Inspection Reports for
Avantara Milbank

The investigation was triggered by two facility-reported incidents: one on 1/28/25 involving resident 9 who was lowered to the floor due to improper sling attachment by CNA K, and another on 2/22/25 involving resident 14 who was lowered to the floor during transfer by CNA M without the required two-staff assistance. Both residents were unharmed. CNA K was suspended and later reinstated after education; CNA M was suspended pending education completion. Resident 9 was cognitively intact with specific transfer needs; resident 14 was severely cognitively impaired and required care in pairs.

The provider failed to ensure resident safety by improper use of mechanical and non-mechanical sit-to-stand lifts, resulting in two residents being lowered to the floor without the required assistance of two staff. Both incidents involved staff not following care plan or manufacturer guidelines, leading to minimal harm or potential for harm.

The facility failed to notify the State Long-Term Care Ombudsman of resident hospital transfers and failed to provide bed hold notices to residents or their representatives. Residents reported delays in call light responses, with documented instances of response times exceeding facility expectations. The kitchen was found to be unclean with improper glove use by dietary staff during food preparation and service.

The complaint investigation was substantiated. Resident 2's family filed a grievance about improper use of mechanical lifts, short staffing, long call light wait times, and COVID-19 exposure risks. Resident 1 was given two long-acting insulins simultaneously causing hypoglycemia and hospitalization. The facility failed to follow grievance policies and timely report the medication error to the state agency.

The facility failed to follow its grievance policy regarding a complaint filed on behalf of resident 2, and failed to timely report suspected abuse and medication errors. Resident 1 was administered two long-acting insulins concurrently for four days, resulting in hypoglycemia and hospitalization. The facility lacked proper communication, documentation, and follow-up with physicians and pharmacy, and did not conduct timely incident reporting or adequate staff education.

The complaint investigation was triggered by reports of bruising and swelling of unknown origin on resident 1's left knee, right wrist, and penis. The investigation revealed failure to conduct thorough abuse and neglect investigations and failure to report to the state health department. Additionally, concerns about inadequate hydration and nutrition for six residents were substantiated, including hospitalization for dehydration of one resident.

The provider failed to thoroughly investigate suspected abuse and neglect for one resident with bruising and swelling of unknown origin and failed to report these incidents to the South Dakota Department of Health. Additionally, the provider failed to ensure adequate fluid intake, monitoring, and interventions for six sampled residents, resulting in dehydration and hospitalization for one resident.

The facility failed to ensure activities of daily living were performed and accurately documented for four sampled residents dependent on staff assistance. Observations and interviews revealed residents were not repositioned as required, call lights were often out of reach, and dependent residents were delayed in receiving feeding assistance.

The facility was found deficient in multiple areas including resident dignity and privacy, care plan development, medication administration errors, smoking safety, and infection control practices. Several residents were not assisted timely or provided privacy, care plans lacked focused goals and interventions, a resident received an incorrect medication dosage, and infection control protocols were not consistently followed.

The provider failed to correctly post and follow contact precautions for cleaning a resident's room with C. diff. The cleaning staff used disinfectants ineffective against C. diff. spores, and staff education and signage on infection control practices were inadequate.