Avera Bormann Manor

• Fine

  CMS changed the fine from June 26, 2025 from $19,135 to $12,438.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 1 of 5.

• Fine

  CMS changed the fine from March 31, 2025 from $22,925 to $14,901.

CMS lists this as a complaint inspection.

• Citation F0550. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on March 5, 2026.

• Citation F0554. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Allow residents to self-administer drugs if determined clinically appropriate.

  CMS lists it as corrected on March 5, 2026.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on March 5, 2026.

  CMS has cited this home for F0658 2 times since 2024.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on March 5, 2026.

  CMS has cited this home for F0689 4 times since 2024.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a standard inspection.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on October 15, 2025.

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CMS lists this as a standard inspection.

• Citation K0293. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have properly located and lighted "Exit" signs.

  CMS lists it as corrected on October 15, 2025.

• Citation K0712. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on October 17, 2025.

  CMS has cited this home for K0712 2 times since 2023.

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CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

37 of 96 South Dakota homes (39%) got a citation at the actual harm level in 2025.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on June 23, 2025.

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CMS fine of $12,438 on June 26, 2025.

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CMS lists this as a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

7 of 96 South Dakota homes (7%) got a citation at the immediate jeopardy level in 2025.

• Citation F0689. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on March 28, 2025.

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CMS fine of $14,901 on March 31, 2025.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• CMS abuse icon

  CMS removed its abuse icon from this home.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

• Fine

  CMS changed the fine from January 30, 2024 from $13,860 to $9,009.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a standard inspection and a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

42 of 96 South Dakota homes (44%) got a citation at the actual harm level in 2024.

• Citation F0604. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

  CMS lists it as corrected on July 31, 2024.

• Citation F0558. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS lists it as corrected on July 31, 2024.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on July 31, 2024.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on June 30, 2024.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on July 31, 2024.

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CMS fine of $10,839 on July 11, 2024.

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• Star rating

  The CMS overall star rating changed from 4 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 2 of 5.

• CMS abuse icon

  CMS added its abuse icon to this home.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

42 of 96 South Dakota homes (44%) got a citation at the actual harm level in 2024.

• Citation F0600. Severity G: actual harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on February 21, 2024.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on February 21, 2024.

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CMS fine of $9,009 on January 30, 2024.

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CMS lists this as a standard inspection.

• Citation F0583. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Keep residents' personal and medical records private and confidential.

  CMS lists it as corrected on July 27, 2023.

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CMS lists this as a standard inspection.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on July 13, 2023.

• Citation K0226. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have horizontal exits used in accordance with safety requirements.

  CMS lists it as corrected on July 7, 2023.

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