01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-12-31 | 7 | 2025-12-31 | 5 |
| Cycle 2 | 2024-08-08 | 9 | 2024-08-08 | 3 |
| Cycle 3 | 2023-07-13 | 1 | 2023-07-13 | 5 |
CMS CCN 4351002026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Sunset Manor Avera Health
129 E Clay St · Irene, SD 57037 · Clay County
Certified beds58CMS provider file
Recent citation rows30current CMS citation release
Penalty rows2current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
30 rows in the current release
4 rows carry G–L scope/severity codes; 0 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-05-05 · HEALTHF0600Severity G · isolated actual harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2026-06-03 · complaint2026-05-05 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2026-06-03 · complaint2025-12-31 · HEALTHF0641Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2026-02-042025-12-31 · HEALTHF0678Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Correction field: Deficient, Provider has date of correction · 2026-02-04 · complaint2025-12-31 · HEALTHF0732Severity F · widespread; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has date of correction · 2026-01-082025-12-31 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-01-162025-12-31 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-02-042025-12-31 · FIREK0222Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-02-042025-12-31 · FIREK0241Severity C · widespread; potential for minimal harm
Egress Deficiencies
Have correct number of accessible exits for each story.
Correction field: No revisit needed · 2025-12-312025-12-31 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-12-312025-12-31 · FIREK0712Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2026-02-042025-12-31 · FIREK0781Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have restrictions on the use of portable space heaters.
Correction field: Deficient, Provider has date of correction · 2025-12-312025-06-18 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-07-16 · complaint2025-06-18 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-07-16 · complaint2025-06-18 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-07-22 · complaint2025-02-12 · HEALTHF0684Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-03-13 · complaint2025-02-12 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-03-13 · complaint2024-09-25 · HEALTHF0600Severity H · pattern of actual harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2024-10-23 · complaint2024-09-25 · HEALTHF0684Severity H · pattern of actual harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-10-23 · complaint2024-08-08 · HEALTHF0604Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Correction field: Deficient, Provider has date of correction · 2024-09-22 · complaint2024-08-08 · HEALTHF0641Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2024-09-06 · complaint2024-08-08 · FIREK0241Severity C · widespread; potential for minimal harm
Egress Deficiencies
Have correct number of accessible exits for each story.
Correction field: Deficient, Provider has no plan of correction2024-08-08 · FIREK0271Severity C · widespread; potential for minimal harm
Egress Deficiencies
Have exits that are accessible at all times.
Correction field: Deficient, Provider has plan of correction · 2024-08-272024-08-08 · FIREK0911Severity C · widespread; potential for minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the installation and maintenance of electrical systems.
Correction field: Deficient, Provider has plan of correction · 2024-08-0703 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-02-12 | Fine | $11,190 | 0 |
| 2024-09-25 | Fine | $29,406 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- DAVIS, BRITTANIIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/01/2022
- GAERTNER, RACHAELIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/01/2024
- JOHNKE, LARRYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/09/2013
- LEARING, SUSANIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/01/2024
- NIELSEN, TAMIEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/01/2022
- KOLBECK, AUDREYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 02/04/1991
- STOCKLAND, ROBINIndividual · CORPORATE OFFICERNOT APPLICABLE · since 11/30/2017
- SACRED HEART HEALTH SERVICESOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/1994
- SUNSET MANOR INC.Organization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/15/1994
- KOLBECK, AUDREYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/04/1991
- STOCKLAND, ROBINIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/30/2017
- SACRED HEART HEALTH SERVICESOrganization · ADP OF THE SNFNOT APPLICABLE · since 08/28/2025
- KOLBECK, AUDREYIndividual · ADP OF THE SNFNOT APPLICABLE · since 02/04/1991
- STOCKLAND, ROBINIndividual · ADP OF THE SNFNOT APPLICABLE · since 09/04/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours5.10per resident day
RN hours0.85per resident day
Weekend nurse hours4.27per resident day
Staff turnover70.4%CMS reported field
06 / LOCAL RECORDS
Open the South Dakota ledger →Other published facilities nearby
No second facility in the same city met the directory rule.