Certified for Medicaid only. It cannot bill Medicare, so a short post-hospital rehabilitation stay would not be covered the usual way here. Who pays for nursing home care →
3/5
Health inspection rating (on-site)
inspected Sep 18, 2025
4
Serious findings on record
most recent Jun 26, 2025
$47,187
Fines, last 3 years
4.48
Nurse hours/resident/day (adjusted)
Every record stays on this page.
What health inspectors found (on-site government inspections — the most independent evidence available)
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and quality measures from resident assessments and claims.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, isolated · Mar 31, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Mar 28, 2025 (Past Non-Compliance)
▲ Actual harm, isolated · Jun 26, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Why it matters: Unneeded restraints can cause injuries, muscle loss, and deep emotional distress.
Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Jul 31, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, isolated · Jan 30, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Feb 21, 2024 (Deficient, Provider has date of correction)
Inspection findings in the public record
Showing the latest 3 of 15 inspection findings. Open the full record below to read every finding.
E · Potential for more than minimal harm, pattern
The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaintF-0550
D · Potential for more than minimal harm, isolated
The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · from a complaintF-0554
D · Potential for more than minimal harm, isolated
The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaintF-0658
View all 15 inspection findingsShow only the latest 3 findings
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
Date
Severity
What the facility was cited for
Feb 4, 2026
E · Potential for more than minimal harm, pattern
The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint · F-0550
Feb 4, 2026
D · Potential for more than minimal harm, isolated
The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · from a complaint · F-0554
Feb 4, 2026
D · Potential for more than minimal harm, isolated
The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint · F-0658
Feb 4, 2026
D · Potential for more than minimal harm, isolated
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Sep 18, 2025
D · Potential for more than minimal harm, isolated
The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · F-0761
Jun 26, 2025
▲ G · Actual harm, isolated
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Mar 31, 2025
▲ J · Immediate jeopardy, isolated
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Jul 11, 2024
▲ G · Actual harm, isolated
The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · F-0604
Jul 11, 2024
D · Potential for more than minimal harm, isolated
The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · F-0558
Jul 11, 2024
D · Potential for more than minimal harm, isolated
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684
Jul 11, 2024
D · Potential for more than minimal harm, isolated
The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880
Jul 11, 2024
D · Potential for more than minimal harm, isolated
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Jan 30, 2024
▲ G · Actual harm, isolated
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint · F-0600
Jan 30, 2024
D · Potential for more than minimal harm, isolated
The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint · F-0658
Jun 8, 2023
E · Potential for more than minimal harm, pattern
The facility did not keep residents' personal and medical information private and confidential. · F-0583
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (4 → 1).
Citations by recorded inspection yearPublished citation counts, not a quality score · Source: CMS, 2026-08-01
All citationsSerious citations (G–L)
2023
All citations:
1
Serious citations (G–L):
0
2024
All citations:
7
Serious citations (G–L):
2
2025
All citations:
3
Serious citations (G–L):
2
2026
All citations:
4
Serious citations (G–L):
0
All bars start at zero. Exact values and supporting details remain below.
Year
Citations
Serious (G–L)
Worst severity that year
2023
1
0
E
2024
7
2
G ▲
2025
3
2
J ▲
2026
4
0
E
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.
Date
Type
Amount / length
Jun 26, 2025
Fine
$12,438
Mar 31, 2025
Fine
$14,901
Jul 11, 2024
Fine
$10,839
Jan 30, 2024
Fine
$9,009
Nurse staffing (from payroll records, adjusted for how much care residents need)
Nurse time, in contextAdjusted hours per resident per day · Source: CMS, 2026-08-01
This facilitySouth Dakota averageU.S. average
Total nurse staffing (hours per resident per day)
This facility:
4.48
South Dakota average:
4.32
U.S. average:
3.95
Registered Nurse hours
This facility:
1.36
South Dakota average:
0.91
U.S. average:
0.69
Weekend total nurse staffing
This facility:
3.68
South Dakota average:
3.71
U.S. average:
3.50
All bars start at zero. Exact values and supporting details remain below.
Measure
This facility
South Dakota avg
U.S. avg
Where it stands
Total nurse staffing (hours per resident per day)
4.48
4.32
3.95
top 35% in South Dakota; top 24% in the U.S.
Registered Nurse hours
1.36
0.91
0.69
top 7% in South Dakota; top 6% in the U.S.
Weekend total nurse staffing
3.68
3.71
3.50
top 43% in South Dakota; top 34% in the U.S.
Weekend RN hours (not acuity-adjusted)
0.74
0.51
0.48
top 11% in South Dakota; top 14% in the U.S.
Total nursing staff turnover (%)
42.6
48.2
45.8
top 36% in South Dakota; top 43% in the U.S.
RN turnover (%)
9.1
34.7
42.9
top 4% in South Dakota; top 3% in the U.S.
Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.63, RN 1.10, weekend 2.98.Comparing with Medicare Care Compare? Care Compare shows the raw figure (3.63 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 5/5.
Quality measures: assessments & claims
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
No verified facility-specific private-pay price is available in our data for Avera Bormann Manor. CMS inspection and staffing records do not tell us what this home will charge you.
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