Avera Oahe Manor: Post-Fall Monitoring Failures - SD
The facility's February 2024 Fall Evaluation and Injury Prevention policy spelled out exactly what was required. After any fall, staff were to monitor the resident every 30 minutes twice, then every four hours four times, then daily for seven days. Vital signs were part of every check. If the resident had hit their head, or if the fall was unwitnessed and the resident couldn't say whether they'd hit their head, staff were required to complete a neurological assessment specifically designed for long-term care residents, at least every four hours four times, then daily for 72 hours. Every shift for the first 72 hours, regardless of circumstances, was supposed to include a formal reassessment covering vital signs, a neurological check, a review of systems, and documentation of whether symptoms were getting better or worse.
That's what the policy said. Inspectors found it wasn't being done.
The violation was cited under F0658, which covers professional standards of care, and was tagged at a level of minimal harm or potential for actual harm, affecting a few residents. That language, standard in federal inspection reports, means inspectors concluded that while the required monitoring wasn't happening, they could not document that a resident had suffered a serious injury as a direct result. What it does not mean is that the gaps didn't matter.
The monitoring protocol exists because falls in nursing home residents carry risks that aren't always visible at the moment someone hits the floor. A resident who appears alert and uninjured after a fall can deteriorate hours later. Subdural hematomas, the slow bleeds that can follow a blow to the head, sometimes take hours or days to produce symptoms. A neurological assessment done at the four-hour mark catches changes that a single check in the immediate aftermath of a fall cannot. The every-30-minutes checks in the first hour are designed to catch the fastest-moving emergencies. The daily checks through day seven are designed to catch the slower ones.
Avery Oahe Manor's own clinical staff wrote those intervals into policy. The question inspectors were answering was whether that policy was being followed in practice. Their finding was that it was not.
The inspection was triggered by a complaint, not a routine survey cycle. That means someone, a resident, a family member, or a staff member, contacted regulators with a concern specific enough to prompt investigators to come and look. The inspection report does not identify who filed the complaint or what initially prompted it.
What the report does document is a facility whose written commitments to post-fall care were not being carried out for at least a few residents. The policy language was detailed and unambiguous. It distinguished between witnessed and unwitnessed falls. It distinguished between residents who could report whether they'd hit their head and those who could not. It built in escalating protections for the most vulnerable scenarios. None of that specificity matters if the assessments aren't being done.
For the residents affected, the gap meant hours, and in some cases days, of monitoring that was supposed to happen and didn't. Whether any of them were harmed by that absence is something the inspection record does not resolve. The finding of potential harm rather than actual harm reflects what inspectors could document, not necessarily what occurred.
Avera Oahe Manor is a long-term care facility serving Gettysburg, a small city in central South Dakota. The complaint inspection was completed September 4, 2025.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avera Oahe Manor from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 25, 2026 · Our methodology
AVERA OAHE MANOR in GETTYSBURG, SD was cited for violations during a health inspection on September 4, 2025.
The facility's February 2024 Fall Evaluation and Injury Prevention policy spelled out exactly what was required.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.