Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Milan Health Care Center during CMS and state inspections, most recent first.
Two residents, one with cognitive impairment and another with a history of mental health conditions, were subjected to non-consensual sexual contact by another resident with moderately impaired cognition. The incidents involved inappropriate touching and exposure, with both victims displaying distress and fear following the events. Staff and care plans did not adequately address or monitor the perpetrator's behaviors, nor did they provide sufficient supervision to prevent these incidents.
The facility did not provide a full-time DON who was not also serving as a charge nurse when the census was over 60, as required by policy. Staffing records and staff interviews confirmed that on several days, there was no DON coverage due to staff shortages and the interim administrator's absence.
The facility did not maintain adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
A resident with a history of mental illness and behavioral symptoms was physically assaulted by another resident with dementia and mood disturbances, despite care plans and behavior monitoring intended to prevent such incidents. The aggressor had previously exhibited hostile behavior and targeted the victim, but staff interventions were not effective in preventing the altercation in the smoking area.
The facility failed to provide a full-time DON who did not serve as a charge nurse, despite having a census over 60 residents. The DON frequently worked as a charge nurse, violating facility policy and federal regulations. Additionally, the facility did not maintain eight consecutive hours of RN staffing on at least two occasions. Interviews revealed staffing challenges, with the DON unable to fulfill administrative duties due to working as a charge nurse.
The facility failed to maintain clean and intact ceilings in food-related areas, risking contamination. Moisture damage, flaking paint, and dust buildup were observed. Additionally, the ice machine lacked a proper air gap, posing a contamination risk. Staff were unaware of these issues, indicating lapses in oversight.
The facility failed to complete required Significant Change in Status Assessments (SCSA) for four residents after significant changes in their conditions, including cognitive decline, new diagnoses, changes in ADLs, and hospice enrollment. The MDS Coordinator was not informed of these changes due to a lack of communication, leading to non-compliance with federal regulations.
The facility failed to accurately code the MDS for four residents, resulting in discrepancies in their assessments. Inaccuracies included cognitive status, preferences, and functional limitations, with residents marked as rarely/never understood despite being alert and oriented. The MDS/Care Plan Coordinator noted past coding issues and a lack of formal training, while the Activity Director reported challenges due to frequent coordinator changes and technical issues. The Administrator expected accurate MDS completion but noted staff were not consistently conducting resident interviews.
The facility failed to update care plans for several residents, leading to deficiencies in care. One resident experienced a decline in cognitive and physical abilities, including a new pressure ulcer and colostomy, without care plan updates. Another resident's care plan lacked documentation for a PICC line used for IV antibiotics. A third resident's care plan did not reflect changes in communication and ADL needs, while a fourth resident's care plan inaccurately documented oxygen therapy and ADL independence.
The facility failed to provide adequate ADL care and hygiene for several residents, as evidenced by inconsistent shower schedules and improper perineal care. Residents were not receiving regular showers, and staff did not perform complete perineal care during incontinence episodes. Documentation was incomplete, and staffing shortages contributed to these deficiencies. The Director of Nursing and Administrator acknowledged the issues but had no plan in place to address them.
The facility failed to provide adequate nursing staff, resulting in missed showers and restorative care for residents. Observations showed residents with poor hygiene and worsening contractures due to insufficient care. Staffing levels were consistently below required numbers, with the DON and department heads covering nursing roles. The facility had previously used agency staff but was not allowed to do so at the time.
The facility failed to ensure meals were served at safe and appetizing temperatures, as required by policy. Observations and interviews revealed that several residents received meals that were not hot enough, with food temperatures not consistently checked during service. The Dietary Manager admitted that the cook did not always monitor temperatures, leading to meals being served outside the acceptable range.
The facility failed to ensure proper hand hygiene and glove use, leading to deficiencies in infection control. Staff did not wash hands between glove changes or sanitize soiled surfaces properly. Respiratory equipment was improperly stored, and medication administration lacked adherence to hygiene protocols. These actions indicate systemic issues with infection control policies.
The facility failed to accommodate the needs of two residents requiring power wheelchairs for independence. One resident, a paraplegic, was denied a power wheelchair despite having a physician's order and Medicaid approval, leaving them dependent on staff. Another resident with multiple sclerosis faced threats of having their motorized chair taken away, despite no documented safety concerns. The administrator's personal preference against motorized chairs led to these denials, contradicting the facility's policy on assistive devices.
The facility failed to provide adequate restorative nursing services to two residents, resulting in a deficiency in maintaining or improving their range of motion and mobility. Resident #30, who is paraplegic, and Resident #55, who has severe cognitive impairment, both required passive range of motion exercises. However, the facility's records showed inconsistent documentation and a lack of comprehensive restorative plans. Interviews revealed that staffing shortages led to the restorative aide being frequently pulled to work as a CNA, contributing to the lack of consistent care.
A facility failed to prevent residents from accessing fire-starting materials, resulting in two fire incidents in a shared room. Staff detected a fire in the bathroom trash can, which a resident extinguished, but later a second fire occurred in a box on one resident's side. The residents had significant medical and behavioral histories, including schizophrenia and COPD, and were listed as unsupervised smokers despite care plans indicating the need for supervision. Staff interviews revealed lapses in monitoring and enforcement of the smoking contraband policy.
The facility failed to report an alleged sexual abuse incident involving two residents to the state agency. A nurse aide found a resident in another's room, leading to concerns of sexual activity. Despite staff reporting the incident to an LPN and the ADON, it was not reported to the state agency as required. The residents involved had diagnoses of dementia and Alzheimer's disease.
The facility failed to investigate an alleged sexual abuse incident between two residents. Despite staff concerns, the LPN and ADON dismissed the situation as exaggerated and did not conduct necessary interviews with other residents or staff. The Director of Nursing and Administrator were unaware of the incident's seriousness, resulting in a deficiency in addressing the alleged abuse.
A resident with impaired cognition and mobility needs was not safely secured in a transport van, leading to an accident. The resident slid out of the wheelchair due to unsecured front wheels and an improperly positioned seatbelt. The incident resulted in minor injuries and a hospital evaluation, revealing no acute injuries but existing degenerative spondylosis.
The facility failed to protect two residents from sexual abuse by not assessing their capacity to consent to sexual activity. Both residents had cognitive impairments and legal guardians, with one having a history of hypersexual behavior. Staff observed inappropriate behaviors but did not implement specific interventions until after the residents were found naked in bed together.
The facility failed to thoroughly investigate an allegation of sexual abuse between two residents, neglecting to interview other residents and all staff present. Both residents had histories of cognitive impairment and inappropriate behavior. The DON was aware of escalating behavior but did not implement specific interventions.
Failure to Protect Residents from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect two residents from sexual abuse by another resident, resulting in two separate incidents involving non-consensual sexual contact. In the first incident, a resident with a history of bipolar disorder, anxiety, and major depressive disorder, who was cognitively intact, reported that another resident with moderately impaired cognition grabbed their breast without consent while they were outside in the courtyard. The victim expressed fear of being alone and of further encounters with the perpetrator. The incident was witnessed by another resident, and the victim was visibly distressed when recounting the event. Approximately four hours after the first incident was reported, staff discovered another resident, who had dementia and impaired cognition, in the perpetrator's room. This resident was found sitting on the bed with their shirt pulled up, exposing their breasts, and their pants were on inside out. The resident was distraught and tearful, refused to return to their room, and instead stayed in the common area overnight. Staff interviews and documentation confirmed that this resident required moderate to maximal assistance with activities of daily living and had no prior behaviors of wandering or entering other residents' rooms. The facility's records and staff interviews revealed that the perpetrator had previously made inappropriate sexual comments and advances toward other residents, including discussing sexually explicit material and making repeated requests for relationships despite being told no. The care plans for the involved residents did not address these behaviors or provide adequate interventions to prevent such incidents. Staff were not monitoring the perpetrator closely enough after the initial report of abuse, and there was a lack of supervision for the cognitively impaired resident who was later found in the perpetrator's room. These failures led to both residents being subjected to non-consensual sexual contact.
Failure to Provide Full-Time DON Coverage When Census Exceeded 60
Penalty
Summary
The facility failed to provide a full-time Director of Nursing (DON) who did not serve as a charge nurse when the facility census exceeded 60 residents, with the census documented at 86 and 87 on the affected dates. Review of staffing sheets revealed that there was no DON coverage on multiple dates in June 2025. Interviews with the DON and administrator confirmed that the DON had been reassigned to charge nurse duties due to staffing shortages, and the interim administrator, who was acting as DON, was absent from the facility for several days, resulting in no DON coverage during those times. The facility's own policy required a full-time DON, and this requirement was not met on the specified dates.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that the required staffing levels and licensed nurse coverage were not consistently maintained as mandated.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident involved a resident with a history of encephalopathy, bipolar II disorder, schizoaffective disorder, and anxiety disorder, who was at risk for aggression and behavioral symptoms, including wandering and verbal aggression. The care plan for this resident included interventions to avoid confrontation and to intervene as necessary to protect the safety of others. Despite these measures, the resident was physically assaulted by another resident who struck them multiple times in the face. The resident who committed the assault had diagnoses of generalized anxiety disorder, major depressive disorder, and dementia, and was noted to have impaired thought processes and mood disturbances with agitation. Prior to the incident, this resident had exhibited aggressive and hostile behaviors, including yelling, using profanity, and threatening others. Behavior monitoring and increased assessment were implemented, but staff were unable to redirect the resident effectively during behavioral crises. On the day of the incident, the resident admitted to hitting the other resident after a confrontation in the smoking area. Interviews with staff and other residents revealed that the aggressor had a history of targeting the victim and had previously intervened in altercations involving the victim and other residents. Staff were aware of the behavioral issues and previous incidents but did not anticipate the physical altercation. The facility's abuse and neglect policy required identification and intervention for residents at risk of abuse or with behaviors that could lead to conflict, but these measures were insufficient to prevent the incident.
Staffing Deficiencies and DON Role Mismanagement
Penalty
Summary
The facility failed to provide a full-time Director of Nursing (DON) who did not serve as a charge nurse, despite having a census over 60 residents. The facility's policy required a full-time DON and stipulated that the DON could only serve as a charge nurse when the facility's average daily occupancy was 60 or fewer residents. However, the facility's staffing sheets revealed that the DON frequently worked as a charge nurse, even when the census was as high as 98. This was a clear violation of the facility's policy and federal regulations. Additionally, the facility did not maintain eight consecutive hours of Registered Nurse (RN) staffing daily on at least two occasions. On January 11 and 12, 2025, the staffing sheets showed no RN coverage for eight consecutive hours, which is a requirement for the facility. The facility's assessment indicated that federal regulations required 3.48 hours per resident day of direct care, with 0.55 hours from RNs, but the facility failed to meet this requirement on those days. Interviews with the DON and the administrator revealed that the facility had been struggling with staffing issues. The DON reported working almost every day as a charge nurse and being unable to fulfill her administrative duties. The facility had previously relied on agency staff to fill charge nurse roles, but this practice stopped on January 1, 2025. The administrator confirmed that the DON worked the floor most of February and was only able to perform her DON role for two days that month. The Regional Director of Operations acknowledged the staffing challenges and mentioned the possibility of bringing agency staff back to the facility.
Ceiling Maintenance and Ice Machine Drain Deficiencies
Penalty
Summary
The facility failed to maintain the cleanliness and condition of ceilings in critical areas such as the dishwasher room, dry food storage room, and above food preparation and serving areas, which could potentially lead to food contamination. Observations revealed moisture damage and dark stains on the ceiling in the dry food storage room, cracked and flaking paint in the dishwasher room, and dust and debris buildup around ceiling vents above the steam table. The Dietary Manager was unaware of these issues, and the Maintenance Director acknowledged the problem but indicated that the maintenance department was responsible for repairs and cleaning, which were not being conducted as frequently as needed. Additionally, the facility did not maintain a proper air gap for the ice machine drain in the dining room, which could lead to contamination. The ice machine's drain pipes extended below the flood rim level of the floor drain, lacking the necessary air gap. The Maintenance Supervisor was unaware of this deficiency, and the Administrator expected the ice machine to have an air gap and the kitchen ceilings to be clean and well-maintained, indicating a lapse in oversight and adherence to facility policies.
Failure to Complete Significant Change Assessments
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for four residents following significant changes in their conditions. The SCSA is a federally mandated assessment tool that must be completed within 14 days after a significant change in a resident's condition is identified. This failure was identified during a review of 24 sampled residents, where four residents experienced significant changes in their health status, including cognitive decline, new diagnoses, changes in activities of daily living (ADLs), and enrollment in hospice care, without the required SCSA being completed. Resident #18 experienced a decline in cognitive function, new diagnoses including pneumonia and a Stage III pressure ulcer, and a decline in ADLs, yet no SCSA was completed. Resident #36 had new delusions, a new diagnosis of bipolar disorder, increased incontinence, significant weight loss, and new IV access, but the facility did not complete an SCSA. Resident #59 had a new diagnosis of pneumonia, cognitive decline, increased pain, significant weight loss, and was placed on hospice care, but the SCSA was not completed within the required timeframe. Resident #79 was admitted to hospice care, but the facility failed to complete the SCSA within 14 days of the hospice start date. The MDS Coordinator, responsible for completing these assessments, was not informed of the hospice admission due to a lack of communication, as daily nursing meetings were not occurring. This lack of communication and oversight led to the failure to complete the necessary assessments, resulting in a deficiency in the facility's compliance with federal regulations.
Inaccurate MDS Coding Leads to Assessment Discrepancies
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for four residents, leading to discrepancies in their assessments. The MDS, a federally mandated assessment tool, was not completed in accordance with the Resident Assessment Instrument (RAI) manual. This resulted in inaccurate reflections of the residents' cognitive status, preferences, and functional limitations. For instance, Resident #30 was marked as rarely/never understood in some sections, despite being alert and oriented during an interview. Similarly, Resident #33, who had severe cognitive impairment, was marked as somewhat important for all preferences, although the resident was unable to consistently answer questions. Resident #36's MDS indicated cognitive intactness, but the resident had multiple diagnoses, including dementia and traumatic brain injury, which could affect cognitive function. The resident's preferences were marked as somewhat important, despite expressing differing interests during an interview. Resident #71's MDS showed inconsistencies in functional limitations and hospice status, with no documentation to support significant changes. The resident was observed with visible limitations in range of motion, contradicting the MDS entries. The facility's MDS/Care Plan Coordinator acknowledged issues with past MDS coding and noted a lack of formal MDS training. The Activity Director also reported challenges with MDS completion due to frequent changes in MDS coordinators and technical issues with data transfer. The Administrator expected accurate MDS completion but noted that staff were not consistently leaving their offices to conduct resident interviews, contributing to the inaccuracies.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans to reflect the current care needs of four residents, leading to deficiencies in their care. Resident #18 experienced a significant decline in cognitive and physical abilities, including the development of a Stage III pressure ulcer, a new urinary catheter, and a colostomy following hospitalization. Despite these changes, the resident's care plan was not updated to reflect the new conditions and care requirements, such as the need for mechanical transfer and increased assistance with activities of daily living (ADLs). Resident #25's care plan did not address the presence or care of a peripherally inserted central catheter (PICC) line, despite the resident receiving intravenous antibiotics for a wound through the PICC line. The resident's quarterly Minimum Data Set (MDS) indicated the use of intravenous access and medications, yet the care plan lacked documentation of these critical medical interventions. Resident #33's care plan was outdated and did not reflect changes in the resident's communication abilities, ADL assistance needs, and ambulatory status. Observations showed the resident with disheveled hair, unshaven, and wearing wet clothing, indicating inadequate personal hygiene care. Similarly, Resident #54's care plan was not updated to reflect changes in oxygen therapy requirements and the need for assistance with ADLs following hospitalization. The care plan inaccurately documented the resident's independence in ADLs and did not address the correct oxygen settings or the use of a BiPAP machine.
Deficiencies in ADL Care and Hygiene Practices
Penalty
Summary
The facility failed to provide adequate care and assistance for activities of daily living (ADLs) to six residents who were unable to perform these tasks independently. Observations and interviews revealed that residents were not receiving necessary personal hygiene care, including regular showers and proper perineal care. For instance, one resident was observed to have not received a shower for 21 days, despite being scheduled for two showers per week. Another resident was found with greasy hair and flaky skin, indicating a lack of regular bathing. Additionally, staff failed to perform complete perineal care during incontinence episodes, as evidenced by the use of only toilet paper instead of soap and water or appropriate peri-care products. The facility's documentation was inconsistent and incomplete, with several instances where there was no record of showers being offered or refused. Residents expressed dissatisfaction with the frequency and timing of showers, and some reported feeling frustrated due to the lack of control over their personal care schedules. Staff interviews confirmed that there were not enough personnel to meet the scheduled shower requirements, and department heads were not assisting with showers as expected. This lack of staffing and support contributed to the failure to provide adequate ADL care. Furthermore, the facility's policies on incontinence care and shower schedules were not consistently followed. Residents were found wearing double incontinence products, which is against facility policy, and were not being checked and changed every two hours as required. The Director of Nursing and the Administrator acknowledged these deficiencies, noting that recent staffing shortages had impacted the ability to provide the necessary care. Despite these acknowledgments, the facility did not have a plan in place to address these issues at the time of the report.
Inadequate Staffing Leads to Missed Care in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by the lack of routine showers and restorative nursing care for several residents. Observations and interviews revealed that residents were not receiving scheduled showers, leading to poor personal hygiene. For instance, one resident, who was dependent on staff for showers due to paraplegia, only received one shower in February and none in early March, despite being scheduled for two showers per week. Another resident with severe cognitive impairment received only two out of eight scheduled showers over a month-long period, with no documentation of refusals. Additionally, the facility did not provide adequate restorative nursing care to prevent the decline in residents' activities of daily living and worsening contractures. One resident with paraplegia and contractures was supposed to receive passive range of motion (PROM) exercises three times a week but reported receiving them sporadically, sometimes going weeks without any restorative care. The resident expressed concerns about worsening contractures and increased spasms due to the lack of consistent care. Another resident with severe cognitive impairment and functional limitations in range of motion was scheduled for daily PROM but had numerous gaps in the documentation, indicating missed sessions. The facility's staffing levels were consistently below the required numbers to meet residents' needs, as documented in the facility's staffing sheets. The Director of Nursing (DON) and other department heads often had to cover nursing roles due to staff shortages. The facility had previously used agency staff to fill gaps but was not allowed to do so at the time of the report. Interviews with the DON and other staff confirmed the ongoing staffing challenges, which directly impacted the facility's ability to provide necessary care to residents.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to adhere to its policy regarding the monitoring and serving of food at safe and appetizing temperatures, resulting in a deficiency. Observations and interviews revealed that residents frequently received meals that were not served at the appropriate temperatures. Several residents reported that their meals were often cold or not hot enough, whether they ate in the dining room or in their rooms. The facility's policy required staff to record food temperatures at the beginning and during the tray line service, and to reheat or chill food items if they did not meet acceptable serving temperatures. However, staff did not consistently check food temperatures during meal service, as evidenced by the test tray showing the tuna noodle casserole at 118.2 degrees Fahrenheit and the tossed salad at 77.0 degrees Fahrenheit, both outside the acceptable temperature range. The Dietary Manager acknowledged that the cook did not always check food temperatures midway through meal service, and the Administrator confirmed the expectation for hot foods to be served hot and cold foods to be served cold. Despite the initial cooking temperatures being within acceptable parameters, the failure to monitor and maintain these temperatures during service led to the deficiency. The facility census was 98, and the issue affected multiple residents, as indicated by their complaints about the temperature of their meals.
Infection Control Deficiencies in Hand Hygiene and Equipment Handling
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove use among nursing staff, leading to multiple deficiencies in infection prevention and control. Observations revealed that staff did not wash their hands after direct resident contact and between glove changes. For instance, a nurse assistant was observed handling soiled incontinence briefs and cleaning feces from surfaces without changing gloves or washing hands. This practice was repeated across different residents, with staff failing to perform hand hygiene before and after glove use, and touching clean surfaces with soiled gloves. Additionally, the facility did not ensure that soiled surfaces were sanitized appropriately. A nurse assistant was observed using perineal wipes to clean feces from surfaces, unaware of the need to use a disinfectant. This lack of proper sanitation was compounded by the improper handling of respiratory care supplies. A resident's BiPAP and nebulizer equipment were found unbagged and improperly stored, with the BiPAP mask even touching the floor, which was not addressed by the staff. Furthermore, the facility failed to adhere to infection control protocols during medication administration. A registered nurse was observed administering insulin without performing hand hygiene between glove changes and after handling the glucometer. Similarly, a certified medication technician administered eye drops without wearing gloves. These actions indicate a systemic issue with adherence to infection control policies, as confirmed by interviews with staff who acknowledged the lapses in hand hygiene and glove use.
Facility Fails to Accommodate Residents' Need for Power Wheelchairs
Penalty
Summary
The facility failed to accommodate the needs and preferences of residents requiring power wheelchairs for independence, as evidenced by the experiences of two residents. Resident #30, who is paraplegic and cognitively intact, was denied assistance in obtaining a power wheelchair despite having a physician's order and Medicaid approval. The facility administrator forbade power chairs, citing safety concerns, and suggested the resident move to another facility. This decision left Resident #30 feeling hopeless, discriminated against, and dependent on staff for mobility, as the resident was confined to a geri chair that required staff assistance for movement. Resident #11, who uses a motorized chair due to multiple sclerosis and is cognitively intact, faced threats from the administrator to have their chair taken away. The resident's medical records showed no documented safety concerns or incidents of running into others, contrary to the administrator's claims. The resident's driving assessment indicated they could drive with some difficulty, but no specific pass or fail criteria were noted. The lack of mirrors and speed adjustments recommended in the assessment were not addressed, and the resident expressed concerns about losing independence and becoming more depressed without the chair. The facility's policy on the use of assistive devices emphasizes the importance of providing necessary equipment to maintain or improve residents' function and dignity. However, the administrator's actions contradicted this policy by preventing residents from using power wheelchairs, which are essential for their independence. The therapy director confirmed that the residents were eligible for power chairs and that therapy could assist in ensuring safe use, but the administrator's personal preference against motorized chairs led to the denial of these necessary accommodations.
Inadequate Restorative Nursing Services for Residents
Penalty
Summary
The facility failed to provide adequate restorative nursing services to two residents, resulting in a deficiency in maintaining or improving their range of motion and mobility. The facility did not adhere to its policy of developing comprehensive restorative plans that include specific interventions, measurable goals, and documentation of the services provided. This failure was observed in the cases of two residents, both of whom had significant physical impairments requiring restorative care. Resident #30, who is paraplegic and uses a gerichair for mobility, was supposed to receive passive range of motion (PROM) exercises as part of their care plan. However, the facility's records showed inconsistent documentation of these exercises, with no clear indication of the frequency, duration, or specific goals of the interventions. The resident reported experiencing increased spasms and worsening contractures, indicating a lack of consistent restorative care. The facility's documentation did not reflect any refusals of care by the resident, suggesting that the services were simply not provided as required. Similarly, Resident #55, who has severe cognitive impairment and functional limitations due to a stroke, was also supposed to receive daily PROM exercises. The facility's records showed numerous gaps in the documentation of these exercises, with no evidence of refusals by the resident. The facility failed to maintain a restorative plan of care that included specific interventions and goals, and there was no documentation of regular evaluations by the Restorative Nurse. Interviews with staff revealed that the restorative aide was frequently pulled to work as a CNA due to staffing shortages, which contributed to the lack of consistent restorative care for the residents.
Failure to Prevent Fire Hazards in Resident Room
Penalty
Summary
The facility failed to provide protective oversight to prevent residents from having materials to start a fire, leading to two fire incidents in a shared room. On the first occasion, staff detected an odor and discovered a small fire in the bathroom trash can, which a resident claimed to have extinguished with water. Despite a search, no lighter was found, but cigarettes and ashes were discovered in the room. Shortly after, a second fire occurred, originating from a box on one resident's side of the room, prompting a Code Red and evacuation of residents. The residents involved had significant medical and behavioral histories. One resident had diagnoses including depression, schizophrenia, and mild cognitive impairment, with a care plan indicating a need for supervision while smoking. The other resident had paranoid schizophrenia and COPD, with a history of hiding lighters and saving cigarette butts. Despite these risks, both residents were listed as unsupervised smokers, contrary to their care plans and smoking safety evaluations. Interviews with staff revealed lapses in monitoring and enforcement of the facility's smoking contraband policy. Staff were aware of the residents' tendencies to sneak cigarette butts and lighters but failed to maintain adequate supervision or conduct thorough searches. The facility's policy required residents to turn in smoking materials, but this was not effectively enforced, contributing to the incidents.
Failure to Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents to the state agency. The incident occurred when a nurse aide entered a resident's room and found another resident standing beside the bed, zipping up their pants. The staff involved reported the incident to a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON), but the ADON did not instruct the LPN to report the incident to the state agency, believing the situation was exaggerated. Resident #1, who was involved in the incident, had a diagnosis of unspecified dementia and bipolar disorder, and was noted to have communication problems related to dementia. Resident #2, who was new to the facility, had a diagnosis of early onset Alzheimer's disease and dementia. Despite the concerns raised by the staff, the ADON assumed nothing had happened after asking Resident #1 if they felt safe and receiving a positive response. The Director of Nursing and the Administrator both stated that they would expect an allegation of sexual abuse to be reported to the state agency. However, due to the ADON's decision not to report the incident, the facility failed to comply with its policy to report all allegations of abuse immediately to the appropriate authorities.
Failure to Investigate Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation of an alleged sexual abuse incident involving two residents. The incident occurred when a nurse aide entered a resident's room and found another resident standing beside the bed, zipping up their pants. Despite the aides' concerns and reports to the Licensed Practical Nurse (LPN) and Assistant Director of Nursing (ADON), the facility did not conduct interviews with other residents or all staff present at the time of the incident. The facility's policy requires a comprehensive investigation of all abuse allegations, including obtaining personal statements from involved staff and residents, and ensuring the resident's safety and well-being. However, the LPN and ADON dismissed the aides' concerns as exaggerations and did not follow through with the necessary investigative steps. The ADON only asked one resident if they felt safe and assumed nothing had happened without further inquiry. The Director of Nursing and the Administrator were not aware of the incident's seriousness and did not ensure that the facility's abuse policy was followed. The lack of a proper investigation and failure to interview all relevant parties led to a deficiency in addressing the alleged abuse incident, leaving the residents' safety and well-being potentially compromised.
Failure to Secure Resident in Transport Van
Penalty
Summary
The facility failed to ensure the safe transport of a resident in a wheelchair within the facility van, leading to an accident. The resident, who had severely impaired cognition and required moderate assistance for transfers, was being transported from the hospital back to the facility. During the transport, the resident slid out of the wheelchair when the van turned into the facility's parking lot. The resident's wheelchair was not equipped with foot pedals, and the front wheels were not secured, which contributed to the incident. The resident was found lying on their left side in the van, with a skin abrasion on the left elbow and complaints of neck pain. The wheelchair's back wheels were secured, and the shoulder/lap belt was still in place, but the seatbelt was incorrectly positioned over the armrests instead of under them. The transporter, who had been trained by a previous staff member, did not secure the front wheels of the wheelchair, which was a critical oversight. The incident was reported by the transporter, and emergency services were called to assist the resident, who was then taken back to the hospital for evaluation. The hospital report indicated that the resident had no acute injuries but showed signs of degenerative spondylosis in the cervical spine. The facility did not have a policy in place for securing residents in the transport van, which contributed to the deficiency.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect two residents' right to be free from sexual abuse. Staff observed the residents engaging in sexual activities without assessing their capacity to consent. Both residents had legal guardians and cognitive impairments, with one resident having a history of hypersexual behavior. Despite these factors, the facility did not complete the required assessments to determine their ability to consent to sexual activity before the incident occurred. Resident #1 had a history of wandering and incarceration related to sexual behaviors. The resident's quarterly Minimum Data Set (MDS) indicated severely impaired cognition. Staff documented multiple instances of Resident #1 wandering into other residents' rooms and being inappropriate with Resident #2. On the evening of 4/28/24, staff found Resident #1 and Resident #2 naked in bed together. The facility initiated 15-minute checks and completed a capacity to consent assessment only after the incident. Resident #2 had a history of hypersexual behavior and was under guardianship. The resident's medical records indicated periods of mania, disrobing, and delusional beliefs. Staff observed Resident #2 engaging in attention-seeking behaviors towards Resident #1, including holding hands and sitting close together. Despite these observations, no specific interventions were put in place until after the incident. The facility's failure to assess the residents' capacity to consent and implement appropriate interventions led to the deficiency.
Failure to Thoroughly Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of sexual abuse between two residents. The investigation did not include interviews with other residents to assess if they felt safe or had been subjected to or witnessed abuse. Additionally, not all staff present at the time of the alleged incident were interviewed. The facility's census was 89 at the time of the incident. Resident #1, who was admitted with diagnoses including unspecified dementia and vascular dementia, was assessed as having severely impaired cognition and had a history of inappropriate behavior. Resident #2, admitted with diagnoses including bipolar disorder and vascular dementia, had a history of hypersexual behavior and delusional beliefs. On the evening of the incident, both residents were found undressed in Resident #1's bed, engaging in consensual acts according to their statements. The Director of Nursing (DON) was aware of the escalating affectionate behavior between the two residents but did not implement specific interventions. After the incident, the DON interviewed the involved residents and one staff member but did not interview other residents or all staff present. The facility's abuse and neglect policy mandates immediate reporting and thorough investigation of all allegations, which was not fully adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Milan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Putnam County Care Center | 21.3 mi | ★★★★★ | 4 | 0 |
| Eastview Manor Care Center | 25.8 mi | ★★★★★ | 7 | 0 |
| Sunnyview Nursing Home & Apartments | 25.9 mi | ★★★★★ | 10 | 1 |
| Brookfield Health Care Center | 27.4 mi | ★★★★★ | 4 | 0 |
| Pearl's Ii Eden For Elders | 27.9 mi | ★★★★★ | 0 | 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.