%
2.8 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 9.1% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.7%
0.6 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 4.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.9% |
78.2%
13.7 pts better
|
79.7%
12.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.1% |
21.5%
3.4 pts better
|
23.9%
5.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.1% · Observed 20.0% · Expected 26.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-16 · Fire 2024-05-16
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-03-23 · Fire 2023-03-23
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
C · Minimal harm
2025-12-17
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2025-12-26
C · Minimal harm
2025-12-17
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-12-26
C · Minimal harm
2024-05-16
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Not marked corrected
C · Minimal harm
2024-05-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Not marked corrected
E · Potential for more than minimal harm
2023-03-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-20
C · Minimal harm
2023-03-23
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2023-05-11
C · Minimal harm
2023-03-23
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-05-11
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-17
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-12-26
F · Potential for more than minimal harm
2025-12-17
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 2026-01-30
E · Potential for more than minimal harm
2025-12-17
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2026-01-24
E · Potential for more than minimal harm
2025-12-17
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2026-01-24
D · Potential for more than minimal harm
2025-12-17
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2026-01-24
D · Potential for more than minimal harm
2025-12-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-12-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-30
E · Potential for more than minimal harm
2025-08-01
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-06-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-27
G · Actual harm
2024-08-28
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 2024-07-31
E · Potential for more than minimal harm
2024-05-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-19
D · Potential for more than minimal harm
2023-08-02
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-09-18
G · Actual harm
2023-03-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-21
G · Actual harm
2023-03-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-21
F · Potential for more than minimal harm
2023-03-23
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 2023-04-21
E · Potential for more than minimal harm
2023-03-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-23
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-23
F849 · Administration Deficiencies
Health
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.
Corrected 2023-04-21
Penalties and ownership
What sits behind the stars
$8,824
2024-08-28
Fine
Fine · fine $8,824
Fine
$11,788
2023-03-23
Fine
Fine · fine $11,788
Fine
Ownership
Avera Health
5% Or Greater Direct Ownership Interest · Organization
Avera Health
Operational/Managerial Control · Organization
Bierne, Kathleen
Corporate Director · Individual
Bjerknes, Daniel
Operational/Managerial Control · Individual
Bjerknes, Daniel
Corporate Officer · Individual
Dover, James
Corporate Officer · Individual
Fauth, Kristen
Corporate Director · Individual
Fritz, John
Corporate Director · Individual
Golz, Heidi
Corporate Director · Individual
Herman, Michael
Corporate Director · Individual
Inman, Richard
Corporate Director · Individual
Jensen, Paula
Corporate Director · Individual
Kerkvliet, Marietta
Corporate Director · Individual
Lautt, Julie
Corporate Officer · Individual
Lefebvre, Adam
Corporate Director · Individual
Panowicz, Kathleen
Corporate Director · Individual
Reynen, Diana
Corporate Director · Individual
Schutz, Amanda
Corporate Officer · Individual
Seyer, Thomas
Corporate Director · Individual
Wickersham, Mary
Corporate Officer · Individual
Wobst, Garret
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Prairie Heights Healthcare
Aberdeen, SD
5-star overall rating with 4-star inspections with 1 recent health deficiencies
#2
Bethesda Home of Aberdeen
Aberdeen, SD
4-star overall rating with 4-star inspections with 4 recent health deficiencies
#3
Aberdeen Health And Rehab
Aberdeen, SD
2-star overall rating with 2-star inspections with abuse icon flag with $44,220 in total fines with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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