Avera Oahe Manor
Gettysburg, South Dakota · CCN 43A113
12 surveys since 2011, 4 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 45
- Surveys
- 12
- Harm or worse
- 4
- Immediate jeopardy
- 0
Findings where a surveyor recorded actual harm to a resident.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 53
- Ownership
- Non profit - Corporation
- Chain
- Independent
- County
- Potter · rural
- Medicare-certified since
- 1991
CMS ratings
- Overall
- 2
- Health inspection
- 3
- Staffing
- 1
- Quality measures
- 2
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat fewer weighted findings than its peer group.
Weighted by harm level, against 48 not-for-profit facilities with fewer than 66 beds in South Dakota.
Last survey on record
Sep 4, 2025
431 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.50 | 3.73 |
| Registered-nurse hours per resident day | 0.62 | — |
| Annual nurse turnover | 43.8% | 49.0% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D444.4% | E444.4% | F111.1% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6582×
Ensure services provided by the nursing facility meet professional standards of quality.
- F5501×
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- F6551×
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- F6571×
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- F6891×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
In the surveyor’s words
From the most serious findings on record at Avera Oahe Manor, in the surveyor’s own words.
- Actual harm, isolatedF689Jul 31, 2025
Based 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.Findings include: Review of the provider's 5/21/25 SD DOH FRI report revealed that resident 9 had spilled her coffee in her lap at a meal on 5/16/25. Findings include:1. Resident 9 had picked up her cup from the table and it caught on her meal container, tipping the coffee into her lap. She wheeled herself out of the dining room. […]
- No harm, potential for more than minimal, widespreadF727Jul 31, 2025
Based 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.Findings include: 1.Interview on 7/29/25 at 8:48 a.m. with director of nursing (DON) B during the entrance conference revealed she thought the provider had a registered nurse (RN) staffing waiver in place that exempted them from the requirement of having an RN in the facility for eight consecutive hours seven days a week.2. […]
- No harm, potential for more than minimal, patternF578Aug 20, 2026
Based on record review, interview, and policy review, the provider failed to ensure the advanced directive (a document that expresses a person's health care wishes if they become unable to speak for themselves) for three of twelve sampled residents (1, 20, and 28) was documented in the residents' electronic medical records (EMR) to inform staff members what the resident wanted in the situation that they stopped breathing or if their heart stopped beating. Findings included: 1. Review of resident 1's EMR revealed she admitted to the facility on [DATE]. Her [DATE] Brief Interview for Mental Status (BIMS) assessment score was 3, which indicated her cognition was severely impaired. […]
- No harm, potential for more than minimal, patternF657Jul 31, 2025
Based 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. Findings include: 1. Observation on 7/29/25 at 2:50 p.m. of resident 5 revealed: *She was sitting in a recliner with her feet elevated in the common area. *She began sitting forward and attempted to scoot forward in the recliner. *Certified nursing assistant (CNA) J asked resident 5 to wait a moment until she got resident 5’s wheelchair. *CNA J then assisted resident 5 in transferring to her wheelchair. Observation and interview on 7/30/25 at 11:28 a.m. […]
- No harm, potential for more than minimal, patternF880Jul 31, 2025
Number 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.Findings include: 1. Observation on 7/29/25 at 9:38 a.m. […]
Read 23 findings in full →The most serious and the most recent: 23 of 45 on record.
Every survey on record
FindingsAt actual harm or above
- Aug 20, 2026Standard and complaint6 findings
- Sep 4, 2025Complaint1 finding
- Jul 31, 2025Standard5 findings · 1 harm
- Jan 25, 2024Standard3 findings
- Jul 15, 2021Standard5 findings
- Apr 3, 2019Standard1 finding
- Oct 19, 2016Standard4 findings
- Sep 2, 2015Standard5 findings · 2 harm
Show the 4 earlier surveys
- Jun 25, 2014Standard5 findings
- Jun 5, 2013—6 findings
- Mar 21, 2012—1 finding · 1 harm
- Mar 9, 2011—3 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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