Cycle 1
Health 2024-10-02 · Fire 2024-10-02
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Milbank, SD
St William's Care Center
3-star overall rating with 3-star inspections with $67,379 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
103 N Viola St, Milbank, SD
(605) 432-5811
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
48
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2005-03-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.39
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
3.19
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.16
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
2.55
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
39%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,541
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.69
Baseline 58.33% · Performance 56.76% · Measure score 1.69 · Achievement 1.69 · Improvement 0
Adjusted total nurse staffing
2.31
Baseline 3.45 hours · Performance 3.73 hours · Measure score 2.31 · Achievement 2.31 · Improvement 0.71
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.72% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 25 · Observed rate 8% · Lower 95% interval 6.83% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.53 |
1.02
0.5 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 33 · Denominator 33 |
| Falls with major injury | 3.03% |
0.77%
2.3 pts worse
|
Numerator 1 · Denominator 33 |
| Discharge self-care score | 70.97% |
53.69%
17.3 pts better
|
Numerator 22 · Denominator 31 |
| Discharge mobility score | 54.84% |
50.94%
3.9 pts better
|
Numerator 17 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 3.03% |
2.29%
0.7 pts worse
|
Numerator 1 · Denominator 33 · Adjusted rate 3.4% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 10.17% |
8.2%
2 pts better
|
Numerator 12 · Denominator 118 |
| Staff flu vaccination coverage | 38.21% |
42%
3.8 pts worse
|
Numerator 47 · Denominator 123 |
| Discharge function score | 64.52% |
56.45%
8.1 pts better
|
Numerator 20 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 59.09% |
25.2%
33.9 pts better
|
Numerator 13 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.5
0.5 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.6 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.9
0.5 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.0 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.4%
4.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.9%
3.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
5.1%
0.2 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 6.4% · Q3 6.2% · Q4 4.3% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.3% |
4.6%
2.7 pts worse
|
11.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 10.9% · Q3 4.4% · Q4 7.5% · 4Q avg 7.3% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
5.5%
2 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 4.4% · Q3 2.3% · Q4 0.0% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.2% |
17.8%
10.4 pts worse
|
19.6%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 37.8% · Q3 23.3% · Q4 22.5% · 4Q avg 28.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.8% |
25.1%
3.3 pts better
|
16.7%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 24.3% · Q3 19.4% · Q4 23.5% · 4Q avg 21.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.1% |
21.3%
1.2 pts better
|
16.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.4% |
21.6%
2.8 pts worse
|
14.9%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 17.1% · Q3 23.1% · Q4 23.7% · 4Q avg 24.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
2.0%
0.4 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.4% · Q3 2.9% · Q4 1.5% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.3%
3.3 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.7% |
25.8%
0.9 pts worse
|
19.8%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 29.3% · Q3 26.2% · Q4 29.7% · 4Q avg 26.7% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
4.6%
0.3 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.6% · Q3 5.1% · Q4 2.7% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
83.2%
14.2 pts better
|
81.7%
15.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 95.2% · 4Q avg 97.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.7%
1.7 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.0% |
78.2%
6.8 pts better
|
79.7%
5.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-10 · Fire 2023-08-10
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-03-01 · Fire 2022-03-01
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-10-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-04
C · Minimal harm
2024-10-02
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-10-24
E · Potential for more than minimal harm
2022-03-01
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2022-05-05
Inspection history
Recent health citations
G · Actual harm
2024-10-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-05
E · Potential for more than minimal harm
2024-10-02
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-10-28
E · Potential for more than minimal harm
2024-10-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-27
E · Potential for more than minimal harm
2024-10-02
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-10-27
D · Potential for more than minimal harm
2024-10-02
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2024-10-27
H · Actual harm
2024-07-24
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-24
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-07-24
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-24
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-08-16
G · Actual harm
2023-08-10
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-01
G · Actual harm
2023-08-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-10
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-10
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-10
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-09-01
E · Potential for more than minimal harm
2022-03-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-05-05
E · Potential for more than minimal harm
2022-03-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-04-25
D · Potential for more than minimal harm
2022-03-01
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-05-05
D · Potential for more than minimal harm
2022-03-01
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2022-05-05
D · Potential for more than minimal harm
2022-03-01
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-04-25
D · Potential for more than minimal harm
2022-03-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-05-05
D · Potential for more than minimal harm
2022-03-01
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-05-05
D · Potential for more than minimal harm
2022-03-01
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2022-05-05
Penalties and ownership
What sits behind the stars
$12,048
2024-10-02
Fine
Fine · fine $12,048
Fine
$41,925
2024-07-24
Fine
Fine · fine $41,925
Fine
$13,406
2023-08-10
Fine
Fine · fine $13,406
Fine
Ownership
Butler, Rita
Corporate Director · Individual
Christenson, Ann
W-2 Managing Employee · Individual
Mccafferty, Patricia
Corporate Director · Individual
Thrift, Rene
W-2 Managing Employee · Individual
Walker, Mary
Corporate Director · Individual
Walker, Mary
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Avantara Milbank
Milbank, SD
1-star overall rating with 2-star inspections with $55,361 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Fairway View Neighborhoods
Ortonville, MN
1-star overall rating with 2-star inspections with abuse icon flag with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Wilmot Care Center Inc
Wilmot, SD
2-star overall rating with 1-star inspections with Special Focus status with $28,028 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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