Cycle 1
Health 2025-04-02 · Fire 2025-04-02
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Tyler, MN
Avera Sunrise Manor
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
240 Willow Street, Tyler, MN
(507) 247-5839
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
28
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Avera Health
Operator or chain grouping
Approved since
1986-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.05
Registered nurse staffing
LPN hours / resident day
0.34
Licensed practical nurse staffing
Aide hours / resident day
2.54
Nurse aide staffing
Weekend hours
3.47
Weekend nurse staffing
RN turnover
43%
Annual RN turnover
Total nurse turnover
36%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
97.3%
0.9 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.9%
1.5 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 5.5% |
4.3%
1.2 pts worse
|
11.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.3% |
4.1%
0.2 pts worse
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.2% |
12.4%
7.8 pts worse
|
19.6%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 22.2% |
17.5%
4.7 pts worse
|
16.7%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.7% |
22.5%
9.8 pts better
|
16.3%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.6% |
18.6%
3 pts worse
|
14.9%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 12.6% |
2.3%
10.3 pts worse
|
1.0%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
2.6%
0.2 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.7% |
24.8%
10.1 pts better
|
19.8%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 8.6% |
5.4%
3.2 pts worse
|
5.1%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.4% |
88.6%
3.2 pts worse
|
81.7%
3.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-03 · Fire 2024-04-03
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-08-03 · Fire 2023-08-03
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-04-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-04-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-28
D · Potential for more than minimal harm
2024-04-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-01
D · Potential for more than minimal harm
2023-08-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-09-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-02
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-02
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-02
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-05-12
F · Potential for more than minimal harm
2024-04-03
F727 · Nursing and Physician Services Deficiencies
Health
Have 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.
Not marked corrected
D · Potential for more than minimal harm
2024-04-03
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-04-03
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-05-01
F · Potential for more than minimal harm
2023-08-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-08-03
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-08-03
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-03
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-03
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-03
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-15
D · Potential for more than minimal harm
2023-08-03
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-09-15
Penalties and ownership
What sits behind the stars
Ownership
Avera Health
5% Or Greater Direct Ownership Interest · Organization
Avera Marshall
Operational/Managerial Control · Organization
Coudron, Christy
Corporate Officer · Individual
Crim, Stephen
Corporate Director · Individual
Dover, James
Corporate Officer · Individual
Fixen, Quentin
Corporate Director · Individual
Goepferich, Gregory
Corporate Director · Individual
Hennen, Sharon
Corporate Director · Individual
Johansen, Laurie
Corporate Director · Individual
Jorgenson, George
Corporate Director · Individual
Koenen, Lavonne
Corporate Director · Individual
Kooiman, Thomas
Operational/Managerial Control · Individual
Kooiman, Thomas
Corporate Officer · Individual
Lautt, Julie
Corporate Officer · Individual
Louwagie, Curtis
Corporate Director · Individual
O'leary, Tim
Corporate Director · Individual
Reynolds, Christopher
W-2 Managing Employee · Individual
Sieling, Amanda
Corporate Director · Individual
Streier, Debra
Corporate Officer · Individual
Strootman, Joyce
Corporate Director · Individual
Vortherms, Mark
Corporate Officer · Individual
Vroman, Jill
Corporate Director · Individual
Zimmerman, Jodelle
Corporate Director · Individual
Nearby options
Other facilities in reach
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Good Samaritan Society - Pipestone
Pipestone, MN
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Avera Morningside Heights Care Center
Marshall, MN
3-star overall rating with 2-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Hendricks Community Hospital
Hendricks, MN
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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