Your report for Avera Mother Joseph Manor Retirement Community
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- South DakotaAbove only 49% of peers95 rated homes · average 2.9★
- Brown CountyAbove 50% of peers5 rated homes · average 3.2★
- United StatesAbove only 41% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point2★−0.8 vs SD avg
- StaffingCan add or remove a star5★+1.5 vs SD avg
- Quality measuresCan add or remove a star2★−0.9 vs SD avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersSD avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover5★Above 85% of peersSD avg3.5★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Above only 15% of peersSD avg2.9★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff4.02hrsAbove 70% of peersSD avg3.89Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.92hrsAbove 78% of peersSD avg0.80Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better46%Above 59% of peersSD avg50%RN turnover31%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$20,612Above only 36% of peersSD avg$25,187Fines · denials2 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthMar 2023 – Dec 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Dec 17, 2025Cycle 1worst F · no actual harm
- F732Post nurse staffing information every day.Nursing and Physician ServicesF · widespreadCorrected Dec 26, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jan 30, 2026
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jan 30, 2026
- F578Honor 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.Resident RightsD · isolatedCorrected Jan 24, 2026
- F585Honor 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.Resident RightsE · patternCorrected Jan 24, 2026
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Jan 16, 2026
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesE · patternCorrected Jan 24, 2026
Aug 1, 2025Cycle 1worst E · no actual harm
- Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the residentâs advance directives.Quality of Life and CareE · patternCorrected Sep 18, 2025
Jun 4, 2025Cycle 1worst D · no actual harm
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected May 27, 2025
Aug 28, 2024Cycle 2worst G · actual harm$8,824
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Jul 31, 2024
May 16, 2024Cycle 2worst E · no actual harm
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Jun 19, 2024
Aug 2, 2023Cycle 3worst D · no actual harm
- F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Sep 18, 2023
Mar 23, 2023Cycle 3worst G · actual harm$11,788
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Apr 21, 2023
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationD · isolatedCorrected Apr 21, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Apr 21, 2023
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareG · isolatedCorrected Apr 21, 2023
- F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Apr 21, 2023
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Apr 21, 2023
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined4.02hrs
- Registered nursesRN hours only0.92hrs
- Licensed practical nursesLPN hours0.53hrs
- Nurse aidesCNA hours2.57hrs
- Weekend nursingAll staff on Saturdays and Sundays3.34hrs
- South Dakota average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better46%Above 59% of peersSD avg 50%
- RN turnoverRegistered nurses only31%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy81 certified beds · ~77 residents a day95%Above 83% of peersSD avg 84%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $20,612In fines
- 2Fines
- 0Payment denials
- $25,187SD avg in fines
Actions on record
- Aug 28, 2024Civil money penalty$8,824
- Mar 23, 2023Civil money penalty$11,788
Ownership
As filed with CMSStructure
- Ownership type
- Non profit - Corporation
- Chain
- Avera Health12 facilities in the chain3.7★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Rural
- Ownership change
- None in the last 12 months
People and entities on file
- Avera Health
- Avera Health
- Daniel Bjerknes
- Kathleen Bierne
- Kristen Fauth
- John Fritz
- Heidi Golz
- Michael Herman
- Richard Inman
- Paula Jensen
- Marietta Kerkvliet
- +5 more
- Daniel Bjerknes
- James Dover
- Julie Lautt
- Amanda Schutz
- Mary Wickersham
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 435042 · 1002 NORTH JAY STREET, ABERDEEN, SD, 57401.
- Percentiles compare this facility with every rated nursing home in South Dakota and Brown County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
