Avantara Milbank
Milbank, South Dakota · CCN 435009
16 surveys since 2012, 10 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
- 57
- Surveys
- 16
- Harm or worse
- 10
- 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
- 55
- Ownership
- For profit - Limited Liability company
- Chain
- LEGACY HEALTHCARE
- County
- Grant · rural
- Medicare-certified since
- 1967
CMS ratings
- Overall
- 1
- Health inspection
- 1
- Staffing
- 2
- Quality measures
- 2
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat more 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
Jul 9, 2026
123 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 | 3.23 | 3.20 |
| Registered-nurse hours per resident day | 0.96 | — |
| Annual nurse turnover | 91.5% | 43.9% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $125,981 across 4 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 | G825.8% | H— | I— |
| No harm, potential for more than minimal | D1135.5% | E1032.3% | F26.5% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6093×
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- F6893×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F5502×
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- F6582×
Ensure services provided by the nursing facility meet professional standards of quality.
- F7602×
Ensure that residents are free from significant medication errors.
In the surveyor’s words
From the most serious findings on record at Avantara Milbank, in the surveyor’s own words.
- Actual harm, isolatedF740May 7, 2026
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 staff followed the care planned interventions for one of one sampled resident (2) who expressed distress and reported allegations of abuse when one of one certified nursing assistant (CNA) (P) did not provide the resident's care with another staff member present, as identified in his care plan and the provider failed to provide necessary behavioral health care and services to support the resident's highest practicable mental, emotional, and psychosocial well-being. Findings include: 1. […]
- Actual harm, isolatedF760May 7, 2026
Based on a South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure that residents were free of significant medication errors for one of one sampled resident (3) who admitted to the facility following a hospitalization for surgical repair of a fractured left hip and did not receive Aspirin 81 milligrams (mg) twice daily as ordered from the 12/19/25 p.m. dose through the 1/18/26 p.m. dose. […]
- Actual harm, isolatedF760Dec 18, 2024
Based on South Dakota Department of Health (SD DOH) complaint online report, interviews, records review, and policy review, the provider failed to ensure one of one resident (1) had been free from a significant medication error when he was administered two long-action insulins at the same time for four consecutive days. Findings include: 1. Review of the SD DOH 12/12/24 intake information revealed: *I am writing to file a complaint regarding [long-term care provider's name]. There was a sentinel event [not anticipated] that could have ended a resident's life. *[Resident 1] (4/5/1956) was transported to [name of hospital] on 12/12/24 for complaints of hypoglycemia and altered mental status. […]
- Actual harm, isolatedF609Oct 8, 2024
Based on a 10/7/24 complaint intake report review, interview, record review, and policy review. The provider failed to ensure a thorough investigation was completed to rule out if abuse and neglect occurred for one of one sampled resident (1) who had bruising and swelling of unknown origin on the left knee, right wrist, and penis and to report the incidents to the South Dakota Department of Health. Findings include. 1. Review of the 10/7/24 South Dakota Department of Health (SD DOH) complaint intake revealed: * On 8/21/24, staff notified the family that resident 1 had fallen in the bathroom and had a small skin tear. * On 9/22/24, staff notified the family that resident 1's knee is swollen, and it was unknown what had happened. […]
- Actual harm, isolatedF610Oct 8, 2024
Based on a 10/7/24 complaint intake report review, interview, record review, and policy review. The provider failed to ensure a thorough investigation was completed to rule out if abuse and neglect occurred for one of one sampled resident (1) who had bruising and swelling of unknown origin on the left knee, right wrist, and penis and to report the incidents to the South Dakota Department of Health. Findings include. 1. Review of the 10/7/24 South Dakota Department of Health (SD DOH) complaint intake revealed: * On 8/21/24, staff notified the family that resident 1 had fallen in the bathroom and had a small skin tear. * On 9/22/24, staff notified the family that resident 1's knee is swollen, and it was unknown what had happened. […]
Read 27 findings in full →The most serious and the most recent: 27 of 57 on record.
Every survey on record
FindingsAt actual harm or above
- Jul 9, 2026Standard1 finding
- May 7, 2026Complaint12 findings · 2 harm
- Mar 13, 2025Standard and complaint5 findings
- Dec 18, 2024Complaint3 findings · 1 harm
- Oct 8, 2024Complaint3 findings · 3 harm
- Aug 6, 2024Complaint1 finding
- Nov 8, 2023Standard5 findings · 2 harm
- Sep 1, 2022Standard1 finding
Show the 8 earlier surveys
- Nov 6, 2019Standard3 findings
- Oct 3, 2018Standard2 findings
- Aug 24, 2016Standard3 findings
- Mar 30, 2016Complaint2 findings · 1 harm
- Oct 7, 2015Standard5 findings
- Jul 16, 2014Standard1 finding
- Jun 12, 2013—4 findings
- May 23, 2012—6 findings · 1 harm
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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