Inspection Report Summary
The most recent inspection on February 28, 2025, found no deficiencies related to the complaints investigated. Earlier inspections showed a pattern of deficiencies primarily involving emergency preparedness and life safety code compliance, as well as resident care issues such as care planning, medication management, and food sanitation. Complaint investigations were mostly unsubstantiated, except for a substantiated case in December 2023 involving abuse and neglect with related deficiencies cited. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements in emergency preparedness and life safety compliance based on recent re-inspections showing compliance after prior citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
17.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
317% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
25 residents
Based on a February 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 0
Feb 28, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00453982, IN00453450, IN00449513, and IN00447376 at the Milton Home facility.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the investigation.
Complaint Details
Complaints IN00453982, IN00453450, IN00449513, and IN00447376 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 22
Census Bed Type - SNF: 3
Census Bed Type - Total: 25
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 18
Census Payor Type - Other: 4
Census Payor Type - Total: 25
Inspection Report
Re-Inspection
Census: 22
Capacity: 34
Deficiencies: 0
Jan 13, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey that exited on 11/21/24.
Findings
At this PSR survey, The Milton Home was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Life Safety
Census: 22
Capacity: 34
Deficiencies: 12
Nov 21, 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 11/21/2024 to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found not in compliance with emergency preparedness requirements including failure to annually review and update the Emergency Preparedness Plan, risk assessment, policies and procedures, communication plan, and training/testing program. Life safety deficiencies included improper exit discharge elevation, non-illuminated exit signage, incomplete maintenance of battery-operated smoke alarms, improper kitchen hood extinguishing system setup, fire alarm system lacking semi-annual visual inspections, and corridor doors that did not close and latch properly.
Severity Breakdown
SS=F: 8
SS=E: 4
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to review and update the Emergency Preparedness Plan at least annually. | SS=F |
| Failed to maintain an emergency preparedness plan based on a documented, facility-based and community-based risk assessment using an all-hazards approach. | SS=F |
| Failed to review and update Emergency Preparedness Plan Policies and Procedures at least annually. | SS=F |
| Failed to review and update the Emergency Preparedness Communication Plan at least annually. | SS=F |
| Failed to review and update the Emergency Preparedness Training and Testing Program at least annually. | SS=F |
| Failed to ensure one of two exit discharges from the first floor was constructed to prevent elevation changes (4-inch step without ramp). | SS=E |
| Failed to ensure one exit sign was continuously illuminated. | SS=F |
| Failed to maintain complete documentation for preventative maintenance of battery-operated smoke alarms; weekly testing required but only monthly documented. | SS=F |
| Failed to provide an approved method to ensure kitchen cooking appliances are returned to approved design location after maintenance or cleaning. | SS=E |
| Failed to maintain kitchen hood extinguishing system's remote pull station at required height (mounted too high at 60.5 inches). | SS=E |
| Failed to maintain fire alarm system with required semi-annual visual inspections. | SS=F |
| Failed to ensure one corridor door on the 200 hall could close and latch properly; latching hardware missing. | SS=E |
Report Facts
Certified beds: 34
Census: 22
Exit discharge elevation change: 4
Remote pull station mounting height: 60.5
Number of resident rooms with battery-operated smoke alarms: 18
Number of corridor doors inspected: 10
Number of residents affected by door deficiency: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hemmington Mwanza | Administrator | Named in relation to emergency preparedness and life safety findings and exit conference |
| National Project Manager | Interviewed and involved in findings and exit conference | |
| Maintenance Director | Interviewed and involved in findings and exit conference; responsible for corrective actions |
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 11
Oct 18, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00440061, IN00437310, and IN00434826.
Findings
The facility was found deficient in multiple areas including care plan development, care plan conferences, activity provision, medication storage and labeling, food sanitation, infection prevention, medication administration, employee health records, medication security, and health statements. No deficiencies were cited related to the investigated complaints.
Complaint Details
Complaint IN00440061 - No deficiencies related to the allegations are cited. Complaint IN00437310 - No deficiencies related to the allegations are cited. Complaint IN00434826 - No deficiencies related to the allegations are cited.
Severity Breakdown
SS=D: 6
SS=F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to develop a person-centered care plan regarding refusal of showers for 1 of 16 residents reviewed (Resident 16). | SS=D |
| Failed to ensure care plan conferences were completed every quarter for 1 of 4 residents reviewed (Resident 16). | SS=D |
| Failed to ensure a resident was provided 1:1 activities per the plan of care for 1 of 1 resident reviewed for activities (Resident 6). | SS=D |
| Failed to adequately label an over the counter medication and failed to monitor and maintain proper temperatures of a medication refrigerator. | SS=D |
| Failed to prepare food under sanitary conditions related to a dirty range and oven in the kitchen. | SS=F |
| Failed to distribute medication in a sanitary manner during medication administration observations (RN 2 & RN 3). | SS=D |
| Failed to have a new employee receive a pre-employment physical timely for 1 of 5 new employees reviewed (Housekeeper 4). | — |
| Failed to ensure PRN medications were administered by a Qualified Medication Aide only after authorization by a licensed nurse for 1 of 5 residents reviewed (Resident 2). | — |
| Failed to prepare food under sanitary conditions related to a dirty oven and range in the kitchen. | — |
| Failed to properly secure medications in a resident's room for 1 of 4 residents reviewed for medication storage (Resident 6). | — |
| Failed to ensure a resident had a health statement by a physician indicating the resident was free of communicable diseases, including tuberculosis in an infectious stage, at admission and yearly thereafter for 1 of 5 residents reviewed (Resident 2). | — |
Report Facts
Survey dates: October 9, 10, 11, 15, 16, 17, & 18, 2024
Census SNF/NF: 24
Census Residential: 19
Total Census: 43
Census Payor Medicaid: 22
Census Payor Other: 2
Medication refrigerator temperature logs missing: 7
Medication refrigerator out of range temperature logs: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hemmington Mwanza | Administrator | Signed the report |
| QMA 7 | Named in PRN medication administration deficiency | |
| RN 2 | Registered Nurse | Named in medication administration deficiency |
| RN 3 | Registered Nurse | Named in medication administration deficiency |
| Housekeeper 4 | Named in new hire physical deficiency |
Inspection Report
Renewal
Deficiencies: 0
Oct 18, 2024
Visit Reason
Paper Compliance to the Recertification and State Licensure Survey completed on October 18, 2024.
Findings
The Milton Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance Review to the Recertification and State Licensure.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 23, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00422710 completed on December 14, 2023.
Findings
Milton Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
The visit was complaint-related, specifically a paper compliance review of Complaint IN00422710. The facility was found to be in compliance.
Inspection Report
Re-Inspection
Census: 30
Capacity: 34
Deficiencies: 0
Jan 11, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey following the initial survey on 11/20/2023.
Findings
At this Emergency Preparedness PSR and Life Safety Code PSR, The Milton Home was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Report Facts
Certified beds: 34
Census: 30
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 2
Dec 13, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00422710, IN00422849, and IN00421811 at Milton Home.
Findings
The facility was found to have deficiencies related to abuse and neglect involving Resident C, specifically regarding rough treatment by a CNA. The facility failed to ensure the resident was free from abuse and failed to report the incident timely. Other complaints were found to have no deficiencies.
Complaint Details
Complaint IN00422710 was substantiated with federal/state deficiencies cited at F600 and F609 related to abuse and neglect. Complaints IN00422849 and IN00421811 were not substantiated with deficiencies.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 6 residents reviewed were free from abuse (Resident C). | SS=D |
| Facility failed to ensure an incident of abuse involving Resident C was reported timely. | SS=D |
Report Facts
Census Bed Type - SNF/NF: 28
Census Bed Type - Residential: 13
Total Census: 41
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 26
Census Payor Type - Other: 0
Total Census Payor: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hemmington Mwanza | Administrator | Signed the report as Administrator |
| CNA 3 | Named in abuse and neglect findings; suspended and terminated due to rough treatment and inappropriate conduct | |
| CNA 2 | Filed grievance regarding Resident C's treatment by CNA 3 | |
| Director of Nursing | Director of Nursing (DON) | Provided statements and interviews related to the abuse investigation and reporting |
Inspection Report
Life Safety
Census: 30
Capacity: 34
Deficiencies: 10
Nov 20, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found not in compliance with emergency preparedness testing requirements, generator maintenance, life safety code corridor obstructions, electrical panel security, elevator inspection and testing, sprinkler system maintenance, smoke detector battery testing, fire alarm system maintenance, and electrical receptacle testing. Corrective actions and plans of correction were provided for each deficiency.
Severity Breakdown
SS=F: 8
SS=E: 2
SS=C: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using emergency procedures. | SS=F |
| Failed to implement emergency power system inspection, testing, and maintenance requirements; missing monthly load testing and weekly visual inspection of generator. | SS=F |
| Failed to maintain corridor means of egress free of obstructions; PPE cart without wheels blocking corridor. | SS=E |
| Failed to ensure documentation for preventative maintenance of battery operated smoke alarms in resident rooms was complete. | SS=E |
| Failed to maintain fire alarm system in accordance with NFPA 70 and NFPA 72; smoke detector in elevator shaft not tested. | SS=F |
| Failed to maintain sprinkler system inspections and testing as required; missing monthly inspections and 5-year internal pipe inspection documentation. | SS=F |
| Failed to ensure electrical panels were secured from unauthorized personnel; panels found unlocked. | SS=C |
| Failed to maintain current elevator inspection documentation and monthly firefighter recall testing. | SS=F |
| Failed to test non-hospital grade electrical receptacles in resident rooms at least annually; testing past due. | SS=F |
| Failed to maintain complete written record of monthly generator load testing and weekly inspections; missing documentation for multiple months. | SS=F |
Report Facts
Certified beds: 34
Census: 30
Deficiencies cited: 11
Generator load testing months missing: 1
Generator weekly inspections missing: 2
Elevator firefighter recall missing months: 10
Battery smoke detector testing missing months: 9
Sprinkler system monthly inspections missing months: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hemmington Mwanza | Executive Director | Signed report and involved in exit conference |
| Maintenance Director | Named in multiple findings related to emergency preparedness exercises, generator maintenance, corridor obstruction, electrical panel security, elevator testing, sprinkler system maintenance, smoke detector testing, fire alarm maintenance, electrical receptacle testing, and generator testing | |
| Administrator | Involved in exit conferences and discussions of findings |
Inspection Report
Annual Inspection
Census: 30
Capacity: 43
Deficiencies: 10
Oct 30, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey and investigation of Complaint IN00416523. The complaint investigation found no deficiencies related to the allegations.
Findings
The facility was found deficient in several areas including failure to provide quarterly statements for resident trust funds, failure to provide SNF-ABN forms after Medicare discharge, food served at improper temperatures, improper food storage including expired items, incomplete or missing service plans for residents, lack of mental health screenings and care plans for residents with major mental illness, missing health statements for communicable diseases, and incomplete tuberculosis testing documentation.
Complaint Details
Complaint IN00416523 was investigated and no deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 3
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to provide quarterly statements to 3 of 9 residents with resident trust funds. | SS=D |
| Failed to ensure SNF-ABN form was provided following end of Medicare skilled services for 1 resident. | SS=D |
| Failed to ensure food was served at a palatable temperature for 3 of 15 residents. | SS=D |
| Failed to store and dispose expired foods and maintain proper food sanitation. | SS=F |
| Failed to ensure service plans were initiated, reviewed, and signed by residents for 4 of 5 residential residents reviewed. | — |
| Failed to ensure mental health screening and history obtained for 1 of 7 residents reviewed with major mental illness. | — |
| Failed to ensure comprehensive care plan developed within 30 days after admission for resident with major mental illness. | — |
| Failed to ensure comprehensive care plan developed in cooperation with mental health service providers for resident with major mental illness. | — |
| Failed to provide health statement from physician indicating resident was free of communicable diseases for 1 of 7 residents reviewed. | — |
| Failed to complete tuberculosis testing and/or assessment for 1 of 7 residents reviewed. | — |
Report Facts
Census SNF/NF beds: 30
Census Residential beds: 13
Total Capacity: 43
Residents with resident trust funds missing quarterly statements: 3
Residents reviewed for food palatability: 15
Expired food items observed: 5
Residents reviewed for service plans: 5
Residents reviewed for mental health screening: 7
Residents reviewed for health statements: 7
Residents reviewed for tuberculosis testing: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Frank Bensema | Executive Director | Signed the inspection report |
| Director of Nursing | Provided policies and interviews related to deficiencies | |
| Business Office Manager | Interviewed regarding resident trust fund quarterly statements | |
| Dietary District Manager | Interviewed regarding food storage and palatability issues | |
| Food Service Supervisor | Interviewed regarding food temperature monitoring |
Inspection Report
Renewal
Deficiencies: 0
Oct 30, 2023
Visit Reason
Paper Compliance to the Recertification and State Licensure Survey completed on October 30, 2023.
Findings
The Milton Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Paper Compliance Review to the Recertification and State Licensure.
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 31, 2023
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00400057 completed on January 30, 2023.
Findings
Milton Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00400057 completed on January 30, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 0
Mar 7, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00403031.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00403031; no deficiencies related to the allegations were cited.
Report Facts
Census: 30
Census Bed Type - SNF: 1
Census Bed Type - NF: 29
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 29
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 2
Jan 30, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00400057 at Milton Home, The.
Findings
The facility failed to ensure hot water temperatures were maintained at a safe level in 2 of 2 nursing units, with several locations exceeding the maximum allowable temperature of 120 degrees Fahrenheit. No residents were found to be affected by the deficient practice and no residents were burned. The building mixing valve was adjusted to 120 degrees and water temperatures were brought into compliance.
Complaint Details
Complaint IN00400057 was substantiated but no deficiencies related to the allegations were cited. The complaint was ultimately unsubstantiated due to lack of evidence.
Severity Breakdown
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure hot water temperatures were maintained at a safe level for 2 of 2 nursing units, with temperatures up to 130 degrees Fahrenheit noted in resident and common areas. | SS=E |
| Hot water temperature for all bathing and hand washing facilities was not controlled by an automatic control valve to maintain temperatures between 100 and 120 degrees Fahrenheit. | — |
Report Facts
Census Bed Type - SNF/NF: 27
Census Bed Type - Residential: 10
Total Census: 37
Hot water temperature readings: 130
Hot water temperature readings: 127
Hot water temperature readings: 124
Hot water temperature readings: 126
Hot water temperature readings: 130
Hot water temperature readings: 130
Hot water temperature readings: 125
Hot water temperature readings: 125
Hot water temperature readings: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Frank Bensema | Executive Director | Signed the report |
| Maintenance Supervisor | Employee 2 who accompanied survey and provided information about water temperatures | |
| Director of Nursing | Provided facility policy and procedure documents related to water temperature safety |
Inspection Report
Re-Inspection
Census: 28
Capacity: 34
Deficiencies: 0
Nov 10, 2022
Visit Reason
A 2nd Post Survey Revisit (PSR) was conducted for the 1st PSR survey that was conducted on 10/21/22 for the Life Safety Code survey conducted on 08/22/22 by the Indiana Department of Health in accordance to 42 CFR 483.90(a).
Findings
At this PSR survey, The Milton Home was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 0
Nov 1, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00389408 completed on September 14, 2022, conducted in conjunction with the Investigation of Complaint IN00391673.
Findings
The Milton Home 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 Investigation of Complaint IN00389408.
Complaint Details
Complaint IN00389408 was corrected.
Report Facts
Census Bed Type Total: 36
Census Payor Type Total: 26
Census SNF/NF: 26
Census Residential: 10
Census Medicare: 2
Census Medicaid: 17
Census Other: 7
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Nov 1, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00391673 and was conducted in conjunction with a Post Survey Revisit to the Investigation of Complaint IN00389408 completed on September 14, 2022.
Findings
Complaint IN00391673 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00391673 was substantiated; however, no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type - SNF/NF: 26
Census Bed Type - Residential: 10
Census Total: 36
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 17
Census Payor Type - Other: 7
Census Payor Type - Total: 26
Inspection Report
Re-Inspection
Census: 36
Capacity: 34
Deficiencies: 1
Oct 21, 2022
Visit Reason
A Post Survey Revisit was conducted on the Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health on 08/22/2022 in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Life Safety Code requirements due to failure to ensure that hazardous area doors, such as storage rooms, were provided with properly working self-closing devices. Specifically, the housekeeping basement storage closet door near Therapy was not self-closing and contained combustible items.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure hazardous area doors, such as storage rooms, were provided with properly working self-closing devices. | SS=E |
Report Facts
Facility capacity: 34
Census: 36
Hazardous area doors: 1
Residents potentially affected: 4
Staff potentially affected: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Frank Bensema | Executive Director | Acknowledged findings during observation and exit conference |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Sep 12, 2022
Visit Reason
This visit was conducted for the investigation of complaint IN00389408, which was substantiated with federal/state deficiencies cited related to the allegations.
Findings
The facility failed to provide adequate services such as assessments and wound dressing changes to promote healing of an unstageable/full thickness pressure ulcer and Moisture Associated Dermatitis for 1 of 3 residents reviewed (Resident B). Documentation and treatment orders were not consistently followed or completed, including wound care treatments and nutritional supplements.
Complaint Details
Complaint IN00389408 was substantiated with federal/state deficiencies cited at F686 related to pressure ulcer treatment and care.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide services, such as assessments and wound dressing changes, to promote healing of an unstageable/full thickness pressure ulcer and Moisture Associated Dermatitis for Resident B. | SS=G |
Report Facts
Census Bed Type - SNF/NF: 30
Census Bed Type - Residential: 11
Total Census: 41
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 21
Census Payor Type - Other: 5
Total Census Payor: 30
Pressure ulcer wound measurements: 2.5
Pressure ulcer wound measurements: 2
Pressure ulcer wound measurements: 2
Pressure ulcer wound measurements: 0.2
Braden Scale score: 13
Deficiency completion date: Oct 13, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident B | Resident | Subject of wound care deficiency |
| Regional Nurse | Interviewed regarding wound care documentation and treatment | |
| Clinical Nurse Specialist | Interviewed regarding wound care documentation and treatment | |
| Wound Physician | Evaluated Resident B's wounds and communicated treatment plans | |
| Director of Nursing | DON | Provided policies and interviewed regarding wound care and prevention |
Inspection Report
Life Safety
Census: 29
Capacity: 34
Deficiencies: 4
Aug 22, 2022
Visit Reason
The inspection was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana State Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Life Safety Code requirements, including issues with egress door locking mechanisms, stairway enclosure door latches, hazardous area door self-closures, and corridor doors with holes compromising smoke resistance.
Severity Breakdown
SS=E: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| The Unit Manager's Office door had two latching devices requiring two separate actions to open, violating egress door requirements. | SS=E |
| One of three stairway enclosure doors failed to self-close and latch positively, affecting at least 10 residents. | SS=E |
| A housekeeping basement storage closet door lacked a self-closing device, affecting 6 staff. | SS=E |
| Two corridor doors had holes penetrating completely through the door, compromising smoke resistance and potentially affecting 4 residents. | SS=E |
Report Facts
Certified beds: 34
Census: 29
Occupants affected: 3
Residents affected: 10
Staff affected: 6
Residents affected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Acknowledged deficiencies and participated in observations and exit conference | |
| Executive Director | Present at exit conference acknowledging findings |
Inspection Report
Recertification
Census: 14
Deficiencies: 17
Aug 1, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey.
Findings
The facility was found deficient in multiple areas including transfer and discharge documentation, baseline and comprehensive care plans, ADL care, quality of care, pressure ulcer prevention, medication management, infection control, resident rights documentation, evaluations, and clinical records.
Severity Breakdown
SS=A: 1
SS=D: 10
Deficiencies (17)
| Description | Severity |
|---|---|
| Failed to ensure transfer/discharge summary and written notice of bed hold policy were completed for residents transferred to hospital. | SS=A |
| Failed to develop baseline care plan within 48 hours of admission related to oxygen use. | SS=D |
| Failed to develop individualized care plan related to diabetes management. | SS=D |
| Failed to provide ADL care related to scheduled showers and shaving for dependent residents. | SS=D |
| Failed to ensure residents received necessary treatment and services related to wound care, chest x-ray, and urinalysis follow-up. | SS=D |
| Failed to ensure pressure offloading boots were in place as ordered for a resident with pressure ulcers. | SS=D |
| Failed to ensure splints were in place as ordered for a resident with limited range of motion. | SS=D |
| Failed to ensure fall was investigated, post-fall monitoring completed, and interventions in place for residents with history of falls. | SS=D |
| Failed to ensure necessary treatment and services related to urinary catheter care were provided including catheter changes, catheter care, and urinary output monitoring. | SS=D |
| Failed to ensure Physician's Order was in place for oxygen use. | SS=D |
| Failed to ensure infection control guidelines were implemented including placing unvaccinated new admissions on transmission based precautions. | SS=D |
| Failed to ensure signed copies of Resident Rights were in records for residents reviewed. | — |
| Failed to ensure pre-admission screening was completed prior to admission. | — |
| Failed to ensure signed service plan was in place for resident. | — |
| Failed to ensure transfer/discharge form was completed for discharged resident. | — |
| Failed to ensure licensed nurse evaluated nursing needs prior to admission. | — |
| Failed to ensure Physician's annual health statement was in place for residents reviewed. | — |
Report Facts
Survey dates: 5
Census: 14
Residents reviewed: 17
Residents reviewed: 7
Residents reviewed: 4
Residents reviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Kegg | VP of Clinical | Named in root cause analysis for infection control citation |
| Frank Bensema | Executive Director | Named in root cause analysis for infection control citation |
| Lisa Cook | Director of Nursing / Infection Preventionist | Named in root cause analysis for infection control citation and education |
| Jody Braun | MDS Coordinator | Named in root cause analysis for infection control citation |
| Shaya Mokfi | Medical Director | Named in root cause analysis for infection control citation |
| Milissa Scully | Admissions Director | Named in root cause analysis for infection control citation and education |
Inspection Report
Renewal
Deficiencies: 0
Aug 1, 2022
Visit Reason
Paper Compliance to the Recertification and State Licensure Survey completed on August 1, 2022.
Findings
The Milton Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1, in regard to the Paper Compliance Review to the Recertification and State Licensure.
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