Milaca Elim Meadows Health Care Center

In the surveyor’s words

From the most serious findings on record at Milaca Elim Meadows Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF908Dec 18, 2025

  Based on observation and interview, the facility failed to ensure the hood vent over the flat top cooking surface and deep [NAME] was free of grease buildup in the secondary kitchen of the dining room. In addition, the facility failed to ensure the grates on a cooling fan were free of debris in the secondary kitchen of the dining room. This had the potential to affect all residents, staff and visitors who had food prepared in the secondary kitchen. During initial tour of main and secondary kitchens in the facility on 12/15/25 at 12:15 p.m., the secondary kitchen observed was a metal hood vent located over the float cook top and deep fryer. There was yellow substance noted in drips along the length of the hood-vent running approximately five inches down the angle of the metal hood. […]

• No harm, potential for more than minimal, patternF880Dec 22, 2022

  Based on observation, interview and document review, the facility failed to ensure handwashing was performed during medication pass for 1 of 8 residents (R57) observed for medications. In addition, the facility failed to follow manufacturer instructions to discard opened tube feeding formula at least every 12 hours, for 1 of 1 residents (R33) reviewed for tube feeding. Also, the facility failed to disinfect a mechanical lift between use for 3 of 7 residents (R9, R3, and R24) observed for transfers with a mechanical lift. Findings include: R57's admission Minimum Data Set (MDS) dated [DATE], identified cognitively intact and diagnoses with right ankle surgery and was receiving intravenous (IV) antibiotics and wound vacuum. R57 was dependent upon staff for transfers and personal hygiene. […]

• No harm, potential for more than minimal, isolatedF554Dec 18, 2025

  Based on observation, interview and document review, the facility failed to comprehensively assess safety with self-administration of medication for 1 of 2 residents (R&) who self-administered medication after set up. R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 had intact cognition. Diagnoses included displaced femur fracture, chronic kidney disease, congestive heart failure and dementia. On 12/16/2025 at 4:07 p.m., R7 was seated in a recliner in her room watching television. The RN-A walked into the room, placed a paper cup containing medications onto the table next to R7 then walked out of the room. The paper cup contained two medications, one oval shaped brown colored and one round pink colored pill. […]

• No harm, potential for more than minimal, isolatedF582Dec 18, 2025

  Based on interview and document review, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to 2 of 5 residents (R7, R16) reviewed whose Medicare A coverage ended and then remained in the facility. R7's Centers for Medicare and Medicaid Services (CMS)-10123 signed as received on 8/27/25, identified a last covered day (LCD) of 8/29/25, when R7's Medicare coverage would end. R7's undated Census Records listing identified R7's payer source changed from Medicare Part A to Private Pay, and remained in the facility. R7 signed a SNFABN on 8/29/25, however, there was no estimated cost per day provided in the notification. […]

• No harm, potential for more than minimal, isolatedF641Dec 18, 2025

  Based on interview and document review, the facility failed to ensure the completed quarterly Minimum Data Set (MDS) was accurately coded to reflect hospice services for 1 of 2 residents (R15) reviewed for MDS accuracy. Findings include:The CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.20.1, dated 10/2025, identified each section of the MDS along with various instructions how to code and/or complete them. The section labeled, Section O: Special Treatments, Procedures, and Programs, listed directions to record any special treatments or programs the resident received during the specified time period (i.e., assessment reference date; ARD). This included, Hemodialysis . […]