Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avantara Redfield during CMS and state inspections, most recent first.
Staff did not consistently monitor and document food temperatures for all meals as required by facility policy, with significant gaps in temperature records over multiple days. Both dietary management and administration acknowledged the ongoing issue with incomplete documentation.
A resident with a known strawberry allergy and severe cognitive impairment was served cake containing strawberries after a cook failed to use meal tray tickets that listed allergies. The resident experienced an allergic reaction requiring emergency treatment. Staff interviews and records confirmed that allergy protocols existed but were not followed during this incident.
The facility failed to maintain sanitary conditions in the kitchen and dining areas, with observations of improper food labeling, storage, and handling. Staff were seen using gloves inappropriately and neglecting hand hygiene while assisting residents. The kitchen had significant cleanliness issues, including grease buildup and expired sanitizer test strips. These deficiencies indicate a failure to adhere to the facility's policies on food safety and sanitation.
The facility failed to maintain a clean and homelike environment, with observations revealing wet floors, peeling caulking, and non-functional equipment in residents' rooms. The dining room and other areas showed signs of neglect, such as gouged walls, rusted heaters, and delaminated doors. The maintenance director acknowledged the issues but did not log repairs from direct reports, indicating a gap in the reporting and repair process.
Essential kitchen equipment in the dietary department was not maintained in safe working condition, with non-functional stove burners and ovens, a leaking flattop grill, and a leaking food preparation sink. The air conditioning unit's condensation was improperly draining into the only handwashing sink. The maintenance director was unaware of these issues, and the maintenance work orders lacked dates, indicating a delay in addressing the problems.
A resident receiving oxygen therapy through a nasal cannula was found to have no foam filter on the oxygen concentrator, and there were no current physician's orders for the therapy. The facility's policy for weekly changes of oxygen tubing and cleaning of the concentrator's foam filter was not followed, and staff were unaware of these deficiencies. The resident's EMR lacked documentation of the necessary orders and maintenance records.
A resident with moderate cognitive impairment and a history of stroke was left unsupervised outside a facility after being assisted out by an RN who failed to inform other staff. The resident's wheelchair became stuck on railroad tracks, and he was found by the county sheriff two hours later. The incident revealed a lapse in communication and supervision, leading to a deficiency in resident safety.
A resident at risk for elopement left the facility undetected for over two hours due to a deactivated door alarm and lack of a Wanderguard. The facility's care plan identified the resident as an elopement risk, but interventions were not adequately monitored. The Wanderguard system was only operational on the central door, and the door used by the resident did not have this system. The facility's policy required daily verification of Wanderguards and door alarms, which was not followed.
A resident with a vascular wound on the left foot did not receive consistent wound care treatments as ordered by the physician, and documentation was incomplete. The resident reported missed dressings by night shift nurses, and the Treatment Administration Record showed missing entries for specific dates. Interviews revealed inconsistencies in staff communication and documentation, with no evidence of physician notification when treatments were not completed.
Failure to Consistently Document Food Temperatures for All Meals
Penalty
Summary
The facility failed to ensure that food temperatures were consistently monitored and documented according to its own policy for all meals prepared and served in the kitchen. Observations revealed that the cook was taking food temperatures five to fifteen minutes before serving, and staff were expected to document these temperatures on a designated chart. However, interviews with the dietary manager and administrator confirmed that there were ongoing issues with staff not documenting food temperatures as required. The dietary manager noted that a new system had been implemented to improve compliance, but significant gaps in documentation persisted. Record review showed that in March, there were no food temperatures documented for 23 out of 31 days, with only partial documentation on several other days. In April, there were also days with missing or incomplete documentation. The facility's policy required food temperatures to be recorded at the beginning and end of the trayline for each meal, and corrective action to be taken if temperatures were not within acceptable ranges. Both the dietary manager and administrator acknowledged the failure to meet these documentation requirements.
Failure to Prevent Allergen Exposure Due to Non-Compliance with Meal Ticket Protocol
Penalty
Summary
A resident with a documented strawberry allergy and severe cognitive impairment was served cake containing strawberries for dessert. The cook responsible for meal service did not use the meal tray tickets, which are intended to identify resident allergies, when preparing and serving the meal. As a result, the resident consumed the allergen, leading to an allergic reaction that required assessment, administration of Benadryl, and subsequent transfer to the emergency department for further evaluation and treatment. Interviews and record reviews confirmed that the facility had systems in place, such as posted allergy lists in the kitchen and allergy information on meal tray tickets, to prevent such incidents. However, these procedures were not followed by the cook on the day of the event. Staff interviews indicated awareness of the process for identifying and accommodating food allergies, but the failure to adhere to established protocols directly resulted in the resident being exposed to an allergen.
Sanitation and Food Handling Deficiencies in Kitchen and Dining Areas
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the kitchen and dining areas, leading to multiple deficiencies. Observations revealed that the kitchen was not kept in a sanitary condition, with substances such as limescale and black residue found on and around the dishwasher, and grease accumulation under the stove. The commercial refrigerator contained unlabeled and undated food items, and expired sanitizer test strips were used. Additionally, the kitchen staff, including the dietary manager and cooks, were observed eating in the kitchen and leaving food preparation areas unattended, with utensils and food items left uncovered. In the dining room, staff members, including CNAs and a restorative aide, were observed using gloves inappropriately and failing to perform proper hand hygiene while assisting residents with meals. They wore the same gloves while touching various surfaces and assisting multiple residents, which is against the facility's handwashing and glove use policy. The ice machine in the dining room also had a buildup of unidentified substances, and dietary staff handled drinking cups improperly, potentially compromising sanitation. The facility's policies on food storage, handwashing, and cleaning were not adhered to, as evidenced by the improper thawing of meat, unlabeled and expired food items, and incomplete cleaning schedules. Interviews with the dietary manager and staff revealed a lack of awareness and adherence to these policies, contributing to the unsanitary conditions observed. The facility's failure to ensure proper food handling, storage, and sanitation practices resulted in a significant deficiency in maintaining a safe environment for residents.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The provider failed to maintain a clean and homelike environment for several residents and areas within the facility. Observations revealed multiple deficiencies, including a wet floor and peeling caulking in a shared bathroom, a faucet with a thick build-up and missing parts in another resident's room, and a non-functional hand sanitizer dispenser outside a room. Additionally, rooms had scratched and scuffed surfaces, flaking paint, exposed drywall, and exposed heating elements, all of which contributed to an unclean and unsafe environment. In the dining room, there were visible signs of neglect, such as a gouged wall, dirty and rusted heaters, exposed drywall, and delaminated doors. The maintenance director acknowledged the issues but did not log repairs made from direct reports, relying instead on an online work order system. However, the work orders log did not reflect any open or unaddressed issues, indicating a gap in the reporting and repair process. The facility's policies emphasized maintaining a safe and homelike environment, but the observations and interviews highlighted a failure to adhere to these standards.
Deficient Kitchen Equipment Maintenance
Penalty
Summary
The provider failed to ensure that essential kitchen equipment in the dietary department was in safe working condition. Observations revealed that five out of eight stove-top burners on the commercial gas stove did not ignite, and both ovens in the commercial gas stove were non-operational. Additionally, the flattop grill was leaking oil onto the floor, and the two-compartment food preparation sink was leaking and not used for food preparation. The air conditioning unit's condensation tubing was improperly draining into the handwashing sink, which was the only handwashing facility available in the kitchen. Interviews with the dietary manager and cook confirmed the non-functioning equipment and improper use of the three-compartment sink for thawing chicken due to the leaking food preparation sink. The maintenance director was unaware of these issues, and the maintenance work orders log showed no dates for the reported leaks, indicating a lack of timely response. The facility's maintenance policy requires staff to report malfunctioning equipment, and the maintenance department is expected to address issues promptly, but this was not adhered to in this case.
Deficiency in Respiratory Care for a Resident
Penalty
Summary
The provider failed to ensure proper respiratory care for a resident by not replacing the foam filter on the oxygen concentrator machine and not having current physician's orders for oxygen therapy. During an observation, it was noted that the resident was receiving oxygen through a nasal cannula at a rate of 3 liters per minute, but there was no foam filter on the back of the oxygen concentrator. The resident's electronic medical record (EMR) lacked documentation of a current physician's order for supplemental oxygen, despite previous assessments indicating oxygen therapy. Additionally, there was no record of when the oxygen tubing was last changed or when the foam filter was last cleaned and replaced. Interviews with facility staff, including a registered nurse and the director of nursing, revealed a lack of awareness regarding the missing foam filter and the absence of physician's orders for oxygen use. The facility's policy required weekly changes of oxygen tubing and cleaning of the concentrator's foam filter, with documentation in the medical record, which was not followed. The staff suggested that the orders might have been lost during the resident's recent trips to the emergency department. The facility's oxygen administration policy emphasized the need for a physician's order and proper documentation, which was not adhered to in this case.
Resident Left Unsupervised and Found on Railroad Tracks
Penalty
Summary
The provider failed to ensure the safety of a resident with moderate cognitive impairment, as indicated by a BIMS score of 9, who was allowed to leave the facility unsupervised. The resident, who had a history of cerebral infarction, arthritis, hemiplegia on the right side, and aphasia, was assisted out of the building by an RN in the early morning hours. The RN did not inform other staff members that the resident was outside and subsequently forgot about him due to being occupied with other tasks. As a result, the resident's wheelchair became stuck on nearby railroad tracks, and he was discovered by the county sheriff approximately two hours later. The resident was found three blocks away from the facility, and the sheriff contacted the provider to report the incident. The resident was retrieved by the facility's administrator and returned to the facility without any noted injuries. The incident highlighted a lapse in communication and supervision, as the resident was outside alone for an extended period. The provider's failure to prevent the resident from leaving the facility unsupervised constituted a deficiency in protecting the resident from potential harm.
Resident Elopement Due to Inadequate Door Alarm and Wanderguard Monitoring
Penalty
Summary
The facility failed to ensure the safety of a resident identified at risk for elopement, resulting in the resident leaving the facility without staff knowledge and being outside for approximately 2 hours and 4 minutes. This incident occurred when a door alarm was deactivated by an RN and not reactivated, allowing the resident to exit the facility undetected. The resident had a history of elopement risk, as indicated by previous physician orders for a Wanderguard, which was not in place at the time of the incident. The facility's care plan identified the resident as an elopement risk, but interventions were not adequately monitored or revised following the elopement. Interviews and observations revealed that the resident was not wearing a Wanderguard, and there was a lack of documentation regarding its placement. The facility's Wanderguard system was only operational on the central door, and the door through which the resident exited did not have this system. The DON and administrator were unaware of the resident's ability to remove the Wanderguard, and the previous Wanderguard was discontinued based on a low-risk assessment. The facility's policy required daily verification and testing of Wanderguards and door alarms, which was not adhered to, contributing to the deficiency.
Failure to Document and Complete Wound Care Treatments
Penalty
Summary
The provider failed to ensure that wound care treatments were completed and documented according to physician orders for a resident with a vascular wound on the left foot. Observations and interviews revealed that the resident had a scheduled appointment with a vascular surgeon for a possible amputation. The resident reported that a nurse on the night shift had not completed his dressings on several occasions. A review of the resident's Treatment Administration Record (TAR) showed missing documentation for wound care treatments on specific dates, indicating that treatments were either not completed or not documented. Interviews with the Director of Nursing (DON) and other staff members highlighted inconsistencies in the documentation and communication of wound care treatments. The DON confirmed that there was no documentation to support that the physician had been notified when wound dressing changes were not completed. Additionally, there were discrepancies in staff reports regarding the resident's refusal of care, with some staff indicating that the resident did not refuse care, while others noted refusals. The facility's job descriptions for RNs and LPNs emphasized the importance of documenting care provided, yet this was not consistently followed, leading to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Redfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eastern Star Home Of South Dakota, Inc | 0.4 mi | — | 0 | 0 |
| Faulkton Senior Living | 32.2 mi | — | 3 | 0 |
| Good Samaritan Society Miller | 33.5 mi | — | 11 | 0 |
| Avantara Clark City | 38 mi | — | 7 | 0 |
| Avantara Huron | 38.6 mi | — | 14 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.