Sunset Manor Avera Health
Irene, South Dakota · CCN 435100
16 surveys since 2012. The first finding at harm level was recorded in 2017.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 55
- Surveys
- 16
- Harm or worse
- 5
- Immediate jeopardy
- 0
Findings where a surveyor recorded actual harm to a resident.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 58
- Ownership
- Non profit - Other
- Chain
- AVERA HEALTH
- County
- Clay · rural
- Medicare-certified since
- 1997
CMS ratings
- Overall
- 2
- Health inspection
- 2
- Staffing
- 4
- Quality measures
- 2
CMS’s own Five-Star ratings.
Compared with similar facilities
Not shown for this facility: too few citations in window (n=19, floor 20).
Last survey on record
May 5, 2026
188 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 5.10 | 3.73 |
| Registered-nurse hours per resident day | 0.85 | — |
| Annual nurse turnover | 70.4% | 49.0% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $56,946 across 3 penalties
- Abuse icon
- Flagged by CMS on Care Compare
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G211.8% | H211.8% | I— |
| No harm, potential for more than minimal | D741.2% | E529.4% | F15.9% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6003×
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- F6843×
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- F6412×
Ensure each resident receives an accurate assessment.
- F6892×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F6041×
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
In the surveyor’s words
From the most serious findings on record at Sunset Manor Avera Health, in the surveyor’s own words.
- Actual harm, patternF600Sep 25, 2024
Based on South Dakota Department of Health (SD DOH) complaint review, record review, interview, video review, and policy review, the provider failed to protect six of eight sampled residents (1, 2, 3, 5, 7, and 8) from neglect by licensed practical nurse (E) who did not offer or provide repositioning or toileting assistance as directed in their plans of care. Findings include: 1. Review of the 9/12/24 SD DOH complaint revealed: *The complainant wanted to remain anonymous. *There was concern regarding neglect for all residents in the Traumatic Brain Injury (TBI) unit. *From 9/7/24 at 10:00 p.m. […]
- Actual harm, patternF684Sep 25, 2024
Based on South Dakota Department of Health (SD DOH) complaint review, record review, interview, and video review, the provider failed to ensure eight of eight sampled residents (1, 2, 3, 4, 5, 6, 7, and 8) who were dependent on staff for their care needs, received those cares as directed on their care plans. Findings include: 1. Review of the 9/12/24 SD DOH complaint revealed: *The complainant wanted to remain anonymous. *There was concern regarding neglect for all residents in the Traumatic Brain Injury (TBI) unit. *From 9/7/24 at 10:00 p.m. […]
- Actual harm, isolatedF600May 5, 2026
Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, observation, interview, and policy review the provider failed to protect the residents' right to be free from physical abuse for one of one sampled resident (1) who was straddled and restrained in his bed by one of one certified nursing assistant (CNA)G while he provided incontinence (involuntary urine and bowel leakage) care to resident 1. Findings include:1. Review of the provider's SD DOH FRI report dated 3/23/26 revealed that resident 1 had a Brief Interview for Mental Status (BIMS) assessment score of 99, which indicated his cognition was severely impaired. The report indicated that on 3/22/26 at 4:00 a.m., resident 1 became combative during incontinence care provided by CNA G. […]
- Actual harm, isolatedF689Feb 12, 2025
Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review the provider failed to ensure the safety of one of one sampled resident (2) with cognitive impairment who ingested an improperly stored and secured Santimine (sanitizing chemical) tablet. Findings include: 1. Review of the provider's 2/6/25 SD DOH FRI regarding resident 2 revealed: *His Brief Interview for Mental Status (BIMS) assessment score was 1 which indicated he had severe cognitive impairment. *On 2/6/25 at 1:50 p.m. […]
- No harm, potential for more than minimal, widespreadF732Dec 31, 2025
Based on observation, record review, interview, and facility assessment review, the provider failed to post the required nursing staffing information in a location readily visible to residents, staff, and visitors that clearly reflected actual hours worked by the nursing staff from October 2025 through December 2025 daily:*For 46 of 92 days reviewed regarding the Traumatic Brain Injury unit (TBI).*For 24 of 92 days reviewed regarding the Challenging Behavior Unit (CBU).*For 13 of 92 days reviewed regarding the main area where residents resided (The Manor). Findings include:1. Observation on 12/29/25 at 2:34 p.m. […]
Read 21 findings in full →The most serious and the most recent: 21 of 55 on record.
Every survey on record
FindingsAt actual harm or above
- May 5, 2026Complaint2 findings · 1 harm
- Dec 31, 2025Standard and complaint5 findings
- Jun 18, 2025Complaint3 findings
- Feb 12, 2025Complaint2 findings · 1 harm
- Sep 25, 2024Complaint2 findings · 2 harm
- Aug 8, 2024Complaint2 findings
- Jul 13, 2023Standard1 finding
- Jan 13, 2022Standard2 findings
Show the 8 earlier surveys
- Aug 8, 2019Standard4 findings
- May 10, 2018Standard1 finding
- May 11, 2017Standard5 findings · 1 harm
- Apr 6, 2016Standard8 findings
- Jun 3, 2015Standard10 findings
- Apr 9, 2014Standard6 findings
- Feb 21, 2013—1 finding
- Feb 28, 2012—1 finding
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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