Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avera Bormann Manor during CMS and state inspections, most recent first.
Surveyors identified that several residents were seated for meals but routinely served last at the request of nursing staff, causing them to wait while others ate, and one resident’s request for additional food (a cut-up apple) was delayed until after meal service and provided without acknowledgment. Call light records showed multiple residents experienced repeated response times exceeding 25–45 minutes, leading to episodes where residents remained in bowel movements or urine while waiting for assistance and one resident having to yell from the doorway for help. Residents reported feeling forgotten, disgusted, embarrassed, and frustrated by these delays, while CNAs and the DON described expected response times of 1–20 minutes, and the facility’s policy required prompt call light response, though completed audits were not acted upon.
Surveyors found that staff left cups containing multiple oral medications with two residents at the breakfast table and then left the area, allowing the residents to take the medications on their own, including one instance where a pill was dropped on the floor. Review of the EMR and staff interviews showed there were no physician orders authorizing these residents to self-administer their routine oral medications, even though each only had limited orders for self-administration of specific treatments (Kenalog paste and nebulizer therapy). Facility policies required an assessment and a physician order for self-administration to be in place before residents could self-administer medications, but this process was not followed in these cases.
A resident experienced a fall in their room and was found on the floor on their side with a walker nearby. A CNA summoned a total body mechanical lift and sling, and an RN assessed the resident, noting unequal leg length and recognizing a likely hip fracture. Despite the suspected injury and the resident’s pain, staff placed a sling under the resident, changed a soiled brief, and used the mechanical lift to transfer the resident onto a medical cart, with documentation failing to clearly describe the transfer process. The DON reported that using a total body lift after falls, even with suspected injuries, was the facility’s usual process, while another RN with ED experience stated she would instead immobilize the area using a backboard and noted that most staff did not know how or where to obtain such equipment. The facility cited a nursing skills text as its professional standard, but staff interviews and the handling of this event showed inconsistent understanding and application of safe transfer practices for suspected fractures.
A resident with paraplegia and fall risk precautions fell to the floor during a transfer from bed to wheelchair using a full body mechanical lift operated by two CNAs while a third CNA observed. Witnesses, including the resident and staff, reported hearing a snap before the resident’s leg, shoulder, and then entire body slipped from the sling, with only three of four sling straps found attached to the lift afterward and no damage to the sling itself. One CNA stated it appeared a black strap was not securely hooked, and the DON later observed that a bottom strap was not attached and assumed it had not been properly placed inside the lift hook. Although staff reported receiving mechanical lift education, at least one CNA had not completed the mechanical lift safety checklist competencies, despite facility policy requiring training on correct mechanical lift use.
A controlled pain medication was left unsecured in a PPE cabinet instead of being stored in a locked medication area, and an RN later signed it off as given after forgetting it সেখানে. The same survey also found that a used Fentanyl patch was not handled and destroyed according to the facility’s controlled-substance policy, which required controlled meds to be stored, tracked, and disposed of in a locked system with proper witness procedures.
A resident with high fall risk and severe cognitive impairment suffered a fall and serious injuries after using a lift chair without a documented safety assessment. The lift chair was found raised, and the resident was unable to recall the incident. Staff interviews and record reviews confirmed that required lift chair safety assessments were not completed prior to the incident, despite facility policy mandating such assessments before use.
A resident with severe cognitive impairment fell from a mechanical bath chair lift after refusing to wear a safety belt, and the CNA failed to ensure its use. The resident sustained multiple rib fractures and a pneumothorax, required hospitalization, was later placed on hospice, and subsequently died. The incident was attributed to inadequate supervision and failure to implement required safety precautions during bathing.
A resident was found with an audible chair alarm clipped to her shirt without proper assessment or documentation. The alarm was used to prevent her from getting up unassisted due to her fall risk, despite her ability to use a call light. Staff interviews revealed no formal assessment process before implementing the alarm, and the facility's policies on falls and restraints were not followed, leading to the inappropriate use of the alarm.
A resident with hand contractures was unable to use a standard call light, and staff failed to provide an accessible alternative for at least a month. Although the resident was eventually given a soft squeeze call light, it was not consistently placed within her reach, particularly when she was in a specialized wheelchair.
Two CNAs failed to properly apply a mechanical stand aide sling and used unsafe transfer techniques for a resident with late-stage dementia. They did not secure the sling before lifting the resident and used an unapproved method of tilting a Broda chair to transfer the resident. The facility lacked documentation of training for these procedures, and the care plan did not include instructions for the observed methods.
Two CNAs failed to follow infection control policies during a resident transfer, neglecting hand hygiene and mechanical lift disinfection. Despite an empty hand sanitizer dispenser, they donned gloves without washing hands and did not sanitize the lift after use. Interviews confirmed these actions did not meet facility standards.
A resident eloped from the facility without staff knowledge, despite functioning door alarms. The incident was not reported as an elopement because the resident remained on campus. The resident was found near a hospital entrance and was unharmed. The staff's lack of awareness about reporting requirements contributed to the deficiency.
Failure to Honor Resident Self-Determination and Timely Call Light Response
Penalty
Summary
The deficiency involves failure to honor residents’ rights to self-determination and a dignified existence during meal service and in response to call lights. Surveyors observed that three residents (6, 8, and 9) were seated in the dining room before other residents but were consistently served last at both breakfast and lunch. A CNA stated these residents were usually served last, and a food service worker reported that nursing staff had requested these residents be served last due to one resident’s high fall risk. Despite the Director of Food Services’ expectation that residents be served when seated, these three residents waited about 19 minutes for their lunch while other residents were already eating. Additionally, another resident (7) requested a cut-up apple during lunch; the cook deferred the request until after meal service and only provided the apple after a surveyor prompted a second time, placing the bowl in front of the resident without verbal acknowledgment. The deficiency also includes prolonged call light response times that resulted in negative outcomes for multiple residents. Call light logs over a several-day period showed repeated response times greater than 25 minutes for four residents (1, 2, 3, and 4), with some instances approaching or exceeding 45–50 minutes. One resident reported having to sit in soiled bowel movements for one to two hours after using her pendant or call light, stating that staff sometimes turned off the light and said they would return but did not. Another resident reported feeling he waited a long time for assistance, urinated on himself while waiting for help to the bathroom, and felt disgusted by being unable to get needed help in time. Further interviews confirmed that another resident frequently waited for his call light to be answered, was incontinent before staff arrived, and sometimes yelled from his doorway for help when his call light had been on for over 30 minutes, which he described as embarrassing. A fourth resident reported waiting 20 to 30 minutes for staff to assist him up for meals and stated that on one occasion he was left in his room at suppertime until staff had finished getting everyone out of the dining room before helping him, which he found frustrating. CNAs interviewed stated their expected call light response times ranged from 1 to 10 minutes, while the DON stated her expectation was that no call light should go unanswered for more than 20 minutes. The facility’s call light policy required prompt responses to resident requests, but the DON acknowledged that although call light audits were done once or twice monthly, nothing had been done with the completed audits.
Failure to Obtain Physician Orders Before Allowing Self-Administration of Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and verify physician orders for self-administration of medications before leaving medications with residents at the dining table. Surveyors observed on multiple occasions that RNs left cups containing multiple oral medications with two residents during breakfast in the dining room and then left the area, allowing the residents to take the medications on their own. One observation showed a resident dropping a yellow pill on the floor and notifying a surveyor, who then alerted the RN. On another occasion, an RN instructed a resident that if he did not want his MiraLAX, he should leave it on the table, and the resident delayed taking his medications while engaging in other activities such as changing the TV channel. Review of the electronic medical records and interviews with nursing staff revealed that neither of the two residents had a physician’s order authorizing self-administration of their routine oral medications, despite one resident having an order only to self-administer Kenalog paste for oral sores and the other having an order only to self-administer/self-consume nebulizer treatments after setup. The facility’s policies on medication management and self-administration required that residents be assessed for clinical appropriateness and that a physician’s order for self-administration be obtained and entered into the EHR before allowing self-administration. Staff interviews confirmed that a self-administration assessment should be completed first, followed by obtaining a physician’s order, and that nurses should verify the presence of such an order before leaving medications with a resident, which did not occur for these two residents.
Improper Transfer After Fall With Suspected Hip Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed professional standards for safely transferring a resident after a fall with a suspected hip injury. A complaint intake review by the South Dakota Department of Health noted multiple areas of care, including falls, and subsequent investigation focused on one resident who fell in his room. A CNA reported seeing the resident walking alone, then hearing a noise and finding him on the floor lying on his right side with his walker nearby and the door partially open. The CNA called for a total body mechanical lift and sling to transfer the resident from the floor, and the RN on duty responded to the fall, performed a nursing assessment including vital signs, ROM, and pain assessment, and observed that the resident’s legs were different lengths, making it obvious to her that his hip was broken. Despite the suspected hip injury and the resident’s pain, staff proceeded to place a total body lift sling under him and used the mechanical lift to transfer him from the floor to a medical cart, also changing his soiled incontinence brief while he was in pain during sling placement. The RN later stated she did not remember how the transfer to the medical cart was done, and the electronic medical record and facility-reported incident did not clearly document how the resident was moved from the floor, although the incident report indicated he was assisted off the floor onto a medical cart by a total lift with multiple CNAs and RNs. Another RN described her own practice as completing assessments on the floor, gathering a total body lift and staff, and calling the physician before moving a resident with a suspected head, neck, or hip injury, but this was not the process followed in this case. Interviews with other staff revealed inconsistency and lack of clarity regarding appropriate transfer methods for residents with suspected fractures. The DON stated it was the facility’s process to lift residents with a total body lift even if a suspected injury was present, and identified a nursing skills text as the professional standard used by the facility. In contrast, an RN coordinator with ED experience stated she would not use a mechanical total body lift for a resident with a suspected hip injury, but would instead obtain a hard backboard from the ED and immobilize the injured area, and she would avoid changing a soiled brief unless enough staff were available to immobilize the area. She also reported that most staff did not know what to do or where to obtain a backboard, and she was unaware of any facility policy on transferring a resident with a hip injury. The referenced nursing skills guide included special considerations for maintaining protected straight alignment (logrolling) for certain clients with spinal injuries or surgery, underscoring that the facility’s actual practice in this incident did not align with the professional standards it cited.
Resident Fall from Mechanical Lift Due to Improper Sling Attachment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe transfer using a full body mechanical lift, resulting in a resident falling from the lift to the floor. A cognitively intact resident with traumatic spinal cord dysfunction and paraplegia, who had documented fall risk precautions, was being transferred from bed to wheelchair by two CNAs using a full body mechanical lift and a medium sling, while a third CNA in training observed. During the transfer, multiple witnesses, including the resident and the CNAs, reported hearing a snap or pop sound, after which the resident’s leg, shoulder, and then the rest of his body slipped out of the sling and he fell, striking his hip, shoulder, and head. The resident reported that he believed a strap was not hooked to the lift, which he thought allowed him to slide out of the sling. CNA H, who was observing, stated it appeared that a black strap on the sling was not securely hooked and slipped off the lift. CNA I, who operated the lift, described that the lower sling strap from the left side of the resident’s body, which had been attached to the right side of the lift bar, came off, leading to the resident landing on his hip, shoulder, and then his head. After the fall, staff observed that only three of the four sling straps remained attached to the lift, with one lower strap not attached, and no tears or broken loops were found on the sling itself. Interviews revealed that CNA I and CNA J each checked different sides of the sling attachments before the transfer, and both stated they typically double-check sling straps prior to lifting. CNA I reported she had never had the mechanical lift safety checklist competencies completed for her, and CNA J was unsure if she had completed those competencies, although both had received some form of mechanical lift education. The DON stated her assumption was that the strap was not on the inside of the hook on the lift bar and confirmed that, upon entering the room after hearing a crash, she saw three straps still attached to the lift and one bottom strap not attached. The facility’s mechanical lifts policy required that nursing personnel receive annual in-services on correct lifting and transferring procedures, including the correct use of mechanical lifts, but the report documents that the specific safety checklist competencies for mechanical lift use had not been completed for at least one of the CNAs involved in the transfer.
Unsecured Controlled Medication and Improper Fentanyl Patch Handling
Penalty
Summary
The facility failed to ensure a controlled medication was securely stored and administered as ordered when a medication cup containing Norco was found in an unsecured PPE cabinet in the north hallway. Observation showed the cabinet contained gowns and gloves, and also had a medicine cup with an unidentified tablet on the bottom shelf. The DON later confirmed the medication was Norco 5 mg/325 mg, a controlled pain medication, and that it belonged to a resident who had an order for Norco to be given at midnight, 6:00 a.m., noon, and 6:00 p.m. RN E stated she had prepared the resident’s Norco for administration, then placed the medication cup in the PPE cabinet while assisting another resident and forgot it was there. She later signed the medication off as given during shift count, and said she knew medications needed to be secured and administered as ordered. The resident stated her pain medications were received as scheduled and her pain was under control. The facility also failed to handle and store controlled medication patches according to policy. Staff interviews showed the process for a resident’s Fentanyl patch was to remove the used patch, place it in a medication cup, store it in the locked box in the medication cart, and destroy it later. The DON stated the used and exposed Fentanyl patch was not stored and destroyed according to the provider’s policy, which required controlled substances to be properly stored, tracked, and disposed of, with controlled medications disposed of by a pharmacist and RN or by two RNs if the pharmacist was unavailable.
Failure to Assess Lift Chair Safety for High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident, identified as having a high fall risk and severely impaired cognition, experienced an unwitnessed fall from a lift chair. The resident was found on the floor in front of the lift chair, which was raised all the way up. She sustained a large hematoma on her forehead, a skin tear and bruise on her right hand, and later complained of neck pain. Subsequent medical evaluation revealed acute nondisplaced fractures of the C2 vertebra, leading to hospitalization for observation, pain control, and a neurosurgery consult. Prior to the fall, no lift chair safety assessment had been documented for the resident, despite her high fall risk and cognitive impairment. The resident's medical record confirmed that she was admitted with these risk factors, and her fall risk assessments consistently identified her as high risk. The lift chair safety assessment was only completed after her return from the hospital, at which point it was determined she required total assistance to operate the lift chair. Interviews with facility staff, including the RN/MDS coordinator, DON, and administrator, confirmed that lift chair safety assessments had not been completed for any residents prior to the incident. The facility's policy required a lift chair safety assessment before use, but this was not followed, resulting in the resident's fall and subsequent injuries.
Failure to Ensure Use of Safety Belt on Mechanical Bath Chair Lift Resulting in Resident Injury and Death
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to ensure the use of a safety belt for a resident with severe cognitive impairment during a whirlpool bath using a mechanical bath chair lift. The resident, who had a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment, resisted wearing the safety belt. While the CNA turned to retrieve the resident's clothing, the resident fell from the chair, which was positioned approximately 25 to 30 inches high. The fall resulted in a left forehead hematoma with a laceration, and the resident required assistance from staff and was transferred to the emergency room for evaluation. Subsequent medical evaluation revealed the resident sustained non-displaced fractures of multiple ribs and a confirmed apical pneumothorax. The resident was hospitalized, later readmitted to the facility on hospice services, and subsequently passed away. The incident was identified as a failure to ensure the area was free from accident hazards and that adequate supervision and safety measures, specifically the use of a safety belt on the mechanical bath chair lift, were provided to prevent accidents.
Improper Use of Audible Chair Alarm Without Assessment
Penalty
Summary
The deficiency involves the improper use of an audible chair alarm for a resident, identified as resident 17, without proper assessment, documentation, or reassessment. The resident was observed with a chair alarm clipped to her shirt, which emitted a loud noise when she attempted to move. The resident expressed discomfort with the alarm, stating it was loud and frightening. Despite the resident's ability to use a call light, the alarm was used as a measure to prevent her from getting up unassisted due to her fall risk. Interviews with staff, including a CNA and the DON, revealed that there was no formal assessment process in place before implementing the chair alarm. The CNA indicated that the alarm did not physically restrain the resident, as it could easily detach. However, the DON confirmed that the alarm was used for residents who were not safe to ambulate independently, and there was no consideration of whether the alarm could be perceived as a restraint or cause fear. Additionally, there was no documentation of a physician's order or duration of use for the alarm. The facility's policies on falls and restraints were not followed, as there was no comprehensive assessment or documentation to justify the use of the chair alarm. The resident's care plan included a silent bed alarm but lacked specific interventions for the audible chair alarm. The facility's restraint policy emphasized the need for clinical justification and documentation, which was not adhered to in this case. The lack of proper assessment and documentation led to the inappropriate use of the chair alarm, potentially impacting the resident's well-being.
Resident Lacked Accessible Call Light Due to Hand Contractures
Penalty
Summary
The provider failed to ensure that a resident with hand contractures had access to a call light she could use. Observations revealed that the resident, who communicated verbally with yes or no, did not have her call light within reach. Interviews with staff indicated that they were aware the resident could not use the standard call light due to her hand contractures. Although staff mentioned checking on her frequently, the resident was unable to activate the call light when it was placed in her hand. Further investigation revealed that the resident previously had a soft squeeze call light in another room, which she could use, but had not had access to it for at least a month. After the issue was identified, the resident was provided with a soft squeeze call light, which she was able to activate. However, another observation showed that the call light was not within her reach when she was in a specialized wheelchair, as it was clipped to her bed. The director of nursing acknowledged awareness of the issue and expressed concern over the resident not having a usable call light for an extended period.
Improper Transfer Techniques and Lack of Training for CNAs
Penalty
Summary
The provider failed to ensure that two certified nursing assistants (CNAs), H and K, applied a mechanical stand aide sling to a resident prior to use and transferred the resident safely from the bathroom to a specialized wheelchair. During an observation, CNAs H and K were seen assisting a resident from a recliner to a Broda wheelchair without initially securing the mechanical stand aide sling around the resident. The resident was visibly shaking and struggling to hold on as the CNAs attempted to position the sling while the resident was standing. Once the sling was correctly placed, they transferred the resident to the bathroom and later to the Broda chair. Further observations revealed that CNAs H and K used an unsafe method to transfer the resident into the Broda chair by tilting the chair forward, lifting the back two wheels off the ground. This method was confirmed by CNA K, who stated it was used to position the resident correctly due to his stiffness and difficulty bending. Interviews with other staff, including a registered nurse and the director of nursing, indicated that this method was not documented or approved, and there was no evidence of training for the CNAs on the proper use of the mechanical stand aide or the Broda chair. The resident involved required extensive to total assistance with activities of daily living due to late-stage dementia. The care plan specified the use of a Broda chair but did not include instructions for tilting the chair during transfers. The facility's transfer policy emphasized the importance of securing transfer surfaces and using safety straps, which were not adhered to in this case. Manufacturer instructions for both the Broda chair and mechanical stand aide also highlighted the necessity of securing the resident and locking transfer surfaces, which were not followed during the observed transfers.
Infection Control Deficiencies in Hand Hygiene and Equipment Disinfection
Penalty
Summary
The provider failed to ensure adherence to infection control policies regarding hand hygiene and mechanical lift disinfection, as observed with two CNAs, H and K, during their interaction with a resident. During a transfer, the CNAs discovered the hand sanitizer dispenser in the resident's room was empty. CNA H left the room to find a new bottle but returned without one, and both CNAs proceeded to put on gloves without performing hand hygiene. They assisted the resident to stand using a mechanical stand aide and later discovered the resident was incontinent. CNA H exited the bathroom without gloves, retrieved a new pair, and re-entered without performing hand hygiene. After assisting the resident, CNA K performed hand hygiene in the hallway after disposing of trash, but both CNAs left the resident on the toilet without sanitizing the mechanical stand aide. They later returned to transfer the resident to a Broda chair, performing hand hygiene before donning gloves. However, they failed to sanitize the mechanical stand aide before moving on to another task, despite having sanitizer wipes available on the aide. Interviews with RN N and the infection preventionist G confirmed that the staff did not meet the expected standards for hand hygiene and equipment disinfection. The facility's policies required hand hygiene before and after glove use and the disinfection of non-critical resident care equipment, such as mechanical lifts, after each use. The CNAs' actions did not align with these policies, leading to the identified deficiencies.
Resident Elopement Due to Staff Oversight
Penalty
Summary
A deficiency occurred when a resident, who had been admitted to the nursing home from an adjoining assisted living facility, eloped from the facility without staff knowledge. The incident took place when the director of plant operations found the resident near the entrance of the adjoining hospital. Although the door alarms were functioning, the staff on duty did not recognize the incident as an elopement because the resident did not leave the campus. This oversight led to a failure in reporting the elopement within the required timeframe. The resident involved in the incident was not injured, and the deficiency was identified as a failure to ensure the safety of the resident. The staff's lack of awareness regarding the classification of the incident as an elopement contributed to the deficiency. The report highlights that the resident was not wearing a wander bracelet at the time of the incident, which was only put in place afterward. This lapse in supervision and safety measures could have resulted in harm to the resident had they not been found promptly.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Parkston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society Corsica | 21 mi | — | 0 | 0 |
| Avera Brady Health And Rehab | 21.5 mi | ★★★★★ | 3 | 0 |
| Firesteel Healthcare Center | 21.9 mi | ★★★★★ | 6 | 0 |
| Good Samaritan Society Scotland | 21.9 mi | ★★★★★ | 0 | 0 |
| Menno-olivet Care Center | 23.8 mi | ★★★★★ | 1 | 0 |
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