Sunset Manor Avera Health: CPR Training Gap Found - SD
That gap sits at the center of a complaint inspection completed at the facility on December 31, 2025. Inspectors found that while Sunset Manor's own policies and its electronic medical records system included information on which residents had Do Not Resuscitate orders, there was no documented proof that nursing staff had actually been trained on how to use that information in an emergency.
The CNA, identified in the report as CNA J, was CPR certified. She knew how to perform the physical act of resuscitation. What her orientation videos did not address was the question that comes before any of that: whether she was supposed to.
Two licensed practical nurses told inspectors a different story. LPN L said she understood she would not start CPR on a resident with a DNR order who had no pulse or respirations. LPN D said she would check a resident's code status before beginning CPR in an emergency and had received mandatory education on the subject. Both said code statuses were accessible in the electronic medical record and on hall sheets posted in the facility.
But knowing where to find the information is not the same as being trained on what to do with it, and the inspection turned on exactly that distinction.
The facility's director of nursing, identified as DON B, could not produce signed documentation showing which nursing staff had attended a required meeting held after an incident involving a resident identified as Resident 52. The date of that incident was redacted from the public version of the report, as were most other dates. What remained was the finding: no paperwork confirming who sat in that room, or whether the meeting changed anything for the staff who weren't there.
Inspectors reviewed Sunset Manor's own education records and found the facility did provide training on advance directives and code statuses as part of new hire orientation and annual education. A code status and resuscitation policy, last reviewed in October 2025, spelled out that CPR should be initiated on any resident in cardiac or respiratory arrest unless a Do Not Resuscitate order was documented in the electronic medical record. A separate advance directive policy said nurses were educated to start CPR, as recommended by the American Heart Association, unless a valid DNR was in place.
The policies existed. The records showing staff had been trained to follow them did not.
CNA J's account made the problem concrete. She had gone through orientation. She had watched the videos. At no point had anyone explained to her the system that governs one of the most consequential decisions a staff member can face on a night shift, when a resident stops breathing and there may be no one else in the hallway.
Inspectors classified the violation as causing minimal harm or potential for actual harm, and noted that few residents were affected. The citation did not allege that any resident had been resuscitated against their wishes, or that anyone with a DNR order had been subjected to unwanted CPR. The finding was narrower than that: the facility could not show its staff had been taught what to do.
What CNA J did know, she had learned from a certification course before she arrived. What she was never taught, in a week of working in a building where some residents had asked not to be resuscitated, was how to tell the difference.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sunset Manor Avera Health from 2025-12-31 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Sunset Manor Avera Health in IRENE, SD was cited for violations during a health inspection on December 31, 2025.
That gap sits at the center of a complaint inspection completed at the facility on December 31, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.