Monument Health Sturgis Care Center
2140 Junction Avenue, Sturgis, SD 57785 · Meade County · 40 certified beds · avg 36 residents/day · certified since May 1, 1997
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
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 · Jun 10, 2025 · F-0610 · triggered by a complaint
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.
Why it matters: When allegations aren't investigated, harm to residents can continue unchecked.
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: Jul 10, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 3, 2024 · F-0656 · triggered by a complaint
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.
Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.
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: Mar 27, 2024 (Past Non-Compliance)
All citations in the current public record (22)
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 |
|---|---|---|
| Mar 19, 2026 | 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. |
| Mar 19, 2026 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Mar 19, 2026 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Mar 19, 2026 | D · Potential for harm, one-off | 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. |
| Jun 10, 2025 | ▲ G · Actual 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 |
| Jun 10, 2025 | D · Potential for 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 |
| Feb 19, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Feb 19, 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. · from a complaint |
| Feb 19, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 3, 2024 | F · Potential for harm, facility-wide | 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. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Oct 3, 2024 | 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. |
| Apr 3, 2024 | ▲ G · Actual 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. · from a complaint |
| Nov 15, 2023 | E · Potential for harm, repeated | 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 20, 2023 | F · Potential for harm, facility-wide | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Jul 20, 2023 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jul 20, 2023 | 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. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jul 20, 2023 | D · Potential for harm, one-off | When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (5 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 7 | 0 | F |
| 2024 | 6 | 1 | G ▲ |
| 2025 | 5 | 1 | G ▲ |
| 2026 | 4 | 0 | E |
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)
2 fines totaling $26,272.
| Date | Type | Amount / length |
|---|---|---|
| Jun 10, 2025 | Fine | $18,254 |
| Apr 3, 2024 | Fine | $8,018 |
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) | 4.56 | 4.32 | 3.95 | top 33% in South Dakota; top 21% in the U.S. |
| Registered Nurse hours | 0.73 | 0.91 | 0.69 | bottom 35% in South Dakota; top 33% in the U.S. |
| Weekend total nurse staffing | 3.80 | 3.71 | 3.50 | top 36% in South Dakota; top 29% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.59 | 0.51 | 0.48 | top 29% in South Dakota; top 24% in the U.S. |
| Total nursing staff turnover (%) | 54.7 | 48.2 | 45.8 | bottom 31% in South Dakota; bottom 26% in the U.S. |
| RN turnover (%) | 54.5 | 34.7 | 42.9 | bottom 20% in South Dakota; bottom 29% 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 5.09, RN 0.81, weekend 4.24. Staffing rating: 4/5.
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: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Abernathy, Phillip | Individual | Corporate Director | NOT APPLICABLE | 07/01/2024 |
| Anglin, Amanda | Individual | Corporate Director | NOT APPLICABLE | 06/19/2025 |
| Avel Ecare Medical Group, PC | Organization | ADP of the SNF | NOT APPLICABLE | 10/06/2021 |
| Brewer, Heather | Individual | Corporate Director | NOT APPLICABLE | 07/01/2020 |
| Davidson, Ruta | Individual | Corporate Officer | NOT APPLICABLE | 08/18/2018 |
| Davidson, Ruta | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 11/26/2025 |
| Deer Oaks Mental Health Associates PC | Organization | Operational/Managerial Control | NOT APPLICABLE | 11/22/2019 |
| Hespen, Barbara | Individual | Corporate Officer | NOT APPLICABLE | 03/21/2022 |
| Johnson, Kathryn | Individual | Corporate Director | NOT APPLICABLE | 07/01/2020 |
| Junek, Shauna | Individual | Corporate Director | NOT APPLICABLE | 07/01/2024 |
| Knudson, Jason | Individual | Corporate Director | NOT APPLICABLE | 07/01/2021 |
| Lamphere, Fred | Individual | Corporate Director | NOT APPLICABLE | 12/14/2023 |
| Lewis, Charles | Individual | Corporate Director | NOT APPLICABLE | 07/01/2022 |
| Maser, Steven | Individual | Corporate Officer | NOT APPLICABLE | 12/30/2022 |
| Maser, Steven | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/30/2022 |
| Monument Health INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/01/2005 |
| Monument Health INC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2005 |
| Monument Health Rapid City Hospital INC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2005 |
| Nylander, Kelsey | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2020 |
| Nylander, Kelsey | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2020 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "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 |
|---|---|---|---|---|---|
| Spearfish Canyon Healthcare | 17.9 mi | Spearfish, SD | ★★☆☆☆ | 2/5 | abuse |
Compare this facility with the 1 closest →
Facility data as of CMS processing date 2026-08-01. CCN 435102.