PARKSTON, SD - Federal health inspectors identified pharmacy service deficiencies at Avera Bormann Manor during a standard health inspection conducted on September 18, 2025, citing the facility for failing to meet federal drug storage and labeling requirements.
The citation, issued under regulatory tag F0761, found that the facility did not ensure all drugs and biologicals were labeled according to accepted professional standards and were not consistently stored in properly locked compartments as mandated by federal nursing home regulations.
Medication Storage Requirements Not Met
The deficiency centered on two core pharmacy service obligations that every Medicare- and Medicaid-certified nursing home must follow. First, all medications and biologicals used within a facility must be clearly labeled in accordance with currently accepted professional principles. Second, all drugs must be stored in locked compartments, with controlled substances kept in separately locked areas from other medications.
At Avera Bormann Manor, inspectors determined that these requirements were not fully met. The scope and severity of the violation was classified as Level D, meaning the issue was isolated in nature and no actual harm to residents was documented at the time of the inspection. However, regulators noted there was potential for more than minimal harm.
The distinction matters. Level D citations indicate that while no resident experienced a direct adverse outcome, the conditions observed could have led to harmful consequences if left unaddressed.
Why Proper Drug Storage Matters
Medication storage protocols exist for well-established safety reasons. When drugs are not stored in locked compartments, the risk of unauthorized access increases significantly. In a nursing home setting, this can mean residents with cognitive impairment could potentially access medications not prescribed to them, or that controlled substances could be diverted.
Improper labeling creates a separate but equally serious concern. When medications are not clearly identified according to professional pharmacy standards, the likelihood of administration errors rises. A mislabeled or unlabeled medication container could lead to a resident receiving the wrong drug, the wrong dosage, or a medication intended for another individual entirely.
Medication errors rank among the most common preventable safety events in long-term care facilities. According to federal data, pharmacy-related deficiencies are frequently cited during nursing home inspections nationwide. Proper labeling ensures that nursing staff can verify the correct medication, dose, route, and expiration date before administering any drug to a resident.
Federal Standards for Nursing Home Pharmacies
Under federal regulations governing nursing home participation in Medicare and Medicaid, facilities are required to maintain pharmaceutical services that meet the needs of each resident. This includes establishing procedures for the accurate acquisition, receipt, dispensing, storage, and administration of all drugs and biologicals.
Controlled substances — including opioid pain medications, sedatives, and certain other drugs with abuse potential — carry additional requirements. These medications must be stored in a separately locked compartment within the already-locked medication storage area, providing a double layer of security.
Facilities are expected to conduct regular audits of their medication storage areas and work with consultant pharmacists to ensure ongoing compliance with both federal standards and state pharmacy regulations.
Facility Response and Correction
Following the inspection, Avera Bormann Manor reported that corrective action was taken. According to the inspection record, the facility indicated a correction date of October 15, 2025, approximately four weeks after the deficiency was identified.
The citation status was listed as "Deficient, Provider has date of correction," meaning the facility acknowledged the problem and committed to a specific timeline for addressing the issue.
Avera Bormann Manor is located in Parkston, a small community in southeastern South Dakota. The facility operates as part of the Avera Health system, one of the largest health care networks in the upper Midwest region.
What Residents and Families Should Know
While this citation did not involve documented harm to any resident, families with loved ones in nursing home care should be aware that pharmacy service compliance is a fundamental component of facility safety. Inspection reports are public records and can be reviewed through the Centers for Medicare & Medicaid Services (CMS) Care Compare website.
The full inspection report for Avera Bormann Manor contains additional details about the findings. Residents and family members who have concerns about medication management at any nursing facility are encouraged to review inspection histories and discuss questions directly with facility administration or their state long-term care ombudsman program.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avera Bormann Manor from 2025-09-18 including all violations, facility responses, and corrective action plans.