Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunset Manor Avera Health during CMS and state inspections, most recent first.
Staff initiated and continued CPR on a resident with a documented DNR/DNI order, failing to verify and honor the resident's code status before and during resuscitation efforts. Despite code status information being available in the EMR and on hall sheets, staff performed CPR for about 20 minutes until the DON intervened and stopped the procedure after confirming the DNR status.
A resident with a history of sexually inappropriate behavior was not properly supervised, resulting in unsolicited sexual contact with another resident in a common area. Despite care plans and staff instructions requiring 1:1 supervision within arm's length, staff failed to monitor the residents as required, and did not intervene during the incident. Afterward, there was no immediate assessment or investigation, contrary to facility policy.
A resident with dementia was subjected to unsolicited touching by another resident with a history of sexually inappropriate behavior while unmonitored in a hallway. Staff failed to provide immediate intervention and did not complete a timely assessment of the affected resident's physical and emotional well-being, despite facility policies requiring close supervision and prompt evaluation after such incidents.
A resident with a history of stroke and limited mobility was transferred using a sit-to-stand lift without the required safety straps, resulting in a fall to the floor. Staff and documentation confirmed that the safety straps were not used, and the care plan lacked clear instructions regarding transfer methods and fall risk. The manufacturer's instructions for the lift, which require the use of safety straps, were not followed.
A resident with severe cognitive impairment ingested a Santimine tablet due to improper storage in an unlocked drawer. The resident was on 1:1 monitoring but accessed the tablets when one CNA was assisting another resident. The drawer lock was broken, and the tablets were left unsecured by a CNA. This incident highlights a lapse in supervision and adherence to hazardous materials storage policy.
A resident with a traumatic brain injury (TBI) did not receive adequate dining assistance and nutritional care due to a lack of specific care planning and staff training. The resident, who required assistance with eating, missed several evening meals because he refused to leave his room and was not allowed meal trays in his room. The care plan lacked specific instructions, and documentation of meal intake was inconsistent. The facility's policy to maintain residents' well-being was not followed.
A significant deficiency was identified in a TBI unit where an LPN failed to provide necessary repositioning and toileting assistance to residents as per their care plans. The residents, who had severe cognitive impairments and complex medical conditions, were left in soiled clothing and bedding. The neglect was discovered through a complaint, video footage, and staff interviews, revealing inadequate training and communication among staff.
In a TBI unit, eight residents did not receive care as per their care plans, with one resident found in the same clothes, cold, and covered in feces. Video footage showed staff, including LPNs and CNAs, not providing necessary care, spending time at desks, and lacking an ADL policy, contributing to the deficiency.
A facility failed to accurately complete elopement risk evaluations for several residents, including one with dementia who eloped undetected due to a malfunctioning door alarm. Despite previous elopement incidents, the resident's risk was not updated in the care plan, and staff did not recognize the event as reportable.
A cognitively impaired resident was physically restrained by an agency CNA without medical necessity, following her return from the hospital. The restraint, which involved holding the resident's arms and pressing the CNA's chin into her scalp, was not documented and only discovered through video footage review. The incident occurred in the facility's challenging behavior unit, and other staff present did not report the abuse.
Failure to Honor Resident DNR Status During CPR
Penalty
Summary
Staff failed to follow a resident's documented Do Not Resuscitate (DNR) code status when the resident was found unresponsive with no pulse or respirations. Despite the presence of an advance directive and an active physician's order indicating DNR/DNI status, staff initiated and continued cardiopulmonary resuscitation (CPR) for approximately 20 minutes before the Director of Nursing (DON) arrived and instructed them to stop after verifying the resident's code status. The nurses involved reported that they began CPR, checked the code status, but continued resuscitation efforts under the belief that once CPR was started, it should not be stopped until emergency medical services arrived. The resident's code status was documented in both the electronic medical record (EMR) and on hall sheets that staff were expected to carry. Interviews revealed that while some staff understood the need to verify code status before initiating CPR, others did not follow this protocol during the incident. Additionally, a certified nursing assistant (CNA) reported that orientation training did not specifically address code status procedures, and the DON was unable to provide signed documentation verifying which staff attended a post-incident educational meeting on advance directives and code statuses. Facility policies required staff to provide basic life support, including CPR, unless a valid DNR order was in place, and indicated that code status information was accessible in the EMR and hall sheets. However, there was no evidence of ongoing auditing or monitoring to ensure staff awareness and adherence to these protocols at the time of the incident. The failure to verify and honor the resident's DNR status before and during resuscitation efforts constituted the deficiency.
Failure to Prevent and Respond to Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a known history of sexually inappropriate behavior was not adequately supervised, resulting in unsolicited sexual contact with another resident. The incident took place in a hallway and common areas where both residents, who ambulated independently via wheelchairs, were left unmonitored by staff. Despite care plan interventions and hall sheets indicating that both residents required 1:1 supervision within arm's length at all times, staff failed to maintain the required level of monitoring. Camera footage confirmed that staff, including a CNA and an LPN, were not present or did not intervene during multiple interactions, allowing the resident to touch the other resident's private area without consent. The resident who committed the inappropriate act had a documented history of dementia, altered mental status, anxiety, and previous sexually inappropriate behaviors, necessitating close supervision in common areas. The other resident had diagnoses including dementia, anxiety, psychotic disturbance, and mood disturbance, with significant communication limitations. Despite these known risks, staff did not follow the supervision protocols outlined in the care plans and staff meeting notes, which specifically required staff to be within arm's length of the resident with a history of inappropriate behavior. Additionally, after the incident, there was a lack of immediate assessment and documentation regarding the well-being of the resident who was touched. The LPN did not complete an assessment or incident report at the time, and the Director of Nursing did not initiate an internal investigation until several days after becoming aware of the incident. The facility's abuse prohibition policy required prompt reporting, assessment, and investigation of suspected abuse, but these procedures were not followed in this case.
Failure to Assess Resident After Unsolicited Physical Contact
Penalty
Summary
A deficiency occurred when staff failed to complete a resident assessment for the physical and emotional well-being of a resident who experienced unsolicited touching by another resident. The incident involved two residents, both with dementia and other cognitive impairments, who were independently ambulating in wheelchairs in a hallway unmonitored by staff. One resident approached the other, rubbed her leg, and later touched her private area without consent. Staff were not present to intervene during the initial incident, and when a CNA did encounter the residents, she did not immediately separate them or stop the inappropriate behavior. The nurse on duty was not aware of the proximity of the residents and did not witness the incident directly. Following the incident, the nurse did not conduct a timely assessment of the affected resident's physical or emotional state. Although the nurse documented a progress note based on secondhand reports from staff and housekeeping, she did not complete an incident report or perform an immediate assessment. The only assessment of the resident's vital signs occurred two days later, after the DON returned and inquired about the event. There was no documentation of a thorough evaluation of the resident's well-being or any follow-up notes addressing the incident's impact on her. The facility's policies required close monitoring of the resident with a history of sexually inappropriate behavior, including 1:1 supervision within arm's length in common areas. Documentation and staff meeting notes reiterated this requirement. However, video footage and staff interviews confirmed that this supervision was not maintained at the time of the incident. Additionally, the facility lacked a clear policy for incident reporting, relying instead on an electronic documentation system with dropdown options, which did not ensure that all necessary steps, such as resident assessment, were completed after such incidents.
Failure to Use Required Safety Straps During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident was transferred using a sit-to-stand mechanical lift without the required safety straps, contrary to the manufacturer's instructions. The incident took place when the resident's right arm gave out during the transfer, causing the waist belt to pop off and resulting in the resident being lowered to the floor. The safety straps on the lift were not used on the resident's waist or legs during the transfer, and this omission was confirmed by both the facility's internal investigation and staff interviews. The resident initially refused medical treatment but later agreed to an x-ray, which showed no injury. The resident involved had a history of stroke resulting in no use of his left arm and leg, but was able to bear weight with a brace on his left leg. Documentation in the electronic medical record (EMR) indicated that the resident had previously refused to use the chest or leg straps during transfers, despite being educated on their necessity for safety. Staff interviews revealed that some staff had not experienced refusals from the resident, while others confirmed his refusals and described him as particular and sometimes verbally abusive regarding his care. The care plan and EMR lacked clear documentation about the resident's fall risk, transfer method, or history of falls. The facility relied on a working care plan and a hall sheet for daily care instructions, but the EMR care plan did not include specific transfer information. The manufacturer's instructions for the lift required the safety strap to be securely fastened around the patient's torso, and the use of a shin strap if necessary. The failure to follow these instructions and ensure the use of safety straps during the transfer directly led to the incident.
Resident Ingests Chemical Due to Improper Storage
Penalty
Summary
The deficiency involved a resident with severe cognitive impairment who ingested a Santimine tablet, a sanitizing chemical, due to improper storage. The resident, who had a Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive impairment, was observed with a blue coloration in his mouth, which was identified as a Santimine tablet. The resident was on close 1:1 monitoring due to his cognitive condition and behavioral disturbances, yet he managed to access the tablets from an unlocked drawer in the Challenging Behaviors Unit (CBU). The incident occurred when two CNAs were present in the CBU, but one was assisting another resident in the bathroom, leaving the resident unsupervised momentarily. The Santimine tablets were supposed to be locked up, but they were found in an unlocked drawer behind resident clothing protectors. The drawer lock had been broken for some time, and the tablets were left unsecured by a CNA who had used them to make a cleaning solution earlier. This lapse in securing hazardous materials led to the resident's access to the tablets. Interviews with staff revealed that the Santimine tablets were not properly secured, and the staff were aware that they should have been locked. The facility's policy on hazardous materials required that such items be stored under lock and key to prevent access by residents. The failure to adhere to this policy and ensure the safety of the resident resulted in the ingestion incident, highlighting a significant lapse in supervision and storage of hazardous materials.
Failure to Provide Adequate Dining Assistance for TBI Resident
Penalty
Summary
The provider failed to ensure that dining assistance and nutritional needs were adequately care planned and implemented for a resident with a traumatic brain injury (TBI). The resident, who resided in the TBI unit, exhibited behavioral problems such as refusing care, medications, and meals. It was reported that if residents requiring assistance did not come out of their rooms, they were not allowed to have meal trays in their rooms. This led to the resident missing evening meals for three consecutive nights. Observations and interviews revealed that the resident was dependent on his spouse for eating assistance, and there was a lack of specific training for CNAs working in the TBI unit. The resident's care plan lacked specific instructions on the amount of eating assistance needed and did not indicate if he could eat in his room. The resident's electronic medical record showed inconsistent documentation of meal and snack intake, with several instances of the resident refusing evening meals without documented reasons or offers of alternative meals or snacks. The facility's policy required documentation of meals three times per day and as needed, but this was not consistently followed. The director of nursing confirmed that there was no specific training for CNAs in the TBI unit and that it was expected for staff to assist the resident with eating in his room if necessary. The facility's Resident Right-Nursing Home booklet emphasized the requirement to provide services to maintain the highest practicable well-being of each resident, which was not adhered to in this case.
Neglect of Residents in TBI Unit Due to Inadequate Care by LPN
Penalty
Summary
The report details a significant deficiency involving neglect of residents in a Traumatic Brain Injury (TBI) unit at a long-term care facility. Six out of eight sampled residents were not provided with necessary repositioning or toileting assistance as outlined in their care plans. The neglect was primarily attributed to a Licensed Practical Nurse (LPN) who failed to perform these duties during a night shift. The residents involved had severe cognitive impairments and required assistance with all activities of daily living, including toileting every two hours. However, the LPN did not provide the necessary care, leaving residents in soiled clothing and bedding. The deficiency was discovered following a complaint to the South Dakota Department of Health, which led to a review of video footage, interviews, and medical records. The footage revealed that the LPN spent significant periods at a desk rather than attending to the residents' needs. Interviews with staff indicated that the LPN was not adequately trained to perform Certified Nursing Assistant (CNA) tasks, and there was a lack of communication and coordination among staff regarding the care needs of the residents. The residents affected by this neglect had complex medical conditions, including traumatic brain injuries, dementia, and paralysis, which made them highly dependent on staff for their care. The failure to provide timely and appropriate care resulted in residents being left in uncomfortable and potentially harmful conditions, such as being cold, covered in feces, and soaked in urine. The facility's policies on neglect were not adhered to, as the staff did not provide the necessary goods and services to prevent physical harm and emotional distress to the residents.
Neglect in TBI Unit: Residents Not Provided Care as Directed
Penalty
Summary
The provider failed to ensure that eight residents in the Traumatic Brain Injury (TBI) unit received care as directed by their care plans. A complaint was filed with the South Dakota Department of Health, highlighting neglect in the TBI unit. Specifically, one resident was found in the same clothes from the previous day, curled up on the floor without a blanket, cold to the touch, and covered in feces. The resident's bed was untouched from the previous day. Other residents were noted to be incontinent of bowel and bladder, yet there was no evidence of care being provided to address these needs. The review of video footage from the TBI unit revealed that staff, including LPNs and CNAs, were present but did not provide the necessary care to the residents. The footage showed staff spending significant time at a desk or performing tasks unrelated to direct resident care. For example, one LPN was observed sitting at a desk for extended periods, and another staff member was seen entering and exiting rooms without providing care. The lack of an ADL policy and the absence of documented care activities further contributed to the deficiency, as staff failed to anticipate and meet the residents' needs, despite their cognitive impairments and dependency on staff for daily living activities.
Inaccurate Elopement Risk Evaluations
Penalty
Summary
The facility failed to ensure accurate elopement risk evaluations for 15 out of 22 residents, including a resident who had previously eloped. This resident, who had diagnoses of macular degeneration and dementia with behavioral disturbances, was able to leave the building undetected due to a malfunctioning door alarm. Despite having a Brief Interview for Mental Status (BIMS) score indicating moderate impairment, the resident's elopement risk evaluations were inaccurately marked as not at risk, even after a previous elopement incident. The facility's policy required elopement risk evaluations to be completed upon admission and after any elopement event, but this was not adhered to. Interviews with staff revealed that the elopement risk was not updated in the resident's care plan, and the incident was not initially recognized as an elopement or a reportable event. The facility's transition to a new electronic medical record system may have contributed to the oversight, as the resident's care plan and risk evaluations were not properly updated to reflect the elopement risk.
Resident Subjected to Unwarranted Physical Restraint by CNA
Penalty
Summary
The report details a deficiency involving a cognitively impaired resident who was subjected to physical restraint by an agency CNA, which was not required for medical treatment. The incident occurred after the resident returned from the hospital, where she had been treated for symptoms including slurred speech and weakness. Upon her return, the resident was restless and attempted to stand up multiple times, leading the CNA to physically restrain her by holding her arms down and pressing her chin into the resident's scalp. The incident was not immediately reported or documented in the resident's medical records, and it was only discovered after a review of video footage several days later. The footage showed the CNA restraining the resident for a total of 20 minutes over a 90-minute period. During this time, other staff members were present in the unit but did not witness or report the restraint. The facility's Director of Nursing and Administrator confirmed the occurrence of abuse after reviewing the footage. The resident involved had a history of unspecified dementia, bipolar disorder, and Alzheimer's disease, and was residing in the facility's challenging behavior unit. Despite the incident, the resident did not recall the event or any mistreatment by staff. The facility's policy prohibits the use of physical restraints unless necessary for medical symptoms, highlighting a failure in adherence to this policy in the reported incident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Irene
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wakonda Heritage Manor | 6 mi | — | 0 | 0 |
| Pioneer Memorial Nursing Home | 7.3 mi | — | 0 | 0 |
| Centerville Care And Rehab Center Inc | 10.5 mi | — | 0 | 0 |
| Sd Human Services Center - Geriatric Program | 16.9 mi | — | 0 | 0 |
| Bethesda Of Beresford | 18.9 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.