Sunset Manor Avera Health

• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 1 of 5.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

30 of 96 South Dakota homes (31%) got a citation at the actual harm level in 2026.

• Citation F0600. Severity G: actual harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on June 3, 2026.

  CMS has cited this home for F0600 3 times since 2024.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on June 3, 2026.

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CMS fine of $16,350 on May 5, 2026.

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• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Fine

  CMS changed the fine from September 25, 2024 from $45,240 to $29,406.

• Fine

  CMS changed the fine from February 12, 2025 from $17,215 to $11,190.

CMS lists this as a standard inspection and a complaint inspection.

• Citation F0732. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Post nurse staffing information every day.

  CMS lists it as corrected on January 8, 2026.

• Citation F0641. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure each resident receives an accurate assessment.

  CMS lists it as corrected on February 4, 2026.

  CMS has cited this home for F0641 2 times since 2024.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on January 16, 2026.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on February 4, 2026.

• Citation F0678. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

  CMS lists it as corrected on February 4, 2026.

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CMS lists this as a standard inspection.

• Citation K0222. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on February 4, 2026.

  CMS has cited this home for K0222 2 times since 2023.

• Citation K0321. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on December 31, 2025.

• Citation K0712. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on February 4, 2026.

• Citation K0781. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have restrictions on the use of portable space heaters.

  CMS lists it as corrected on December 31, 2025.

• Citation K0241. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Have correct number of accessible exits for each story.

  CMS lists it as corrected on December 31, 2025.

  CMS has cited this home for K0241 3 times since 2023.

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• Ownership

  CMS lists this home under a new chain.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on July 16, 2025.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on July 16, 2025.

  CMS has cited this home for F0684 3 times since 2024.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on July 22, 2025.

  CMS has cited this home for F0689 2 times since 2025.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS overall star rating changed from 4 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.

• CMS abuse icon

  CMS added its abuse icon to this home.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

37 of 96 South Dakota homes (39%) got a citation at the actual harm level in 2025.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on March 13, 2025.

• Citation F0684. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on March 13, 2025.

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CMS fine of $11,190 on February 12, 2025.

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• Star rating

  The CMS overall star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS health inspection star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS overall star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 5 of 5.

CMS lists this as a complaint inspection.

Severity H is the second-highest of CMS's four levels. It means a resident was harmed.

42 of 96 South Dakota homes (44%) got a citation at the actual harm level in 2024.

• Citation F0600. Severity H: actual harm, pattern.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on October 23, 2024.

• Citation F0684. Severity H: actual harm, pattern.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on October 23, 2024.

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CMS fine of $29,406 on September 25, 2024.

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CMS lists this as a complaint inspection.

• Citation F0641. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure each resident receives an accurate assessment.

  CMS lists it as corrected on September 6, 2024.

• Citation F0604. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

  CMS lists it as corrected on September 22, 2024.

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CMS lists this as a standard inspection.

• Citation K0241. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Have correct number of accessible exits for each story.

• Citation K0271. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Have exits that are accessible at all times.

  CMS lists it as corrected on August 27, 2024.

• Citation K0911. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Meet requirements for the installation and maintenance of electrical systems.

  CMS lists it as corrected on August 7, 2024.

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• Star rating

  The CMS overall star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 1 of 5 to 2 of 5.

CMS lists this as a standard inspection.

• Citation F0638. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assure that each resident’s assessment is updated at least once every 3 months.

  CMS lists it as corrected on August 25, 2023.

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CMS lists this as a standard inspection.

• Citation K0222. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on July 12, 2023.

• Citation K0226. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have horizontal exits used in accordance with safety requirements.

  CMS lists it as corrected on July 12, 2023.

• Citation K0293. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have properly located and lighted "Exit" signs.

  CMS lists it as corrected on July 12, 2023.

• Citation K0355. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on July 12, 2023.

• Citation K0241. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Have correct number of accessible exits for each story.

  CMS lists it as corrected on July 12, 2023.

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