Avantara Redfield
1015 Third Street East, Redfield, SD 57469 · Spink County · 58 certified beds · avg 50 residents/day · certified since Feb 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: ★★☆☆☆2/5 · 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 · Mar 17, 2025 · F-0806 · triggered by a complaint
The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives.
Why it matters: Ignoring allergies can be dangerous, and ignoring preferences leads residents to eat less and lose weight.
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: Mar 14, 2025 (Past Non-Compliance)
▲ Actual harm, one-off · Aug 28, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
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: Aug 26, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Aug 28, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
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: Sep 19, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (17)
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 |
|---|---|---|
| Jan 28, 2026 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. · from a complaint |
| Jan 28, 2026 | 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. |
| Jan 28, 2026 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jan 28, 2026 | E · Potential for harm, repeated | 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. |
| Jan 28, 2026 | 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. |
| Jan 28, 2026 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Apr 15, 2025 | E · Potential for harm, repeated | 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. · from a complaint |
| Mar 17, 2025 | ▲ G · Actual harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint |
| Dec 5, 2024 | F · Potential for harm, facility-wide | 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. |
| Dec 5, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Dec 5, 2024 | E · Potential for harm, repeated | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Dec 5, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Aug 28, 2024 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Aug 28, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jul 17, 2024 | 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. · from a complaint |
| Aug 31, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Aug 31, 2023 | E · Potential for harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (4 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 2 | 0 | E |
| 2024 | 7 | 2 | G ▲ |
| 2025 | 2 | 1 | G ▲ |
| 2026 | 6 | 0 | E |
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)
3 fines totaling $23,044.
| Date | Type | Amount / length |
|---|---|---|
| Mar 17, 2025 | Fine | $7,008 |
| Aug 28, 2024 | Fine | $8,018 |
| Aug 28, 2024 | Fine | $8,018 |
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) | 3.33 | 4.32 | 3.95 | bottom 11% in South Dakota; bottom 28% in the U.S. |
| Registered Nurse hours | 0.69 | 0.91 | 0.69 | bottom 30% in South Dakota; top 37% in the U.S. |
| Weekend total nurse staffing | 2.71 | 3.71 | 3.50 | bottom 8% in South Dakota; bottom 16% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.25 | 0.51 | 0.48 | bottom 8% in South Dakota; bottom 22% in the U.S. |
| Total nursing staff turnover (%) | 52.1 | 48.2 | 45.8 | bottom 41% in South Dakota; bottom 32% in the U.S. |
| RN turnover (%) | 20.0 | 34.7 | 42.9 | top 24% in South Dakota; top 13% 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 3.03, RN 0.63, weekend 2.46. 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: 2/5 · long-stay residents: 2/5 · short-stay residents: 1/5
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 |
| Doros Generation Trust U/A/D 1/3/12 | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| Forgey, Diane | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2019 |
| Forgey, Diane | Individual | 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 |
| Legacy Healthcare Financial Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2001 |
| Rajchenbach, Chaim | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2019 |
| Rajchenbach, Chaim | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2019 |
| Rajchenbach, Chaim | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| Redfield SD Property Holdings, LLC | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 07/01/2019 |
| Redfield SD Property Holdings, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| 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 |
| Waldner, Randall | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
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 track each resident's food allergies and preferences, and what happens if they don't like what's served?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Does your facility have an active resident council, and how does management respond to its concerns?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "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 |
|---|---|---|---|---|---|
| Eastern Star Home of South Dakota, INC | 0.4 mi | Redfield, SD | ★★★★☆ | 4/5 |
Compare this facility with the 1 closest →
Facility data as of CMS processing date 2026-08-01. CCN 435054.