Avera Prince of Peace
4513 South Prince of Peace Place, Sioux Falls, SD 57103 · Minnehaha County · 126 certified beds · avg 121 residents/day · certified since Oct 1, 1992
Part of chain: AVERA HEALTH (13 facilities, chain avg rating 3.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jul 3, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 5, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (17)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Nov 6, 2025 | D · Potential for harm, one-off | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint |
| Nov 6, 2025 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint |
| Aug 21, 2025 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Aug 21, 2025 | E · Potential for harm, repeated | The facility did not keep residents' personal and medical information private and confidential. |
| Aug 21, 2025 | E · Potential for harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Aug 21, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Aug 21, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 21, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 21, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Aug 21, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Aug 21, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jul 3, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jul 3, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Mar 14, 2024 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Mar 14, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Mar 30, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 30, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 2 | 0 | E |
| 2024 | 2 | 0 | E |
| 2025 | 13 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $8,278.
| Date | Type | Amount / length |
|---|---|---|
| Jul 2, 2025 | Fine | $8,278 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | South Dakota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.89 | 4.32 | 3.95 | top 6% in South Dakota; top 5% in the U.S. |
| Registered Nurse hours | 1.51 | 0.91 | 0.69 | top 3% in South Dakota; top 5% in the U.S. |
| Weekend total nurse staffing | 5.46 | 3.71 | 3.50 | top 4% in South Dakota; top 3% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.09 | 0.51 | 0.48 | top 2% in South Dakota; top 5% in the U.S. |
| Total nursing staff turnover (%) | 25.0 | 48.2 | 45.8 | top 1% in South Dakota; top 7% in the U.S. |
| RN turnover (%) | 11.1 | 34.7 | 42.9 | top 6% in South Dakota; top 4% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.74, RN 1.47, weekend 5.32. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Avera Health | Organization | 5% or Greater Direct Ownership Interest | 100% | 06/15/1992 |
| Abourezk, Sanaa | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2024 |
| Avera Health | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2000 |
| Avera Health | Organization | Trustee of the SNF | NOT APPLICABLE | 01/01/2000 |
| Avera Health | Organization | ADP of the SNF | NOT APPLICABLE | 06/18/2025 |
| Berry, Patrick | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/25/2025 |
| Berry, Patrick | Individual | ADP of the SNF | NOT APPLICABLE | 06/18/2025 |
| Boschee, Ryan | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2024 |
| Bunkers, Jennifer | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2021 |
| Chrystal, Candyce | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2023 |
| Costello, Joseph | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2017 |
| Curran, Mary | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2015 |
| Dover, James | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/23/2023 |
| Fishback, Van | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2018 |
| Gordon, Jeffrey | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2023 |
| Hill Jensen, Cristina | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2018 |
| Kallemeyn, Brenda | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2023 |
| Kirby, Jennifer | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2020 |
| Knecht, Randy | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2018 |
| Knutson, Laurie | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2017 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Before a resident is discharged or transferred, how do you make sure the new place can actually meet their needs?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "Does your facility have an active resident council, and how does management respond to its concerns?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avantara Norton | 2.6 mi | Sioux Falls, SD | —/5 | abuseSFF | |
| Good Samaritan Society Luther Manor | 3.1 mi | Sioux Falls, SD | ★★☆☆☆ | 2/5 | |
| Bethany Home Sioux Falls | 3.9 mi | Sioux Falls, SD | ★★★☆☆ | 4/5 | |
| Good Samaritan Society Sioux Falls Center | 4.3 mi | Sioux Falls, SD | ★★☆☆☆ | 2/5 | abuse |
| Dow Rummel Village | 5.0 mi | Sioux Falls, SD | ★★★☆☆ | 2/5 | |
| Good Samaritan Society Sioux Falls Village | 5.3 mi | Sioux Falls, SD | ★★☆☆☆ | 2/5 | |
| Bethany Home - Brandon | 9.3 mi | Brandon, SD | ★☆☆☆☆ | 1/5 | abuse |
| Good Samaritan Society Canton | 14.3 mi | Canton, SD | ★★☆☆☆ | 3/5 | |
| Tuff Memorial Home | 16.7 mi | Hills, MN | ★★★★☆ | 5/5 | |
| Palisade Healthcare Center | 17.5 mi | Garretson, SD | ★☆☆☆☆ | 1/5 | abuse |
| Fellowship Village | 18.7 mi | Inwood, IA | ★★★★☆ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 435066.