Avera Bormann Manor
501 North 4th Street, Parkston, SD 57366 · Hutchinson County · 50 certified beds · avg 47 residents/day · certified since Jul 1, 2011
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
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 self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · 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): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Mar 28, 2025 (Past Non-Compliance)
▲ Actual harm, one-off · 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): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 23, 2025 (Past Non-Compliance)
▲ Actual harm, one-off · Jul 11, 2024 · F-0604
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): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 31, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · 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): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 21, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (15)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 4, 2026 | E · Potential for harm, repeated | 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 |
| Feb 4, 2026 | D · Potential for harm, one-off | 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 |
| Feb 4, 2026 | D · Potential for harm, one-off | 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 |
| Feb 4, 2026 | D · Potential for harm, one-off | 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 |
| Sep 18, 2025 | D · Potential for harm, one-off | 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. |
| Jun 26, 2025 | ▲ G · Actual harm, one-off | 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 |
| Mar 31, 2025 | ▲ J · Immediate jeopardy, one-off | 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 |
| Jul 11, 2024 | ▲ G · Actual harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. |
| Jul 11, 2024 | D · Potential for harm, one-off | 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. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jul 11, 2024 | D · Potential for harm, one-off | 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. |
| Jul 11, 2024 | D · Potential for harm, one-off | 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 |
| Jan 30, 2024 | ▲ G · Actual harm, one-off | 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 |
| Jan 30, 2024 | D · Potential for harm, one-off | 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 |
| Jun 8, 2023 | E · Potential for harm, repeated | The facility did not keep residents' personal and medical information private and confidential. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (4 → 1).
| 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.
Fines and enforcement (last 3 years)
4 fines totaling $47,187.
| 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)
| 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, 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. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: —/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ownership Data Not Available |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What is your policy on physical restraints, and what alternatives do you try first?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avera Brady Health and Rehab | 21.5 mi | Mitchell, SD | ★★★★★ | 5/5 | |
| Firesteel Healthcare Center | 21.9 mi | Mitchell, SD | ★☆☆☆☆ | 1/5 | |
| Good Samaritan Society Scotland | 21.9 mi | Scotland, SD | ★★★★★ | 5/5 | |
| Menno-Olivet Care Center | 23.8 mi | Menno, SD | ★★★★★ | 5/5 | |
| Good Samaritan Society - Wagner | 26.5 mi | Wagner, SD | —/5 | ||
| Diamond Care Center | 26.8 mi | Bridgewater, SD | ★☆☆☆☆ | 1/5 | |
| Oakview Terrace | 28.3 mi | Freeman, SD | ★★★★★ | 3/5 | |
| Good Samaritan Society Tyndall | 28.4 mi | Tyndall, SD | ★★★☆☆ | 3/5 | |
| Lake Andes Senior Living | 32.2 mi | Lake Andes, SD | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 43A137.