Avera Granite Falls Care Ctr

Penalties

• May 2, 2024 — Fine ($15,642)

Inspection findings

1. Sep 19, 2025 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Sep 12, 2025 · CMS health inspection

2. Sep 10, 2025 Health · 4 findings
   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Nov 26, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Nov 26, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0882 Infection Control Deficiencies

     Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

     Corrected Nov 26, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Nov 26, 2025 · CMS health inspection

3. Jul 17, 2024 Health · 10 findings
   • Not serious Scope/severity E

     F0557 Resident Rights Deficiencies

     Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

     Corrected Aug 8, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0576 Resident Rights Deficiencies

     Ensure residents have reasonable access to and privacy in their use of communication methods.

     Corrected Aug 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0604 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

     Corrected Aug 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Aug 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Aug 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Aug 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     K0226 Egress Deficiencies

     Have horizontal exits used in accordance with safety requirements.

     Corrected Sep 3, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Aug 8, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Aug 8, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Sep 3, 2024 · CMS fire safety

4. May 2, 2024 Health · 2 findings
   • Serious Scope/severity J Complaint

     F0678 Quality of Life and Care Deficiencies

     Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

     Corrected Apr 30, 2024 · CMS health inspection

   • Severity not stated

     H52433434C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

5. Feb 29, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Mar 21, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0773 Administration Deficiencies

     Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

     Corrected Mar 21, 2024 · CMS health inspection

6. Aug 10, 2023 Health · 4 findings
   • Not serious Scope/severity D

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected Sep 6, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Sep 6, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Sep 6, 2023 · CMS health inspection

   • Not serious Scope/severity D

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Sep 6, 2023 · CMS fire safety

7. Jun 30, 2022 Fire Safety · 1 finding
   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Aug 17, 2022 · CMS fire safety

Owners and managers (as published by CMS)

• BARBER, DANIEL — managing control - governing body, NOT APPLICABLE, since 07/01/2024
• CARTER, DARRELL — operational/managerial control, NOT APPLICABLE, since 01/01/2020
• CARTER, DARRELL — adp of the snf, NOT APPLICABLE, since 12/16/2025
• COUDRON, CHRISTY — corporate officer, NOT APPLICABLE, since 09/01/2020
• JENSEN, MARK — managing control - governing body, NOT APPLICABLE, since 07/01/2023
• KOENEN, LAVONNE — managing control - governing body, NOT APPLICABLE, since 07/01/2020
• KOOIMAN, THOMAS — adp of the snf, NOT APPLICABLE, since 12/16/2025
• KOOIMAN, THOMAS — corporate officer, NOT APPLICABLE, since 01/01/2020
• KOOIMAN, THOMAS — operational/managerial control, NOT APPLICABLE, since 01/01/2020
• LAUTT, JULIE — adp of the snf, NOT APPLICABLE, since 03/01/2020
• LAUTT, JULIE — corporate officer, NOT APPLICABLE, since 03/01/2020
• RIOS AVENDANO, ROSA — managing control - governing body, NOT APPLICABLE, since 07/01/2023
• STREICH, LISA — managing control - governing body, NOT APPLICABLE, since 07/01/2024
• STREIER, DEBRA — corporate officer, NOT APPLICABLE, since 02/01/2021
• WELBIG, LUCILLE — managing control - governing body, NOT APPLICABLE, since 07/01/2023
• AVERA HEALTH — indirect ownership interest, NOT APPLICABLE, since 01/01/2020
• AVERA MARSHALL — 5% or greater direct ownership interest, 100%, since 01/01/2020