Home / South Dakota / Mitchell
Avera Brady Health and Rehab
500 S Ohlman, Mitchell, SD 57301 · Davison County · (605) 996-7701
84 certified beds, about 75 residents a day · Non profit - Corporation · Medicare and Medicaid since 1991
CMS Care Compare ratings, data as of September 1, 2026 · CCN 435061 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on April 27, 2026, inspectors cited 2 health deficiencies (the South Dakota average is 6.7, the national average 9.2).
None of its 8 health citations since August 2023 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 4.40 hours per resident per day, against 3.79 across South Dakota and 3.86 nationally. Registered nurses accounted for 1.39 of those hours.
43.4% of nursing staff left within the year CMS measured (South Dakota average 48.2%).
CMS links it to Avera Health, an affiliated group of 13 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 8 health citations on file.
April 27, 2026Standard inspection, Complaint inspection · 2 citations
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, observation, interview, document review, record review, and policy review, the provider failed to protect the resident's right to quality of care according to the resident's assessment and needs for one of one sampled resident (41) whose call system cord was not working and was on a commode (portable toilet) for one hour and fifteen minutes, which was 30 minutes longer than the resident's preference, by one of one certified nursing assistant (CNA) N who did not return to resident 41's room to check on her. That failure resulted in emotional distress for the resident, who was observed by administrator (A) as being distressed, upset, and having tears in her eyes when discussing the incident. [...]
- D Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, employee education review, and policy review, the provider failed to ensure standard food safety practices were followed for one of one observed cook I who did no perform hand hygiene (washing or sanitizing hands) after she dropped and picked up a butter container lid from the floor, and coughed into her right hand and drank from her personal beverage cup while preparing and serving resident meals during the lunch meal service.
February 26, 2026Complaint inspection · 1 citation
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review, interview, observation, policy review, and manufacturer's manual review, the provider failed to ensure a safe environment for one of one sampled resident (1), who chose not to wear the whirlpool tub chair's safety belt by not educating the resident of the risks for adverse outcomes of not using the belt, to make an informed safety decision regarding the use of that safety belt. That failure put the resident at risk for falling and potential injury.
December 12, 2024Standard inspection · 3 citations
- E Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on record review, interview, and policy review the provider failed to review with the resident, their representative, or their responsible family member and provide a written summary of the baseline care plan for five of eighteen sampled residents (2, 26, 68, 69, and 71) within 48 hours of their admission.
- E Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to maintain the physical, mental, and psychosocial well-being by ensuring staff promptly responded to call lights for two of eighteen sampled residents (1 and 16) who used call lights to alert staff of their assistance needs.
- D Ensure that residents are free from significant medication errors.
Inspectors wroteBased on Observation, interview, record review, and policy review, the provider failed to correctly administer medication for one of one sampled resident (8) by registered nurse (RN) (E) who did not verify resident had a self-administration medication order for her nebulizer treatment.
August 17, 2023Standard inspection · 2 citations
- D Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, interview, menu review, and policy review, the provider failed to follow written menus and serve adequate portion sizes that would have had the potential to effect all residents who dined in the main dining room for one of one meal observed.
- D Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and policy review, the provider failed to minimize potential cross-contamination by improperly sanitizing the food thermometer in between checking temperatures of different food items during one of one meal service observation.
Fire safety inspections
1 fire safety citation on file: 1 on August 17, 2023.
Every fire safety citation1 citation
- D Meet requirements for sections of health care facilities separated by fire resistive construction.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | South Dakota | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.40 | 3.79 | 3.86 |
| Registered nurses | 1.39 | 0.80 | 0.69 |
| All nursing staff on weekends | 3.88 | 3.26 | 3.42 |
| Nurse aides | 2.84 | ||
| Licensed practical nurses | 0.17 | ||
| Nursing staff turnover (share who left in a year) | 43.4% | 48.2% | 45.8% |
| Registered nurse turnover | 21.7% | 34.7% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.60 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.62 on weekdays and 3.88 on weekends, 16% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 1.3% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.79 in April to June 2025 to 4.40 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.40 | 1.39 | 4.62 | 3.88 | 1.3% | 0 of 90 | 75 |
| Oct to Dec 2025 | 4.26 | 1.44 | 4.48 | 3.68 | 0.0% | 0 of 92 | 78 |
| Jul to Sep 2025 | 4.73 | 1.44 | 4.97 | 4.10 | 0.0% | 0 of 92 | 74 |
| Apr to Jun 2025 | 4.79 | 1.43 | 5.04 | 4.16 | 0.3% | 0 of 91 | 69 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| South Dakota, Jan to Mar 2026 | 3.76 | 0.79 | 3.97 | 3.25 | 9.1% | 1.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | South Dakota | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 10.7 | 21.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.3 | 2.1 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.6 | 2.9 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 7.0 | 5.5 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 2.7 | 2.0 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 9.4 | 19.4 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 2.1 | 4.6 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 11.9 | 24.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 22.1 | 19.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 8.4 | 12.0 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.2 | 1.5 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.5 | 1.8 | 1.8 |
Owners and operators
Legal business name: AVERA QUEEN OF PEACE. CMS links this home to Avera Health, a group of 13 nursing homes averaging 3.8 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Avera Health | 5% or greater direct ownership interest | Organization | 100% | 07/01/2009 |
| Bergeleen, Darlene | Managing control - governing body | Individual | 07/01/2023 | |
| Buckmiller, Ann | Managing control - governing body | Individual | 07/01/2025 | |
| Claussen, Jessica | Managing control - governing body | Individual | 07/01/2023 | |
| Dierks, Trevor | Managing control - governing body | Individual | 07/01/2023 | |
| Feteral, Joyce | Managing control - governing body | Individual | 07/01/2024 | |
| Hunhoff, Mark | Managing control - governing body | Individual | 07/01/2019 | |
| Larson, Vicky | Managing control - governing body | Individual | 07/01/2024 | |
| Puetz, Mark | Managing control - governing body | Individual | 07/01/2023 | |
| Sandhoff, Diane | Managing control - governing body | Individual | 07/01/2023 | |
| Stahle, Nicole | Managing control - governing body | Individual | 07/01/2023 | |
| Tegethoff, Jennifer | Managing control - governing body | Individual | 07/01/2021 | |
| Thomas, Fredel | Managing control - governing body | Individual | 07/01/2024 | |
| Thompson, Ryan | Managing control - governing body | Individual | 07/01/2018 | |
| Zomer, Brad | Managing control - governing body | Individual | 07/01/2018 | |
| Margallo, Lucio | Corporate director | Individual | 07/01/2020 | |
| Dover, James | Corporate officer | Individual | 10/23/2023 | |
| Lautt, Julie | Corporate officer | Individual | 03/01/2020 | |
| Longe, Kimberly | Corporate officer | Individual | 06/01/2024 | |
| Rockwell, Hilary | Corporate officer | Individual | 07/01/2023 | |
| Longe, Kimberly | Operational/managerial control | Individual | 06/01/2024 | |
| Margallo, Lucio | Operational/managerial control | Individual | 07/01/2020 | |
| Rockwell, Hilary | Operational/managerial control | Individual | 07/01/2023 | |
| Dover, James | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 03/03/2026 | |
| Longe, Kimberly | Adp of the SNF | Individual | 02/12/2026 | |
| Margallo, Lucio | Adp of the SNF | Individual | 02/12/2026 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 3 problems in this area, most recently on April 27, 2026: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 3 problems in this area, most recently on April 27, 2026: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards."
- When is the care plan meeting, and can family attend it?Inspectors cited 1 problem in this area, most recently on December 12, 2024: "Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted"
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 1 problem in this area, most recently on December 12, 2024: "Ensure that residents are free from significant medication errors."
Other nursing homes nearby
- Firesteel Healthcare Center Mitchell, 2 mi · 1 of 5 stars · 39 citations
- Avera Bormann Manor Parkston, 21.5 mi · 3 of 5 stars · 15 citations
South Dakota contacts for a concern about a nursing home
These are the official offices in South Dakota. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: South Dakota Department of Health, Office of Health Facilities Licensure and Certification, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: South Dakota Long-Term Care Ombudsman Program, Department of Human Services. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: South Dakota Department of Health Nursing Facility Reports, where South Dakota publishes its own records on licensed homes.
Common questions
- What is Avera Brady Health and Rehab's Medicare star rating?
- CMS rates Avera Brady Health and Rehab 5 out of 5 stars overall, with 5 for health inspections, 5 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Avera Brady Health and Rehab get at its last inspection?
- 2 health deficiencies at the standard inspection on April 27, 2026. The South Dakota average is 6.7.
- Has Avera Brady Health and Rehab been fined?
- CMS lists no fines in the last three years.
- Does Avera Brady Health and Rehab accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Avera Brady Health and Rehab?
- CMS lists 26 owners and managers, and links the home to Avera Health. Legal business name: AVERA QUEEN OF PEACE.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.