Avera Missouri River Health Center
A critical access hospital in Gettysburg, South Dakota 57442
606 East Garfield, Gettysburg, South Dakota 57442. (605) 765-2488.
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The short answer
Record last released by CMS on Oct 20, 2026.
- Not rated CMS’s overall rating
- Not rated patient survey rating
- 3 deficiencies cited in the last three years
- 7 beds
Each figure’s source sits beside it, in its section below.
What these words mean2
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Feb 25, 2026: a standard inspection.
3 deficiencies cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
3 deficiencies in 1 month of the last 36. Last cited Feb 2026. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Feb 25, 2026: standard inspection2 deficiencies
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Emergency And Supplies
The inspectors’ words, 405 words
“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 50915 Based on observation, interview, record review, and manufacturer’s instructions for use (IFU), the provider failed to ensure; *Two of two defibrillators (a device that delivers an electrical shock to correct life-threatening heart rhythms) were checked daily for proper functioning according to the manufacturer’s IFU and provider’s daily checklist. Findings include: 1. Observation and review of crash cart checklists on 2/24/26 at 3:10 p.m. in the emergency department (ED) trauma room 1 revealed the Manual Defibrillator-Lifepak 15 had not been completed during the day shift on 2/22/26. Further review of weekly checklists for February 2026 revealed that between February 1, 2026 through February 21, 2026, there were 16 times the defibrillator checklist was not completed. 2. Observation and record review on 2/24/26 at 3:20 p.m. in emergency department treatment room 1 revealed the Manual Defibrillator weekly checklist had not been completed during the day shift on 2/22/26. Further review of the weekly checklists for February 2026 revealed that between February 1, 2026 through February 21, 2026, there were 16 times the defibrillator checklist was not completed. 3. Interview on 2/24/26 at 9:45 a.m. with registered nurse (RN)/unit manager D revealed that she expected staff to complete the defibrillator checklist at the beginning of the shift and to document the checks on the weekly checklist. 4. Interview on 2/25/26 at 10:12 a.m. with Director of Nursing (DON) B revealed that ED defibrillator checks should be performed at the beginning of each shift and documented on the weekly checklist. The checklist includes visually inspecting the defibrillator unit, its cables, supplies required to operate the unit, ensuring the battery is charged, and ensuring the crash cart is locked. 5. Review of 2019 Physio-Control LifePak 15 Monitor/Defibrillator Operation Instructions revealed: “The User Test is a functional test of the LifePak 15 monitor/defibrillator. The user test should be performed only as a test and not while using the defibrillator during patient care. Perform the User Test as part of completing the daily Operator’s Checklist.” 6. Review of the provider’s Manual Defibrillator weekly checklist insturctions revealed “At the beginning of each shift, inspect the unit. Initialing each shift indicates all requirements have been met.””
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Protection Of Record Information
The inspectors’ words, 305 words
“PROTECTION OF RECORD INFORMATION CFR(s): The CAH maintains the confidentially of record information and provides safeguards against loss, destruction, or unauthorized use. This Standard is not met as evidenced by: 50915 Based on observation, interview, and policy review, the provider failed to ensure that one of one sampled patient’s (24) health information was protected from view by staff and other patients on one observed computer monitor in emergency department (ED) trauma room 1. Findings include: 1. Observation on 2/23/26 at 3:10 p.m. in ED trauma room 1 revealed a yellow post-it note placed on the computer monitor with patient 24’s name, date of birth, and vital signs. 2. Observation and interview on 2/24/26 at 9:45 a.m. in ED trauma room 1 with registered nurse (RN)/unit manager D revealed the yellow post-it note was still placed onto the computer monitor. RN/Unit manager D removed the post-it note and acknowledged that this was protected health information and should not have been there. 3. Interview on 2/24/26 at 10:12 a.m. with director of nursing (DON) B revealed that she expected that protected health information would not be visible to unauthorized staff or other patients. 4. Review of the provider’s 1/13/2025 Confidential Information policy revealed “It is the policy of the covered entities of Avera Health (hereinafter referred to collectively as “Avera”) to respect and protect the privacy rights of patients, their families, employees and third parties. All information (either hard copy, electronic, or verbal) associated with medical records, human resources, performance improvement, quality/risk management, research, financial, or organizational of any kind is strictly confidential and release of information should be directed to the source department for proper release. In addition, any information about Avera’s business, patients, families, employees or third parties which is disclosed or becomes known in the course of an employee’s job must be kept confidential.””
Feb 24, 2026: standard inspection1 deficiency
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Initial Comments - Not A Deficiency Citation
“A recertification survey was conducted on 2/24/2026 for compliance with 42CFR 485.623(d)(1), requirements for critical access hospitals (and swing bed). Avera Missouri River Health Center was found in compliance.”
All 2 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Feb 25, 2026 | Standard inspection | 2 deficiencies cited |
| Feb 24, 2026 | Standard inspection | 1 deficiency cited |
How do patients fare?
- CMS gives no overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “There are too few measures or measure groups reported to calculate a star rating or measure group score.”
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 2; readmission, 0 better and 0 worse of 2.
- CMS gives no CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “The number of cases/patients is too few to report a star rating.”
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): pneumonia 16.5%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): pneumonia 17.7%. CMS gives no comparison with the national rate for them in this release.
- Emergency department patients spent a median of 112 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 0% left before being seen.
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | Not rated |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | Not rated |
Is it certified, and in good standing?
- Medicare-certified critical access hospital since Aug 25, 1994.
- Ownership: voluntary non-profit - private.
- It is not accredited by a private organisation, so the state carries out its routine inspections for Medicare.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- Voluntary non-profit - Private.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- CMS’s HAC Reduction Program file has no result for it: the program covers general acute care hospitals Medicare pays under its inpatient prospective payment system.
- None of the deficiencies cited in the last three years came from an inspection that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- 91% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Avera St Marys owns 100% directly since Jan 1, 2013.
- 16 owners or officers are people: James Francis Dover (corporate officer); Robert Wylie (corporate director); Amy Kathryn Lueking (corporate director); Debra Ann Kolecka (corporate director); Kimberly Olson (corporate director); Michael Weisgram (corporate director); Rena J Robbennolt (corporate director); Meredith Lee (corporate director); Amanda Marie Schutz (corporate officer); Julie Lautt (corporate officer); Lynn Marie Welbig (corporate director); Jami Kay Cronin (corporate director); Shantel Shamiele Krebs (corporate officer); Shantel Shamiele Krebs (runs it (operational or managerial control)); Mark L Hagy (corporate director); Kristin Brost (corporate director).
- CMS’s Provider of Services file records 2 changes of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Avera St Marys | Owns 5% or more directly | 100% | Jan 1, 2013 |
| Avera Health | Owns 5% or more through other companies | 100% | Jan 1, 2013 |
How does it compare nearby?
- No other hospital CMS lists is in Potter County.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.