Avantara Milbank

• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5.

CMS lists this as a standard inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on August 23, 2026.

  CMS has cited this home for F0812 2 times since 2025.

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CMS lists this as a standard inspection.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on August 23, 2026.

• Citation K0911. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Meet requirements for the installation and maintenance of electrical systems.

  CMS lists it as corrected on August 23, 2026.

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CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

30 of 96 South Dakota homes (31%) got a citation at the actual harm level in 2026.

• Citation F0740. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

  CMS lists it as corrected on June 6, 2026.

• Citation F0760. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on June 6, 2026.

  CMS has cited this home for F0760 2 times since 2024.

• Citation F0550. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on June 6, 2026.

  CMS has cited this home for F0550 2 times since 2023.

• Citation F0602. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Protect each resident from the wrongful use of the resident's belongings or money.

  CMS lists it as corrected on June 6, 2026.

• Citation F0684. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on June 6, 2026.

• Citation F0689. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on June 6, 2026.

  CMS has cited this home for F0689 3 times since 2023.

• Citation F0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on June 6, 2026.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on June 6, 2026.

  CMS has cited this home for F0609 3 times since 2024.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on June 6, 2026.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on June 6, 2026.

  CMS has cited this home for F0658 2 times since 2023.

• Citation F0693. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

  CMS lists it as corrected on June 6, 2026.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on June 6, 2026.

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CMS fine of $70,620 on May 7, 2026.

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• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 1 of 5 to 2 of 5.

• Fine

  CMS changed the fine from October 8, 2024 from $23,140 to $15,041.

• Fine

  CMS changed the fine from December 18, 2024 from $44,480 to $28,912.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 2 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 3.7 to 3.3 hours per resident per day.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 4 of 5.

CMS lists this as a standard inspection and a complaint inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on April 21, 2025.

• Citation F0675. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor each resident's preferences, choices, values and beliefs.

  CMS lists it as corrected on April 21, 2025.

• Citation F0689. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on April 21, 2025.

• Citation F0623. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  CMS lists it as corrected on April 21, 2025.

• Citation F0625. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

  CMS lists it as corrected on April 21, 2025.

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CMS lists this as a standard inspection.

• Citation K0211. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Keep aisles, corridors, and exits free of obstruction in case of emergency.

  CMS lists it as corrected on June 19, 2025.

  CMS has cited this home for K0211 2 times since 2023.

• Citation K0351. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install an approved automatic sprinkler system.

  CMS lists it as corrected on March 18, 2025.

• Citation K0712. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on April 18, 2025.

  CMS has cited this home for K0712 2 times since 2023.

• Citation K0741. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  CMS lists it as corrected on March 24, 2025.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

42 of 96 South Dakota homes (44%) got a citation at the actual harm level in 2024.

• Citation F0760. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on January 17, 2025.

• Citation F0585. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

  CMS lists it as corrected on January 17, 2025.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on January 17, 2025.

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CMS fine of $28,912 on December 18, 2024.

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• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

42 of 96 South Dakota homes (44%) got a citation at the actual harm level in 2024.

• Citation F0609. Severity G: actual harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on November 2, 2024.

• Citation F0610. Severity G: actual harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on November 2, 2024.

• Citation F0692. Severity G: actual harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on November 2, 2024.

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CMS fine of $15,041 on October 8, 2024.

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CMS lists this as a complaint inspection.

• Citation F0677. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on September 10, 2024.

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• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

• Fine

  CMS changed the fine from November 8, 2023 from $17,550 to $11,408.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS overall star rating changed from 4 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 2 of 5.

CMS lists this as a standard inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

14 of 96 South Dakota homes (15%) got a citation at the actual harm level in 2023.

• Citation F0658. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on December 6, 2023.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on December 6, 2023.

• Citation F0550. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on December 6, 2023.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on December 6, 2023.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on December 6, 2023.

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CMS lists this as a standard inspection.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on December 4, 2023.

• Citation K0211. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Keep aisles, corridors, and exits free of obstruction in case of emergency.

  CMS lists it as corrected on November 24, 2023.

• Citation K0363. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on November 24, 2023.

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CMS fine of $11,408 on November 8, 2023.

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