Avera Bormann Manor
Parkston, South Dakota · CCN 43A137
16 surveys since 2011. The first finding at harm level was recorded in 2015.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 56
- Surveys
- 16
- Harm or worse
- 5
- Immediate jeopardyall corrected before survey
- 1
Findings at the most serious level CMS records. All were recorded as past non-compliance — corrected before the survey.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 50
- Ownership
- Non profit - Corporation
- Chain
- Independent
- County
- Hutchinson · rural
- Medicare-certified since
- 2011
CMS ratings
- Overall
- 3
- Health inspection
- 3
- Staffing
- 5
- Quality measures
- 1
CMS’s own Five-Star ratings.
Compared with similar facilities
Not shown for this facility: too few citations in window (n=16, floor 20).
Last survey on record
Feb 4, 2026
278 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.63 | 3.73 |
| Registered-nurse hours per resident day | 1.10 | — |
| Annual nurse turnover | 42.6% | 49.0% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $47,187 across 4 penalties
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J16.7% | K— | L— |
| Actual harm | G320.0% | H— | I— |
| No harm, potential for more than minimal | D960.0% | E213.3% | F— |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6894×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F6582×
Ensure services provided by the nursing facility meet professional standards of quality.
- F5501×
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- F5541×
Allow residents to self-administer drugs if determined clinically appropriate.
- F5581×
Reasonably accommodate the needs and preferences of each resident.
In the surveyor’s words
From the most serious findings on record at Avera Bormann Manor, in the surveyor’s own words.
- Immediate jeopardy, isolatedF689Mar 31, 2025
Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI) review, record review, observation, interview, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who fell from a mechanical bath chair lift, suffered injuries that required emergency room treatment, hospitalization , and subsequently died when one of one certified nursing assistant (CNA) (C) failed to ensure a safety belt was used. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. On [DATE] at 9:00 a.m. […]
- Actual harm, isolatedF689Jun 26, 2025
Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to assess for safe usage of a lift chair for one of one sampled resident (1) who had an unwitnessed fall and required hospitalization for injuries acquired from the fall and pain management. This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident. Findings include: 1. […]
- Actual harm, isolatedF604Jul 11, 2024
Based on observation, interview, record review, and policy review, the provider failed to implement the following for one of one sampled resident (17): *Assess for the use of an audible chair alarm. *Document the use of the chair alarm. *Reassess for the continued use of the chair alarm. *Ensure the audible chair alarm was not causing harm. Findings include: 1. Observation on 7/9/24 at 9:58 a.m. in resident 17's room revealed: *She was seated in her recliner. *There were two alarm devices on her bedside table. One was connected to her bed, and the other was connected to her recliner and shirt. *She was wearing a pendant call light around her neck. *She pressed the pendant call light because she needed to use the bathroom. Staff promptly responded to the call light. 2. […]
- Actual harm, isolatedF600Jan 30, 2024
Based on review of the South Dakota Department of Health (SD DOH) online report, observation, record review, interview, and policy review, the provider failed to ensure one of three sampled residents (20) received appropriate care to prevent a burn from a warm pack. 1. Review of the SD DOH online report revealed the following: *On 1/20/24 restorative aide F applied a warm pack on the back of resident 20's neck. -The warm pack was a heated wet hand towel wrapped in Chux (disposable waterproof-under pad). -Resident 20's cognition score was a 4. Observation and interview on 1/30/24 at 12:22 p.m. […]
- No harm, potential for more than minimal, patternF550Feb 4, 2026
Based on South Dakota Department of Health (SD DOH) complaint the review of observations, interviews, electronic medication records and policy review revealed the facility failed to allow resident their right of self-determination.* 3 of 36 residents were not allowed to eat until the end of the meal service per a nurses request (6,8,9).* 1 additional food request was not granted* Call light times were reviewed due to excess wait times. 4 of 11 residents (1,2,3,4) had negative outcomes from wait times.Findings include:1. […]
Read 21 findings in full →The most serious and the most recent: 21 of 56 on record.
Every survey on record
FindingsAt actual harm or above
- Feb 4, 2026Complaint4 findings
- Sep 18, 2025Standard1 finding
- Jun 26, 2025Complaint1 finding · 1 harm
- Mar 31, 2025Complaint1 finding · 1 harm
- Jul 11, 2024Standard and complaint5 findings · 1 harm
- Jan 30, 2024Complaint2 findings · 1 harm
- Jun 8, 2023Standard1 finding
- Jan 20, 2022Standard1 finding
Show the 8 earlier surveys
- May 15, 2019Standard2 findings
- Feb 22, 2018Standard4 findings
- Jan 26, 2017Standard3 findings
- Nov 18, 2015Standard6 findings · 1 harm
- Nov 19, 2014Standard12 findings
- Sep 25, 2013—7 findings
- Aug 29, 2012—3 findings
- Aug 3, 2011—3 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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