Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avera Oahe Manor during CMS and state inspections, most recent first.
A resident who fell and hit her head did not receive consistent or complete neurological assessments as required by facility policy. Multiple neuro checks were missing critical documentation, including the Glasgow Coma Scale and pupil assessments, over several days. Staff interviews revealed unclear expectations and issues with the EMR system allowing incomplete entries to be marked as finished.
The facility did not provide RN coverage for eight consecutive hours on multiple days due to a lapsed staffing waiver and lack of awareness among leadership. Review of schedules and timecards confirmed the absence of an RN on required days, and interviews revealed that both the DON and administrator were unaware of the waiver's expiration and the ongoing regulatory requirement.
Surveyors identified that care plans for two residents were not updated to reflect their current care needs, including one who no longer had a urinary catheter and another whose mobility and incontinence care were inaccurately documented. Staff interviews revealed inconsistencies between care plans and actual care provided, and some staff were unaware of how to update care plans, contrary to facility policy.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Two residents used CPAP devices without documented physician orders, and staff lacked a clear, standardized process for CPAP use and cleaning. Staff training on CPAP procedures was inconsistent, and the facility did not have a formal policy or include CPAP on order checklists, resulting in inconsistent practices and missing required documentation.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Failure to Consistently Complete and Document Post-Fall Neurological Assessments
Penalty
Summary
The provider failed to follow nursing professional standards by not ensuring consistent completion and documentation of neurological checks for a resident who fell and hit her head. The incident occurred when a certified nursing assistant (CNA) let go of the resident's gait belt to turn on a bathroom light, resulting in the resident losing balance, falling, and striking her head on the floor. The resident was assessed by an LPN at the time, with no injuries identified, and was subsequently taken to the emergency room by her husband. Upon return to the facility, the resident was diagnosed with mild dehydration and advised to increase fluid intake. A review of the resident's electronic medical record revealed multiple deficiencies in the documentation of post-fall neurological assessments. The neuro assessments were incomplete at several required intervals, with missing documentation in critical areas such as the Glasgow Coma Scale, pupil assessment, ocular assessment, visual acuity, neurological symptoms, and movement/strength/sensation. These omissions occurred repeatedly over several days following the fall, despite the facility's policy and post-fall worksheet specifying the frequency and components required for neurological checks after a head injury. Interviews with nursing staff and facility leadership confirmed that the expectations for completing neuro assessments were unclear, and the electronic medical record system allowed staff to mark the task as complete even when only partial information was entered. Both the infection preventionist and the administrator acknowledged that the neuro assessments were not completed consistently or thoroughly, as required by facility policy. The facility's policies clearly outlined the need for comprehensive and regular neurological assessments following a fall with head impact, but these were not adhered to in this case.
Failure to Ensure Required RN Coverage Due to Lapsed Waiver and Scheduling Issues
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was scheduled for eight consecutive hours each day, as required, for multiple days across two fiscal quarters. Payroll Based Journal (PBJ) reports, nurse schedules, and staff timecards revealed that there was no RN coverage for eight consecutive hours on ten days in quarter four of fiscal year 2024 and seven days in quarter one of fiscal year 2025. The Director of Nursing (DON) initially believed the facility had an RN staffing waiver in place, but review of the waiver application showed that the waiver had expired and was not reapproved by the required date. The facility attempted to reapply for the waiver, but the state health department instructed them to wait until after the next recertification survey. During this period, there were documented days with no RN scheduled for the required hours. Interviews with the DON and the administrator revealed a lack of awareness regarding the expiration of the RN waiver and the ongoing requirement for RN coverage. The administrator was responsible for submitting the waiver renewal but was unaware of the renewal deadline, only realizing the lapse months later. The DON confirmed that there were days without the required RN coverage and also stated that the facility did not have a staffing policy in place. No information about specific residents or their conditions was provided in the report.
Failure to Update and Maintain Accurate Resident Care Plans
Penalty
Summary
Surveyors found that the facility failed to ensure care plans were updated to reflect the current care needs of two residents. For one resident, observations and interviews revealed inconsistencies between her actual care needs and what was documented in her care plan. She was observed primarily using a wheelchair and requiring staff assistance for ambulation and toileting, yet her care plan indicated she was independent with these activities and used incontinence products inconsistently with her current needs. Staff interviews confirmed that care sheets and care plans contained conflicting information regarding her mobility and incontinence care. For another resident, the care plan was not updated after his urinary catheter was discontinued, despite medical records and staff interviews confirming he no longer had a catheter. The DON acknowledged that care plans were not being audited for accuracy and that staff, including some nurses, were not updating care plans as required. Additionally, one LPN reported not knowing how to update care plans. The facility's policy required licensed professionals to update care plans, but this was not consistently followed.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Lack of Physician Orders and Standardized Procedures for CPAP Devices
Penalty
Summary
The facility failed to obtain physician orders for the use of CPAP devices for two residents, as evidenced by record review and staff interviews. Both residents' care plans indicated the use of CPAP devices, but there were no corresponding medical orders documented in their electronic medical records. Staff interviews revealed a lack of clarity and consistency regarding training and procedures for CPAP use and cleaning. The DON confirmed that there was no current policy for obtaining physician orders for CPAP devices, and CPAP was not included on any of the checklists used by nurses for new orders, admissions, or returns from the hospital. Additionally, the facility did not have a formal policy or standardized process for cleaning CPAP devices. Staff members, including CNAs and a CMA, reported being trained on CPAP cleaning either by other staff or by a resident's family, but could not recall specific details about the training or its frequency. The DON stated that the facility relied on manufacturer guidelines for equipment but did not have a written policy for CPAP cleaning or physician orders. The lack of a structured process and documentation led to inconsistent practices and the absence of required physician orders for residents using CPAP devices.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gettysburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bowdle Nursing Home | 33.2 mi | ★★★★★ | 0 | 0 |
| Walworth County Care Center, Inc | 34.4 mi | ★★★★★ | 6 | 0 |
| Faulkton Senior Living | 39.9 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.