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

Compare this facility

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

Staffing

Hours and turnover

RN hours / resident day

0.58

Registered nurse staffing

LPN hours / resident day

0.86

Licensed practical nurse staffing

Aide hours / resident day

3.51

Nurse aide staffing

Weekend hours

4.26

Weekend nurse staffing

RN turnover

80%

Annual RN turnover

Total nurse turnover

68%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

Survey summary

Recent inspection cycles

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)

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

0% 2 facilities 2022-04-01

Gaertner, Rachael

Corporate Director · Individual

0% 1 facilities 2024-04-01

Johnke, Larry

Corporate Director · Individual

0% 1 facilities 2013-04-09

Kolbeck, Audrey

Operational/Managerial Control · Individual

0% 1 facilities 1991-02-04

Kolbeck, Audrey

Corporate Officer · Individual

0% 1 facilities 1991-02-04

Learing, Susan

Corporate Director · Individual

0% 1 facilities 2024-04-01

Nielsen, Tamie

Corporate Director · Individual

0% 1 facilities 2022-04-01

Sacred Heart Health Services

Operational/Managerial Control · Organization

0% 2 facilities 1994-01-01

Stockland, Robin

Operational/Managerial Control · Individual

0% 2 facilities 2017-11-30

Stockland, Robin

Corporate Officer · Individual

0% 2 facilities 2017-11-30

Sunset Manor Inc.

Operational/Managerial Control · Organization

0% 1 facilities 1994-06-15

Nearby options

Other facilities in reach

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Wakonda Heritage Manor

Wakonda, SD

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

Overall: 4 / 5
Health: 4 / 5
Staffing: 4 / 5
Fines: $12,675

#2