Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Milton Home, The during CMS and state inspections, most recent first.
Missed Pre- and Post-Dialysis Assessments: A resident with ESRD on HD had orders and a care plan requiring access-site checks, thigh BP readings, and post-dialysis monitoring, but the record lacked completed post-dialysis communication forms for the month reviewed. The facility policy required pre- and post-treatment access assessment, and the DON/Corporate Regional Nurse Consultant confirmed multiple dialysis visits when a post-dialysis assessment should have been done.
Unsecured PRN Medications Found in Resident Room: A resident was found with 2 pills in a plastic medicine cup stored in her closet after stating a QMA had given her Tylenol and tramadol but did not witness her swallowing them. The resident was cognitively intact and had PRN pain orders for acetaminophen and tramadol, and the facility's med storage policy required drugs and biologicals to be kept in a safe, secure, and orderly manner.
A resident with multiple complex medical conditions was injured when their wheelchair tipped over during van transport due to improper securement. Investigation found that the emergency release lever for the floor restraint system was accessible and not installed per manufacturer guidelines, allowing the restraint to loosen and the wheelchair to fall, resulting in minor injuries requiring emergency care.
The facility failed to maintain sanitary conditions in the kitchen, with a dirty gas range and oven observed during inspections. The Dietary Director acknowledged the issue, which violated the facility's cleaning schedule and food safety policy.
A resident with intact cognition and multiple diagnoses, including diabetes and dementia, repeatedly refused showers, but the facility failed to document these refusals in the care plan. The care plan only noted the resident's preference for showers and need for assistance, without addressing the refusals. Inconsistent documentation practices were identified, and no policy on shower refusals was provided.
A facility failed to conduct quarterly care plan conferences for a resident, as required. The resident reported never attending a care plan conference, and a record review confirmed the lack of documentation for the year. The Social Services Director acknowledged missed conferences and the facility could not provide a relevant policy before the survey exit.
A resident with Parkinson's and Alzheimer's was not provided 1:1 activities as per her care plan, which specified twice-weekly individual activities due to her preference for them over group activities. Observations showed the resident alone in her room, and the Activity Director admitted to not documenting visits, contrary to facility policy.
The facility failed to label an over-the-counter medication with resident information and did not maintain proper temperatures in a medication refrigerator. An opened bottle of multivitamins was found unlabeled, and the refrigerator had inconsistent temperature readings, with logs showing numerous out-of-range temperatures. The staff acknowledged the labeling and temperature monitoring responsibilities.
The facility failed to maintain sanitary conditions during medication administration. A nurse dropped a Vitamin D tablet and another nurse picked it up with gloves and administered it to a resident. In another instance, a nurse dropped a Lisinopril tablet, picked it up with a spoon, and administered it. The facility lacked a policy for handling dropped medications.
Missed Pre- and Post-Dialysis Assessments
Penalty
Summary
The facility failed to provide ongoing pre- and post-dialysis evaluations for 1 resident who required hemodialysis for end stage renal disease. The resident’s record showed diagnoses including end stage renal disease on dialysis, lower left leg amputation, gastrostomy status, and type II diabetes mellitus. Physician orders directed staff to check the permacath site daily upon return from dialysis, avoid blood pressure readings and lab draws from either arm with the dialysis site and instead take blood pressure by thigh every shift, and check the dialysis access site for bruit and thrill with abnormalities recorded and reported. The care plan also directed staff to check for thrill and bruit twice per shift on the day the resident returned from dialysis and then daily, with vital signs checked every shift for 24 hours post-dialysis or per physician order. The record review found no post-dialysis communication record forms completed and available for review for the month of December 2025. The facility’s Hemodialysis policy stated that the nurse would ensure the dialysis access site was checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill, and that the resident would not receive blood pressures or laboratory sticks on the arm where the dialysis access device was located. During interview, the DON/Corporate Regional Nurse Consultant stated the resident’s blood pressures should have been taken in the thigh as ordered and identified multiple dialysis dates when a post-dialysis assessment should have been completed.
Unsecured PRN Medications Found in Resident Room
Penalty
Summary
The facility failed to ensure resident medications were secured in a resident room. During an interview, Resident 21 stated she had been given Tylenol and Tramadol several days earlier by a QMA during the evening shift, but the QMA did not witness her swallowing the pills, so she placed them away in case she needed to show someone. When observed, Resident 21 removed 2 round white pills from her closet in a plastic medicine cup; one pill was imprinted AN 627 and the other PH 020. The Regional Corporate Nurse Consultant later stated the pills should not have been unsecured in the resident's room. Resident 21's record showed diagnoses including metabolic encephalopathy, acute and chronic respiratory failure, hemiplegia and hemiparesis following intracranial hemorrhage, hypertension, muscle wasting and atrophy, history of pulmonary embolism, obesity, cardiomegaly, depression, and anxiety. The resident's MDS indicated she was cognitively intact and receiving PRN pain medication. Orders included acetaminophen 325 mg, 2 tablets every 4 hours as needed for pain, and tramadol 50 mg every 6 hours as needed for pain or discomfort. The December 2025 MAR showed the resident had received tramadol on multiple dates and acetaminophen on several dates. The facility policy titled Storage of Medications stated that all drugs and biologicals are to be stored in a safe, secure, and orderly manner, and that nursing staff are responsible for maintaining medication storage.
Improper Wheelchair Securement During Transportation Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident's wheelchair was not properly secured during transportation in the facility van, resulting in the wheelchair tipping over. The incident led to the resident sustaining a skin tear to the elbow and an abrasion to the head, requiring evaluation and treatment at an emergency room. The resident had multiple medical diagnoses, including a stage 4 pressure ulcer, chronic respiratory failure, chronic pain, atherosclerotic heart disease, coronary artery disease, and anxiety. The facility's investigation revealed that, although the employee responsible for securing the wheelchair had been previously validated as competent, the wheelchair was not installed according to the manufacturer's instructions. Specifically, the emergency release lever for the floor securement system was accessible to the resident and could be engaged accidentally. During the incident, three of the four floor safety restraints remained secured, but the left front restraint was found to be loosened, which allowed the wheelchair to tip over when the vehicle turned a corner. Further review and interviews with the manufacturer confirmed that the emergency release lever should not have been accessible to the resident and that the straps should have been positioned at a 45-degree angle to prevent accidental engagement. The improper installation of the wheelchair securement system directly contributed to the loosening of the restraint and the subsequent accident.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, specifically regarding the cleanliness of the gas range and oven. During an initial kitchen tour, it was observed that the gas range had four burners with a black substance on all of the grates, and the single door oven had a buildup of grease and a black substance inside. A subsequent tour confirmed that these unsanitary conditions persisted. The Dietary Director acknowledged that the range and oven were dirty and should have been cleaned according to the facility's daily cleaning schedule. The facility's policy on food safety and sanitation required adherence to a regular written cleaning schedule, which was not followed in this instance.
Failure to Document and Address Resident's Shower Refusals
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who consistently refused showers. Resident 16, who has diagnoses including type 2 diabetes mellitus, vascular dementia, and adjustment disorder with depressed mood, was noted to have intact cognition according to a recent MDS assessment. Despite this, the resident's care plan did not reflect their repeated refusals of showers, which were documented on several occasions in September and October 2024. The care plan only noted that the resident preferred showers and required extensive assistance, without addressing the refusals. Interviews and record reviews revealed that the facility's documentation practices were inconsistent. Certified Nursing Assistant (CNA) 6 indicated that refusals were supposed to be charted in the Point of Care (POC) system and reported to the nurse, but the POC records for Resident 16 showed 'not applicable' instead of documenting the refusals. Additionally, the facility was unable to provide a policy regarding the refusal of showers when requested by surveyors, indicating a lack of formal procedures to address such situations.
Failure to Conduct Quarterly Care Plan Conferences
Penalty
Summary
The facility failed to ensure that care plan conferences were completed every quarter for Resident 16, as required. During an interview, Resident 16 reported that he had never attended a care plan conference since his admission to the facility. A record review confirmed the absence of documentation for a care plan conference for the year. The Social Services Director acknowledged that Resident 16 attended care plan conferences on specific dates but missed one in February or March, which should have been conducted. Additionally, the facility was unable to provide a policy regarding care plan conferences before the survey exit.
Failure to Provide 1:1 Activities for Resident
Penalty
Summary
The facility failed to provide 1:1 activities for a resident as per the care plan. The resident, who has diagnoses including Parkinson's Disease with dyskinesia and Alzheimer's Disease, was observed multiple times sitting alone in her room, either folding clothes or looking through a coloring book. Despite the care plan indicating that the resident should receive 1:1 activities at least twice a week due to her preference for individual activities over group ones, there was no documentation of such activities being provided. The Activity Director admitted during an interview that she did not document her visits with the resident, although she should have. The facility's policy on activities, which includes provisions for one-to-one programs and special considerations for residents with dementia, was not followed in this case. The lack of documentation and adherence to the care plan resulted in the resident not receiving the individualized activities she was supposed to have.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to adequately label an over-the-counter medication stored in a medication cart. During an observation, an opened bottle of Women 50+ Complete Multivitamin was found in a drawer without any resident identifying information. The LPN present was unaware of the medication's ownership, and the Unit Manager confirmed that all medications should be labeled with the resident's name, date of birth, physician's name, and dosing information. Additionally, the facility did not properly monitor and maintain the temperatures of a medication refrigerator. Observations revealed that the refrigerator had two thermometers showing different temperatures, one of which was below the safe range. The temperature logs were incomplete, with several dates missing entries and numerous entries showing temperatures outside the safe range of 36 to 46 degrees Fahrenheit. The Unit Manager and Director of Nursing acknowledged the responsibility of the nursing staff to check and log temperatures daily, and the policy provided confirmed the required temperature range.
Medication Administration Sanitation Deficiency
Penalty
Summary
The facility failed to distribute medication in a sanitary manner during two separate medication administration observations. In the first instance, a registered nurse (RN 2) dropped a tablet of Vitamin D onto the medication cart. Another nurse (RN 4) applied hand sanitizer and gloves, picked up the tablet, and placed it into the medication cup with other medications, which was then given to the resident. In the second instance, another registered nurse (RN 3) dropped a tablet of Lisinopril onto the medication cart and used a spoon to pick it up and place it into the medication cup, which was subsequently administered to the resident. During interviews, RN 2 acknowledged that the medication should have been discarded and replaced, while RN 3 was uncertain about the correct procedure and did not follow up before the survey exit. The Director of Nursing indicated that the facility lacked a specific policy for handling dropped medications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near South Bend
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cardinal Nursing And Rehabilitation Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Holy Cross Village At Notre Dame Inc | 1 mi | ★★★★★ | 20 | 0 |
| Wellbrooke Of South Bend | 2 mi | ★★★★★ | 19 | 0 |
| Trailpoint Village | 3.1 mi | ★★★★★ | 19 | 0 |
| Holy Cross Rehabilitation And Wellness | 3.1 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.