Avantara Groton
1106 North Second Street, Groton, SD 57445 · Brown County · 37 certified beds · avg 41 residents/day · certified since Jan 1, 1991
Part of chain: LEGACY HEALTHCARE (89 facilities, chain avg rating 2.9★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Nov 26, 2024 · F-0578 · triggered by a complaint
The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Why it matters: Ignoring these rights means residents may receive treatments they refused, or miss having their end-of-life wishes respected.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 24, 2024 (Past Non-Compliance)
All citations in the current public record (22)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 11, 2025 | F · Potential for harm, facility-wide | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Dec 11, 2025 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Dec 11, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Dec 11, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Dec 11, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Dec 11, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Dec 11, 2025 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Dec 11, 2025 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Dec 11, 2025 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Nov 26, 2024 | ▲ G · Actual harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · from a complaint |
| Jul 31, 2024 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jul 31, 2024 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jul 31, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 14, 2023 | E · Potential for harm, repeated | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Apr 14, 2023 | E · Potential for harm, repeated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Apr 14, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 14, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Apr 14, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand. |
| Apr 14, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Apr 14, 2023 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Apr 14, 2023 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Apr 14, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 9 | 0 | E |
| 2024 | 4 | 1 | G ▲ |
| 2025 | 9 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $6,168.
| Date | Type | Amount / length |
|---|---|---|
| Nov 26, 2024 | Fine | $6,168 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | South Dakota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.47 | 4.32 | 3.95 | bottom 18% in South Dakota; bottom 35% in the U.S. |
| Registered Nurse hours | 0.58 | 0.91 | 0.69 | bottom 12% in South Dakota; bottom 49% in the U.S. |
| Weekend total nurse staffing | 3.04 | 3.71 | 3.50 | bottom 23% in South Dakota; bottom 33% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.38 | 0.51 | 0.48 | bottom 32% in South Dakota; bottom 47% in the U.S. |
| Total nursing staff turnover (%) | 37.0 | 48.2 | 45.8 | top 20% in South Dakota; top 29% in the U.S. |
| RN turnover (%) | 33.3 | 34.7 | 42.9 | bottom 48% in South Dakota; top 33% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.72, RN 0.62, weekend 3.27. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: 2/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Doros Generation Trust U/A/D 1/3/12 | Organization | 5% or Greater Direct Ownership Interest | 43% | 07/01/2019 |
| GPN Family Trust U/A/D 4/28/08 | Organization | 5% or Greater Direct Ownership Interest | 43% | 07/01/2019 |
| Oakway Operations LLC | Organization | 5% or Greater Direct Ownership Interest | 15% | 07/01/2019 |
| Bokf,na | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 03/04/2024 |
| Bokf,na | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/04/2024 |
| Carda, Brenda | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/16/2022 |
| Carda, Brenda | Individual | ADP of the SNF | NOT APPLICABLE | 09/16/2022 |
| Doros Generation Trust U/A/D 1/3/12 | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| GPN Family Trust U/A/D 4/28/08 | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| Groton SD Property Holdings, LLC | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 07/01/2019 |
| Groton SD Property Holdings, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| Legacy Healthcare Financial Services LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/01/2019 |
| Legacy Healthcare Financial Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 11/21/2025 |
| Roth & Co, LLP | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Shabat, Menachem | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2019 |
| Shabat, Menachem | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2019 |
| Shabat, Menachem | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| Steger, Brandon | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2019 |
| Steger, Brandon | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
- "Who reviews your menus, and can I see this week's menu and join my family member for a meal?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Bethesda Home of Aberdeen | 17.7 mi | Aberdeen, SD | ★★★☆☆ | 3/5 | |
| Sun Dial Manor | 18.6 mi | Bristol, SD | ★★★☆☆ | 2/5 | |
| Avera Mother Joseph Manor Retirement Community | 18.7 mi | Aberdeen, SD | ★☆☆☆☆ | 2/5 | |
| Prairie Heights Healthcare | 19.1 mi | Aberdeen, SD | ★★★★☆ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 435048.