Cycle 1
Health 2025-12-31 · Fire 2025-12-31
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Irene, SD
Sunset Manor Avera Health
2-star overall rating with 2-star inspections with abuse icon flag with $40,596 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
129 E Clay St, Irene, SD
(605) 263-3318
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
58
Certified beds
Average residents
49
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Avera Health
Operator or chain grouping
Approved since
1997-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 4 overall / 3 health / 5 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
3.51
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
4.95
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
4.26
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
6.21
CMS adjusted total nurse staffing hours
Case-mix index
1.09
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,116
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9992
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 61.02% · Performance 62.90% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
9.18
Baseline 5.27 hours · Performance 5.69 hours · Measure score 9.18 · Achievement 9.18 · Improvement 7.76
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 6 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.57% |
8.2%
4.6 pts worse
|
Numerator 3 · Denominator 84 |
| Staff flu vaccination coverage | 9.24% |
42%
32.8 pts worse
|
Numerator 22 · Denominator 238 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 0.8 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.9
0.2 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.0% |
95.4%
2.4 pts worse
|
93.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.0% · Q2 100.0% · Q3 100.0% · Q4 97.9% · 4Q avg 93.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.9%
3.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
5.1%
1.6 pts better
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 4.1% · Q3 2.0% · Q4 6.2% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.4% |
4.6%
11.8 pts worse
|
11.4%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 20.8% · Q3 20.9% · Q4 12.5% · 4Q avg 16.4% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
5.5%
1.8 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 6.5% · Q3 2.1% · Q4 4.3% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 36.1% |
17.8%
18.3 pts worse
|
19.6%
16.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.3% · Q2 30.4% · Q3 38.8% · Q4 37.5% · 4Q avg 36.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 75.7% |
25.1%
50.6 pts worse
|
16.7%
59 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.9% · Q2 75.0% · Q3 77.8% · Q4 74.1% · 4Q avg 75.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.0% |
21.3%
1.3 pts better
|
16.3%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 24.1% · Q3 19.5% · Q4 19.9% · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.5% |
21.6%
3.9 pts worse
|
14.9%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 18.6% · Q3 25.5% · Q4 28.9% · 4Q avg 25.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
2.0%
1.4 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
3.3%
1.3 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.0% · Q3 2.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.7% |
25.8%
9.1 pts better
|
19.8%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 17.9% · Q3 14.8% · Q4 11.6% · 4Q avg 16.7% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.6%
4.6 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-08 · Fire 2024-08-08
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-07-13 · Fire 2023-07-13
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-12-31
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2026-02-04
D · Potential for more than minimal harm
2025-12-31
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-12-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-02-04
D · Potential for more than minimal harm
2025-12-31
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-12-31
C · Minimal harm
2025-12-31
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2025-12-31
C · Minimal harm
2024-08-08
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Not marked corrected
C · Minimal harm
2024-08-08
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-08-27
C · Minimal harm
2024-08-08
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-08-07
D · Potential for more than minimal harm
2023-07-13
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-07-12
D · Potential for more than minimal harm
2023-07-13
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2023-07-12
D · Potential for more than minimal harm
2023-07-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-07-12
D · Potential for more than minimal harm
2023-07-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-07-12
C · Minimal harm
2023-07-13
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2023-07-12
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-31
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2026-01-08
E · Potential for more than minimal harm
2025-12-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-02-04
E · Potential for more than minimal harm
2025-12-31
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 2026-01-16
E · Potential for more than minimal harm
2025-12-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-04
D · Potential for more than minimal harm
2025-12-31
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2026-02-04
D · Potential for more than minimal harm
2025-06-18
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 2025-07-16
D · Potential for more than minimal harm
2025-06-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-06-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-22
G · Actual harm
2025-02-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-13
E · Potential for more than minimal harm
2025-02-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-13
H · Actual harm
2024-09-25
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 2024-10-23
H · Actual harm
2024-09-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-23
E · Potential for more than minimal harm
2024-08-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-08
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-09-22
D · Potential for more than minimal harm
2023-07-13
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-08-25
Penalties and ownership
What sits behind the stars
$11,190
2025-02-12
Fine
Fine · fine $11,190
Fine
$29,406
2024-09-25
Fine
Fine · fine $29,406
Fine
Ownership
Davis, Brittani
Corporate Director · Individual
Gaertner, Rachael
Corporate Director · Individual
Johnke, Larry
Corporate Director · Individual
Kolbeck, Audrey
Operational/Managerial Control · Individual
Kolbeck, Audrey
Corporate Officer · Individual
Learing, Susan
Corporate Director · Individual
Nielsen, Tamie
Corporate Director · Individual
Sacred Heart Health Services
Operational/Managerial Control · Organization
Stockland, Robin
Operational/Managerial Control · Individual
Stockland, Robin
Corporate Officer · Individual
Sunset Manor Inc.
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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4-star overall rating with 4-star inspections with $12,675 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Pioneer Memorial Nursing Home
Viborg, SD
3-star overall rating with 3-star inspections with $32,536 in total fines with 1 recent health deficiencies
#3
Centerville Care and Rehab Center Inc
Centerville, SD
2-star overall rating with 2-star inspections with $55,059 in total fines with 9 recent health deficiencies
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