Milner Community Health Care

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 5, 2023

  Based on interview and record review, the facility failed to ensure a resident was free from injury while using a stand-up lift during a transfer for 1 of 2 residents reviewed for accident hazards. (Resident 54). Resident 54 received an acute left mid clavicle fracture during a stand-up lift transfer. Finding includes: A FRI (facility reported incident), dated 1/14/23 at 8:30 p.m., indicated Resident 54 was transferred with a stand up lift and let go of the lift which caused her arms to go over her head. The resident felt something pop at the time although it did not hurt. The resident later complained of pain and was evaluated at the emergency room . She was diagnosed with a fracture of the left clavicle. The record for Resident 54 was reviewed on 6/1/23 at 1:34 p.m. […]

• No harm, potential for more than minimal, widespreadF812Jun 5, 2023

  Based on observation, interview and record review, the facility failed to ensure the dishwasher had reached and maintained the appropriate temperature during the wash and final rinse cycle and the ice machine was clean from a black substance inside the machine. This deficient practice had the potential to affect 54 of 54 residents who received food from the kitchen. Findings include: 1. During an observation, on 5/30/23 at 11:27 a.m., the Dietary Manager (DM) ran the facility dishwasher through a cycle. The wash temperature was 120 degrees, and the final rinse was 152. The DM completed a second cycle, and the temperature was 124 degrees for the wash cycle and 152 degrees for the final rinse cycle. 2. […]

• No harm, potential for more than minimal, patternF638Jul 28, 2025

  Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed timely for 6 of 6 residents reviewed for MDS assessments. (Residents 15, 23, 32, 36, 39 and 43)Findings include: 1. The clinical record for Resident 15 was reviewed on 7/24/25 at 11:00 a.m.The last completed MDS assessment was dated 3/17/25.The MDS assessment, dated 6/20/25, indicated it was incomplete and still in progress.2. The clinical record for Resident 23 was reviewed on 7/24/25 at 11:00 a.m.The last completed MDS assessment was dated 3/19/25.The MDS assessment, dated 6/18/25, indicated it was incomplete and still in progress.3. […]

• No harm, potential for more than minimal, patternF684Aug 16, 2024

  Based on observation, interview and record review, the facility failed to follow the physician ordered hold parameters for medications, to notify the physician of a high blood sugar reading as ordered, and to monitor and document bowel movements for 4 of 4 residents reviewed for quality of care. (Resident 34, 44, 25 and 40) Findings include: 1. The clinical record for Resident 34 was reviewed on 8/13/24 at 10:33 a.m. The diagnoses included, but were not limited to, chronic diastolic heart failure, major depressive disorder, essential hypertension, and stage 3 chronic kidney disease. A physician's order, dated 4/3/24, indicated to give metoprolol (a medication used to treat high blood pressure) 50 mg (milligram) twice daily. […]

• No harm, potential for more than minimal, patternF688Jun 5, 2023

  Based on observation, interview and record review, the facility failed to ensure a resident received a splint device recommended by physical therapy, to obtain physician orders for braces/splint devices and to follow physician's orders for splint devices for 4 of 4 residents reviewed for position and mobility. (Resident 10, 104, 5 and 38) Findings include: 1. During an interview and observation, on 5/30/23 at 12:41 p.m., Resident 10 indicated she had pain in the left ankle, and it was a new pain. The left ankle appeared contracted, and the right ankle appeared like it may be contracted also. During an observation, on 6/1/23 at 9:34 a.m., the resident was sitting up in a wheelchair in her room, her feet were on the footrests of the wheelchair. […]