Sunset Manor Avera Health
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 13 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Abuse citation on record
- Low overall rating (2/5 stars)
- Above-median deficiencies (8 vs median 5.0)
- High staff turnover (68%)
- High RN turnover (80%)
Below average in SD · Below recommended RN staffing · Above recommended total nurse staffing · Worst in AVERA HEALTH chain · $40,596 in fines · Abuse citation
What this means for your family
Given the extreme disparity in reviews, it is essential to conduct an in-person tour and ask direct questions about their fall prevention protocols and staff-to-patient ratios. While some families report excellent care, the recurring, severe allegations of neglect warrant extreme caution and thorough vetting before choosing this facility.
Google Reviews
Google Reviews
13 reviews on Google“Sunset Manor Avera Health receives highly polarized feedback, with some families praising the nursing staff for their kindness and others reporting severe concerns regarding patient safety and neglect. While recent positive experiences highlight compassionate care, multiple critical reviews allege abusive conditions and a lack of accountability for patient falls.”
Quality Themes
Tap a score for detailsStrengths
- Kind and loving nursing staff
- Appreciative of individual care
Concerns
- Allegations of patient neglect and physical abuse (mentioned by 3 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 14 analyzed
How They Respond to Reviews
This facility rarely responds to reviews.
Questions for Your Tour
- 1Given the recent feedback regarding resident safety and oversight, what specific protocols have you implemented to ensure the physical security and well-being of every resident?
- 2With a 2-star CMS health inspection rating, what is your current plan for addressing the recent state violations and improving your overall compliance standards?
- 3I noticed your staffing rating is quite strong compared to your overall CMS score; how do you leverage that consistent staffing to ensure residents receive personalized, attentive care throughout the day?
- 4What specific steps are taken to ensure that the 'kind and loving' care mentioned by some families is consistently applied across all shifts and all residents?
- 5How does your leadership team handle concerns or complaints from families, and what is your process for ensuring those issues are resolved quickly and transparently?
- 6What does a typical day look like for residents here, and how do you tailor activities to keep them engaged given the facility's smaller size of 58 residents?
Personalized based on this facility's data
Key Review Excerpts
“My mom went here, and everyone was so kind to my mom, I wanted to thank the nursing staff for all the love and care they gave her, I truly appreciate it.”
“This is the worst place i have ever seen in my life! The dont take care of people here. Let them fall off bed and say its not their fault.”
“Horrifically abusive. Do not send your loved ones here. It should be shut down.”
Staffing
Staffing Hours
per resident/day · Medicare 2026RN hours are below the national benchmark. RNs handle complex medical needs and medication, so ask about coverage during your visit.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 14 measures
6
measures
6
measures
2
measures
Residents on antipsychotic medication
Residents on anti-anxiety or sleep medication
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents needing more daily help over time
Residents whose bladder or bowel control got worse
Residents whose walking got worse
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Families have filed multiple complaints about abuse protection and care quality issues that recur across surveys, with the most serious being high-severity deficiencies for resident protection from abuse and failure to provide appropriate treatment. The facility has ongoing problems with resident safety, care planning assessments, and building safety issues including fire exits and electrical systems, though all violations show correction dates indicating the facility addresses identified problems.
Dec 31, 2025Routine9
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
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.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Miscellaneous Deficiencies
Have restrictions on the use of portable space heaters.
Egress Deficiencies
Have correct number of accessible exits for each story.
Dec 31, 2025Complaint1
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.
Jun 18, 2025Complaint3
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.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Feb 12, 2025Complaint2
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Sep 25, 2024Complaint2
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.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Aug 8, 2024Complaint2
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Federal Penalties
Fine
Feb 12, 2025
$11,190
Fine
Sep 25, 2024
$29,406
Ownership & Operations
Who Operates This Facility
Sunset Manor Avera Health
nonprofit
Chain Affiliation
Avera Health
13 facilities nationwide
Chain avg rating: 3.7/5 · Rank 12 of 12 (Worst)
Ownership & Management
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
13 reviews from families & visitors
Official Website
Visit avera.org
Medicare data downloads
Original nursing home datasets
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Safer Alternatives Nearby
Based on current clinical data, we identified 2 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.