Map showing the location of AVANTARA REDFIELD in REDFIELD, South Dakota
1015 THIRD STREET EAST, REDFIELD, SD, 57469

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • South DakotaLowest tier among peers95 rated homes · average 2.9★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.8 vs SD avg
  • StaffingCan add or remove a star2★−1.5 vs SD avg
  • Quality measuresCan add or remove a star1★−1.9 vs SD avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersSD avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 7% of peersSD avg3.5★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments1★Lowest tier among peersSD avg2.9★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff2.98hrsAbove only 7% of peersSD avg3.89Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.49hrsAbove only 13% of peersSD avg0.80Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better55%Above only 33% of peersSD avg50%RN turnover17%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$30,051Above only 30% of peersSD avg$25,187Fines · denials3 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
20citations
7inspection dates
3actual harm (G–I)
0immediate jeopardy (J–L)
Apr 15, 2025most recent

Citations by monthSep 2022 – Apr 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Apr 15, 20251 citationCycle 1worst E · no actual harm
  1. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected May 12, 2025
Mar 17, 20251 citationCycle 1worst G · actual harm$14,015
  1. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryG · isolatedCorrected Mar 14, 2025
Dec 5, 20244 citationsCycle 1worst F · no actual harm
  1. F584Honor 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.Resident RightsE · patternCorrected Jan 13, 2025
  2. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jan 13, 2025
  3. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Jan 13, 2025
  4. F908Keep all essential equipment working safely.EnvironmentalE · patternCorrected Jan 13, 2025
Aug 28, 20242 citationsCycle 2worst G · actual harm$8,018, $8,018
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Aug 26, 2024
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Sep 19, 2024
Jul 17, 20241 citationCycle 2worst D · no actual harm
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Aug 8, 2024
Aug 31, 20232 citationsCycle 2worst E · no actual harm
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Oct 6, 2023
  2. F584Honor 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.Resident RightsE · patternCorrected Oct 6, 2023
Sep 9, 20229 citationsCycle 3worst F · no actual harm
  1. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Oct 7, 2022
  2. F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Resident RightsD · isolatedCorrected Oct 7, 2022
  3. F584Honor 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.Resident RightsF · widespreadCorrected Oct 7, 2022
  4. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Oct 7, 2022
  5. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Oct 7, 2022
  6. F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected Oct 7, 2022
  7. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Oct 7, 2022
  8. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryD · isolatedCorrected Oct 7, 2022
  9. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Oct 7, 2022

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined2.98hrsAbove only 7% of peers−0.91 vs SD avg
  • Registered nursesRN hours only0.49hrsAbove only 13% of peers−0.31 vs SD avg
  • Licensed practical nursesLPN hours0.55hrs
  • Nurse aidesCNA hours1.94hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.47hrs
  • South Dakota average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better55%Above only 33% of peersSD avg 50%
  • RN turnoverRegistered nurses only17%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy51 certified beds · ~50 residents a day99%Top 8%SD avg 84%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $30,051In fines
  • 3Fines
  • 0Payment denials
  • $25,187SD avg in fines
Above only 30% of peersFewer fines than 30% of rated homes in South Dakota

Actions on record

  1. Mar 17, 2025Civil money penalty$14,015
  2. Aug 28, 2024Civil money penalty$8,018
  3. Aug 28, 2024Civil money penalty$8,018

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Legacy Healthcare90 facilities in the chain3.0★ chain average
Certification
Medicare and Medicaid
Location type
Rural
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Doros Generation Trust U/A/D 1/3/12
  • Gpn Fam Tr Ua 04282008
  • Oakway Operations LLC
Operational or managerial control
  • Bokf,na
  • Diane Forgey
  • Chaim Rajchenbach
  • Menachem Shabat
  • Randall Waldner
5% Or Greater Security Interest
  • Bokf,na
  • Redfield Sd Property Holdings, LLC

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 435054 · 1015 THIRD STREET EAST, REDFIELD, SD, 57469.
  • Percentiles compare this facility with every rated nursing home in South Dakota and Spink County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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