Avera Oahe Manor
700 E Garfield, Gettysburg, SD 57442
Avera Oahe Manor is a nursing home in Gettysburg, South Dakota. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 4 of 5CMS overall star rating
- 3 of 5CMS health inspection star rating
- 5 of 5CMS staffing star rating
- 2 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (605) 765-2461
- Last standard health inspection
- August 20, 2026 (2 months ago)
- Certified beds
- 40
- Residents per day, on average
- 33.7
- Ownership type
- Non profit - Corporation
- Legal business name
- Legal Business Name Not Available
- Chain
- Not listed by CMS
- Takes part in
- Medicaid
Fewer health citations than the South Dakota average (15 vs 18).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 5 of 5.
6 citations
Health inspection on August 20, 2026
CMS lists this as a standard inspection and a complaint inspection.
Citation F0578. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
CMS lists it as corrected on October 4, 2026.
Citation F0605. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on October 4, 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 October 4, 2026.
CMS has cited this home for F0658 3 times since 2025.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on October 4, 2026.
Citation F0732. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on October 4, 2026.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on October 4, 2026.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
Health citation
CMS changed citation F0689 from severity G to D. It is from the health inspection on July 31, 2025. Severity D: potential for more than minimal harm, isolated.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 4 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
1 citation
Health inspection on September 4, 2025
CMS lists this as a complaint inspection.
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 October 10, 2025.
5 citations
Health inspection on July 31, 2025
CMS lists this as a standard inspection.
Citation F0727. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on August 28, 2025.
Citation F0657. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on August 28, 2025.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 2, 2025.
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 September 3, 2025.
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 August 28, 2025.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 4 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 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 1 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of March 28, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 3 of 5.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.0 to 3.5 hours per resident per day.
3 citations
Health inspection on January 25, 2024
CMS lists this as a standard inspection.
Citation F0655. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on March 10, 2024.
Citation F0909. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on March 10, 2024.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
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 10, 2024.
1 citation
Fire safety inspection on January 25, 2024
CMS lists this as a standard inspection.
Citation K0321. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on March 8, 2024.
3 citations
Fire safety inspection on December 7, 2022
CMS lists this as a standard inspection.
Citation K0916. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have a battery powered remote alarm panel in a location accessible by operating personnel.
CMS lists it as corrected on January 25, 2023.
Citation K0241. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have correct number of accessible exits for each story.
CMS lists it as corrected on January 25, 2023.
Citation K0293. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on January 9, 2023.
Questions
When was Avera Oahe Manor last inspected?
CMS lists August 20, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Avera Oahe Manor have?
CMS lists 15 health citations since January 25, 2024. CMS also calls these deficiencies.
Has Avera Oahe Manor been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Avera Oahe Manor?
Its CMS overall star rating is 4 of 5.
Is Avera Oahe Manor a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.