SIOUX FALLS, SD - Federal health inspectors found Avera Prince of Peace failed to meet documentation requirements related to resident rights during a complaint investigation completed on November 6, 2025, resulting in two deficiency citations for the Sioux Falls nursing facility.
Resident Documentation Requirements Not Met
The inspection identified that Avera Prince of Peace did not provide required documentation or notification connected to resident needs, appeal rights, or bed-hold policies — protections that federal regulations mandate nursing facilities communicate clearly and consistently to residents and their families.
The deficiency was cited under federal regulatory tag F0628, which addresses a facility's obligation to furnish residents with specific written information about their care, their rights within the facility, and policies that directly affect their living arrangements.
Inspectors classified the violation at Scope/Severity Level D, indicating an isolated incident where no actual harm occurred but where the potential existed for more than minimal harm to affected residents.
Why Documentation and Notification Requirements Exist
Federal nursing home regulations require facilities to provide residents with written documentation covering several critical areas. These include information about medical treatment plans, the right to appeal care decisions, and bed-hold policies that determine whether a resident's bed will be reserved during a hospital stay or temporary absence.
When facilities fail to deliver this documentation, residents and families may be unaware of their legal protections. Bed-hold policies, for example, are particularly significant — without proper notification, a resident transferred to a hospital could return to find their placement at the facility is no longer available. This can result in displacement, disruption of established care routines, and significant distress for elderly and medically fragile individuals.
Appeal rights documentation serves a similar protective function. Residents who are not informed of their right to challenge care decisions, discharge plans, or changes in service levels are effectively unable to exercise those rights. Federal law requires that this information be communicated proactively, not simply made available upon request.
Complaint-Driven Investigation
The deficiencies were identified not through a routine annual survey but through a complaint investigation, meaning concerns were raised by a resident, family member, or other party that prompted federal inspectors to examine the facility's practices.
Complaint investigations frequently uncover issues that may not surface during scheduled inspections, as they are typically targeted at specific areas of concern reported by individuals with direct knowledge of facility operations.
The investigation yielded a total of two deficiency citations for Avera Prince of Peace, indicating that the documentation failure was not the only area where inspectors identified regulatory shortcomings during their review.
Correction Plan and Industry Context
Avera Prince of Peace submitted a plan of correction and reported that the identified deficiencies were addressed as of January 22, 2026 — approximately two and a half months after the inspection findings.
Under federal regulations, facilities found deficient must submit a detailed plan outlining specific steps they will take to correct each violation and prevent recurrence. State survey agencies then verify compliance through follow-up reviews.
Documentation and notification requirements represent a foundational element of resident rights protections in nursing homes. The Centers for Medicare & Medicaid Services (CMS) considers proper communication of rights, policies, and care information essential to ensuring residents can participate meaningfully in decisions about their own care.
What Proper Compliance Looks Like
Facilities meeting federal standards in this area typically provide written notification of rights and policies at the time of admission, update residents when policies change, and maintain documentation confirming that information was delivered and understood. Many facilities obtain signed acknowledgment forms and conduct periodic reviews to ensure ongoing compliance.
Looking at the Broader Record
While the Level D severity classification indicates this was an isolated incident without documented harm, the fact that it emerged from a complaint investigation suggests that the gap in documentation had a tangible impact on at least one individual connected to the facility.
Families considering long-term care placement at any facility can review complete inspection histories, deficiency citations, and staffing data through the CMS Care Compare database or through the full inspection report available on NursingHomeNews.org.
The complete inspection details, including all deficiency citations from the November 2025 investigation, are available in the full report linked on this page.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avera Prince of Peace from 2025-11-06 including all violations, facility responses, and corrective action plans.
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