SIOUX FALLS, SD - Federal health inspectors cited Avera Prince of Peace for failing to ensure resident transfers and discharges were conducted safely during a complaint investigation completed on November 6, 2025, marking one of two deficiencies identified at the facility.
Unsafe Transfer and Discharge Practices
The inspection, triggered by a formal complaint, found that Avera Prince of Peace did not adequately ensure that resident transfers and discharges met the individual needs and preferences of those being moved. Inspectors determined the facility fell short of federal requirements under regulatory tag F0627, which mandates that nursing homes properly prepare residents for safe transitions out of care.
Under federal nursing home regulations, facilities are required to develop and execute discharge plans that account for a resident's medical condition, cognitive status, support system, and post-discharge care needs. The regulation exists because poorly managed transfers can result in medication errors, gaps in treatment continuity, and preventable hospital readmissions.
The deficiency was classified at Scope/Severity Level D, meaning it was isolated in nature and did not result in documented actual harm. However, inspectors noted there was potential for more than minimal harm to residents, a designation that indicates the problem posed genuine risk if left unaddressed.
Why Safe Discharge Planning Matters
Discharge and transfer planning is a foundational component of nursing home care. When a resident leaves a facility, whether moving to another care setting, a hospital, or returning home, a comprehensive plan must be in place to ensure continuity of care.
A properly executed discharge involves several key steps: a thorough assessment of the resident's current medical needs, coordination with receiving providers, medication reconciliation, clear written instructions for the resident and family, and confirmation that appropriate follow-up care is arranged. When any of these elements are missing, residents face elevated risk of adverse outcomes.
Research published in medical literature has consistently shown that inadequate discharge planning from long-term care facilities is associated with higher rates of 30-day hospital readmissions, medication discrepancies, and decline in functional status. Elderly patients are particularly vulnerable during care transitions because they often manage multiple chronic conditions and complex medication regimens that require careful coordination between providers.
The fact that this deficiency was identified through a complaint investigation rather than a routine survey suggests that a resident, family member, or advocate raised concerns about how a transfer or discharge was handled, prompting federal regulators to examine the facility's practices.
Two Deficiencies Identified
The unsafe discharge finding was one of two deficiencies cited during the complaint investigation. The citation fell under the broader category of Resident Rights Deficiencies, which encompasses federal protections designed to ensure nursing home residents are treated with dignity and have their preferences respected in care decisions.
Resident rights provisions under federal law require that facilities provide adequate notice before transfers and discharges, that the move serves a legitimate purpose, and that the resident is given an opportunity to appeal the decision. These protections are particularly important for elderly individuals who may have limited ability to advocate for themselves during stressful transitions.
Facility Response and Correction
Avera Prince of Peace submitted a plan of correction in response to the findings and reported that corrective measures were implemented as of January 22, 2026. The plan of correction process requires facilities to outline specific steps they will take to address the deficiency, prevent recurrence, and protect residents from future harm.
Avera Prince of Peace is part of the Avera Health system, a regional health care network operating across the upper Midwest. The Sioux Falls facility provides skilled nursing and long-term care services.
Understanding Severity Classifications
The Level D classification assigned to this deficiency indicates the lowest tier of confirmed deficiency on the federal severity scale. While it confirms that a regulatory violation occurred, it reflects an isolated incident without documented harm. Classifications at higher levels, such as Level G through Level L, indicate patterns of harm or immediate jeopardy to resident health and safety.
Families considering nursing home options are encouraged to review facility inspection histories through the Centers for Medicare & Medicaid Services (CMS) Care Compare database, which provides publicly accessible records of all federal nursing home inspections, deficiency citations, and penalty actions.
The full inspection report for Avera Prince of Peace contains additional details regarding both deficiencies cited during the November 2025 complaint investigation.
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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