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 Milton Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to notify resident representatives of significant changes in condition and care for three cognitively impaired residents, despite a policy requiring notification of the resident, MD, and representative. One resident with dementia and traumatic brain injury experienced multiple episodes of large emesis, blood in stool, and full body tremors with slurred speech, with no documented contact to the representative. A second resident with dysphagia and Alzheimer’s disease had vomiting, MD notification, and progressive weight loss over several months with dietary changes, but no documented notification of the representative about these changes. A third resident with CAD, diabetes, and dementia had repeated diarrhea, skin excoriation, abnormal stool characteristics, and new lab orders, again without documentation that the representative was informed. The NHA and DON acknowledged that representatives were not notified in these cases.
Three residents with significant physical and cognitive impairments were found to have their call bells placed out of reach or inaccessible, despite care plans requiring call bell accessibility and encouragement to use it for assistance. Observations included call bells being placed at the head of the bed, covered by blankets, clipped to the mattress perimeter, or hidden under personal items, preventing residents from calling for help when needed.
The facility's main kitchen had multiple sanitation issues, including food splatter, dirt buildup, and improper storage practices. Additionally, there was a failure to monitor dishwasher temperatures for optimal sanitization on specific days, as confirmed by a staff member.
The facility failed to adhere to physician orders and care plans for several residents. A resident with severe malnutrition did not receive ordered weekly weight checks. Another resident with dysphagia was not positioned out of bed for meals as required, despite documentation indicating compliance. Additionally, two residents with CHF were not monitored for significant weight changes as ordered, with no physician notifications made for numerous instances of weight fluctuations.
The facility failed to provide necessary dental services for three residents, resulting in unresolved dental issues. One resident experienced jaw swelling and tooth pain but was not referred to an oral surgeon as recommended. Another resident was not seen by an oral surgeon despite repeated referrals and complaints of pain. A third resident did not receive recommended fluoride treatment and faced scheduling issues for oral surgery. These deficiencies were identified through interviews and record reviews.
A resident was observed multiple times with an uncovered catheter bag full of urine hanging under his wheelchair, compromising his dignity. The issue was addressed only after a surveyor's intervention.
The facility failed to maintain a clean and homelike environment in the West Side Nursing Unit. Observations revealed a significant build-up of a black substance on an air unit, debris accumulation on a resident lift, and various debris in a canvas storage bag. The shower stall had black stains, dead insects, and a stained shower curtain. These issues were reported to a nurse aide and the DON.
The facility failed to ensure accurate assessments for four residents, leading to discrepancies in clinical records. Two residents were incorrectly documented as receiving insulin, while another had dental issues not reflected in their MDS. Additionally, a resident's discharge location was inaccurately recorded.
A resident requiring partial/moderate assistance for bathing did not receive showers for over a month after admission, despite preferences documented in their clinical record. The facility's task documentation showed no showers were provided, and there were no refusals recorded. The DON confirmed the absence of documentation for the resident's showers.
A facility failed to provide trauma-informed care for a resident with PTSD, as they did not identify triggers or collaborate with the resident and relevant parties to develop interventions. The care plan was delayed and lacked specific measures to prevent re-traumatization until the issue was highlighted.
The facility failed to secure and label medications properly on the West Side Nursing Unit. Unlabeled pills were found in the medication cart, and the LPN was unaware of their origin or duration in the cart. Additionally, the cart had peeling adhesive tape with debris, and the LPN could not confirm how long it had been there or how it was cleaned. These issues were discussed with the DON.
Failure to Notify Resident Representatives of Changes in Condition and Care
Penalty
Summary
The deficiency involves the facility’s failure to notify residents’ representatives or responsible parties of changes in condition or care, as required by facility policy and state regulations. The facility’s policy titled “Change in Condition,” dated 6/1/25, states that the resident, attending physician, and representative must be notified of changes in the resident’s medical or mental condition and/or status. Surveyors reviewed clinical records and staff interviews and determined that this notification did not occur for three of seven residents reviewed, all of whom had severe cognitive impairment and therefore relied on their representatives for information and decision-making. For one resident with diagnoses including hypertension, dementia, and traumatic brain injury, the MDS showed severe cognitive impairment. Progress notes documented multiple significant clinical events: a large episode of emesis on 1/3/26; a report on 1/7/26 of a small amount of blood in the stool; an episode on 3/5/26 of full body tremors and slurred speech with MD notification via communication paper; and multiple episodes of large, projectile brown emesis on 3/15/26 treated with Zofran. In each of these instances, review of the progress notes did not show any documentation that the resident’s representative or responsible party was notified of these changes in condition. For a second resident with dysphagia and Alzheimer’s disease and severe cognitive impairment, a progress note on 2/9/26 documented vomiting, holding of medications, and MD notification, but there was no documentation that the resident’s representative was notified. Weight change notes showed a five‑pound loss between 11/17/25 and 12/17/25, a 7.7% loss by 2/9/26 with continued decline in oral intake and a recommendation for an enhanced diet, and a 10.4% loss by 3/6/26 with continued dietary interventions; however, there was no documentation that the representative was notified of the ongoing weight loss. For a third resident with coronary artery disease, diabetes, and dementia and severe cognitive impairment, progress notes documented episodes of diarrhea on 12/17/25, excoriation to the sacrum and groin later that day, abnormal stool characteristics and a new liver profile lab order on 12/22/25, and continued loose stools on 1/9/26. In each of these events, the progress notes lacked evidence that the resident’s representative or responsible party was notified. The Nursing Home Administrator and DON confirmed that the facility failed to notify representatives for these three residents.
Failure to Ensure Call Bell Accessibility for Multiple Residents
Penalty
Summary
The facility failed to accommodate the needs of three residents regarding the accessibility of their call bells, as identified through clinical record review, observation, and interviews. For one resident with dementia, blindness, muscle weakness, and unsteadiness, the care plan required the call bell to be within reach and encouraged its use for assistance. However, observations showed the resident was seated in a wheelchair at the foot of the bed, with the call bell placed at the head of the bed, at least six feet away and later covered by blankets, making it inaccessible. The resident was heard loudly calling for assistance, indicating the inability to use the call bell. Another resident with muscle wasting, unsteadiness, and a history of falls had a care plan instructing staff to keep the call bell and frequently used objects within reach. During observation, the resident was lying in bed and unable to locate the call bell, which was clipped to the outer perimeter of the mattress and hanging away from the bed, out of the resident's reach. The resident attempted to search for the call bell but was unsuccessful in accessing it. A third resident with dementia, repeated falls, and muscle weakness also had a care plan requiring the call bell to be within reach. Observation found this resident sitting in a wheelchair at the foot of the bed, with the call bell not visible and later discovered underneath a large stuffed animal at the head of the bed, making it inaccessible. The care plan did not include any intervention regarding the resident's preference for call bell placement. These findings were reviewed with the Nursing Home Administrator, confirming the lack of accommodation for resident needs regarding call bell accessibility.
Sanitation and Monitoring Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the main kitchen, as observed during a survey. The right side of the food steamer was covered in dried food splatter, and the flooring under the steamer, two-door cooler, and stove area contained a buildup of dirt, dried food, and debris. Potholders in the meal service area were blackened and stained, and dust and debris were present on the shelves in the dry storage area. Additionally, a set of plastic risers in the dry storage area had crumbs and debris in the crevices, and a lunch bag used for residents going out for dialysis was improperly placed, causing a wet area on the riser. Peeling paint was noted on the walls in the dry storage area, and a ceiling light cover was broken. The walk-in freezer had dust buildup on wire shelving units, and a pork loin was found on the floor. Dust was also observed on condenser units in the walk-in coolers, and a wooden shelf used for meal services was damaged. Furthermore, the facility did not adequately monitor dishwasher temperatures to ensure optimal sanitization. Although a completed log for October 2024 was available, there was no evidence of temperature checks for November 1 or 2, 2024, despite washing resident tray items and food service items on those days. Employee 3 confirmed the absence of a new form for November and acknowledged the lack of monitoring. These deficiencies were reviewed with the Director of Nursing.
Failure to Follow Physician Orders and Care Plans
Penalty
Summary
The facility failed to provide the highest practicable care for several residents, as evidenced by deficiencies in following physician orders and care plans. For Resident 84, who was diagnosed with severe protein-calorie malnutrition, the facility did not complete the physician-ordered weekly weights despite a significant weight loss being documented. The care plan aimed to maintain the resident's nutritional status, but the lack of adherence to the weight monitoring order was confirmed by both the nutritional technician and the Director of Nursing. Resident 105, who had diagnoses including dysphagia and cognitive impairment, was not positioned out of bed for meals as per physician orders and speech therapy recommendations. Despite documentation indicating compliance, observations showed the resident eating meals in bed, which contradicted the orders meant to facilitate safe swallowing. There was no documentation of the resident refusing to be out of bed or any reason for not following the orders. For Residents 22 and 51, both with orders for daily weights due to congestive heart failure, the facility failed to notify the physician of significant weight changes on multiple occasions. The orders required notification of weight changes of three pounds in a day or five pounds in a week, but this was not done on numerous specified dates. These failures were acknowledged during interviews with the Director of Nursing.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for three residents, leading to deficiencies in their care. Resident 63 experienced jaw swelling and tooth pain, and although the dentist recommended a referral to an oral surgeon for extractions, the facility did not follow through with the referral. Despite multiple visits to the dentist and a prescription for antibiotics, the resident's condition was not adequately addressed, as they had not seen an oral surgeon by the time of the survey. Similarly, Resident 46 was referred to an oral surgeon for extractions but had not been seen by one despite repeated dental visits and complaints of tooth pain. The facility also failed to implement the dentist's recommendation for Resident 36 to use a high-concentrate fluoride toothpaste, and despite attempts to schedule an appointment with a medical facility oral surgeon, the resident had not received the necessary dental care. These failures were identified during interviews with the residents and staff, and through clinical record reviews.
Failure to Maintain Resident Dignity with Uncovered Catheter Bag
Penalty
Summary
The facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one resident. Observations on November 3, 2024, revealed that the resident was seen wheeling himself down the hallway, participating in an activity, and outside his room with an uncovered catheter bag full of urine hanging under his wheelchair. This situation persisted throughout the day, indicating a lack of attention to the resident's dignity and privacy. An interview with the resident confirmed that the facility only placed a catheter bag covering after the surveyor discussed the issue with him on November 4, 2024. The findings were reviewed with the Director of Nursing on November 5, 2024.
Deficiency in Maintaining a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in the West Side Nursing Unit. During an observation, a white air unit on the ceiling in the resident hallway near the nurse's station was found to have a significant build-up of a black-colored substance on the interior vents. Additionally, in the shower room, a resident lift had a substantial accumulation of debris on the standing pad, and the attached canvas storage bag contained various debris, including partially dissolved pill-like objects, an open elastic bandage, an exam glove, a crushed plastic cup, and other unidentified dirt. The shower stall had black dot-like stains on the perimeter wall where it met the floor, multiple dead winged insects on the exterior of the light, and a shower curtain with multiple black stains, particularly near the bottom. These findings were communicated to a nurse aide and the Director of Nursing.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate assessments for four residents, leading to discrepancies in their clinical records. For Resident 84, a quarterly Minimum Data Set (MDS) assessment inaccurately indicated that the resident received insulin during the assessment period, despite no evidence supporting this in the clinical records. This was confirmed by Employee 4, the registered nurse assessment coordinator. Similarly, Resident 113's significant change MDS also incorrectly noted insulin administration, which was not supported by the clinical records, as confirmed by the same employee. Resident 63's annual MDS inaccurately reported no dental issues, despite prior documentation of jaw swelling and a broken molar. Additionally, Resident 115's discharge MDS incorrectly stated that the resident was discharged to an acute care hospital, while social service documentation indicated discharge to home with family. These inaccuracies were discussed with the Director of Nursing during the surveyor's interviews.
Failure to Provide Bathing Assistance
Penalty
Summary
The facility failed to provide necessary bathing support for a resident who required staff assistance. Resident 57, admitted on August 29, 2024, reported not receiving a shower for the first month of his stay. His clinical record, including the Minimum Data Set (MDS) assessment dated September 5, 2024, indicated that he required partial/moderate assistance for bathing due to conditions such as spina bifida and paraplegia. Despite his preference for showers on Mondays and Thursdays, task documentation showed that he did not receive a shower from August 29 to October 6, 2024, with no documented refusals. These findings were confirmed during a meeting with the Director of Nursing on November 5, 2024, who acknowledged the lack of documentation indicating that Resident 57 received showers according to his preference.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with chronic Post-Traumatic Stress Disorder (PTSD). Resident 25 was admitted with a history of trauma related to complications during childbirth. However, the facility did not identify potential triggers for the resident's PTSD or collaborate with the resident, their family, or mental health professionals to develop individualized interventions to prevent re-traumatization. The care plan addressing the resident's history of trauma was not added until one month after admission, and it only indicated a potential for ineffective coping without specifying triggers or preventive measures. The deficiency was identified during a clinical record review and staff interview, revealing that the facility had not taken necessary steps to understand and mitigate the resident's trauma triggers. It was only after the Director of Nursing was informed of the oversight that the social worker met with Resident 25 to identify specific triggers, such as seeing or speaking about small children or babies, which could cause increased frustration and sadness. The resident's care plan was subsequently revised to include these triggers and interventions, but this was done only after the deficiency was brought to the facility's attention.
Medication Security and Labeling Deficiency
Penalty
Summary
The facility failed to properly secure and account for resident medications and biologicals on the West Side Nursing Unit. During an observation of the resident medication pass, a clear medication cup containing three unlabeled pills was found in the top drawer of the medication cart. The identity of these pills was unknown, and the licensed practical nurse on duty was unaware of how long the cup had been there, as it was present at the start of their shift. Additionally, three unsecured pills were found in the bottom drawer of the cart, with no identification or knowledge of their duration in the cart. Further inspection of the medication cart revealed that the front left, top corner was taped with multiple pieces of adhesive tape, which were peeling and discolored, containing small debris. The licensed practical nurse was unable to provide information on how long the tape had been there or how the area was cleaned or sanitized. These observations were reviewed with the Director of Nursing, highlighting the facility's failure to adhere to proper medication storage and labeling protocols.
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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 Milton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Buffalo Valley Lutheran Villag | 4.8 mi | ★★★★★ | 19 | 0 |
| Oak Glen Healthcare And Rehabilitation Center | 4.8 mi | ★★★★★ | 17 | 0 |
| Watsontown Rehabilitation And Nursing Center | 5.6 mi | ★★★★★ | 24 | 0 |
| Nottingham Village | 7.4 mi | ★★★★★ | 8 | 0 |
| Sunbury Skilled Nursing And Rehabilitation Center | 10.8 mi | ★★★★★ | 11 | 0 |
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