Sunset Manor Avera Health
129 E Clay St, Irene, SD 57037 · Clay County · 58 certified beds · avg 50 residents/day · certified since Jan 1, 1997 · Medicare and Medicaid certified
Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →
Abuse citation flag (CMS)
Part of chain: AVERA HEALTH (13 facilities, chain avg rating 3.7★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · May 5, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 3, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 12, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 13, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Sep 25, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Oct 23, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Sep 25, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Oct 23, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (17)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 5, 2026 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 5, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Dec 31, 2025 | F · Potential for harm, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Dec 31, 2025 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Dec 31, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 31, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Dec 31, 2025 | D · Potential for harm, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jun 18, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 12, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 12, 2025 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 25, 2024 | ▲ H · Actual harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Sep 25, 2024 | ▲ H · Actual harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Aug 8, 2024 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Aug 8, 2024 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint |
| Jul 13, 2023 | D · Potential for harm, one-off | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 0 | D |
| 2024 | 4 | 2 | H ▲ |
| 2025 | 10 | 1 | G ▲ |
| 2026 | 2 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $40,596.
| Date | Type | Amount / length |
|---|---|---|
| Feb 12, 2025 | Fine | $11,190 |
| Sep 25, 2024 | Fine | $29,406 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | South Dakota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 6.29 | 4.32 | 3.95 | top 4% in South Dakota; top 3% in the U.S. |
| Registered Nurse hours | 1.05 | 0.91 | 0.69 | top 28% in South Dakota; top 14% in the U.S. |
| Weekend total nurse staffing | 5.27 | 3.71 | 3.50 | top 7% in South Dakota; top 4% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.54 | 0.51 | 0.48 | top 40% in South Dakota; top 28% in the U.S. |
| Total nursing staff turnover (%) | 70.4 | 48.2 | 45.8 | bottom 6% in South Dakota; bottom 5% in the U.S. |
| RN turnover (%) | 72.7 | 34.7 | 42.9 | bottom 6% in South Dakota; bottom 9% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.10, RN 0.85, weekend 4.27. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: —/5
Who owns this facility
Non profit - Other
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Davis, Brittani | Individual | Corporate Director | NOT APPLICABLE | 04/01/2022 |
| Gaertner, Rachael | Individual | Corporate Director | NOT APPLICABLE | 04/01/2024 |
| Johnke, Larry | Individual | Corporate Director | NOT APPLICABLE | 04/09/2013 |
| Kolbeck, Audrey | Individual | Corporate Officer | NOT APPLICABLE | 02/04/1991 |
| Kolbeck, Audrey | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/04/1991 |
| Kolbeck, Audrey | Individual | ADP of the SNF | NOT APPLICABLE | 02/04/1991 |
| Learing, Susan | Individual | Corporate Director | NOT APPLICABLE | 04/01/2024 |
| Nielsen, Tamie | Individual | Corporate Director | NOT APPLICABLE | 04/01/2022 |
| Sacred Heart Health Services | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/1994 |
| Sacred Heart Health Services | Organization | ADP of the SNF | NOT APPLICABLE | 08/28/2025 |
| Stockland, Robin | Individual | Corporate Officer | NOT APPLICABLE | 11/30/2017 |
| Stockland, Robin | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/30/2017 |
| Stockland, Robin | Individual | ADP of the SNF | NOT APPLICABLE | 09/04/2025 |
| Sunset Manor INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 06/15/1994 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "Where do you post your daily staffing numbers, and can I see today's?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Wakonda Heritage Manor | 6.0 mi | Wakonda, SD | ★★★★★ | 4/5 | |
| Pioneer Memorial Nursing Home | 7.3 mi | Viborg, SD | ★★★★★ | 5/5 | |
| Centerville Care and Rehab Center INC | 10.5 mi | Centerville, SD | ★☆☆☆☆ | 1/5 | abuse |
| SD Human Services Center - Geriatric Program | 16.9 mi | Yankton, SD | ★★★★★ | 4/5 | |
| Bethesda of Beresford | 18.9 mi | Beresford, SD | ★★☆☆☆ | 2/5 | |
| Avera Sister James Care Center | 19.6 mi | Yankton, SD | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 435100.