Avera Prince Of Peace
Inspection Findings
F-Tag F0627
F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
revealed:*Conditions of Discharge or Transfer included:- The Facility Reserves the Right to Transfer or Discharge a Resident for the Following Reasons:-- 1. The transfer or discharge is necessary for the Resident's welfare and the Resident's needs cannot be met in the Facility.--2. The transfer or discharge is appropriate because the Resident's health has improved sufficiently so the Resident no longer needs the services provided by the Facility.--3. The safety of individuals in the Facility is endangered.--4. The health of individuals in the facility would otherwise be endangered.-- 5. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility.-- 6. The facility ceases to operate.*The Resident will be notified of the right to appeal the transfer or discharge to the state. Review of the provider's revised January 2024 admission Agreement Addendum for Residents admitted to Rehabilitation, Transitional Care, or Ventilator Units indicated:* By signing this admission Agreement Addendum, you are consenting to be transferred from the Unit when you have met the goals set out in the plan of care. The determination will be made by an interdisciplinary care team that either: (i) your condition has improved to the point where you can be discharged from the Unit in accordance with your post-discharge plan of care; or (ii) your condition is such that you will no longer benefit from placement within, but require long-term residential care.*If we determine that you can be discharged from the Unit, both you and the Resident Representative consent to discharge from the Facility Unit and agree to fully cooperate with the Facility discharge planning staff in conjunction with your discharge. You will receive advance notice of discharge regarding this decision along with a notice of termination of Medicare Part A benefits, if applicable.*If you can not [cannot] be safely discharged as you require long term residential care, the Facility will provide notification to both the Resident and Resident Representative and begin making referrals to other long term residential care facilities. You and the Resident Representative consent to fully cooperate with the facility discharge planning staff in transferring to a long term residential care facility. Resident and Resident Representative are advised and consent to such transfer understanding the long-term residential care facility may be outside the Sioux Falls area.*This Addendum is integrated into the admission Agreement of this same date. Review of the provider's revised June 2024 LTC [Long Term Care] Transfer & [and] Discharge policy revealed:* It is the policy of this facility that each resident has the right to remain in the facility and not transfer or discharge a resident unless a transfer or discharge from the facility is:- The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met
in the facility;- The resident required immediate transfer or discharge based on the resident's urgent medical need.- The transfer or discharge is appropriate because the resident's health has improved sufficiently so that the resident no longer needs the services provided by the facility;- The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;- The health of individuals in the facility would otherwise be endangered;- The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility .- The facility ceases to operate.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/06/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avera Prince of Peace
4513 South Prince of Peace Place Sioux Falls, SD 57103
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0628
F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
2024 admission Agreement Addendum for Residents admitted to Rehabilitation, Transitional Care, or Ventilator Units indicated:*If we determine that you can be discharged from the Unit, both you and the Resident Representative consent to discharge from the Facility Unit and agree to fully cooperate with the Facility discharge planning staff in conjunction with your discharge. You will receive advance notice of discharge regarding this decision along with a notice of termination of Medicare Part A benefits, if applicable. Review of the provider's revised June 2024 LTC [Long Term Care] Transfer & [and] Discharge policy revealed:*The objective of the transfer/discharge policy is to ensure that the resident is informed of
an impending discharge and their right to appeal the discharge. *.The facility must provide notice of discharge to the resident and resident representative along with a copy of the notice to the Office of the State LTC Ombudsman at least 30 days prior to the discharge or as soon as possible. The copy of the notice to the Ombudsman must be sent at the same time the notice is provided to the resident representative.*The notice contains information about the transfer and information about the resident's appeal rights. The facility will assist the resident to obtain, complete and submit an appeal form at the resident's request.
Event ID:
Facility ID:
If continuation sheet
AVERA PRINCE OF PEACE in SIOUX FALLS, SD inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SIOUX FALLS, SD, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AVERA PRINCE OF PEACE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.