Avantara Milbank
1103 South Second Street · Milbank, SD · 57252 · 6054324556
55 certified beds For profit - Corporation Chain: Legacy Healthcare
Why this verdict
- Federal penalties on record: $43,953 in fines in the last 24 months.
- 6 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
Red flags
2 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
Total nurse staffing below 3.0 hours per resident-day
3.00 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
86% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 2 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 3.00 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.98 | 0.55–0.75 |
| Weekend hours / resident-day | 2.75 | ≈ weekday level |
| Nursing turnover / year | 86% | median 45% |
| Fines (3-yr window) | 3 · $55,361 |
Inspection citations (18 in the current record)
-
Potential for harm · D March 13, 2025
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected April 21, 2025 · Resident Rights
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Potential for harm · D March 13, 2025
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.
Corrected April 21, 2025 · Resident Rights
-
Potential for harm · E March 13, 2025
Honor each resident's preferences, choices, values and beliefs.
Corrected April 21, 2025 · Quality of Life and Care
-
Potential for harm · F March 13, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected April 21, 2025 · Nutrition and Dietary
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Potential for harm · E March 13, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 21, 2025 · Quality of Life and Care
-
Actual harm · G December 18, 2024 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected January 17, 2025 · Pharmacy Service
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Potential for harm · D December 18, 2024 · found via complaint
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.
Corrected January 17, 2025 · Resident Rights
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Potential for harm · D December 18, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected January 17, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G October 8, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected November 2, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G October 8, 2024 · found via complaint
Respond appropriately to all alleged violations.
Corrected November 2, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G October 8, 2024 · found via complaint
Provide enough food/fluids to maintain a resident's health.
Corrected November 2, 2024 · Quality of Life and Care
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Potential for harm · E August 6, 2024 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected September 10, 2024 · Quality of Life and Care
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Actual harm · G November 8, 2023
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected December 6, 2023 · Resident Assessment and Care Planning
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Actual harm · G November 8, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 6, 2023 · Quality of Life and Care
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Potential for harm · E November 8, 2023
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected December 6, 2023 · Resident Rights
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Potential for harm · D November 8, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected December 6, 2023 · Resident Assessment and Care Planning
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Potential for harm · D November 8, 2023
Provide and implement an infection prevention and control program.
Corrected December 6, 2023 · Infection Control
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Potential for harm · E September 1, 2022
Provide and implement an infection prevention and control program.
Corrected October 21, 2022 · Infection Control
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| December 18, 2024 | Fine | $28,912 |
| October 8, 2024 | Fine | $15,041 |
| November 8, 2023 | Fine | $11,408 |
Better-scoring options nearby
No better-scoring facility within 25 miles in the current data. See the whole state.
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 435009 · certified since February 1, 1967. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.