Milan Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jan 22, 2025

  Based on interview and record review, the facility failed to provide protective oversight to ensure residents did not have materials to start a fire after staff identified a fire had been started in Resident #1 and Resident #2's room. On 1/12/25 at approximately 12:45 A.M., staff noted an odor coming from Resident #1 and Resident #2's room. Resident #1 said there was a small fire in the bathroom trash can that he/she extinguished with water. Staff noted a small amount of melted plastic in the bathroom trash can. Staff searched the room and found cigarettes in Resident #2's drawer, ashes in Resident #2's bed, and a cigarette butt on Resident #1's side of the room. Staff did not locate a lighter or any other lighting materials. On 1/12/25 at 1:07 A.M., the fire alarm sounded and at 1:09 A.M. […]

• Actual harm, isolatedF600Oct 30, 2025

  Based on interview and record review, the facility failed to ensure two residents, (Resident #7 and #10) were free from sexual abuse by one resident (Resident #11), in a review of 12 sampled residents. On 10/26/25 Resident #11 grabbed Resident #7's breasts over his/her clothing, without the resident's consent while they were outside in the courtyard. Resident #7 reported the incident to staff on 10/26/25 around 4:00 P.M. Resident #7 was tearful when recounting the abuse and reported he/she had never been grabbed like that before. Resident #7 feared being alone and Resident #11 coming around him/her again. […]

• Actual harm, isolatedF600Jan 18, 2022

  Based on interview and record review, the facility failed to ensure three residents with mental illness, one resident (Resident #2 with a prior history of childhood abuse including sexual, physical and emotional abuse (Resident #1, #2 and #4), remained free from verbal abuse by NA (Nurse Aide) A in a review of seven sampled residents when NA A cursed the residents and used derogatory names. The abuse upset and angered Resident #1, hurt Resident #4's feelings, and caused Resident #2 to be anxious and start to experience a panic attack. The facility census was 94. […]

• No harm, potential for more than minimal, widespreadF727May 23, 2025

  Based on interview and record review, the facility failed to provide a full time Director of Nursing (DON), who did not serve as a charge nurse, when the facility had a census over 60. The facility census was 86.Based on interview and record review, the facility failed to provide a full time Director of Nursing (DON), who did not serve as a charge nurse, when the facility had a census over 60. The facility census was 86. Review of the facility Registered Nurse (RN) Policy, revised 04/30/24, showed the facility will designate a Registered Nurse to serve as the Director of Nursing on a full-time basis. […]

• No harm, potential for more than minimal, widespreadF727Mar 5, 2025

  Based on observation, interview and record review, the facility failed to provide a full time Director of Nursing (DON), who did not serve as a charge nurse, when the facility had a census over 60. Further review showed the facility did not have eight consecutive hours of Registered Nurse staffing daily for two days. The facility census was 98. Review of the facility Registered Nurse (RN) Policy, revised 04/30/24, showed the following: -It is the intent of the facility to comply with Registered Nurse staffing requirements; -Full-time is defined as working 40 or more hours a week; -Charge Nurse is a licensed nurse with specific responsibilities designated by the facility that may include staff supervision, emergency coordinator, physician liaison, as well as direct resident care; -The… […]