Avera Bormann Manor
501 North 4th Street, Parkston, SD 57366 · Non profit - Corporation · 50 certified beds · (605) 928-3384 Medicaid only — no Medicare
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has abuse, neglect, or exploitation citations (F0600, F0604) — most recent Jul 2024
- it has 2 actual-harm citations
- inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $47,187 in federal fines (most recent 2025-06-26)
- its payroll-based staffing score sits well above its independent inspection score
- its facility-reported quality-measure rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 23.1% | 21.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.0% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.4% | 2.1% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 4.3% | 2.9% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 5.7% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 9.8% | 5.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 16.1% | 19.4% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 21.0% | 17.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.0% | 96.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.8% | 4.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 23.0% | 25.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.3% | 24.6% | 17.1% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.25 | 1.52 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.13 | 1.75 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Staffing
How full it usually is: this home is certified for 50 beds and averages 46.8 residents a day — about 94% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.63 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.10 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.52 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.98 hrs/resident/day on weekends vs 3.89 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 1.25 to 0.74 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
15 citations, most serious first — scroll within the box to see all.
- Immediate jeopardy · Jcited before2025-03-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Immediate Jeopardy (IJ) was identified for resident safety related to a facility-reported incident that occurred on [DATE] when a resident (1) fell from a bath chair, received serious injuries, and later died. The investigation revealed staff education and competencies initiated on [DATE] removed the immediacy. On [DATE] at 5:00 p.m. administrator A was informed of the IJ and was given…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-06-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Review of provider's 5/27/25 SD DOH FRI for resident 1 revealed: *On 5/24/25 the resident was found on the floor in front of her lift chair laying on her right side. *Her lift chair was raised all the way up in the air. *She was unsure how she fell and ended up on the floor. *She had a large hematoma (collection of blood outside a blood vessel) to the left side of her forehead. *She had a skin tear and bruise on the top of her right hand. *She had adequate range of motion (ROM) to all four extremities. *Her neurological…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2024-07-11 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Observation and interview on 7/9/24 at 2:04 p.m. with resident 17 in her room revealed she: *Was seated in the same recliner. *Showed the surveyor a chair alarm was clipped to her shirt. *Was able to explain the purpose of the alarm. *Explained…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2024-01-30 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. resident 22 in his room revealed: *He was seated in a Broda [a specialized wheelchair] chair. *He made no eye contact, and was unable to respond coherently to questions. Review of resident 20's electronic medical record revealed his: *12/27/23 Brief Interview of Mental Status score was a 4, meaning he was cognitively impaired. *Diagnoses included Alzheimer's Disease and Lewy Body dementia with behavioral disturbance, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-02-04 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
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. Review of the12/2/2025 SD DOH complaint intake revealed: *Medications were given in the dining room. *Staff were available to assist residents to eat each meal. *Blood sugars were being taken at appropriate time and locations as per resident doctors' orders and care plan preferences. *Unwitnessed and unreported falls. *Licensed staff were working in the facility within their scope of practice. *Hygiene with nails, hair, bathing and shaving were completed. 2. Observation on 2/3/26 at 7:50 a.m. in the dining room during the breakfast meal service revealed that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-04 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) complaint report review, observations, interviews, and policy review, the provider failed to ensure physician orders were received for self-administration of medications for two of seven observed sampled residents (2 and 3) who self-administered medications. Findings Include:1. Review of the12/2/2025 SD DOH complaint intake revealed:*Medications were given in the dining room.*Staff were available to assist residents to eat each meal.*Blood sugars were being taken at appropriate time and locations as per resident doctors' orders and care plan preferences.*Unwitnessed and unreported falls.*Licensed staff were working in the facility within their scope of practice.*Hygiene with nails, hair, bathing and shaving were completed. 2. Observation on 2/3/26 at 8:20 a.m. revealed registered nurse (RN) E left resident 2's cup of medications containing 14 pills with him at the breakfast table. Resident 2 then dropped a yellow pill onto the floor and told a DOH surveyor, who…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-04 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) complaint intake review, observations, interviews, record review, electronic medication records and policy review, the provider failed to ensure the staff followed professional standards regarding the safe transfer of one of one sampled resident (5) who was transferred with a total body mechanical lift by the certified nursing assistant (CNA) K and registered nurse (RN) F after he fell and had a suspected hip injury.Findings Include:1. Review of the12/2/2025 SD DOH complaint intake revealed:*Medications were given in the dining room.*Staff were available to assist residents to eat each meal.*Blood sugars were being taken at appropriate time and locations as per resident doctors' orders and care plan preferences.*Unwitnessed and unreported falls.*Licensed staff were working in the facility within their scope of practice.*Hygiene with nails, hair, bathing and shaving were completed. 2. Interview on 2/3/26 at 9:20 a.m. with registered nurse (RN) F revealed she was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, record review, interview, and policy review the provider failed to ensure the safety of one of one sampled resident (1) who fell from a full body mechanical lift (a lift and sling used to lift a person's body) while being transferred from his bed to his wheelchair by certified nursing assistant (CNA) I and CNA J which required him to go to the emergency room for evaluation. Findings include:1. Review of the 1/6/26 SD DOH FRI report revealed:*On 1/6/26 at 5:20 p.m. resident 1 was being transferred by CNA I and CNA J from his bed to his wheelchair with a full body mechanical lift CNA H was in training and was observing.*CNA's I and J and resident 1 reported hearing a snap sound before resident 1 fell out of the full body mechanical lift.*Resident 1's left leg slipped out of the sling first, followed by his left shoulder, and then the rest of his body.*Resident 1 hit his head but did not lose consciousness.*When director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-18 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to:Ensure a controlled medication (medications at risk for abuse and addiction) was securely stored by one of one registered nurse (RN) E who placed a controlled medication (Norco) in an unsecured cabinet in the north hallway and did not administer that medication to one of one sampled resident (4) as ordered by the resident's physician.Ensure controlled medication patches were handled and securely stored for destruction according to the provider's policy.Findings include:1. Observation on 9/16/25 11:12 a.m. of the personal protective equipment (PPE) cabinet in the north hallway next to room [ROOM NUMBER] revealed: *The cabinet was recessed in the north hallway and contained washable gowns and disposable gloves on the shelves. *A medicine cup with an unidentified medication tablet on the bottom shelf of that cabinet. 2. Observation and interview on 9/16/25 at 12:24 p.m. with director of nursing (DON) B of the north hallway PPE cabinet…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the provider failed to ensure one of one sampled resident (13) with hand contractures had a call light she was able to use and was within her reach. Findings include: 1. Observation on 7/9/24 at 10:44 a.m. of resident 13 revealed: *She had hand contractures to both of her hands. *She communicated verbally with yes or no. *She did not have her call light within her reach. Interview on 7/9/24 at 10:44 am. with registered nurse (RN) O in regard to resident 13's use of a call light revealed: *She did not believe resident 13 could push her call light button because her hands were tight due to contractures. *Staff would check on her frequently. Observation and Interview on 7/10/24 at 8:32 a.m. with resident 13 and certified nursing assistant (CNA) Q in regard to resident 13 and use of her call light revealed: *Resident 13 could use her left hand and CNA Q placed the call light in her hand. *She was unable to activate the call light when she held it with her left hand. *He stated he would check on her every hour and a half. Interview on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-11 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and policy review, the provider failed to ensure two certified nursing assistants (H and K): *Applied a mechanical stand aide sling to sampled resident (22) prior to use. *Transferred a sampled resident (22) safely from the bathroom to a specialized wheelchair. *Received documented training for the use of a mechanical stand aide and resident transfers using a specialized wheelchair (Broda chair). Findings include: 1. Observation on 7/9/24 at 2:22 p.m. in resident 22's room revealed: *Resident 22 was resting in his recliner. *Certified nursing assistant (CNA) H and K entered his room to assist him with transferring him from the recliner to his Broda (specialized) wheelchair. *They used the recliner remote to lift him upwards. *They positioned the mechanical stand aide in front of resident 22 and placed his feet on the footboard. *They guided his hands up to the handlebars and instructed him to hold on. *Without strapping the mechanical stand aide sling around him, CNA H raised the mechanical stand aide slightly so that resident 22 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-11 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and policy review, the provider failed to ensure current infection control policies for hand hygiene and mechanical lift disinfection were followed by two of five staff observed (certified nursing assistant (CNA) H and K). Findings include: 1. Observation on 7/9/24 at 2:22 p.m. with CNAs H and K during a transfer with resident 22 revealed: *The CNAs entered resident 22's room and discovered the hand sanitizer dispenser was empty. *CNA H exited the room to retrieve a new bottle of hand sanitizer. *CNA K proceeded to put on a clean pair of gloves without performing hand hygiene. *CNA H came back into the room and stated she could not find a new bottle of hand sanitizer. -She proceeded to put on a clean pair of gloves without performing hand hygiene. *They assisted resident 22 to stand up from his recliner using the mechanical stand aide. *While he was standing, CNA K checked his brief and discovered he was incontinent. *The CNAs brought him into his bathroom. *A few minutes later, CNA H came out of the bathroom without gloves on. -She…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and observation, the provider failed to ensure the safety of one of one sampled resident (47) who eloped from the facility (left without staff's knowledge) and failed to report the elopement within the required timeframe. Failure to ensure safety could have led to resident injury had he not been found. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of the provider's 6/24/24 SD DOH FRI revealed: *Resident 47 was admitted to the nursing home on 6/17/24. He was previously living at the adjoining assisted living facility. *At around 5:15 p.m., director of plant operations E found resident 47 near the adjoining hospital entrance. *The resident was brought back to the nursing home. *A wander bracelet was put in place afterward. *The door alarms were functioning at the time of the incident. *The resident was not injured. *The nurse on staff that day…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-30 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the South Dakota Department of Health (SD DOH) online report, interview, and policy review, the provider failed to ensure one of one sampled restorative aide (F) provided appropriate care to prevent a burn on one of one sampled resident (20) 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). Interview on 1/30/24 at 10:44 a.m. with restorative aide (RA) F regarding the above-referenced report revealed: *She had started placing warm packs on residents' necks before completing their restorative nursing care to help loosen the neck muscles. -She had no training in the use of warm packs. -She had no guidance from a nurse or physical therapist in the use of warm packs. Interview on 1/30/24 at 12:45 p.m. of resident 20 with registered nurse (RN) D revealed: *CNAs and RA F were able to use warm…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-08 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the provider failed to ensure the privacy and confidentiality of resident electronic health records had been maintained by three of three staff (registered nurse (RN) D, RN E, and certified nurse assistant/medication aide (CNA/MA) F) during medication administration. Findings include: 1. Observation on 6/6/23 from 9:14 a.m. to 9:20 a.m. of one medication cart computer in the north hall revealed: *It was placed in the north hallway and there were no staff within view of the medication cart. *The medication computer screen had been facing the hallway and was open to a resident's medication administration record. *The unattended computer screen was visible to any resident, staff, or visitors that would have been passing by the medication cart. *It contained the following information: -The resident's name and room location. -Age and date of birth . -Gender. -Cardiopulmonary status. -Height, weight and body mass index (BMI). -Allergies -Medical record number. -Medications ordered by the physician. *RN D had come out of a resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$47,187 in federal fines across 4 penalties.
- $12,438 — penalty dated 2025-06-26
- $14,901 — penalty dated 2025-03-31
- $10,839 — penalty dated 2024-07-11
- $9,009 — penalty dated 2024-01-30
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
What families pay in SD
CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the South Dakota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 43A137. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-18, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.