Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Milbank during CMS and state inspections, most recent first.
The facility failed to maintain a clean kitchen and proper glove use during food service. Observations showed food debris on equipment and improper glove handling by a dietary aide. The dietary manager admitted to inconsistent cleaning practices, and the facility lacked a certified dietary manager.
The facility failed to ensure prompt response to call lights, causing frustration among residents due to significant delays, especially during meal times and medication passes. Despite a new call light system and staff reminders, response times often exceeded the expected five to ten minutes, with some residents waiting over 30 minutes for assistance.
Two residents were transferred using sit-to-stand lifts by a single CNA instead of the required two staff, contrary to care plans and manufacturer instructions. One resident with an above-the-knee amputation was lowered to the floor after the lift sling was improperly attached, while another resident with severe cognitive impairment was also lowered to the floor during a transfer. Staff did not consistently follow protocols for safe lift use or ensure adequate supervision during transfers.
A resident with Type 2 diabetes was administered two long-acting insulins simultaneously for four days due to a lack of communication and documentation errors at the facility. The resident experienced hypoglycemic episodes, leading to an emergency hospital admission. The facility had recently changed pharmacies, and the new process for updating medication orders was not adequately implemented or monitored, contributing to the significant medication error.
A facility failed to follow its grievance policy after a resident's daughter filed a complaint about improper use of mechanical lifts, short staffing, and other concerns. The resident experienced stomach pain and dark/tarry bowel movements, but there was no documentation of follow-up with her primary physician. The facility did not investigate or respond to the grievance, and the administrator admitted the grievance process was not followed.
A resident with type 2 diabetes was given two long-acting insulins simultaneously for four days, leading to hypoglycemia and emergency hospitalization. The facility failed to report the incident to the SD DOH, despite policy requirements. Staff did not clarify insulin orders with the physician or pharmacy, and the incident was not documented or communicated as required.
A resident in an LTC facility experienced bruising and swelling of unknown origin on the left knee, right wrist, and penis, which were not thoroughly investigated or reported to the South Dakota Department of Health. Staff reported a possible abuse incident involving improper transfer methods, but no follow-up was documented. The facility's policies required reporting and investigation of such injuries, but these were not adhered to, resulting in a deficiency.
A resident in a LTC facility experienced bruising and swelling of unknown origin on the left knee, right wrist, and penis, which were not thoroughly investigated or reported to the South Dakota Department of Health. The resident had a history of a fall and was later diagnosed with a right scapholunate ligament tear. A CNA reported an improper transfer by other CNAs, but it is unclear if this was investigated. The facility's incident reporting database showed no reports were made, and the provider's policies on incident reporting and abuse were not followed.
A facility failed to ensure adequate fluid intake and monitoring for residents, resulting in dehydration and hospitalization for one. Observations showed water pitchers out of reach or missing, and interviews revealed inconsistencies in documenting and encouraging fluid intake. Care plans highlighted risks for dehydration, but the facility's hydration policy was not effectively implemented.
The facility failed to provide adequate assistance and documentation for ADL tasks for four residents dependent on staff. Observations showed residents left without call lights within reach and delayed feeding during meals. Interviews revealed a lack of specific rounding policies, and care plans requiring repositioning and toileting assistance were not consistently followed. Residents with severe cognitive impairments were not adequately supported, and the facility's call light policy was not consistently implemented.
Deficiencies in Kitchen Sanitation and Glove Use
Penalty
Summary
The provider failed to maintain the kitchen in a clean and sanitary condition and did not adhere to proper glove use during food preparation and service. Observations revealed food debris and a yellow film on serving pans, pan lids, and the steam table. Dust was found on storage racks, and a knife was observed on the floor under a storage rack. Cook/dietary aide J was seen using the same gloves to handle various food items, touch resident menu slips, and open the refrigerator, which is not in line with acceptable food service practices. The dietary manager acknowledged that the kitchen carts were not cleaned daily as required, and the floors were not mopped every day. Interviews with the dietary manager and administrator confirmed the lack of adherence to the facility's policies on handwashing, glove use, and cleaning procedures. The dietary manager admitted that the cleaning tasks were not consistently completed, and the administrator observed a yellow residue on kitchen equipment. The facility did not have a certified dietary manager, and the dietary manager was still in the process of obtaining certification. The provider's policies on handwashing, glove use, and cart cleaning were reviewed, highlighting the need for proper glove use and regular cleaning to maintain sanitary conditions.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure prompt response to call lights and necessary care and services for six residents, leading to frustration and potential risks to their well-being. Residents reported significant delays in staff response to call lights, with some waiting up to an hour for assistance. These delays were particularly noted during meal times and medication passes, contributing to residents' dissatisfaction and concerns about their safety. Interviews with residents and staff revealed inconsistencies in the expected response times for call lights. While the facility's policy and staff expectations were to respond within five to ten minutes, actual response times often exceeded these limits. Call light logs showed multiple instances where response times were over ten minutes, with some exceeding 30 minutes. Residents expressed frustration, particularly when needing urgent assistance, such as using the bathroom. The facility had implemented a new call light system with pagers to notify staff of activated call lights, but this system did not prevent delays. Staff interviews indicated a lack of urgency in responding to call lights, with some staff waiting five minutes before answering. Despite daily reminders during shift huddles, the facility's procedures were not consistently followed, leading to prolonged wait times and resident dissatisfaction.
Failure to Ensure Safe Use of Lift Equipment and Adequate Supervision During Resident Transfers
Penalty
Summary
The facility failed to ensure resident safety by not following proper procedures for the use of lift equipment as directed in residents' care plans and the manufacturer's instructions. In one instance, a certified nursing assistant (CNA) attempted to transfer a resident with an above-the-knee amputation, morbid obesity, and epilepsy using a mechanical sit-to-stand lift without the required assistance of a second staff member. During the transfer, the right side of the sling became detached from the lift due to incorrect attachment, resulting in the resident being lowered to the floor and experiencing pain in her residual limb. The resident was cognitively intact and her care plan specified the need for two staff during transfers when she felt weak or tired, as well as specific instructions regarding the use of her prosthesis and choice of lift. In another incident, a CNA used a non-mechanical sit-to-stand lift to transfer a resident with severe cognitive impairment, Alzheimer's dementia, anxiety, congestive heart failure, and chronic kidney disease. The resident, who required 'cares in pairs' (assistance of two staff for all care), was being transferred by only one CNA. During the transfer, the resident sat down prematurely before the lift's padded seat could be positioned, and was subsequently lowered to the floor without injury. The CNA involved was not aware that two staff were required for this resident's care, despite this being clearly indicated in the care plan. Observations and interviews confirmed that staff were expected to use all lifts with two staff members and to follow both care plan interventions and manufacturer guidelines for equipment use. However, there was a lack of ongoing audits to ensure compliance with these procedures, and not all staff demonstrated awareness of the specific requirements for each resident. These failures resulted in unsafe transfers and residents being lowered to the floor during lift use, contrary to established safety protocols.
Resident Administered Two Long-Acting Insulins Simultaneously
Penalty
Summary
The provider failed to ensure that a resident was free from significant medication errors when they were administered two different types of long-acting insulin simultaneously for four consecutive days. The resident, who had a diagnosis of Type 2 diabetes and was dependent on insulin, was given both Toujeo SoloStar and Tresiba Flex injections daily, despite instructions to switch from Toujeo to Tresiba due to insurance coverage issues. This error led to the resident experiencing hypoglycemic episodes, with a critically low blood sugar level of 24, resulting in an emergency hospital admission. The incident was compounded by a lack of communication and documentation among the nursing staff and between the facility and the pharmacy. The pharmacy had instructed the facility to continue administering Toujeo until it was depleted before starting Tresiba, but this information was not effectively communicated to all staff members. The MAR contained orders for both insulins to be administered simultaneously, and there was no documentation of any attempts to clarify these orders with the pharmacy or the physician. Additionally, the nursing staff failed to communicate discrepancies or concerns during shift changes, leading to the continuation of the error. Interviews with staff revealed that there was a lack of understanding and adherence to medication administration protocols, including the importance of verifying and clarifying medication orders. The facility had recently changed pharmacies, and the new process for updating medication orders was not adequately implemented or monitored. The staff did not complete medication administration competencies, and there was no evidence of recent training or audits to ensure the safety and accuracy of medication administration, contributing to the significant medication error experienced by the resident.
Failure to Follow Grievance Policy and Address Resident Concerns
Penalty
Summary
The facility failed to adhere to its grievance policy following a complaint filed by the daughter of a resident. The complaint included concerns about the improper use of mechanical lifts during resident transfers, which may have led to the resident's dislocated hip, short staffing, long call light wait times, a COVID-19 positive resident wandering the facility, and the resident experiencing black/tarry bowel movements. Despite these concerns, there was no documentation indicating that the facility conducted an investigation or responded to the grievance as required by their policy. The resident's medical record showed that she had been experiencing stomach pain, a poor appetite, and dark/tarry bowel movements. Although the on-call physician was notified and advised monitoring and setting up an appointment with the primary physician, there was no documentation that the resident was seen by her primary physician the following day. Eventually, the resident was transferred to the emergency room due to a suspected gastrointestinal bleed. The facility's administrator acknowledged the lack of documentation and investigation into the grievance. The administrator admitted that the grievance process was not followed, and there was no evidence of communication with the resident's family regarding their concerns. The facility's grievance policy requires that grievances be investigated and addressed promptly, but this was not done in this case.
Failure to Report Insulin Administration Error and Resulting Hypoglycemia
Penalty
Summary
The provider failed to report a critical incident involving a resident who was administered two different long-acting insulins simultaneously for four days, leading to episodes of hypoglycemia and requiring emergency medical evaluation. The resident, a male with type 2 diabetes, was found unresponsive with a blood sugar level of 24, necessitating transport to the emergency department. The incident was not reported to the South Dakota Department of Health (SD DOH) as required by the facility's policy. The medication administration record (MAR) indicated that the resident received both Toujeo and Tresiba insulins from December 8 to December 11, despite instructions that the new insulin, Tresiba, should not be administered until the existing supply of Toujeo was depleted. Nursing staff failed to clarify the insulin orders with the physician or pharmacy, and there was no documentation of any attempts to address the discrepancy. The resident experienced multiple hypoglycemic episodes, with blood sugar levels dropping to critically low levels, yet the facility did not report the incident to the SD DOH. Interviews with facility staff, including a nurse consultant, director of nursing, and administrator, revealed awareness of the reporting guidelines but a failure to act on them. The staff acknowledged that the incident should have been reported, as it involved a critical drop in blood sugar requiring emergency medical services and hospitalization. The facility's policy on abuse and neglect mandates immediate reporting of such incidents, but this protocol was not followed in this case.
Failure to Investigate and Report Suspected Abuse and Neglect
Penalty
Summary
The provider failed to conduct a thorough investigation and report incidents of potential abuse and neglect for a resident who exhibited bruising and swelling of unknown origin on multiple body parts, including the left knee, right wrist, and penis. The incidents were not reported to the South Dakota Department of Health as required. The resident had a history of a fall in the bathroom, which was reported to the family, but subsequent injuries were not adequately investigated or reported. Interviews with staff revealed that a certified nurse aide (CNA) reported a possible abuse incident involving two other CNAs who did not use the care-planned mechanical lift for a transfer, potentially causing injury to the resident. Despite reporting this to a nurse, there was no follow-up or investigation documented. Additionally, the resident's family noticed swelling in the resident's wrist, which was not previously identified by the nursing staff, and a bruise on the resident's penis, which was also not investigated. The facility's incident reporting and abuse and neglect policies were reviewed, indicating that injuries of unknown origin should be reported and investigated. However, the facility did not report the incidents to the state health department, and the administrator was unaware of the allegations of abuse. The facility's failure to investigate and report these incidents constitutes a deficiency in ensuring resident safety and compliance with regulatory requirements.
Failure to Investigate and Report Injuries of Unknown Origin
Penalty
Summary
The provider failed to conduct a thorough investigation to rule out abuse and neglect for a resident who presented with bruising and swelling of unknown origin on the left knee, right wrist, and penis. The incidents were not reported to the South Dakota Department of Health as required. The resident had a history of a fall in the bathroom, which resulted in a small skin tear, and later developed swelling in the knee and wrist, with the cause of these injuries remaining unclear. The resident was eventually diagnosed with a right scapholunate ligament tear, which is commonly caused by a fall on the wrist. A certified nurse aide (CNA) reported an incident involving two other CNAs who allegedly did not follow the care plan for the resident, opting for a two-assist transfer instead of using a total body mechanical lift. This incident was reported to an unidentified nurse, but it is unclear if it was investigated. Additionally, the CNA reported bruising on the resident's penis, which was suspected to be caused by the improper transfer. There was no follow-up with the CNA regarding the incident, and the director of nursing and administrator were not notified of the allegations of abuse. The facility's incident reporting database showed no reports were made regarding the resident's fall, swollen knee, swollen wrist, or bruising on the penis. The provider's incident reporting policy required reporting of serious injuries not expected from the disease process, but the policy did not classify skin tears or bruises as physical harm unless they required hospital treatment. The provider's abuse and neglect policy outlined the criteria for injuries of unknown origin and the steps to be taken if abuse was suspected, including immediate protection of residents, notification of authorities, and a thorough investigation, none of which were documented in this case.
Inadequate Fluid Management Leads to Dehydration
Penalty
Summary
The provider failed to ensure adequate fluid intake, monitoring, and interventions for six sampled residents, resulting in dehydration and hospitalization for one resident. Resident 1 was observed by a family member to have difficulty eating and was denied additional fluids despite asking for more water. The resident's water pitcher was out of reach and unmarked, and the facility was unable to locate intake and output records when requested by the family. Resident 1 was hospitalized with acute dehydration and malnutrition, with laboratory findings indicating low potassium, high blood urea nitrogen, and low albumin levels. Observations on a specific date revealed that Resident 2's water pitcher was out of reach, Resident 3 did not have a water pitcher, and Residents 4 and 5 had full water pitchers without visible ice. Interviews with dietary aides and CNAs indicated inconsistencies in documenting and encouraging fluid intake. It was noted that residents requiring thickened liquids were not consistently offered fluids between meals, and there was no process in place to accurately document residents' fluid intakes. Care plans for the residents highlighted risks for impaired skin integrity, dehydration, and nutritional status alterations, with interventions to encourage good nutrition and hydration. However, the provider's hydration policy, which aimed to ensure adequate hydration, was not effectively implemented. Staff interviews revealed gaps in communication and documentation, with dietary staff not reporting lack of fluid intake to nursing staff, and CNAs not routinely encouraging fluid intake between meals.
Deficiency in ADL Assistance and Documentation
Penalty
Summary
The facility failed to ensure that activities of daily living (ADL) tasks were performed and accurately documented for four residents who were dependent on staff assistance. Observations revealed that Resident 1 was frequently left in his wheelchair without his call light within reach, and visitors reported that call lights were left on for extended periods without response. Interviews with staff indicated that the facility lacked a specific rounding or positioning policy, and the administrator expected rounding to occur every two hours, as specified in each resident's care plan. Resident 1's electronic medical record (EMR) showed severe cognitive impairment and a need for assistance with positioning and toileting, which was not consistently documented. During meal times, residents 1, 2, 3, and 4, who were dependent on staff for feeding, were observed seated in their wheelchairs at the assist table without being fed promptly. A registered nurse stated that these residents were the first to be brought in but the last to be fed. Resident 2's EMR indicated severe cognitive impairment and a need for repositioning every two hours, which was not consistently documented. Similarly, Resident 3's EMR showed severe cognitive impairment and dependency on staff for mobility, transfers, and repositioning, with inconsistent toileting documentation. Resident 4, who had a primary diagnosis of Parkinson's disease and severe cognitive impairment, was observed in her wheelchair for extended periods without repositioning, contrary to her care plan. Interviews with staff confirmed that care plans required repositioning every two hours, but this was not adhered to. The facility's call light policy required call lights to be within reach of residents, and alternative systems were to be evaluated for those unable to use traditional call lights, which was not consistently implemented.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Milbank
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St William's Care Center | 0.9 mi | — | 10 | 0 |
| Fairway View Neighborhoods | 11.9 mi | — | 1 | 1 |
| Wilmot Care Center Inc | 17.6 mi | — | 0 | 0 |
| Madison Healthcare Services | 25.7 mi | — | 10 | 0 |
| Essentia Health Grace Home | 26.2 mi | — | 0 | 0 |
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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.