Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avantara Milbank during CMS and state inspections, most recent first.
A resident with quadriplegia, anxiety, and depression had a care plan requiring cares in pairs, but a CNA did not follow that intervention during an interaction that led to a reported threat allegation on social media. The resident repeatedly said he felt overwhelmed, unsafe at times, and unable to bring concerns to staff, while the record showed limited behavioral health support and no documentation that cultural services, support groups, or other mental health resources were offered or refused.
A resident admitted after hip fracture repair did not receive ordered Aspirin 81 mg BID because a pharmacy order-entry error caused the order to disappear from the EMR. During the omission, she developed worsening leg pain, swelling, bruising, and a hematoma, and a Doppler later showed bilateral DVTs. The resident had HTN, COPD, and moderate cognitive impairment.
Resident rights were not protected when a cognitively intact resident was not given a written copy of his rights or facility rules, despite asking for them. Staff also removed his vape, tattoo gun, and computer, including taking items from his room while he was asleep, and the DON closed and moved his computer during a discussion about a Facebook post. The resident said staff did not always honor his requests for privacy and to leave his room, even though his care plan called for staff to reapproach him when upset and to provide care with two staff present.
A facility failed to protect residents’ property when controlled meds went missing from medication cards and were not found. A contracted travel RN took a resident’s Hydrocodone/APAP card into the room, and 13 tablets later could not be located after searches and camera review. In a separate incident, an LPN and a contracted travel LPN found one lorazepam tablet missing during shift-change count, but the card was not fully checked against the narcotic log and the tablet was never recovered. The residents involved had significant medical and cognitive conditions, including pain from thoracic compression fractures and severe cognitive impairment with dementia.
A CNA applied Nair to a resident’s anal area and inner buttocks without a physician’s order and outside CNA scope, after the resident requested hair removal and had purchased the product himself. The resident later had superficial excoriation/pink irritated skin in the area. The facility also had repeated delays answering call lights for several residents, with reports and resident interviews showing waits of 15 minutes to nearly an hour, despite staff stating call lights should be answered promptly.
A resident spilled coffee that had been served too hot, and two other residents were observed drinking coffee without the lid precautions identified in their hot liquid safety evaluations and care plans. In a separate incident, a CNA left a resident alone in the shower despite a care plan requiring supervision/touching assistance, and the resident fell and bruised his knees.
A facility failed to securely handle controlled meds when an RN took a resident’s Hydrocodone/APAP card into the room and later could not locate 13 missing tablets, and when staff discovered a missing lorazepam tablet during shift-change count. Staff did not fully remove controlled med cards from the locked narcotic drawer or verify pill counts against the count sheets, and the missing meds were not found after searches.
Failure to Timely Report Resident Elopement: A resident eloped through the facility’s front door and was redirected back inside by staff, but the incident was not reported to SD DOH within the required timeframe. The administrator stated she initially misunderstood the event and only later determined it was an elopement after reviewing notes and video; she acknowledged the report was not submitted on time despite the facility policy requiring immediate reporting of abuse allegations to the state agency.
A resident with post-stroke weakness was supposed to use a slide board for transfers and have 2 staff present for toileting, but a CNA transferred him alone and used inappropriate language in front of the resident and family. Another resident with quadriplegia had a care plan for cares in pairs, yet a CNA was alone in his room when an accusation of abuse arose during a conversation. Interviews and record review showed staff relied on inconsistent transfer information sources, and the CNA involved acknowledged not following the care plan.
A resident with a severe sacral Kennedy ulcer, osteomyelitis, and a wound vac did not receive the ordered dressing change when due. An RN said she only changed the canister, was not comfortable doing the dressing change alone, and did not call for help, then passed it to the next shift. When the dressing was finally changed, the wound was odorous with abnormal drainage and had worsened, and the resident was sent to the ER with fever and low BP; the ER noted erosion to bone and diagnosed cellulitis.
A resident with a feeding tube and diagnoses including stroke and dysphagia received continuous enteral formula through a bag that was reused instead of replaced when supplies were unavailable. The DON stated she rinsed the bag and reused it, and formula was kept in the bag beyond the expected hang time while staff continued administering the resident’s nutrition.
A resident admitted after hip fracture repair had an order for Aspirin 81 mg BID, but the pharmacy entered the order incorrectly into the EMR/EMAR system, causing the BID order to disappear and the resident to miss scheduled doses for the ordered period. During that time, she developed worsening leg pain, bruising, swelling, and impaired mobility, and Doppler testing later showed bilateral DVTs. The consultant pharmacist identified the omitted aspirin during the med regimen review, and the report states the facility used a pharmacy-initiated order process in which pharmacy staff entered physician orders into the system.
The facility failed to maintain a clean kitchen and proper glove use during food service. Observations showed food debris on equipment and improper glove handling by a dietary aide. The dietary manager admitted to inconsistent cleaning practices, and the facility lacked a certified dietary manager.
The facility failed to ensure prompt response to call lights, causing frustration among residents due to significant delays, especially during meal times and medication passes. Despite a new call light system and staff reminders, response times often exceeded the expected five to ten minutes, with some residents waiting over 30 minutes for assistance.
Two residents were transferred using sit-to-stand lifts by a single CNA instead of the required two staff, contrary to care plans and manufacturer instructions. One resident with an above-the-knee amputation was lowered to the floor after the lift sling was improperly attached, while another resident with severe cognitive impairment was also lowered to the floor during a transfer. Staff did not consistently follow protocols for safe lift use or ensure adequate supervision during transfers.
A resident with Type 2 diabetes was administered two long-acting insulins simultaneously for four days due to a lack of communication and documentation errors at the facility. The resident experienced hypoglycemic episodes, leading to an emergency hospital admission. The facility had recently changed pharmacies, and the new process for updating medication orders was not adequately implemented or monitored, contributing to the significant medication error.
A facility failed to follow its grievance policy after a resident's daughter filed a complaint about improper use of mechanical lifts, short staffing, and other concerns. The resident experienced stomach pain and dark/tarry bowel movements, but there was no documentation of follow-up with her primary physician. The facility did not investigate or respond to the grievance, and the administrator admitted the grievance process was not followed.
A resident with type 2 diabetes was given two long-acting insulins simultaneously for four days, leading to hypoglycemia and emergency hospitalization. The facility failed to report the incident to the SD DOH, despite policy requirements. Staff did not clarify insulin orders with the physician or pharmacy, and the incident was not documented or communicated as required.
A resident in an LTC facility experienced bruising and swelling of unknown origin on the left knee, right wrist, and penis, which were not thoroughly investigated or reported to the South Dakota Department of Health. Staff reported a possible abuse incident involving improper transfer methods, but no follow-up was documented. The facility's policies required reporting and investigation of such injuries, but these were not adhered to, resulting in a deficiency.
A resident in a LTC facility experienced bruising and swelling of unknown origin on the left knee, right wrist, and penis, which were not thoroughly investigated or reported to the South Dakota Department of Health. The resident had a history of a fall and was later diagnosed with a right scapholunate ligament tear. A CNA reported an improper transfer by other CNAs, but it is unclear if this was investigated. The facility's incident reporting database showed no reports were made, and the provider's policies on incident reporting and abuse were not followed.
A facility failed to ensure adequate fluid intake and monitoring for residents, resulting in dehydration and hospitalization for one. Observations showed water pitchers out of reach or missing, and interviews revealed inconsistencies in documenting and encouraging fluid intake. Care plans highlighted risks for dehydration, but the facility's hydration policy was not effectively implemented.
The facility failed to provide adequate assistance and documentation for ADL tasks for four residents dependent on staff. Observations showed residents left without call lights within reach and delayed feeding during meals. Interviews revealed a lack of specific rounding policies, and care plans requiring repositioning and toileting assistance were not consistently followed. Residents with severe cognitive impairments were not adequately supported, and the facility's call light policy was not consistently implemented.
Failure to Follow Cares-in-Pairs and Provide Behavioral Health Support
Penalty
Summary
The facility failed to ensure that resident 2 received necessary behavioral health care and services and that staff followed his care plan intervention requiring cares in pairs. Resident 2 was admitted with quadriplegia, anxiety, and depression, and his BIMS score was 15, indicating intact cognition. His care plan included an intervention that he receive care with two caregivers present at all times, along with interventions for mood distress and anxiety that included encouraging him to talk with the DON or ADON, discuss concerns, evaluate causal factors, and observe psychosocial and emotional functioning. The deficiency was triggered by an incident reported to the SD DOH in which resident 2 posted a video on Facebook alleging that CNA P threatened to pull his hair and punch him in the face after he called her a curse word. The facility’s investigation could not determine whether the threat was actually made, but it did confirm that CNA P did not follow the care plan requirement for cares in pairs and was joking around with resident 2 during the interaction. Resident 2 stated he felt safe during that conversation, but the event showed that the required two-person care intervention was not followed. Resident 2 repeatedly expressed distress about staff interactions, feeling that staff made assumptions about him, argued with him, and treated him in ways that caused him to shut down and stop asking for help. He reported that he did not feel he had anyone he could go to for help resolving problems, that he was not comfortable speaking with SSD HH or DON B, and that he had been told to direct all concerns to administrator A. He also stated he had not received therapy services, did not have a tribal caseworker after admission, and did not know who could help him with his concerns. The record showed only limited documentation of mental health-related interventions, including an offer of counseling and telehealth psychiatry that he declined, but there was no documentation that cultural services, support groups for young adults with quadriplegia, mental health telehealth services, or religious services had been offered or refused. The social services role described in the facility’s job description required meeting residents’ medically related emotional and social needs, and the resident rights booklet stated residents are to receive services to attain or maintain their highest practicable mental, emotional, and psychosocial well-being.
Omitted Aspirin Order Led to Bilateral Lower-Leg DVTs
Penalty
Summary
The facility failed to ensure that a resident was free from a significant medication error when Aspirin 81 mg ordered twice daily was not administered from the p.m. dose on 12/19/25 through the p.m. dose on 1/18/26. The resident had been admitted after hospitalization for surgical repair of a fractured left hip and had diagnoses including hypertension and COPD. Her BIMS score was 12, indicating moderate cognitive impairment. The medication was intended to continue for 30 days after admission, but the pharmacy-initiated order system entered an incorrect end date for the twice-daily Aspirin order, which caused a discontinued medication message in the EMR and prevented the corrected order from reappearing for administration. During the period when the Aspirin was omitted, the resident developed increasing lower-extremity symptoms documented in progress notes and therapy notes. She began reporting increased swelling in her left lower leg, then pain in both lower legs, significant bilateral lower-extremity swelling, difficulty bearing weight, and worsening weakness and pain that limited transfers, standing, walking, balance, and bed mobility. Nursing notes also documented purple bruising on the right leg, a dark bruise on the left lower leg, and 3+ pitting edema in the right lower extremity. Therapy staff noted a hematoma to the left medial gastrocnemius and a positive Homans' sign in the left lower leg, prompting notification of nursing leadership and a request for a Doppler exam. The Doppler exam completed on 12/31/25 showed bilateral DVTs in both lower legs, and the resident was started on Eliquis. A consultant pharmacist later identified that the Aspirin had not been administered since the last dose on 12/19/25 and had not been continued as ordered. Interviews with facility leadership and therapy staff confirmed that the pharmacy order entry error resulted in the resident not receiving the scheduled Aspirin for approximately two weeks and that the resident experienced increased pain, spontaneous bruising, and increased swelling in her lower legs before the DVTs were discovered.
Resident Rights, Privacy, and Possessions Not Protected
Penalty
Summary
The facility failed to protect a resident’s rights to dignity, self-determination, communication, and freedom from interference with his possessions and personal boundaries. The resident was admitted with quadriplegia, anxiety, and depression, and his BIMS score was 15, indicating intact cognition. He stated that he wanted a written copy of his resident rights and the facility rules, but said he was never provided them on admission and that repeated requests to administration and nursing leadership were not fulfilled. He also stated that staff took his vape, tattoo gun, and computer from his room, including while he was sleeping, and that he did not know where his tattoo gun was located. The resident reported that staff told him he was not allowed to post about staff members on Facebook and that his computer was closed and taken away from him by the DON during a discussion about a social media post. He stated he was upset because the computer was his personal property and he could not retrieve it himself due to paralysis. He also stated that when he asked staff to leave his room, they did not always do so, and that he wanted staff to respect his request for privacy and boundaries. His care plan required two staff members to be present during care, and he stated this helped most of the time but not always. Staff interviews confirmed that the resident was not present for the admission discussion of resident rights, and the SSD stated she did not provide him a copy of his resident rights. The DON confirmed she closed the resident’s computer and moved it away from him during the Facebook-related discussion, and she acknowledged that his care plan stated staff were to leave his room and reapproach him regarding behaviors. The SSD and administrator stated the vape and tattoo gun were removed for safety reasons, but both acknowledged they were unaware the tattoo gun had been removed while the resident was asleep and that the facility did not have a policy regarding his use of the tattoo gun. The resident rights booklet reviewed by surveyors stated residents have the right to be fully informed of facility rules and regulations, including a written copy of resident rights, and the right to dignity, respect, and security of possessions.
Missing Controlled Medications Not Protected
Penalty
Summary
The facility failed to protect residents’ property when controlled medications went missing from medication cards and were not located. For one resident, 13 Hydrocodone/APAP 5-325 mg tablets were missing after a contracted travel RN entered the resident’s room with the resident’s medication card and later reported that the card was missing. Camera footage showed multiple staff and another resident entering and exiting the room during the morning and early afternoon, and the medication card was never found after searches of the facility. The resident had a history of seizure disorder, cardiac arrest, lower extremity weakness, and compression fractures of the thoracic spine, and his cognition was intact on BIMS testing. For another resident, one lorazepam 0.5 mg tablet was discovered missing during the controlled medication count at shift change. The nurses involved did not fully remove the controlled medication cards from the locked narcotic drawer to view all pills, and they did not compare the actual pill counts in the cards with the controlled drug record forms. The missing tablet was not found in the cart or surrounding area, and the investigation concluded it may have been accidentally ejected from the card and swept up by housekeeping. The resident had weakness, repeated falls, abnormal gait, delusional disorder, bipolar disorder, anxiety disorder, and dementia with behavioral disturbance, and her BIMS score indicated severe cognitive impairment. The report also described that education related to the missing medication incidents was incomplete, with only some nurses receiving the written instructions. Staff interviews showed inconsistent understanding of the search and reporting process when controlled medications were missing, and the facility acknowledged that routine audits to monitor medication passes and controlled medication counts had not been conducted effectively. The facility’s policies required two licensed nurses to count controlled substances at shift change, immediate reporting of discrepancies, and investigation of missing medications, but the events described showed that these processes were not followed consistently.
Improper Use of Hair Removal Cream and Delayed Call Light Response
Penalty
Summary
A CNA applied Nair hair removal cream to a resident’s anal area and inner buttocks during a shower even though the resident did not have a physician’s order for the product and the application was outside the CNA’s scope of practice. The resident had quadriplegia and an intact BIMS score of 15, and he had asked about using the cream after purchasing it online. He told an LPN about his request, but he believed it was acceptable when he did not receive a follow-up response. The CNA later stated she applied the cream to the resident’s anal and groin area, left it on during a bath, and then wiped off the remainder afterward. Facility records and interviews showed the resident’s inner buttocks and anal area became superficially excoriated after the cream was used. A physician was notified after the event, and a barrier cream was ordered for the affected area. A later skin evaluation noted a pink area around the anus that was not open. The DON stated that a request to use a chemical hygiene product such as Nair required a physician’s order and that a CNA should not apply it because it was not part of CNA delegated tasks. The facility also failed to ensure timely response to call lights for multiple residents. Residents reported waiting 15 minutes or more, and in some cases 30 to 60 minutes, for staff to answer their call lights. One resident stated staff sometimes turned the light off and did not return promptly, another said she had called 911 a few times because staff took too long, and another said the delays upset her. Call light reports documented repeated instances lasting longer than 15 minutes, including waits up to 59 minutes. Staff interviews showed differing expectations for response times, with some stating 10 minutes and others stating 5 minutes, while the facility policy required prompt response.
Unsafe Hot Liquids and Missed Shower Supervision
Penalty
Summary
The facility failed to ensure safe handling of hot liquids and adequate supervision during bathing. One resident spilled coffee on his hand and pant leg after coffee was served to him at a temperature documented at 170 degrees Fahrenheit from the kitchen coffee pot, and the temperature was not checked again after it was placed in the carafe. The resident’s skin was assessed after the spill and was pink where the coffee contacted him, with no injury found on follow-up assessments. His record showed prior hot liquid safety evaluations with different interventions over time, including use of a half-full cup, then a lid on the cup or mug, and later drinking hot liquids while seated because of unsteady gait and balance. Two other residents were observed drinking coffee from cups without lids in the dining room, despite hot liquid safety evaluations identifying safety interventions. One resident’s evaluation indicated she was at risk for burning herself and was to use a lid on her cup or mug, but her care plan did not include those hot liquid safety interventions. Another resident’s evaluation indicated he was not at risk for burning himself, but he was also to use a lid on his cup or mug, and his care plan likewise did not include those interventions. Staff interviews showed that hot liquid safety interventions were expected to be communicated to dietary staff and included on care plans, diet cards, and the kitchen whiteboard, but the observed residents were not following the identified lid requirement. The facility also failed to follow a resident’s shower supervision care plan. A resident with hepatic failure, cirrhosis, kidney failure, hypotension, hepatic encephalopathy, and left-sided hemiplegia had a care plan requiring supervision or touching assistance in the shower and staff presence while showering. According to the incident record, a CNA left him alone in the shower, and he fell in the shower room, landing on his stomach and bruising his knees. The administrator acknowledged that the CNA did not stay with the resident in the shower as required by the care plan.
Controlled Medication Storage and Count Failures
Penalty
Summary
The facility failed to ensure safe and secure storage of controlled medications when a contracted travel RN took a resident’s Hydrocodone/APAP medication card into the resident’s room and later could not locate the card containing 13 tablets. The RN reported the missing medication card to the former DON after discovering it was misplaced. Camera footage showed multiple staff members and another resident entering and exiting the room during the morning and early afternoon, and the medication card was never found after searches of the facility. The RN stated she took the card into the room to save time because she was in a hurry and the resident often requested that medication in the morning. The resident involved had a history of a seizure with a fall that caused compression fractures of the T4, T5, and T6 vertebrae and was admitted to the facility for therapy services. His diagnoses included seizure disorder, cardiac arrest, and lower extremity weakness. His BIMS score was 15, indicating intact cognition. During interview, he recalled the missing medication incident, stated he had been taking the Hydrocodone/APAP for pain from his back fractures, and said he requested and received one PRN tablet from the RN that morning. He denied keeping the medication card or taking the medication himself and stated he never saw a medication card left in his room. The facility also failed to ensure accurate controlled medication counting when one resident’s lorazepam tablet was found missing during shift-change count. Nurses were not fully removing controlled medication cards from the locked narcotic drawer to view all pills and were not comparing the actual pill counts with the controlled drug record forms. The missing tablet was not found after searches of the cart and surrounding area, and the investigation concluded it may have been accidentally ejected from the medication card and swept up by housekeeping. The resident involved had weakness, repeated falls, abnormal gait, delusional disorder, bipolar disorder, anxiety disorder, and dementia with behavioral disturbance, and her BIMS score was 7, indicating severe cognitive impairment.
Failure to Timely Report Resident Elopement
Penalty
Summary
The provider failed to report a resident’s elopement within the required time frame. According to the facility reported incident, a CNA observed the resident outside after he had left the facility through the front door without staff knowledge and stated he was going to a wake for a friend who had died. Staff redirected him back into the facility, and the previous administrator was notified immediately after the incident by an RN. The initial report to the SD DOH was not filed until several days later by the administrator who was in training at the time. During interview, the administrator stated she initially understood the resident had gone out the lobby door rather than the facility’s exit door, and only after reviewing notes and video did she determine it was an elopement. She acknowledged that the incident was not reported to SD DOH within the required reporting time frame. The facility’s abuse and neglect policy stated that all allegations of abuse must be reported to the Administrator immediately and to the state agency immediately, within 2 hours, after the initial allegation is received.
Failure to Follow Care Plans for Transfers and Two-Person Care
Penalty
Summary
The facility failed to follow residents’ care plans for transfers and care provided in pairs. One resident with left-sided weakness following a stroke was documented to require a slide board for bed or chair transfers and, when toileting, one staff member plus an additional person to remove the wheelchair and place the commode. On 10/14/25, the resident’s family member reported that a CNA used inappropriate words in front of the resident and family and stood the resident up from his wheelchair without another staff member present. The facility’s investigation found that the CNA transferred the resident alone at the sink, and the CNA confirmed that this occurred. Record review showed the resident’s care plan had been revised to specify one-person slide board transfers from the recliner, wheelchair, or bed, and two staff members for toileting when the resident needed to stand. Interviews with therapy and nursing staff showed that transfer information was communicated through multiple sources, including the EMR, whiteboard, paper worksheets, and a binder, but staff described inconsistent locations and differing information. The therapy coordinator stated that one staff member should have stood with the resident while another moved the wheelchair and placed the commode behind him, and that it would have been unsafe for one staff member to do this alone because of the resident’s one-sided weakness and fall risk. A second resident with quadriplegia, anxiety, and depression had a care plan directing that cares be provided in pairs. A facility incident report stated that a CNA was in the resident’s room alone when a conversation occurred in which the CNA allegedly said she would pull his hair and punch him in the face if he called her a curse word again. The resident stated the staff member was in his room without another staff member present and that they were talking when the statement was made. The CNA’s written statement acknowledged being in the room by herself and stated, “I know I didn’t follow the care plan.” Interviews with nursing leadership confirmed that the resident’s care plan required two staff members present for cares and that staff were expected to follow the plan.
Missed Wound Vac Dressing Change
Penalty
Summary
The nursing facility failed to provide wound care as ordered for a resident with a severe sacral Kennedy ulcer and wound vac. The resident had intact cognition with a BIMS score of 15, was dependent on staff for most activities of daily living, and had diagnoses including osteomyelitis of the vertebrae, gait and mobility abnormalities, mononeuropathy of both lower limbs, and weakness. Her physician ordered the wound vac dressing to be changed three times per week, and her care plan stated that wound treatments were to be completed as ordered by the physician. On 5/3/26, the wound vac dressing was not changed as ordered. RN R later stated she did not complete the dressing change because she had only changed the suction canister, had not received education on how to change the wound vac dressing, and was scared to do it by herself. She said she did not call the on-call LPN or the RN/MDS coordinator for help and instead passed it to the next shift. The TAR showed the dressing change was not signed off as completed, and there were no nurse’s notes from RN R documenting the missed treatment. When the dressing was changed the next day, the wound was described as odorous with reddish-brown and gray drainage in the canister, and the wound had worsened. The resident had also had a fever and low blood pressure, and the physicians directed transfer to the ER. The ER documented a sacral wound with erosion to the level of bone and diagnosed cellulitis and a non-pressure chronic ulcer of the back. The RN/MDS coordinator stated the black foam dressing was to be changed every three days because of bacteria build-up, and if it was not changed on time, the resident’s risk for infection increased. The DON and administrator both stated they expected the ordered dressing change to be completed and help to be obtained if needed.
Reused Enteral Feeding Bag and Extended Formula Hang Time
Penalty
Summary
Appropriate enteral feeding care was not provided for a resident with a feeding tube when the facility reused a feeding bag instead of replacing it with a new one for formula administration. Resident 7 had diagnoses including stroke affecting the left side, altered mental status, and dysphagia, and had an order for continuous enteral feeding of Compleat 1.4 calorie at 50 ml per hour through a feeding pump. The resident’s MAR and TAR showed the formula was administered on multiple night shifts by nursing staff, including the LPN, DON, and RN involved in the event. The event occurred when the feeding bag that had been dated and hung by an LPN remained in use after the staff member returned from days off and found it still hanging with formula in it. The DON stated she cleaned and reused the bag because no more feeding bags were available and that the facility had received the wrong bags after an order was placed. She also stated she rinsed the bag with clear water and reused it to administer the resident’s formula, and that formula was added to the bag so it would continue running until the next shift. The facility policy stated formula bags are to be changed daily and PRN, and the registered dietitian stated the formula should be hung for a maximum of 12 hours, while nursing reference material stated the maximum hang time for formula in an open system is 8 hours.
Incorrect aspirin order entry led to missed doses and bilateral DVTs
Penalty
Summary
The facility failed to ensure that medication orders were processed accurately for one resident who was admitted after surgical repair of a fractured left hip and later developed bilateral lower-extremity DVTs. The resident had diagnoses including HTN and COPD and a BIMS score of 12, indicating moderate cognitive impairment. She was ordered Aspirin 81 mg twice daily for 30 days after admission, but the pharmacy entered the order incorrectly into the facility’s electronic order system, which caused the twice-daily aspirin order to disappear from the EMR and not reappear as a corrected or continued order for administration. Because of the order entry error, the resident last received the twice-daily aspirin dose in the morning and then did not receive the scheduled aspirin from the evening dose onward through the end of the ordered 30-day period. During this time, progress notes documented increasing swelling in the lower leg, pain in both lower legs, difficulty bearing weight, bruising, and significant edema. Therapy staff noted limited standing, walking, balance, and transfers, and one therapist documented a positive Homans' sign and recommended a Doppler exam. The resident later underwent Doppler testing, which showed bilateral DVTs in both lower legs. The consultant pharmacist identified during medication regimen review that the aspirin had not been administered as ordered and had not been continued for the full ordered duration. The report also states that the nursing facility used a pharmacy-initiated order system in which pharmacy personnel entered physician orders into the EMR and EMAR, and that the pharmacy entered an incorrect end date for the aspirin order, triggering a discontinued medication message. Although the incorrect discontinuation date was corrected by the pharmacy, the facility’s order system was unable to update the discontinuation date, and the twice-daily aspirin order never reappeared in the EMR for administration to the resident.
Deficiencies in Kitchen Sanitation and Glove Use
Penalty
Summary
The provider failed to maintain the kitchen in a clean and sanitary condition and did not adhere to proper glove use during food preparation and service. Observations revealed food debris and a yellow film on serving pans, pan lids, and the steam table. Dust was found on storage racks, and a knife was observed on the floor under a storage rack. Cook/dietary aide J was seen using the same gloves to handle various food items, touch resident menu slips, and open the refrigerator, which is not in line with acceptable food service practices. The dietary manager acknowledged that the kitchen carts were not cleaned daily as required, and the floors were not mopped every day. Interviews with the dietary manager and administrator confirmed the lack of adherence to the facility's policies on handwashing, glove use, and cleaning procedures. The dietary manager admitted that the cleaning tasks were not consistently completed, and the administrator observed a yellow residue on kitchen equipment. The facility did not have a certified dietary manager, and the dietary manager was still in the process of obtaining certification. The provider's policies on handwashing, glove use, and cart cleaning were reviewed, highlighting the need for proper glove use and regular cleaning to maintain sanitary conditions.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure prompt response to call lights and necessary care and services for six residents, leading to frustration and potential risks to their well-being. Residents reported significant delays in staff response to call lights, with some waiting up to an hour for assistance. These delays were particularly noted during meal times and medication passes, contributing to residents' dissatisfaction and concerns about their safety. Interviews with residents and staff revealed inconsistencies in the expected response times for call lights. While the facility's policy and staff expectations were to respond within five to ten minutes, actual response times often exceeded these limits. Call light logs showed multiple instances where response times were over ten minutes, with some exceeding 30 minutes. Residents expressed frustration, particularly when needing urgent assistance, such as using the bathroom. The facility had implemented a new call light system with pagers to notify staff of activated call lights, but this system did not prevent delays. Staff interviews indicated a lack of urgency in responding to call lights, with some staff waiting five minutes before answering. Despite daily reminders during shift huddles, the facility's procedures were not consistently followed, leading to prolonged wait times and resident dissatisfaction.
Failure to Ensure Safe Use of Lift Equipment and Adequate Supervision During Resident Transfers
Penalty
Summary
The facility failed to ensure resident safety by not following proper procedures for the use of lift equipment as directed in residents' care plans and the manufacturer's instructions. In one instance, a certified nursing assistant (CNA) attempted to transfer a resident with an above-the-knee amputation, morbid obesity, and epilepsy using a mechanical sit-to-stand lift without the required assistance of a second staff member. During the transfer, the right side of the sling became detached from the lift due to incorrect attachment, resulting in the resident being lowered to the floor and experiencing pain in her residual limb. The resident was cognitively intact and her care plan specified the need for two staff during transfers when she felt weak or tired, as well as specific instructions regarding the use of her prosthesis and choice of lift. In another incident, a CNA used a non-mechanical sit-to-stand lift to transfer a resident with severe cognitive impairment, Alzheimer's dementia, anxiety, congestive heart failure, and chronic kidney disease. The resident, who required 'cares in pairs' (assistance of two staff for all care), was being transferred by only one CNA. During the transfer, the resident sat down prematurely before the lift's padded seat could be positioned, and was subsequently lowered to the floor without injury. The CNA involved was not aware that two staff were required for this resident's care, despite this being clearly indicated in the care plan. Observations and interviews confirmed that staff were expected to use all lifts with two staff members and to follow both care plan interventions and manufacturer guidelines for equipment use. However, there was a lack of ongoing audits to ensure compliance with these procedures, and not all staff demonstrated awareness of the specific requirements for each resident. These failures resulted in unsafe transfers and residents being lowered to the floor during lift use, contrary to established safety protocols.
Resident Administered Two Long-Acting Insulins Simultaneously
Penalty
Summary
The provider failed to ensure that a resident was free from significant medication errors when they were administered two different types of long-acting insulin simultaneously for four consecutive days. The resident, who had a diagnosis of Type 2 diabetes and was dependent on insulin, was given both Toujeo SoloStar and Tresiba Flex injections daily, despite instructions to switch from Toujeo to Tresiba due to insurance coverage issues. This error led to the resident experiencing hypoglycemic episodes, with a critically low blood sugar level of 24, resulting in an emergency hospital admission. The incident was compounded by a lack of communication and documentation among the nursing staff and between the facility and the pharmacy. The pharmacy had instructed the facility to continue administering Toujeo until it was depleted before starting Tresiba, but this information was not effectively communicated to all staff members. The MAR contained orders for both insulins to be administered simultaneously, and there was no documentation of any attempts to clarify these orders with the pharmacy or the physician. Additionally, the nursing staff failed to communicate discrepancies or concerns during shift changes, leading to the continuation of the error. Interviews with staff revealed that there was a lack of understanding and adherence to medication administration protocols, including the importance of verifying and clarifying medication orders. The facility had recently changed pharmacies, and the new process for updating medication orders was not adequately implemented or monitored. The staff did not complete medication administration competencies, and there was no evidence of recent training or audits to ensure the safety and accuracy of medication administration, contributing to the significant medication error experienced by the resident.
Failure to Follow Grievance Policy and Address Resident Concerns
Penalty
Summary
The facility failed to adhere to its grievance policy following a complaint filed by the daughter of a resident. The complaint included concerns about the improper use of mechanical lifts during resident transfers, which may have led to the resident's dislocated hip, short staffing, long call light wait times, a COVID-19 positive resident wandering the facility, and the resident experiencing black/tarry bowel movements. Despite these concerns, there was no documentation indicating that the facility conducted an investigation or responded to the grievance as required by their policy. The resident's medical record showed that she had been experiencing stomach pain, a poor appetite, and dark/tarry bowel movements. Although the on-call physician was notified and advised monitoring and setting up an appointment with the primary physician, there was no documentation that the resident was seen by her primary physician the following day. Eventually, the resident was transferred to the emergency room due to a suspected gastrointestinal bleed. The facility's administrator acknowledged the lack of documentation and investigation into the grievance. The administrator admitted that the grievance process was not followed, and there was no evidence of communication with the resident's family regarding their concerns. The facility's grievance policy requires that grievances be investigated and addressed promptly, but this was not done in this case.
Failure to Report Insulin Administration Error and Resulting Hypoglycemia
Penalty
Summary
The provider failed to report a critical incident involving a resident who was administered two different long-acting insulins simultaneously for four days, leading to episodes of hypoglycemia and requiring emergency medical evaluation. The resident, a male with type 2 diabetes, was found unresponsive with a blood sugar level of 24, necessitating transport to the emergency department. The incident was not reported to the South Dakota Department of Health (SD DOH) as required by the facility's policy. The medication administration record (MAR) indicated that the resident received both Toujeo and Tresiba insulins from December 8 to December 11, despite instructions that the new insulin, Tresiba, should not be administered until the existing supply of Toujeo was depleted. Nursing staff failed to clarify the insulin orders with the physician or pharmacy, and there was no documentation of any attempts to address the discrepancy. The resident experienced multiple hypoglycemic episodes, with blood sugar levels dropping to critically low levels, yet the facility did not report the incident to the SD DOH. Interviews with facility staff, including a nurse consultant, director of nursing, and administrator, revealed awareness of the reporting guidelines but a failure to act on them. The staff acknowledged that the incident should have been reported, as it involved a critical drop in blood sugar requiring emergency medical services and hospitalization. The facility's policy on abuse and neglect mandates immediate reporting of such incidents, but this protocol was not followed in this case.
Failure to Investigate and Report Suspected Abuse and Neglect
Penalty
Summary
The provider failed to conduct a thorough investigation and report incidents of potential abuse and neglect for a resident who exhibited bruising and swelling of unknown origin on multiple body parts, including the left knee, right wrist, and penis. The incidents were not reported to the South Dakota Department of Health as required. The resident had a history of a fall in the bathroom, which was reported to the family, but subsequent injuries were not adequately investigated or reported. Interviews with staff revealed that a certified nurse aide (CNA) reported a possible abuse incident involving two other CNAs who did not use the care-planned mechanical lift for a transfer, potentially causing injury to the resident. Despite reporting this to a nurse, there was no follow-up or investigation documented. Additionally, the resident's family noticed swelling in the resident's wrist, which was not previously identified by the nursing staff, and a bruise on the resident's penis, which was also not investigated. The facility's incident reporting and abuse and neglect policies were reviewed, indicating that injuries of unknown origin should be reported and investigated. However, the facility did not report the incidents to the state health department, and the administrator was unaware of the allegations of abuse. The facility's failure to investigate and report these incidents constitutes a deficiency in ensuring resident safety and compliance with regulatory requirements.
Failure to Investigate and Report Injuries of Unknown Origin
Penalty
Summary
The provider failed to conduct a thorough investigation to rule out abuse and neglect for a resident who presented with bruising and swelling of unknown origin on the left knee, right wrist, and penis. The incidents were not reported to the South Dakota Department of Health as required. The resident had a history of a fall in the bathroom, which resulted in a small skin tear, and later developed swelling in the knee and wrist, with the cause of these injuries remaining unclear. The resident was eventually diagnosed with a right scapholunate ligament tear, which is commonly caused by a fall on the wrist. A certified nurse aide (CNA) reported an incident involving two other CNAs who allegedly did not follow the care plan for the resident, opting for a two-assist transfer instead of using a total body mechanical lift. This incident was reported to an unidentified nurse, but it is unclear if it was investigated. Additionally, the CNA reported bruising on the resident's penis, which was suspected to be caused by the improper transfer. There was no follow-up with the CNA regarding the incident, and the director of nursing and administrator were not notified of the allegations of abuse. The facility's incident reporting database showed no reports were made regarding the resident's fall, swollen knee, swollen wrist, or bruising on the penis. The provider's incident reporting policy required reporting of serious injuries not expected from the disease process, but the policy did not classify skin tears or bruises as physical harm unless they required hospital treatment. The provider's abuse and neglect policy outlined the criteria for injuries of unknown origin and the steps to be taken if abuse was suspected, including immediate protection of residents, notification of authorities, and a thorough investigation, none of which were documented in this case.
Inadequate Fluid Management Leads to Dehydration
Penalty
Summary
The provider failed to ensure adequate fluid intake, monitoring, and interventions for six sampled residents, resulting in dehydration and hospitalization for one resident. Resident 1 was observed by a family member to have difficulty eating and was denied additional fluids despite asking for more water. The resident's water pitcher was out of reach and unmarked, and the facility was unable to locate intake and output records when requested by the family. Resident 1 was hospitalized with acute dehydration and malnutrition, with laboratory findings indicating low potassium, high blood urea nitrogen, and low albumin levels. Observations on a specific date revealed that Resident 2's water pitcher was out of reach, Resident 3 did not have a water pitcher, and Residents 4 and 5 had full water pitchers without visible ice. Interviews with dietary aides and CNAs indicated inconsistencies in documenting and encouraging fluid intake. It was noted that residents requiring thickened liquids were not consistently offered fluids between meals, and there was no process in place to accurately document residents' fluid intakes. Care plans for the residents highlighted risks for impaired skin integrity, dehydration, and nutritional status alterations, with interventions to encourage good nutrition and hydration. However, the provider's hydration policy, which aimed to ensure adequate hydration, was not effectively implemented. Staff interviews revealed gaps in communication and documentation, with dietary staff not reporting lack of fluid intake to nursing staff, and CNAs not routinely encouraging fluid intake between meals.
Deficiency in ADL Assistance and Documentation
Penalty
Summary
The facility failed to ensure that activities of daily living (ADL) tasks were performed and accurately documented for four residents who were dependent on staff assistance. Observations revealed that Resident 1 was frequently left in his wheelchair without his call light within reach, and visitors reported that call lights were left on for extended periods without response. Interviews with staff indicated that the facility lacked a specific rounding or positioning policy, and the administrator expected rounding to occur every two hours, as specified in each resident's care plan. Resident 1's electronic medical record (EMR) showed severe cognitive impairment and a need for assistance with positioning and toileting, which was not consistently documented. During meal times, residents 1, 2, 3, and 4, who were dependent on staff for feeding, were observed seated in their wheelchairs at the assist table without being fed promptly. A registered nurse stated that these residents were the first to be brought in but the last to be fed. Resident 2's EMR indicated severe cognitive impairment and a need for repositioning every two hours, which was not consistently documented. Similarly, Resident 3's EMR showed severe cognitive impairment and dependency on staff for mobility, transfers, and repositioning, with inconsistent toileting documentation. Resident 4, who had a primary diagnosis of Parkinson's disease and severe cognitive impairment, was observed in her wheelchair for extended periods without repositioning, contrary to her care plan. Interviews with staff confirmed that care plans required repositioning every two hours, but this was not adhered to. The facility's call light policy required call lights to be within reach of residents, and alternative systems were to be evaluated for those unable to use traditional call lights, which was not consistently implemented.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 11 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Milbank
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St William's Care Center | 0.9 mi | ★★★★★ | 10 | 0 |
| Fairway View Neighborhoods | 11.9 mi | ★★★★★ | 1 | 1 |
| Wilmot Care Center Inc | 17.6 mi | ★★★★★ | 0 | 0 |
| Madison Healthcare Services | 25.7 mi | ★★★★★ | 10 | 0 |
| Essentia Health Grace Home | 26.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.