Cycle 1
Health 2025-01-08 · Fire 2025-01-08
2 health deficiencies
Top issue: Environmental (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Yankton, SD
Avera Sister James Care Center
5-star overall rating with 5-star inspections with 2 recent health deficiencies
2111 West 11th Street, Yankton, SD
(605) 668-8900
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
187
Certified beds
Average residents
187
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.04
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.21
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
2.71
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
3.97
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.64
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.14
CMS adjusted RN staffing hours
Adjusted total hours
4.33
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
619
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
66.45
Composite VBP score used to determine payment impact.
Payment multiplier
1.0203
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.17
Baseline 16.68% · Performance 17.65% · Measure score 8.17 · Achievement 8.17 · Improvement 0
Healthcare-associated infections
6.94
Baseline 5.23% · Performance 5.76% · Measure score 6.94 · Achievement 6.94 · Improvement 0
Total nurse turnover
8.97
Baseline 28.57% · Performance 27.01% · Measure score 8.97 · Achievement 8.97 · Improvement 3.69
Adjusted total nurse staffing
2.50
Baseline 3.75 hours · Performance 3.79 hours · Measure score 2.50 · Achievement 2.50 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.21% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 237 · Observed rate 8.86% · Lower 95% interval 7.27% |
| Discharge to community | 53.08% |
50.57%
2.5 pts better
|
No Different than the National Rate · Eligible stays 200 · Observed rate 50.5% · Lower 95% interval 47.42% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.49% |
95.27%
3.2 pts better
|
Numerator 196 · Denominator 199 |
| Falls with major injury | 1.01% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 199 |
| Discharge self-care score | 67.5% |
53.69%
13.8 pts better
|
Numerator 108 · Denominator 160 |
| Discharge mobility score | 60.62% |
50.94%
9.7 pts better
|
Numerator 97 · Denominator 160 |
| Pressure ulcers or injuries, new or worsened | 1.51% |
2.29%
0.8 pts better
|
Numerator 3 · Denominator 199 · Adjusted rate 1.77% |
| Healthcare-associated infections requiring hospitalization | 5.76% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 129 · Observed rate 3.1% · Lower 95% interval 2.9% |
| Staff COVID-19 vaccination coverage | 2.88% |
8.2%
5.3 pts worse
|
Numerator 12 · Denominator 416 |
| Staff flu vaccination coverage | 89.47% |
42%
47.5 pts better
|
Numerator 561 · Denominator 627 |
| Discharge function score | 69.38% |
56.45%
12.9 pts better
|
Numerator 111 · Denominator 160 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 102 · Denominator 102 |
| Resident COVID-19 vaccinations up to date | 52.38% |
25.2%
27.2 pts better
|
Numerator 55 · Denominator 105 |
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 1.0 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.9
1.2 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
95.4%
4.4 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.4% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.9%
3.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
5.1%
1.7 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.0% · Q3 1.9% · Q4 3.8% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
4.6%
1.4 pts better
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.3% · Q3 6.7% · Q4 2.1% · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
5.5%
2.3 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.4% · Q3 3.1% · Q4 1.5% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.9% |
17.8%
2.9 pts better
|
19.6%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 16.5% · Q3 14.9% · Q4 16.2% · 4Q avg 14.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.9% |
25.1%
4.2 pts better
|
16.7%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 21.0% · Q3 18.8% · Q4 21.0% · 4Q avg 20.9% · 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 | 20.4% |
21.3%
0.9 pts better
|
16.3%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 23.4% · Q3 12.8% · Q4 20.5% · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.8% |
21.6%
0.8 pts better
|
14.9%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 19.5% · Q3 21.3% · Q4 16.7% · 4Q avg 20.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
2.0%
1.2 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 0.6% · Q4 0.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
3.3%
1.9 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 1.9% · Q4 1.3% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.0% |
25.8%
0.2 pts worse
|
19.8%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 31.2% · Q3 27.3% · Q4 21.8% · 4Q avg 26.0% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
4.6%
About the same
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 5.4% · Q3 5.8% · Q4 2.2% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
83.2%
16.8 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.1% |
11.7%
5.6 pts better
|
12.0%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 6.3% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.7%
1.1 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.1% · Q3 2.4% · Q4 2.2% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
78.2%
21.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.2% |
21.5%
2.3 pts better
|
23.9%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.2% · Observed 17.3% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-14 · Fire 2023-09-14
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-08-11 · Fire 2022-08-11
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2022-08-11
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-09-07
D · Potential for more than minimal harm
2022-08-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-08
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2025-02-15
D · Potential for more than minimal harm
2025-01-08
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-02-15
E · Potential for more than minimal harm
2024-01-24
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-02-15
D · Potential for more than minimal harm
2023-09-14
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-09-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-13
E · Potential for more than minimal harm
2022-08-11
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 2022-09-07
Penalties and ownership
What sits behind the stars
Ownership
Avera Health
5% Or Greater Direct Ownership Interest · Organization
Becker, Carolyn
Corporate Director · Individual
Ekeren, Douglas
Corporate Officer · Individual
Ekeren, Douglas
W-2 Managing Employee · Individual
Greeneway, Kathy
Corporate Director · Individual
Hunhoff, Bernie
Corporate Director · Individual
Hurley, John
Corporate Director · Individual
Kolecka, Debra
Corporate Director · Individual
Lautt, Julie
Corporate Officer · Individual
Leon, Amy
Corporate Director · Individual
Loecker, Ryan
Corporate Director · Individual
Lorang, Thomas
Corporate Director · Individual
Mikkelsen, Beth
Corporate Director · Individual
Reifenrath, Bruce
Corporate Director · Individual
Schindler, Steve
Corporate Director · Individual
Seifert, Roxanne
Corporate Director · Individual
Steward, Brian
Corporate Director · Individual
Strom, Richard
Corporate Director · Individual
Sutton, Bobby
Corporate Director · Individual
Welbig, Lucille
Corporate Director · Individual
Nearby options
Other facilities in reach
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#2
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#3
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