Home / South Dakota / Gettysburg
Avera Oahe Manor
700 E Garfield, Gettysburg, SD 57442 · Potter County · (605) 765-2461
53 certified beds, about 35 residents a day · Non profit - Corporation · Medicaid since 1991
CMS Care Compare ratings, data as of September 1, 2026 · CCN 43A113 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on July 31, 2025, inspectors cited 5 health deficiencies (the South Dakota average is 6.7, the national average 9.2).
None of its 9 health citations since December 2022 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.50 hours per resident per day, against 3.79 across South Dakota and 3.86 nationally. Registered nurses accounted for 0.62 of those hours.
43.8% of nursing staff left within the year CMS measured (South Dakota average 48.2%).
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 9 health citations on file.
September 4, 2025Complaint inspection · 1 citation
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to follow nursing professional standards to ensure one of one sampled resident (1) had consistent neurological checks completed and documented after the resident fell and hit her head, according to the provider's policies.
July 31, 2025Standard inspection · 5 citations
- F Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on Payroll Based Journal (PBJ) reports review, interview, posted nurse schedule review, and staff timecard review, the provider failed to ensure a registered nurse (RN) had been scheduled for eight consecutive hours of coverage for ten days in quarter four (Q4) (July 1 through September 30) of fiscal year 2024, and for seven days in quarter one (Q1) (October 1 through December 31) of fiscal year 2025.
- E Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, record review, interview, and policy review the provider failed to ensure, the care plans were updated for one of one sampled resident (5) to reflect her current care needs, and one of one sampled resident (38) who no longer had a urinary catheter.
- E Provide and implement an infection prevention and control program.
Inspectors wroteNumber of residents sampled:Number of residents cited:Based on observation, interview, and policy review the provider failed to follow infection control practices to ensure:*Enhanced barrier precautions (EBP) (glove and gown use when providing contact care) and contact precautions (gown and gloves must be worn when entering a resident's room to prevent the spread of an identified organism) were properly followed for two of two sampled residents (3 and 26).*The sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) slings were not shared or properly disinfected between residents (4 and 17) use.
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, record review, the provider failed to have a physician order for two of two sampled residents' (12 and 38) use of continuous positive airway pressure (CPAP) devices, which deliver pressurized air through a mask to keep a person's airways open.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), interview, record review, and policy review, the provider failed to ensure a safe environment by not having checked the coffee temperature to ensure it was within a safe temperature range before serving it to one of one sampled residents (9) who spilled her coffee and sustained a burn to her upper anterior (front) thighs.
January 25, 2024Standard inspection · 3 citations
- E Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on electronic medical record (EMR) review, interview, and policy review, the provider failed to ensure documentation in the EMR had indicated that three of three sampled residents (332, 182, and 82) had received their baseline care plan.
- E Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Inspectors wroteBased on observation, interview, electronic medical record (EMR) review, and policy review the provider failed to ensure two of two sampled resident's (332 and 27) had a physician's order, assessment, consent, care planned, and inspection of the side rails they had been using.
- D Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to offer or provide dignified positioning for one sampled vulnerable resident (82) while in the activity room.
December 7, 2022Standard inspection · 0 citations
Fire safety inspections
6 fire safety citations on file: 1 on January 25, 2024, 3 on December 7, 2022, 2 on July 15, 2021.
Every fire safety citation6 citations
- F Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D Have a battery powered remote alarm panel in a location accessible by operating personnel.
- C Have correct number of accessible exits for each story.
- C Have properly located and lighted "Exit" signs.
- D Provide properly protected cooking facilities.
- C Have correct number of accessible exits for each story.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | South Dakota | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.50 | 3.79 | 3.86 |
| Registered nurses | 0.62 | 0.80 | 0.69 |
| All nursing staff on weekends | 3.03 | 3.26 | 3.42 |
| Nurse aides | 2.01 | ||
| Licensed practical nurses | 0.87 | ||
| Nursing staff turnover (share who left in a year) | 43.8% | 48.2% | 45.8% |
| Registered nurse turnover | 28.6% | 34.7% | 42.9% |
| Administrators who left | 0 |
CMS expects 2.87 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.69 on weekdays and 3.03 on weekends, 18% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.88 in April to June 2025 to 3.50 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.50 | 0.62 | 3.69 | 3.03 | 0.0% | 4 of 90 | 35 |
| Oct to Dec 2025 | 3.82 | 0.70 | 4.01 | 3.35 | 0.0% | 5 of 92 | 35 |
| Jul to Sep 2025 | 4.01 | 0.73 | 4.36 | 3.13 | 0.0% | 2 of 92 | 35 |
| Apr to Jun 2025 | 3.88 | 0.79 | 4.16 | 3.18 | 0.0% | 6 of 91 | 32 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| South Dakota, Jan to Mar 2026 | 3.76 | 0.79 | 3.97 | 3.25 | 9.1% | 1.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | South Dakota | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 19.0 | 21.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 4.6 | 2.1 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 2.9 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 6.9 | 5.5 | 3.2 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 23.5 | 19.4 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 1.8 | 4.6 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 16.1 | 24.6 | 15.4 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.9 | 1.5 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.3 | 1.8 | 1.8 |
Owners and operators
Legal business name: Legal Business Name Not Available.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Ownership data not available |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- When is the care plan meeting, and can family attend it?Inspectors cited 4 problems in this area, most recently on September 4, 2025: "Ensure services provided by the nursing facility meet professional standards of quality."
- How many nurses and aides work each shift, nights and weekends included?Inspectors cited 1 problem in this area, most recently on July 31, 2025: "Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis."
- What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 1 problem in this area, most recently on July 31, 2025: "Provide and implement an infection prevention and control program."
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 1 problem in this area, most recently on July 31, 2025: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.03 hours per resident per day, below the South Dakota average of 3.26.
South Dakota contacts for a concern about a nursing home
These are the official offices in South Dakota. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: South Dakota Department of Health, Office of Health Facilities Licensure and Certification, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: South Dakota Long-Term Care Ombudsman Program, Department of Human Services. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: South Dakota Department of Health Nursing Facility Reports, where South Dakota publishes its own records on licensed homes.
Common questions
- What is Avera Oahe Manor's Medicare star rating?
- CMS rates Avera Oahe Manor 2 out of 5 stars overall, with 3 for health inspections, 1 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Avera Oahe Manor get at its last inspection?
- 5 health deficiencies at the standard inspection on July 31, 2025. The South Dakota average is 6.7.
- Has Avera Oahe Manor been fined?
- CMS lists no fines in the last three years.
- Does Avera Oahe Manor accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Avera Oahe Manor?
- CMS lists 1 owner or manager. Legal business name: Legal Business Name Not Available.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.