Avantara Redfield
Redfield, South Dakota · CCN 435054
16 surveys since 2011, 8 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 80
- Surveys
- 16
- Harm or worse
- 8
- Immediate jeopardy
- 0
Findings where a surveyor recorded actual harm to a resident.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 58
- Ownership
- For profit - Limited Liability company
- Chain
- LEGACY HEALTHCARE
- County
- Spink · rural
- Medicare-certified since
- 1991
CMS ratings
- Overall
- 2
- Health inspection
- 2
- Staffing
- 3
- Quality measures
- 2
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat fewer weighted findings than its peer group.
Weighted by harm level, against 18 for-profit facilities with fewer than 66 beds in South Dakota.
Last survey on record
Jan 28, 2026
285 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.03 | 3.20 |
| Registered-nurse hours per resident day | 0.63 | — |
| Annual nurse turnover | 52.1% | 43.9% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $23,044 across 3 penalties
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G317.6% | H— | I— |
| No harm, potential for more than minimal | D317.6% | E1058.8% | F15.9% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F8123×
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F5842×
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F6002×
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- F6582×
Ensure services provided by the nursing facility meet professional standards of quality.
- F5651×
Honor the resident's right to organize and participate in resident/family groups in the facility.
In the surveyor’s words
From the most serious findings on record at Avantara Redfield, in the surveyor’s own words.
- Actual harm, isolatedF806Mar 17, 2025
Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) record review, interview, and policy review, the provider failed to ensure the safety for one of one sampled resident (1) who was served a food item she had a documented food allergy to. The failure of serving the resident a food item that was identified as a food allergy resulted in the resident's allergic reaction symptoms and need for evaluation and treatment at the emergency department. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of the provider's 3/10/25 SD DOH FRI regarding resident 1 revealed: *On 3/8/25 at 5:22 p.m. […]
- Actual harm, isolatedF600Aug 28, 2024
Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, policy review, and interview the provider failed to ensure the safety for one of one sampled resident (1) who staff let out of the building in the early morning hours. Resident left the grounds and his wheelchair got stuck on the railroad tracks, and was unable to get himself free. The county sheriff found him and called the provider to let them know that he was gone. This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident. […]
- Actual harm, isolatedF689Aug 28, 2024
Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, observation, interview, and policy review the provider failed to ensure the safety for one of one sampled resident (2) identified at risk for elopement, had eloped (left the facility without staff knowledge) and was outside the building approximately 2 hours and 4 minutes when an activity door was left unalarmed. Failure of staff to ensure the door alarm was rearmed resulted in the resident's elopement and put him at risk for physical injury or serious harm. Specifically, the provider failed to monitor/revise interventions after elopement to ensure resident safety. Findings include: 1. Review of the SD DOH FRI revealed: *On 7/23/24 at 4:41 a.m. […]
- No harm, potential for more than minimal, widespreadF812Dec 5, 2024
51471 Based on observation, interview, and document review, the provider failed to ensure food items were appropriately labeled, stored, handled, prepared, and served to residents in a safe and sanitary manner in one of one kitchen and one of one dining rooms for the following: *One of one kitchen was not maintained in a safe and sanitary manner. *One of one commercial refrigerator contained beverage items that were not labeled, dated, or discarded by the use-by date. *Unsafe meat thawing practices. *Inappropriate glove use and hand hygiene by four of four observed dietary staff (dietary manager C, cook D, cook E, and dietary aide (DA) I) while preparing and serving residents' food. […]
- No harm, potential for more than minimal, widespreadF584Sep 9, 2022
Based on observation, interview, record review, and policy review, the provider failed to ensure all areas of the building were maintained in a clean, clutter-free, fresh smelling, and homelike manner for: *Seven of 17 sampled residents (6, 11, 14, 26, 33, 34, and 39) rooms had urine odors and were cluttered. *Five of five hallways (100, 200, 300, and 400) including residents' room doors, hand rails, and public areas had areas which had a strong urine odor and the finish was missing making them uncleanable. Findings include: 1. Observation on 9/7/22 at 7:45 a.m. […]
Read 25 findings in full →The most serious and the most recent: 25 of 80 on record.
Every survey on record
FindingsAt actual harm or above
- Jan 28, 2026Standard and complaint6 findings
- Apr 15, 2025Complaint1 finding
- Mar 17, 2025Complaint1 finding · 1 harm
- Dec 5, 2024Standard4 findings
- Aug 28, 2024Complaint2 findings · 2 harm
- Jul 17, 2024Complaint1 finding
- Aug 31, 2023Standard2 findings
- Sep 9, 2022Standard and complaint9 findings
Show the 8 earlier surveys
- Apr 29, 2021Standard and complaint4 findings
- Apr 25, 2019Standard7 findings
- Jan 18, 2018Standard4 findings
- Nov 30, 2016Standard1 finding
- Oct 22, 2015Standard4 findings · 1 harm
- Aug 21, 2014Standard and complaint3 findings · 2 harm
- Nov 7, 2013Standard24 findings · 2 harm
- Jul 7, 2011—7 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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