Inspection visit
Inspection
Citations
8 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
- 0353GeneralS&S Bno actual harm
Inspect, test, and maintain automatic sprinkler systems.
- 0531GeneralS&S Bno actual harm
Have elevators that firefighters can control in the event of a fire.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0226GeneralS&S Cno actual harm
Have horizontal exits used in accordance with safety requirements.
- 0311GeneralS&S Cno actual harm
Have an enclosure around a vertical opening shaft.
- 0321GeneralS&S Bno actual harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
FAQ · About this visit
Common questions about this visit
What happened during the September 11, 2025 survey of AVERA MARYHOUSE LONG TERM CARE?
This was a inspection survey of AVERA MARYHOUSE LONG TERM CARE on September 11, 2025. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AVERA MARYHOUSE LONG TERM CARE on September 11, 2025?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Allow residents to self-administer drugs if determined clinically appropriate."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.