Avantara Milbank
1103 South Second Street, Milbank, SD 57252 · Grant County · 55 certified beds · avg 38 residents/day · certified since Feb 1, 1967
Part of chain: LEGACY HEALTHCARE (89 facilities, chain avg rating 2.9★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · May 7, 2026 · F-0740 · triggered by a complaint
The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.
Why it matters: A resident's untreated mental health needs can worsen and take a toll on their physical health too.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 6, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 7, 2026 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 6, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 18, 2024 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 17, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 8, 2024 · F-0609 · triggered by a complaint
The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Why it matters: When incidents aren't reported promptly, abusers may continue harming residents and outside authorities can't step in.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 2, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 8, 2024 · F-0610 · triggered by a complaint
The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Why it matters: When allegations aren't investigated, harm to residents can continue unchecked.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 2, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 8, 2024 · F-0692 · triggered by a complaint
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 2, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 8, 2023 · F-0658
The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Why it matters: Care that falls below professional standards can directly harm a resident's health and recovery.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 6, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 8, 2023 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 6, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (30)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 7, 2026 | ▲ G · Actual harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint |
| May 7, 2026 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| May 7, 2026 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| May 7, 2026 | E · Potential for harm, repeated | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| May 7, 2026 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| May 7, 2026 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 7, 2026 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| May 7, 2026 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| May 7, 2026 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| May 7, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Mar 13, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 13, 2025 | E · Potential for harm, repeated | The facility did not honor residents' individual preferences, choices, values, and beliefs in their daily life and care. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Mar 13, 2025 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 18, 2024 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Dec 18, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Dec 18, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 8, 2024 | ▲ G · Actual harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 8, 2024 | ▲ G · Actual harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Oct 8, 2024 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Aug 6, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Nov 8, 2023 | ▲ G · Actual harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Nov 8, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Nov 8, 2023 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Nov 8, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Nov 8, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 1, 2022 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (5 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 1 | 0 | E |
| 2023 | 5 | 2 | G ▲ |
| 2024 | 7 | 4 | G ▲ |
| 2025 | 5 | 0 | F |
| 2026 | 12 | 2 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $55,361.
| Date | Type | Amount / length |
|---|---|---|
| Dec 18, 2024 | Fine | $28,912 |
| Oct 8, 2024 | Fine | $15,041 |
| Nov 8, 2023 | Fine | $11,408 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | South Dakota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.29 | 4.32 | 3.95 | bottom 10% in South Dakota; bottom 26% in the U.S. |
| Registered Nurse hours | 0.98 | 0.91 | 0.69 | top 36% in South Dakota; top 16% in the U.S. |
| Weekend total nurse staffing | 2.99 | 3.71 | 3.50 | bottom 19% in South Dakota; bottom 31% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.72 | 0.51 | 0.48 | top 14% in South Dakota; top 15% in the U.S. |
| Total nursing staff turnover (%) | 91.5 | 48.2 | 45.8 | bottom 1% in South Dakota; bottom 1% in the U.S. |
| RN turnover (%) | 86.7 | 34.7 | 42.9 | bottom 2% in South Dakota; bottom 3% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.23, RN 0.96, weekend 2.94. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: —/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Doros Generation Trust U/A/D 1/3/12 | Organization | 5% or Greater Direct Ownership Interest | 43% | 07/01/2019 |
| GPN Family Trust U/A/D 4/28/08 | Organization | 5% or Greater Direct Ownership Interest | 43% | 07/01/2019 |
| Oakway Operations LLC | Organization | 5% or Greater Direct Ownership Interest | 15% | 07/01/2019 |
| Doros Generation Trust U/A/D 1/3/12 | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| Eggers, Austin | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Eggers, Austin | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| GPN Family Trust U/A/D 4/28/08 | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| Legacy Healthcare Financial Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| Milbank SD Property Holdings, LLC | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 07/01/2019 |
| Milbank SD Property Holdings, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| Pulse, Rebecca | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/02/2024 |
| Pulse, Rebecca | Individual | ADP of the SNF | NOT APPLICABLE | 01/02/2024 |
| Rajchenbach, Chaim | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2019 |
| Rajchenbach, Chaim | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2019 |
| Rajchenbach, Chaim | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| RSM Us LLP | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Shabat, Menachem | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2019 |
| Shabat, Menachem | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2019 |
| Shabat, Menachem | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| Truist Bank | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 04/01/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What mental health services do you provide on-site, and who delivers them?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| St William's Care Center | 0.9 mi | Milbank, SD | ★★☆☆☆ | 2/5 | |
| Fairway View Neighborhoods | 11.9 mi | Ortonville, MN | ★★☆☆☆ | 2/5 | abuse |
| Wilmot Care Center INC | 17.6 mi | Wilmot, SD | ★☆☆☆☆ | 1/5 | SFF |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 435009.