Avantara Milbank
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 8 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Low overall rating (1/5 stars)
- Low staffing rating (2/5 stars)
- High staff turnover (82%)
- High RN turnover (77%)
Bottom 25% in SD · Meets national RN staffing standard · Very high staff turnover · Worst in LEGACY HEALTHCARE chain · $55,361 in fines
What this means for your family
While the facility received high praise in 2019, the most recent review from 2023 raises severe concerns regarding medical oversight and communication during health crises. If you are considering this facility, I strongly advise asking for specific protocols on how the nursing team escalates medical concerns to families and physicians, and verifying their current staffing ratios.
Google Reviews
Google Reviews
8 reviews on Google“Avantara Milbank has a significant disparity in feedback, with older reviews from 2019 praising the staff as caring and respectful, while a more recent 2023 review reports severe neglect regarding medical care. The facility faces critical allegations concerning delayed communication and failure to provide timely medical intervention for a resident in distress.”
Quality Themes
Tap a score for detailsStrengths
- Historically praised for respectful staff
- Long-term resident satisfaction
- Responsive management to positive feedback
Concerns
- Failure to provide timely medical intervention and communication
Rating Trends
Tap a year to see what changed
Distribution · 9 analyzed
How They Respond to Reviews
This facility actively engages with reviewer feedback.
Questions for Your Tour
- 1It's great to see how much management engages with the community feedback; how do you typically incorporate family suggestions into your daily operations?
- 2What is the specific process for ensuring medications are administered accurately and on schedule every day?
- 3In the event of a sudden change in a resident's health, what are the immediate steps the nursing staff takes to ensure timely medical intervention?
- 4How does the nursing team ensure that families are kept updated and informed about any changes in a resident's condition or care plan?
- 5What kind of daily activities or social outings do you have planned to keep the residents engaged and connected with one another?
- 6With a smaller, intimate community of 55 residents, how do you ensure that every person's specific care needs are being closely monitored by the staff?
Personalized based on this facility's data
Key Review Excerpts
“If you care about your loved ones, do not put them here. My great grandmother was placed here. We got a phone call several days into her fighting influenza A, but not until after she was unresponsive and purple from the knees down.”
“Our relatives were given extra ordinary care while they were there. Great place and great service.”
“Excellent staff!! Very caring and respectful!”
Staffing
Staffing Hours
per resident/day · Medicare 2026Total nursing hours are below minimum, though RN coverage is adequate. This may mean fewer aides for daily tasks like bathing and mobility.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 16 measures
3
measures
11
measures
2
measures
Residents needing more daily help over time
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents whose walking got worse
Residents vaccinated for pneumonia
Residents on antipsychotic medication
Residents on anti-anxiety or sleep medication
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Multiple families have filed complaints triggering inspections, with concerning issues found in abuse/neglect reporting, medication management, and daily care assistance. The facility shows recurring problems with safety (exit obstructions), resident rights, and quality of care across recent surveys. While all deficiencies have reported correction dates, the pattern of complaint-driven investigations and repeated violations in critical care areas warrants careful consideration during any visit.
Mar 13, 2025Routine8
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Quality of Life and Care Deficiencies
Honor each resident's preferences, choices, values and beliefs.
Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Smoke Deficiencies
Install an approved automatic sprinkler system.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Mar 13, 2025Complaint1
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Dec 18, 2024Complaint3
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Oct 8, 2024Complaint3
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Aug 6, 2024Complaint1
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Nov 8, 2023Routine8
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Federal Penalties
Fine
Dec 18, 2024
$28,912
Fine
Oct 8, 2024
$15,041
Fine
Nov 8, 2023
$11,408
Ownership & Operations
Who Operates This Facility
Avantara Milbank
for profit
Chain Affiliation
Legacy Healthcare
89 facilities nationwide
Chain avg rating: 3.0/5 · Rank 83 of 89 (Worst)
Ownership & Management
Owners
Doros Generation Trust U/a/d 1/3/12
Owner · Organization
Gpn Family Trust U/a/d 4/28/08
Owner · Organization
Oakway Operations LLC
Owner · Organization
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
8 reviews from families & visitors
Official Website
Visit avantaramilbank.com
Medicare data downloads
Original nursing home datasets
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Safer Alternatives Nearby
Based on current clinical data, we identified 1 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.