St William's Care Center
103 N Viola St, Milbank, SD 57252 · Grant County · 60 certified beds · avg 50 residents/day · certified since Mar 15, 2005
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
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 · Feb 19, 2026 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
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: Mar 31, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 2, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
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 5, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Jul 24, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Aug 16, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 10, 2023 · F-0609
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: Sep 1, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 10, 2023 · F-0610
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: Sep 1, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (25)
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 |
|---|---|---|
| Feb 19, 2026 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Feb 19, 2026 | F · Potential for harm, facility-wide | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Feb 19, 2026 | 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. |
| Feb 19, 2026 | F · Potential for harm, facility-wide | 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. |
| Feb 19, 2026 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Feb 19, 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. |
| Feb 19, 2026 | D · Potential for harm, one-off | The facility did not have doctor's orders in place for a resident's immediate care at the time the resident was admitted. |
| Feb 19, 2026 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Feb 19, 2026 | D · Potential for 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. · from a complaint |
| Feb 19, 2026 | D · Potential for harm, one-off | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Oct 2, 2024 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Oct 2, 2024 | E · Potential for harm, repeated | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Oct 2, 2024 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Oct 2, 2024 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Oct 2, 2024 | 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. |
| Jul 24, 2024 | ▲ H · Actual harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jul 24, 2024 | D · Potential for harm, one-off | 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 |
| Jul 24, 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 |
| Jul 24, 2024 | D · Potential for 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 |
| Jul 24, 2024 | D · Potential for harm, one-off | 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 |
| Aug 10, 2023 | ▲ 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. |
| Aug 10, 2023 | ▲ 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. |
| Aug 10, 2023 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Aug 10, 2023 | 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. |
| Aug 10, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (4 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 2 | G ▲ |
| 2024 | 10 | 2 | H ▲ |
| 2026 | 10 | 1 | 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 $132,723.
| Date | Type | Amount / length |
|---|---|---|
| Feb 19, 2026 | Fine | $78,750 |
| Oct 2, 2024 | Fine | $12,048 |
| Jul 24, 2024 | Fine | $41,925 |
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) | 3.67 | 4.32 | 3.95 | bottom 31% in South Dakota; bottom 45% in the U.S. |
| Registered Nurse hours | 0.57 | 0.91 | 0.69 | bottom 8% in South Dakota; bottom 47% in the U.S. |
| Weekend total nurse staffing | 2.99 | 3.71 | 3.50 | bottom 17% in South Dakota; bottom 30% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.34 | 0.51 | 0.48 | bottom 20% in South Dakota; bottom 40% in the U.S. |
| Total nursing staff turnover (%) | 39.1 | 48.2 | 45.8 | top 28% in South Dakota; top 34% in the U.S. |
| RN turnover (%) | 0.0 | 34.7 | 42.9 | — |
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 3.11, RN 0.48, weekend 2.53. Staffing rating: 3/5.
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: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5
Who owns this facility
Non profit - Other
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Butler, Rita | Individual | Corporate Director | NOT APPLICABLE | 03/04/2005 |
| Butler, Rita | Individual | ADP of the SNF | NOT APPLICABLE | 03/04/2005 |
| Christenson, Ann | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/17/2012 |
| Christenson, Ann | Individual | ADP of the SNF | NOT APPLICABLE | 08/17/2012 |
| Denna, Paul | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/26/2023 |
| Denna, Paul | Individual | ADP of the SNF | NOT APPLICABLE | 01/26/2023 |
| Kosman, Janet | Individual | Corporate Director | NOT APPLICABLE | 05/26/2026 |
| Thrift, Rene | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/26/2023 |
| Thrift, Rene | Individual | ADP of the SNF | NOT APPLICABLE | 01/26/2023 |
| Walker, Mary | Individual | ADP of the SNF | NOT APPLICABLE | 05/26/2026 |
| Williams, Sharon | Individual | Corporate Officer | NOT APPLICABLE | 02/06/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "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?"
- "Who reviews your menus, and can I see this week's menu and join my family member for a meal?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "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 |
|---|---|---|---|---|---|
| Avantara Milbank | 0.9 mi | Milbank, SD | ★☆☆☆☆ | 1/5 | |
| Fairway View Neighborhoods | 11.1 mi | Ortonville, MN | ★★☆☆☆ | 2/5 | abuse |
| Wilmot Care Center INC | 17.3 mi | Wilmot, SD | ★☆☆☆☆ | 1/5 | SFF |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 435122.