Milaca Elim Meadows Health Care Center

Inspectors wroteBased 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. In the top of the hood there were three lightbulbs covered with glass bulb covers. [...]

Inspectors wroteBased 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. R7 stated the nurses always just bring them to and I take them when I am ready to. [...]

Inspectors wroteBased 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. R16's CMS-10123 signed as received on 10/7/25, identified a last covered day (LCD) of 10/10/25, when R16's Medicare coverage would end. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a mobility device was in good repair for 1 of 2 residents (R49), reviewed for accidents. R49's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R49 had severe cognitive impairment and was independent with ambulation and transfers with use of a cane. R49's care plan dated 08/28/2025, indicated R49 ambulated independently, used a cane/staff. R49's care plan further indicated R49 was high risk for falls. Progress note dated 11/20/25 at 6:19 p.m., indicated R49 was more confused than baseline. R49 had very unsteady gait and the walking stick resident used had been broken and temporarily mended for weeks. Have reported to daughter he needed a new one with the level of weight he applied on it being unsteady and she stated it is fine. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure appropriate hand hygiene was completed during observations of personal cares completed with 1 of 2 residents (R5) observed during personal cares.

Inspectors wroteBased on interview and document review, the facility failed to notify the Ombudsman of transfers and discharge for 1 of 3 residents (R61) reviewed for discharge and/or hospitalizationR61's admission minimum data set (MDS) dated [DATE], indicated R61 admitted on [DATE], and was cognitively intact. R61 had diagnoses of hypertension, atrial fibrillation, end stage renal disease, quadriplegia, and diabetes. R61's discharge MDS dated [DATE], indicated R61 discharged to home. Review of the October-November 2025 Ombudsman log identified residents who transferred to the hospital, however, the log failed to identify notification to the Ombudsman was completed for any residents who discharged from the facility. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure a comprehensive, person-centered care plan was developed, accurate, and revised to assure assessed care needs were implemented for 1 of 2 residents (R54) reviewed for care planning.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure confidential information was not readily available for all residents, staff, and visitors to view for 1 of 1 resident (R24) observed to have private information visible on an open computer screen in a common area.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure residents received appropriate catheter care as ordered by the provider to maintain urinary catheter function for 1 of 1 residents (R37) who was reviewed for indwelling urinary catheter use. This had the potential to impact R37's catheter function and cause an increase risk of infection.

Inspectors wroteBased on interview and document review, the facility failed to assure the use of PRN (as needed) psychotropic medications (a drug which affects mood/behavior) were limited to 14 days, or had a physician specified, time limited, order for 1 of 1 resident, R57, reviewed for Hospice.