Avantara Milbank

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

35.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 38 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 23% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 55 beds and averages 38.0 residents a day — about 69% occupied, or roughly 17 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.23 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.96 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.94 hrs/resident/day on weekends vs 3.35 on weekdays — 12% thinner on weekends. RN hours go from 1.07 to 0.72 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 92% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

30 citations, most serious first. The 18 most serious are shown; the remaining 12 are one tap away and print in full.

• Actual harm · G2026-05-07 · tag F0740 — failed to provide behavioral / mental-health care — isolated
  Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review, the provider failed to ensure the staff followed the care planned interventions for one of one sampled resident (2) who expressed distress and reported allegations of abuse when one of one certified nursing assistant (CNA) (P) did not provide the resident's care with another staff member present, as identified in his care plan and the provider failed to provide necessary behavioral health care and services to support the resident's highest practicable mental, emotional, and psychosocial well-being. Findings include: 1. Review of the provider's 2/9/26 SD DOH FRI revealed that on 2/9/26, resident 2 posted a video on his Facebook page (social media site) that certified nursing assistant (CNA) P told him that if he called her a [curse word redacted] again, that she was going to pull his hair and punch him in the face. In that video, resident 2 stated he felt it was his First…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-05-07 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure that residents were free of significant medication errors for one of one sampled resident (3) who admitted to the facility following a hospitalization for surgical repair of a fractured left hip and did not receive Aspirin 81 milligrams (mg) twice daily as ordered from the 12/19/25 p.m. dose through the 1/18/26 p.m. dose. Following that medication error, resident 3 experienced increased pain, spontaneous bruising, and increased swelling in her lower legs, which required medical intervention and developed Deep Vein Thrombosis (DVTs) (a blood clot that forms in a vein deep inside the body, most commonly in the lower leg or thigh) in both of her lower legs. Findings include:1. Review of the provider's 1/7/26 SD DOH FRI revealed that during the consultant pharmacist (CP) medication regimen review on 1/2/26, the CP identified the pharmacy's order entry…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-12-18 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) complaint online report, interviews, records review, and policy review, the provider failed to ensure one of one resident (1) had been free from a significant medication error when he was administered two long-action insulins at the same time for four consecutive days. Findings include: 1. Review of the SD DOH 12/12/24 intake information revealed: *I am writing to file a complaint regarding [long-term care provider's name]. There was a sentinel event [not anticipated] that could have ended a resident's life. *[Resident 1] (4/5/1956) was transported to [name of hospital] on 12/12/24 for complaints of hypoglycemia and altered mental status. It was reported by [registered nurse (RN) K] (nursing home staff) that the patient's blood sugar was 24 at their facility. No interventions were completed by the nursing home staff at that time, only waiting for [ambulance name] to arrive. [RN K] reported that the patient has been having hypoglycemic episodes for the past 5…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-10-08 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on a 10/7/24 complaint intake report review, interview, record review, and policy review. The provider failed to ensure a thorough investigation was completed to rule out if abuse and neglect occurred for one of one sampled resident (1) who had bruising and swelling of unknown origin on the left knee, right wrist, and penis and to report the incidents to the South Dakota Department of Health. Findings include. 1. Review of the 10/7/24 South Dakota Department of Health (SD DOH) complaint intake revealed: * On 8/21/24, staff notified the family that resident 1 had fallen in the bathroom and had a small skin tear. * On 9/22/24, staff notified the family that resident 1's knee is swollen, and it was unknown what had happened. * On 9/29/24, staff was notified by family that resident 1's right wrist was swollen. Nursing was unaware of the swelling, assessed the wrist, and notified the physician. The staff thought the swelling may have been caused by the sling during a transfer. It was also reported that resident 1 had a small bruise on his penis. Review of resident 1's 9/30/24…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-10-08 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on a 10/7/24 complaint intake report review, interview, record review, and policy review. The provider failed to ensure a thorough investigation was completed to rule out if abuse and neglect occurred for one of one sampled resident (1) who had bruising and swelling of unknown origin on the left knee, right wrist, and penis and to report the incidents to the South Dakota Department of Health. Findings include. 1. Review of the 10/7/24 South Dakota Department of Health (SD DOH) complaint intake revealed: * On 8/21/24, staff notified the family that resident 1 had fallen in the bathroom and had a small skin tear. * On 9/22/24, staff notified the family that resident 1's knee is swollen, and it was unknown what had happened. * On 9/29/24, staff was notified by family that resident 1's right wrist was swollen. Nursing was unaware of the swelling, assessed the wrist, and notified the physician. The staff thought the swelling may have been caused by the sling during a transfer. It was also reported that resident 1 had a small bruise on his penis. Review of resident 1's 9/30/24…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-10-08 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint intake report review, record review, observation, interview, and policy review. The provider failed to ensure adequate fluid intake, monitoring, and interventions for 6 of 6 sampled residents [1, 2, 3, 4, 5, & 6] resulting in dehydration and hospitalization for one of six sampled residents [1]. Findings include: 1. Review of the 10/7/24 South Dakota Department of Health (SD DOH) complaint intake report revealed: *On 7/29/24, it was observed by resident 1's family member that he was having difficulty eating and was asking for more water. He had already had his liquid limitation for supper. Resident 1's family member asked for additional fluids for resident 1 and was denied additional fluids due to resident's fluid restriction. *On 8/29/24, it was observed by a family member that resident 1's water pitcher was out of reach for the resident, it was unmarked and sitting next to his roommate's urinal. The straw wrapper was still on the straw that was placed in the water pitcher. *On 9/30/24,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-11-08 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on observation, interview, and record review, the provider failed to clarify one of one sampled resident's (35) medication dosage from a physician's order which resulted in the resident receiving 8 times the intended prescribed dose of an antipsychotic medication for 14 days, which potentially contributed to his increased lethargy during that time. Findings include: 1. Observation and interview on 11/6/23 at 2:19 p.m. with resident 35 revealed: *He was hard of hearing and could not answer questions. *He was sitting in a Broda chair. *He appeared very thin, his eyes and temples were sunken, and was calling for his mother and father. 2. Review of resident 35's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *Relevant diagnoses included unspecified dementia, diffuse traumatic brain injury, and bilateral hearing loss. *A 9/14/23 physician's fax order for Start Zyprexa 205 mg [milligrams] po [orally] BID [twice daily] from a hospital in Sioux Falls. *The physician's order that was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-11-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, record review, and policy review, the provider failed to adequately assess one of four resident's (43) ability to safely smoke unsupervised that resulted in the resident falling outside on two separate occasions and sustaining head injuries. Findings include: 1. Interview on 11/7/23 at 3:56 p.m. with registered nurse (RN) V about the residents who smoked revealed: *None of the residents who chose to smoke were supervised while they were outside. -They had been evaluated and determined to be safe to smoke independently. *It was the expectation that the residents were responsible for notifying staff when they wanted to be let back inside via the doorbell on the wall outside. *The doorbell was out of the resident's reach if they were to have fallen outside. Interview on 11/8/23 at 8:58 a.m. with licensed practical nurse (LPN) F about the residents who smoked revealed: *Resident 43 had fallen at least twice while outside smoking in the courtyard. *She said, We don't have enough staff…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-05-07 · tag F0550 — failed to protect resident dignity and rights — pattern
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review, the provider failed to protect the resident's rights for one of one sampled resident (2) who was not provided a copy of his resident rights, or could exercise his rights without interference, when staff members took away his personal possessions (his tattoo gun, his vape, and his computer), and failed to honor his requests for privacy and staff boundaries as documented in his care plan. Findings include:1. Review of the provider's 2/9/26 SD DOH FRI revealed that on 2/9/26, resident 2 posted a video on his Facebook page (social media site) that certified nursing assistant (CNA) P told him that if he called her a [curse word redacted] again, that she was going to pull his hair and punch him in the face. In that video, resident 2 stated he felt it was his First Amendment right to speak to staff disrespectfully and call them a [curse word redacted] if he wants to. The…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-05-07 · tag F0602 — failed to protect residents from theft of their belongings — pattern
  Protect each resident from the wrongful use of the resident's belongings or money.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRIs), personnel files, record review, observation, interview, and policy review, the facility failed to protect the residents' property for one of one sampled resident (4) who had 13 Hydrocodone/APAP (acetaminophen) (a narcotic medication to treat moderate to severe pain) 5-325 milligram (mg) tablets go missing by one of one contracted travel registered nurse (RN) (N) and one of one sampled resident (5) who had one lorazepam (a medication to treat anxiety) 0.5 mg tablet found missing by licensed practical nurse (LPN) L and contracted travel LPN (T) and was not found. Findings include: 1. Review of the provider's 1/20/26 SD DOH FRI revealed that at approximately 8:30 a.m. on 1/20/26, contracted travel registered nurse (RN) N entered resident 4's room with his medication card, which contained his PRN (as needed) Hydrocodone/APAP 5-325 mg tablets, and the rest of his morning medications for administration to the resident.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-05-07 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, observation, and policy review, the provider failed to ensure: residents received quality care when one of one certified nursing assistant (CNA) H applied Nair (chemical hair removal cream) cream to one of one sampled resident's (2) anal area and inner buttocks who did not have a physician's order for the use of that cream and subsequently sustained a chemical skin burn; and ensure call lights were answered timely for four of six sampled residents (1, 6, 11, and 13) who reported having to wait a long time for the staff to answer their call lights. Findings include: 1. Review of the provider's 4/24/26 SD DOH FRI revealed that on 4/23/26, CNA H applied Nair cream to resident 2's anal area and inner buttocks when she gave the resident his shower. On 4/22/26, administrator A has told resident 2 that Nair cream was not recommended for use on sensitive skin areas. Administrator A was unaware that resident 2…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-05-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), record review, interview, observation, and document review, the provider failed to ensure the safety for one of one resident (10) who spilled coffee on his hand and leg that was not at safe temperature, two of seven observed residents (11 and 12) who were drinking hot liquids and did not have identified safety inventions followed, and for one of one sampled resident (8) who fell in the shower when certified nursing assistant (CNA) (AA) did not follow his care plan (personalized plan that addresses a resident's care needs, goals, and interventions). Findings include: 1. Review of the provider's 1/5/26 SD DOH FRI report revealed that on 1/4/26 at 8:26 a.m., registered nurse (RN)/former director of nursing (DON) MM witnessed resident 10 spill his coffee. The video camera footage indicated that resident 10's coffee was served to him at 7:29 a.m. He went to wave at the staff while drinking his coffee and bumped his coffee cup,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-05-07 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRIs), personnel files, record review, observation, interview, and policy review, the facility failed to ensure safe and secure storage of controlled medications (medications with risk for abuse and addiction) for one of one sampled resident (4) with 13 missing Hydrocodone /APAP (acetaminophen) (a medication to treat moderate to severe pain) 5-325 milligram (mg) tablets and one of one sampled resident (5) missing one lorazepam (a medication to treat anxiety) 0.5 mg tablet.Findings include: 1. Review of the provider's 1/20/26 SD DOH FRI revealed that at approximately 8:30 a.m. on 1/20/26, contracted travel registered nurse (RN) N entered resident 4's room with his medication card, which contained his PRN (as needed) Hydrocodone/APAP 5-325 mg tablets, and the rest of his morning medications for administration to the resident. Approximately two hours later, RN N discovered she had misplaced the medication card of 13 tablets of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-07 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, observation, document review, record review, and policy review, the provider failed to report within the required time frame for one of one sampled resident (1) who eloped (left the facility without staff knowledge) from the facility's front door.Findings include: 1. Review of the provider's 11/3/25 SD DOH FRI revealed that on 10/30/25 at 5:40 p.m., certified nursing assistant (CNA) F observed that resident 1 was outside. He had eloped from the facility's front door and indicated he was going to a wake (visitation before a funeral) for a friend who had passed away. He was easily redirected back into the facility by the staff. Previous administrator C was notified of resident 1's elopement immediately following the incident on 10/30/25 by registered nurse (RN) G. On 11/3/25, administrator A, who was in training at the time, filed an initial report regarding resident 1's elopement to the SD DOH. 2. Previous administrator C was no longer at the facility and was not available for an…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-07 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to ensure the staff followed the resident's care plan (personalized plan that addresses a resident's care needs, goals, and interventions) for:*One of one sampled resident (14) who was transferred from his wheelchair to the commode (portable toilet) by one of one certified nursing assistant (CNA) GG when he required the assistance of two staff members.*One of one sampled resident (2) who required two staff members present during all of his cares and was assisted by one of one CNA (P), and an accusation of resident abuse was made. Findings include:1. Review of the provider's 10/14/25 SD DOH FRI revealed that on 10/14/25, resident 14's family member reported to the assistant director of nursing that CNA GG was using inappropriate words in front of the family and resident 14 and stood the resident up from his wheelchair without assistance from another staff member at…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-07 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to provide wound care as ordered by the physician for one of one sampled resident (9) who had a wound vac (a device that uses negative pressure to remove excess fluid and debris from a wound to promote wound healing) dressing that was not changed as prescribed by the physician by one of one registered nurse (RN) (R) and needed emergent medical attention. Findings include:1. Observation on 5/5/26 at 9:50 a.m. and at 10:57 a.m. of resident 9 in her room revealed she was sleeping and positioned on her left side. There was a wound vac tube under her blanket that connected to the wound vac device on her nightstand. She had intravenous (IV) (used to deliver medication to a person's bloodstream through a needle or tube (catheter) inserted into a vein), and she declined an interview. 2. Interview on 5/5 at 10:50 a.m. with licensed practical nurse (LPN) I revealed that resident 9 went to the emergency room (ER) on 5/4/26 to have her…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-07 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the South Dakota Department of Health (SD DOH) Facility Reported Event (FRI), SD DOH complaint report, record review, interview, professional reference review, and policy review, the provider failed to provide appropriate enteral (passing through the digestive tract) feeding care regarding using a new enteral feeding bag for administering formula and safely storing nutritional formula for one of one sampled resident (7) who received nutritional formula through a feeding tube (a tube surgically placed through the abdomen into the stomach to administer liquid nutrition, fluids and medications) when an enteral feeding bag was not replaced with a new bag for administration of nutritional formula to the resident when a new bag was not found by the director of nursing (DON) B.Findings include: 1. Review of the provider's 8/23/25 SD DOH Facility FRI report stated that licensed practical nurse (LPN) BB put a tube feeding nutritional formula bag on resident 7 on 8/20/25 at 5:00 a.m. She had two days off and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-07 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure that procedures were implemented to process medication orders to ensure medications were administered accurately for one of one sampled resident (3) who admitted to the facility following a hospitalization for surgical repair of a fractured left hip and did not receive Aspirin 81 milligrams (mg) twice daily as ordered from the 12/19/25 p.m. dose through the 1/18/26 p.m. dose after the order was incorrectly entered into the provider's electronic order system (PCC) by the pharmacy. Resident 3 experienced increased pain, spontaneous bruising, and increased swelling in her lower legs, which required medical intervention and developed Deep Vein Thrombosis (DVTs) (a blood clot that forms in a vein deep inside the body, most commonly in the lower leg or thigh) in both of her lower legs. Findings include:1. Review of the provider's 1/7/26 SD DOH FRI revealed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$55,361 in federal fines across 3 penalties.

• $28,912 — penalty dated 2024-12-18
• $15,041 — penalty dated 2024-10-08
• $11,408 — penalty dated 2023-11-08

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to LEGACY HEALTHCARE — 89 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 21 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $495K paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in SD