Avera Oahe Manor
700 E Garfield, Gettysburg, SD 57442 · Non profit - Corporation · 53 certified beds · (605) 765-2461 Medicaid only — no Medicare
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
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) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 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 fell from 2 to 1 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 | 19.0% | 21.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.3% | 5.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 4.6% | 2.1% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 2.9% | 2.0% | better |
| 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 | 6.9% | 5.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 23.5% | 19.4% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 21.3% | 17.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.8% | 4.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 22.7% | 25.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.0% | 24.6% | 17.1% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.88 | 1.52 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.32 | 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.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.01 therapist hours per resident per day in 2026Q1 — more than 1% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 53 beds and averages 35.4 residents a day — about 67% occupied, or roughly 18 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 is below 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 3.03 hrs/resident/day on weekends vs 3.69 on weekdays — 18% thinner on weekends. RN hours go from 0.70 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% 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 more than at the previous inspection — worsening. 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.
9 citations, most serious first — scroll within the box to see all.
- Potential for harm · Dcited before2025-09-04 · 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 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.Findings include:1. Review of the 8/3/25 SD DOH FRI regarding resident 1 revealed:*On 8/3/25 at 12:00 p.m. resident 1 was walking with certified nursing assistant (CNA) E to the bathroom.*CNA E let go of resident 1's gait belt (a waist strap gripped as support for safe mobility and transfers) to turn on the bathroom light.*Resident 1 lost her balance, fell to the floor, and hit her head on the floor.*Resident 1 was assessed by licensed practical nurse (LPN) F, who did not identify any injuries at that time.*Resident 1 was taken to the emergency room by her husband, who was present at the time of the fall.*While in the emergency department…
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 · F2025-07-31 · tag F0727 — failed to provide required RN coverage — widespreadHave 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 the surveyor found here — an excerpt from the official record, may be distressing
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. Review of the provider's RN waiver application revealed:*The provider had an RN waiver in place that required to have been reapproved by 7/10/24.*The provider sent an email to the South Dakota Department of Health (SD DOH) to reapply for the RN waiver on 5/16/25.*On 6/5/25 the SD DOH replied to the provider's application with direction from the Center for…
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 · E2025-07-31 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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, 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. with registered nurse (RN) G revealed: *She pushed resident 5 in her wheelchair into her room. *RN G stated resident 5 was able to walk, but she was unsteady and had a high risk for falling. *RN G assisted resident 5 to a standing position, held her hands, and provided cues for resident 5 to walk…
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 · E2025-07-31 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
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. of resident 3's room revealed:*A sign on the outside of his door indicated the need for contact precautions.*Personal Protective Equipment (PPE) was hanging on the door across the hall from resident 3's room.Review of resident 3's electronic medical record (EMR) revealed:*He had a left knee abscess that was drained on 1/27/25.-The culture obtained during the abscess being drained was positive for…
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 before2025-07-31 · 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
Based 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. Findings include: 1. Observation and interview on 7/29/25 at 10:22 a.m. with resident 38 revealed: *He had a CPAP machine that he cleaned himself. He stated, “I am going to as them [the staff] to do it because I think it could use a women’s touch.” 2. Interview on 7/30/25 at 8:10 a.m. with director of nursing (DON) B revealed they did not have a CPAP policy. She stated they did not have a current CPAP cleaning process but they were working on one. *She stated the current CPAP machines in the facility were newer and were cleaned in self-cleaning devices. *She stated the certified nursing assistants (CNAs) had been trained on the CPAPs by the family of a previous resident, but a newly contracted travel CNA had not been trained. 3. Interview and observation on 7/30/25 at 8:49 a.m. with CNA L revealed: *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 · D2025-07-31 · 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 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. One of her tablemates notified the activities director (who is also a CNA) who had been in the dining room, and found resident 9 attempting to enter the lobby restroom and immediately assisted her in getting the wet clothing away from her skin. The resident suffered burning 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 · E2024-01-25 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings include: 1. Review of resident 82, 182, and 332's EMR confirmed no documentation they had received a copy of their baseline care plan. Interview on 1/24/24 at 3:20 p.m. with director of resident care J regarding documentation of resident's receiving a copy of their baseline care plan revealed: *She agreed that their was no documentation that resident 82, 182, and 332 had received a copy of her baseline care plan. *Licensed practical nurse (LPN) H should have provided the copy of the baseline care plan to the resident and documented that it was given. Interview on 1/25/24 at 2:40 p.m. with LPN H regarding documentation of resident 182 and 82 had received a copy of their baseline care plan revealed: *She did not have documentation that a copy of the baseline care plan had been provided to the residents and representatives. *They would…
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 · E2024-01-25 · tag F0909 — failed to maintain a comfortable temperature — patternRegularly 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings include: 1. Observation and interview on 1/23/24 at 10:43 a.m. with resident 332's regarding the use of her side rail that was raised at the head of her bed revealed she used the side rail for bed mobility. Review of resident 332's EMR revealed: *On 1/8/24 a device evaluation was completed and was marked no for currently using a device to assist with mobility/positioning/safety. *No physician's order, consent, or care plan had indicated the use of the side rail. 2. Observation and interview on 1/23/24 during the initial tour revealed resident 27: *Had one side rail in the up position near the head of the bed, on the left side. *Resident stated she uses it to move herself around in bed. Interview on 1/24/24 at 3:44 p.m. with LPN H regarding request for resident 27's side rail revealed she: *Had not…
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 · D2024-01-25 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Observation on 1/24/24 at 9:40 a.m. of the front activity room revealed: *Resident 27 was seated in a chair at the table across from resident 82. *Resident 82 was positioned approximately 3 feet from the activity table in her wheelchair, slumped forward with her head hung over her knees, her arms hung down in front of her, and her hands resting on her ankles/feet by the front wheelchair pedals. *Activities assistant E was placing bingo cards on the activity table. *Activities coordinator F had then entered the room. *Shortly after, activities assistant G had entered the room. *All three staff sat at the opposite end of the table from the residents and had what appeared to be a meeting. *Resident 82 was noted to be in the same position, with her head at her knee level, moving her left hand 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.
“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
No federal fines in the current CMS record.
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 43A113. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-31, 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.