Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Milaca Elim Meadows Health Care Center during CMS and state inspections, most recent first.
Kitchen Hood Vent and Fan Not Kept Clean: Surveyors observed a metal hood vent over the flat cook top and deep fryer with yellow grease-like buildup dripping along the hood and on the lightbulb covers, and the condition remained on recheck. A white oscillating fan in the secondary kitchen also had grates coated with brown/yellow substance and dust. The cook said the fan was used to cool staff, was unsure of its cleaning schedule, and stated the hood and bulb covers should have been cleaned to prevent grease from dropping onto food while it was being cooked.
A resident with intact cognition and diagnoses including CHF, CKD, dementia, and a displaced femur fracture was observed receiving meds in a cup left on the table by an RN for self-administration after set up. Although there was an order allowing self-administration after set up, the SAM was not completed until later and documented that the resident did not want to self-administer meds. The UC confirmed there was no completed assessment supporting self-administration at the time, and the DON stated the timing for completing the SAM was unclear.
The facility failed to provide required SNFABNs to two residents whose Medicare Part A coverage ended and who remained in the facility. One resident signed a SNFABN that did not include an estimated daily cost, and another resident’s record lacked evidence that a SNFABN was provided to explain the estimated cost per day or the extended care services/items to be furnished, reduced, or terminated. The admission coordinator stated the cost information was missed for one resident and that the notice had not yet been provided for the other when surveyors requested it.
MDS Incorrectly Coded for Hospice Services: A resident enrolled in hospice had a quarterly MDS that incorrectly coded dialysis in Section O instead of hospice services. The resident's face sheet, care plan, and facility matrix all identified hospice enrollment, and the MDS Coordinator stated the dialysis entry was made in error and hospice should have been marked.
Broken Walking Stick Not Kept in Good Repair: A resident with severe cognitive impairment and high fall risk used a walking stick that had been broken and temporarily mended for weeks. Staff and the spouse observed tape on the device, and later the stick was found cracked and glued together. The resident was seen using the device repeatedly despite staff noting his balance was poor and that they did not trust the stick’s stability.
A resident with an indwelling urinary catheter and pressure ulcer was on EBP requiring gown and glove use for high-contact care. During morning personal care, an NA removed soiled gloves after peri care but did not perform hand hygiene or put on fresh gloves before continuing care, including transfer assistance and catheter bag handling. The ADON stated staff were expected to perform hand hygiene after dirty tasks and before donning new gloves, and facility policy identified hand hygiene as the key method to prevent spread of microorganisms.
The facility failed to notify the Ombudsman of a resident’s transfer and discharge. The resident was cognitively intact and had HTN, A-fib, ESRD, quadriplegia, and DM. Review of the Ombudsman log showed notifications for hospital transfers, but no documentation that notifications were completed for residents discharged from the facility. The SSD stated she knew to send Ombudsman notifications monthly or when a resident was sent to the hospital, but was unaware discharge notifications were required.
A facility failed to include a resident's smoking habits in their care plan, despite the resident having multiple health conditions and a history of nicotine dependence. The omission was confirmed by staff, who were aware of the resident's smoking but noted the absence of this information in the care documentation. The facility's policy requires comprehensive care plans, but this was not followed, leading to a lack of documented measures for the resident's safety when smoking.
Kitchen Hood Vent and Fan Not Kept Clean
Penalty
Summary
The facility failed to keep essential kitchen equipment clean and maintained in safe working condition in the secondary kitchen of the dining room. During an initial tour on 12/15/25 at 12:15 p.m., surveyors observed a metal hood vent located over the flat cook top and deep fryer with a yellow substance dripping along the length of the hood and running approximately five inches down the angle of the metal hood. Three lightbulbs in the top of the hood had glass bulb covers coated with the same yellow substance, including a drip hanging from the far-left bulb. When the hood vent and bulb covers were observed again on 12/16/25 at 12:56 p.m., the yellow substance was still present. During observation and interview on 12/16/25 at 2:42 p.m., surveyors observed a white, stand-up oscillating fan in the secondary kitchen with grates containing a brown/yellow substance and black and brown dust particles clinging to it. The cook stated the fan was used to cool kitchen staff when the kitchen got hot and was unsure of the cleaning schedule for the fan. The cook also stated kitchen staff removed the vent covers and cleaned them every night, but they could and should have been cleaning off the metal hood. Maintenance would have cleaned the bulb covers. The cook stated cleaning the hood and bulb covers was important to ensure grease did not drop onto food while it was being cooked. Facility policy stated all counters, shelves, and equipment shall be kept clean and maintained in good repair.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility failed to comprehensively assess safety for self-administration of medication for 1 of 2 residents who self-administered medication after set up. The resident had a quarterly MDS that identified intact cognition and diagnoses including displaced femur fracture, chronic kidney disease, congestive heart failure, and dementia. On observation, an RN placed a paper cup containing two medications on the resident’s table and left the room, and the resident stated that nurses always bring the medications and she takes them when she is ready to. The resident had an order allowing self-administration after set up, but the EMR showed the self-administration medication assessment was not completed until later and indicated the resident did not want to self-administer medications. The UC stated that when a resident wanted to self-administer medication, an assessment with observation and a provider order were needed, and confirmed the resident did not have a completed assessment supporting self-administration at the time the medications were left in the room. The DON stated there was no clear awareness of the timeframe for completing the assessment when an order for self-administration existed, though it should not go beyond a few days.
Failure to Provide Required SNFABN for Residents After Medicare Coverage Ended
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to 2 of 5 residents reviewed whose Medicare Part A coverage ended and who remained in the facility. For R7, the CMS-10123 signed as received on 8/27/25 identified a last covered day of 8/29/25, after which Medicare coverage would end. R7’s census record showed the payer source changed from Medicare Part A to private pay, and R7 remained in the facility. R7 signed a SNFABN on 8/29/25, but the notice did not include an estimated cost per day. For R16, the CMS-10123 signed as received on 10/7/25 identified a last covered day of 10/10/25, after which Medicare coverage would end. R16’s census record showed the payer source changed from Medicare Part A to Medicaid, and R16 remained in the facility. The medical record lacked evidence that a SNFABN was provided to explain the estimated cost per day or to provide a rationale or explanation of the extended care services or items to be furnished, reduced, or terminated. During interview, the admission coordinator stated the estimated cost was missed for R7, and for R16 stated the SNFABN had not yet been provided when surveyors requested it.
MDS Incorrectly Coded for Hospice Services
Penalty
Summary
The facility failed to ensure that a completed quarterly Minimum Data Set (MDS) was accurately coded to reflect hospice services for one resident reviewed for MDS accuracy. The CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual directs that Section O of the MDS be used to record special treatments, procedures, and programs received during the assessment reference date, including hospice care and dialysis. In this case, the resident's admission face sheet identified chronic kidney disease stage three and enrollment in hospice services, and the resident's diagnoses included COPD. The resident's care plan, last reviewed and revised, also indicated enrollment in a hospice program with COPD as the admitting diagnosis, and the facility matrix showed the resident was enrolled in hospice. The MDS dated [DATE] marked Section O to indicate the resident was receiving dialysis, but it did not indicate hospice services. During interview, the MDS Coordinator stated dialysis had been marked in error and that hospice should have been marked instead. The facility policy stated that the LTC Facility RAI process is used to complete a comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences, and that assessments are to be completed according to the RAI Manual and applicable CMS and state regulations.
Broken Walking Stick Not Kept in Good Repair
Penalty
Summary
The facility failed to ensure a mobility device was in good repair for one resident who had severe cognitive impairment, was independent with ambulation and transfers using a cane, and was identified as high risk for falls. The resident’s care plan indicated he ambulated independently and used a cane/staff. A progress note stated the resident was more confused than baseline, had a very unsteady gait, and had been using a walking stick that had been broken and temporarily mended for weeks; the note also stated the resident’s daughter had been told he needed a new one because of the weight he applied on it and she said it was fine. During observations, the resident was repeatedly seen with the walking stick resting against him or nearby, and the stick had clear tape wrapped around it. The spouse stated the walking stick had broken and was taped together. Later observations showed the tape had been removed, and the walking stick had a U-shaped crack about five inches long with a gluelike substance in the crack area. Maintenance stated the stick had a split along the grain of the wood and had been repaired with heavy-duty glue and an activating agent. The DON stated she had not been aware the walking stick was broken until the evening before the repair and that the resident had been using the walking stick until a cane was provided.
Failure to Perform Hand Hygiene During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure appropriate hand hygiene was completed during personal care for a resident with an indwelling urinary catheter and pressure ulcer of the sacral region. The resident’s face sheet listed urinary retention with an indwelling catheter and a pressure ulcer, and the care plan identified the resident required enhanced barrier precautions related to chronic wounds and the catheter. The care plan directed staff to wear a gown and gloves during high-contact care activities, including personal hygiene, changing briefs, toileting, and catheter care. During observation of morning cares, a nursing assistant properly donned a gown and gloves before entering the resident’s room and began providing personal care, including washing the resident, changing clothing, performing peri care, and cleansing the catheter. After soiled gloves were removed following peri care, the nursing assistant did not perform hand hygiene or replace gloves before continuing care. The nursing assistant then assisted with positioning the resident for a sling transfer, placed the catheter bag on top of the resident’s brief, and later attached the catheter bag to the wheelchair frame while still not wearing gloves. The infection control nurse/ADON stated staff were expected to perform hand hygiene before entering the room, after dirty tasks, and before donning fresh gloves, and to remove gloves and gown before exiting the room. A facility policy identified handwashing/alcohol-based hand sanitizer as the single most important means of preventing the spread of microorganisms, and the enhanced barrier precautions policy identified gown and glove use for residents with chronic wounds and indwelling medical devices, including urinary catheters. The observed care did not follow those expectations when hand hygiene and glove replacement were not completed after contaminated care tasks.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Ombudsman of resident transfers and discharge for 1 of 3 residents reviewed for discharge and/or hospitalization. The resident had an admission MDS showing admission to the facility and was cognitively intact, with diagnoses of hypertension, atrial fibrillation, end stage renal disease, quadriplegia, and diabetes. A discharge MDS showed the resident was discharged to home. Review of the October-November 2025 Ombudsman log identified residents who transferred to the hospital, but the log did not identify notification to the Ombudsman as completed for any residents who discharged from the facility. During interview, the social service director stated she had been trained to send Ombudsman notifications either monthly or each time a resident was sent to the hospital, but she was not aware of the need to inform the Ombudsman’s office of residents discharged from the facility. Facility policy Discharge Planning and Ombudsman Notification stated notice to the ombudsman is required for emergency transfers.
Failure to Document Smoking Habits in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident, identified as R54, who was admitted with multiple diagnoses including coronary artery disease, depression, anxiety, asthma, emphysema, and a history of nicotine dependence. Despite the resident's smoking habits being documented in a Smoking Risk assessment, the care plan and nursing assistant care sheet did not reflect that R54 was a smoker. This omission was confirmed during interviews with nursing staff, who were aware of R54's smoking but noted the absence of this information in the care documentation. The deficiency was identified during a survey conducted from January 6 to January 9, 2025. The surveyors noted that the care plan did not address the resident's smoking habits or provide guidance for staff, including agency pool staff, on monitoring the resident's smoking activities. The facility's policy requires that care plans be comprehensive and updated to reflect the resident's current condition, but this was not adhered to in R54's case, leading to a lack of documented measures to ensure the resident's safety and whereabouts when smoking.
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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 Milaca
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elim Wellspring Health Care Center | 13.1 mi | ★★★★★ | 2 | 0 |
| The Gardens At Foley Llc | 14.7 mi | ★★★★★ | 10 | 0 |
| St Clare Living Community Of Mora | 18.8 mi | ★★★★★ | 8 | 1 |
| Cura Of Onamia | 21.8 mi | ★★★★★ | 6 | 0 |
| Gracepointe Crossing Gables | 22.9 mi | ★★★★★ | 9 | 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.