Inspection Reports for Milner Community Health Care
370 E MAIN ST, IN, 46065
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 16, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily related to life safety code compliance, including issues with means of egress, sprinkler system maintenance, and fire safety equipment, as well as care coordination concerns such as medication management and PASARR assessments. Complaint investigations were consistently unsubstantiated, with no enforcement actions or fines listed in the available reports. Prior reports noted issues with emergency preparedness exercises, hazardous door closures, and medication labeling, but the facility demonstrated compliance in several follow-up inspections. The overall trend suggests some improvement in life safety and regulatory compliance over time, with recent inspections showing fewer or no deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
58 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 0
Apr 16, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457111.
Findings
No deficiencies related to the allegations in Complaint IN00457111 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00457111 was investigated and found to have no deficiencies related to the allegations.
Report Facts
SNF/NF census: 45
Residential census: 13
Total census: 58
Medicare census: 2
Medicaid census: 29
Other payor census: 14
Total payor census: 45
Inspection Report
Re-Inspection
Census: 52
Capacity: 80
Deficiencies: 0
Oct 31, 2024
Visit Reason
This was a Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health to verify compliance with fire safety and licensure requirements.
Findings
Milner Community Health Care was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinklered except for a detached storage shed and garage storage area, and has a fire alarm system with smoke detection throughout resident areas.
Report Facts
Facility capacity: 80
Census: 52
Inspection Report
Life Safety
Census: 52
Capacity: 80
Deficiencies: 9
Sep 10, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 09/10/2024 to assess compliance with emergency preparedness and life safety code requirements.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Multiple deficiencies were identified including obstructions in corridors, malfunctioning delayed egress locks, hazardous area door issues, improper interior wall finish materials, sprinkler obstructions, blocked electrical panel access, smoking area maintenance issues, use of portable space heaters, and use of extension cords as wiring substitutes.
Severity Breakdown
SS=E: 8
SS=D: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to maintain means of egress free from obstructions in 2 of 4 corridors; trash containers and a non-wheeled table stored in corridors. | SS=E |
| Failed to ensure means of egress through 1 of 9 delayed egress locks was readily accessible; 15 second delay function on three doors failed to open. | SS=E |
| Failed to ensure 1 of 6 hazardous areas (soiled linen room) was separated by smoke resistant partitions and doors; door held open by paper towels. | SS=E |
| Failed to ensure materials used as interior finish in 1 of 7 smoke compartments had required flame spread rating; vinyl siding used without documentation. | SS=E |
| Failed to ensure sprinkler heads spray pattern was not obstructed in 1 of 2 foyers; ceiling fans obstructed sprinkler spray pattern. | SS=E |
| Failed to maintain access and working space in 1 of 1 Assisted Living Dining/Activities storage room; items stored in front of electrical panels. | SS=E |
| Failed to provide ashtrays and metal containers with self-closing covers in 1 of 2 outdoor smoking areas; cigarette butts found on ground. | SS=E |
| Failed to ensure portable space heaters were not used in the facility; a portable space heater was found in the Business office. | SS=D |
| Failed to ensure 1 of 2 foyers did not use flexible cords as substitute for fixed wiring; a yellow 50-foot extension cord was used for window air conditioner. | SS=E |
Report Facts
Certified beds: 80
Census: 52
Residents affected: 18
Residents affected: 12
Residents affected: 12
Residents affected: 17
Residents affected: 12
Residents affected: 12
Residents affected: 2
Staff affected: 4
Visitors affected: 2
Staff affected: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Richard G Jackson | Administrator | Named in relation to exit conference and survey report |
| Maintenance Director | Interviewed and involved in observations and corrective actions | |
| Environmental Services Director | Responsible for monitoring and corrective actions related to deficiencies |
Inspection Report
Recertification
Census: 59
Deficiencies: 4
Aug 16, 2024
Visit Reason
This was a Recertification and State Licensure Survey that also included the investigation of Complaint IN00439112.
Findings
The facility was found to have deficiencies related to coordination of PASARR assessments, quality of care including medication administration and bowel movement monitoring, bed rail assessments, and medication labeling. Complaint IN00439112 was investigated with no deficiencies related to the allegations cited.
Complaint Details
Complaint IN00439112 was investigated and no deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 3
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure a new PASARR was completed when a new mental health diagnosis or psychiatric medication was added for 2 residents. | SS=D |
| Failed to follow physician ordered hold parameters for medications, notify physician of high blood sugar, and monitor/document bowel movements for 4 residents. | SS=E |
| Failed to ensure an accurate bed rail assessment was completed for 1 resident. | SS=D |
| Failed to ensure refrigerated medications had open dates, multidose supplement had resident labeling, and controlled substances had open dates in medication carts and refrigerators. | SS=D |
Report Facts
Survey dates: 5
Census Bed Type - SNF/NF: 47
Census Bed Type - Residential: 12
Total Census: 59
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 37
Census Payor Type - Other: 5
Medication labeling audits: 3
Plan of Correction review period: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Richard G Jackson | Administrator | Signed the report. |
| Social Services Director | Interviewed regarding PASARR deficiencies and policy. | |
| Assistant Director of Nursing | Interviewed regarding medication administration and bowel movement monitoring deficiencies. | |
| Director of Nursing | Interviewed regarding notification of high blood sugar and bed rail assessment deficiencies. | |
| QMA 1 | Interviewed regarding medication labeling deficiencies. | |
| RN 3 | Interviewed regarding bowel movement monitoring procedures. |
Inspection Report
Renewal
Deficiencies: 0
Aug 16, 2024
Visit Reason
Paper compliance review for the Recertification and State Licensure survey completed on August 16, 2024.
Findings
Milner Community Health Care was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Apr 30, 2024
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaint IN00429356 and Residential Complaint IN00432683.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Nursing Home Complaint IN00429356 and Residential Complaint IN00432683 found no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 50
Census Bed Type - Residential: 15
Census Bed Type - Total: 65
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 30
Census Payor Type - Other: 16
Census Payor Type - Total: 50
Inspection Report
Re-Inspection
Census: 48
Capacity: 80
Deficiencies: 1
Sep 21, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on previous Emergency Preparedness and Life Safety Code Recertification surveys conducted on 07/05/23.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements due to failure to maintain automatic sprinkler systems in accordance with NFPA 25. Documentation of sprinkler system maintenance and replacement of recalled sprinkler heads was not provided at the time of the survey.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain automatic sprinkler systems in accordance with NFPA 25, including lack of documentation for inspection, testing, and maintenance, and incomplete replacement of recalled sprinkler heads. | SS=F |
Report Facts
Certified beds: 80
Census: 48
Plan of correction completion date: Nov 15, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| R. Gregg Jackson | Administrator | Facility Administrator involved in waiver discussion |
| Director of Maintenance | Interviewed regarding sprinkler system maintenance and deficiencies |
Inspection Report
Re-Inspection
Census: 48
Capacity: 48
Deficiencies: 0
Aug 21, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on June 5, 2023.
Findings
Milner Community Health Care was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 40
Census Payor Type - Other: 6
Inspection Report
Life Safety
Census: 52
Capacity: 80
Deficiencies: 6
Jul 5, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with emergency preparedness requirements and life safety code regulations.
Findings
The facility was found not in compliance with emergency preparedness testing requirements, life safety code requirements including delayed egress lock accessibility, hazardous area door self-closure, fire alarm system maintenance, and sprinkler system maintenance. Specific deficiencies included failure to conduct required emergency plan exercises, a delayed egress lock that did not release properly, a hazardous area door without a self-closing device, a propped open hazardous area door, missing smoke detector sensitivity testing documentation, and missing hydraulic nameplate and recalled sprinkler heads in the sprinkler system.
Severity Breakdown
SS=F: 3
SS=E: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to conduct required emergency preparedness exercises at least twice per year including unannounced staff drills. | SS=F |
| Delayed egress lock on East Hall exit did not release upon pushing the door as required. | SS=E |
| Corridor door to converted storage room lacked a self-closing device. | SS=E |
| Corridor door to Medical Records office was propped open with a door wedge, preventing proper closure. | SS=E |
| Fire alarm system lacked documentation of smoke detector sensitivity testing within the last two years. | SS=F |
| Sprinkler system inspection records showed missing hydraulic nameplate and presence of recalled sprinkler heads without evidence of correction. | SS=F |
Report Facts
Certified beds: 80
Census: 52
Deficiencies cited: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Richard Jackson | Administrator | Facility administrator present during exit conference |
| Director of Maintenance | Interviewed and provided information regarding deficiencies and corrective actions |
Inspection Report
Annual Inspection
Census: 54
Capacity: 66
Deficiencies: 7
Jun 5, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted from May 30 to June 5, 2023.
Findings
The facility was found to have multiple deficiencies including failure to complete PASARR assessments, update care plans for long-term antibiotic therapy, ensure use of splints and braces as ordered, prevent injury during stand-up lift transfers, maintain catheter hygiene, control psychotropic medication use, and maintain food service sanitation standards.
Severity Breakdown
SS=D: 4
SS=E: 1
SS=F: 1
SS=G: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure a PASARR was completed when a resident was prescribed an antipsychotic medication. | SS=D |
| Failed to update care plans for long-term antibiotic therapy for a resident. | SS=D |
| Failed to ensure residents received splint devices as recommended by physical therapy and to follow physician orders for splints and braces. | SS=E |
| Failed to ensure a resident was free from injury while using a stand-up lift during transfer, resulting in a fracture. | SS=G |
| Failed to ensure indwelling catheter bag and tubing were off the floor to prevent infection risk. | SS=D |
| Failed to ensure PRN antianxiety medications were prescribed only for 14 days and reviewed for continued need. | SS=D |
| Failed to ensure dishwasher reached and maintained appropriate sanitizing temperatures and ice machine was clean. | SS=F |
Report Facts
Census SNF/NF: 54
Census Residential: 12
Total Capacity: 66
PRN lorazepam administrations: 7
Dishwasher wash temperature: 120
Dishwasher final rinse temperature: 152
Dishwasher wash temperature: 124
Dishwasher final rinse temperature: 152
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| R. Gregg Jackson | Administrator | Signed the report |
| LPN 12 | Witness statement regarding resident transfer incident | |
| CNA 9 | Witness statement regarding resident transfer incident | |
| CNA 10 | Witness statement regarding resident transfer incident | |
| CNA 11 | Witness statement regarding resident transfer incident | |
| ADON | Assistant Director of Nursing | Provided multiple interviews and explanations regarding deficiencies and incidents |
| LPN 7 | Interviewed about catheter care | |
| QMA 8 | Qualified Medication Aide | Observed catheter care and discussed catheter bag placement |
| LPN 3 | Interviewed about resident splint use | |
| LPN 6 | Interviewed about resident antibiotic use | |
| RN 5 | Registered Nurse | Interviewed about resident splint use |
| CNA 4 | Certified Nursing Assistant | Interviewed about resident splint use |
| Dietary Manager | Interviewed about dishwasher and ice machine issues |
Inspection Report
Follow-Up
Census: 47
Capacity: 80
Deficiencies: 0
Aug 16, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 06/21/22.
Findings
At the Emergency Preparedness survey, the facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. At the Life Safety Code survey, the facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Report Facts
Certified beds: 80
Census: 47
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