Milton Home, The
MILTON HOME, THE in SOUTH BEND, IN — inspection on November 7, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
indicated Resident B's seatbelt and 3 of the 4 floor safety restraints were still properly secured, but the left front floor restraint was loosened.
Employee 3 indicated Resident B had not complained of pain, but due to the scrapes on his head and right arm, she had called for EMS services.During an observation with Employee 3, of the process to secure a wheelchair in the facility bus, on 11/6/2025 at 10:00 A.M., a red level was noted under the front left footrest of the wheelchair and able to be accessed by the feet of resident's in the wheelchair.
Employee 3 pushed the red lever and the floor security restraint strap loosened when the wheelchair was purposely tipped to the right side for demonstration.
Once the wheelchair was completely placed on it's right side, on the floor of the bus, the security strap on the left front was still attached to the floor of the bus, but was extremely loose.
The other 3 security restraint straps remained locked in place and had not loosened when the wheelchair was tipped to the side.
During an interview, on 11/6/2025 with a Customer Service Representative (CSR) 4, for the wheelchair floor securement device manufacturer, they indicated the red lever on the floor securement was an emergency release level. CSR 4 indicated the floor securment device was designed so the passengers using the floor securement device were not to have access to the red release lever on the device. CSR 4 indicated if the wheelchair had been properly secured, the straps on the floor securement system would have been at a 45 degree angle, leaving too much room between the resident's foot and the emergency release lever, to prevent accidental engagement. CSR 4 indicated the emergency release lever was to be on the outside of the safety straps not on the inside of the safety straps.
The CSR 4 representative indicated the whelechair had been improperly installed by Employee 3, which had allowed the emergency release device to have been activated, which had led to the loosening of the restraint safety strap and the tipping of Resident B's wheelchair.
During an interview with the RNC, on 11/6/2025 at 2:00 P.M., she indicated the facility had spoken with the manufacturer of the floor securement devices and had found that Resident B's wheelchair had likely fell over, on 10/27/2025, because Employee 3 had incorrectly secured the wheelchair in the facility bus.Review of Employee 3's skill valadation check off sheet, provided by the RNC on 11/6/2025 at 2:00 P.M. indicated she had been found competent regarding securing a wheelchair correctly in the facility bus, on 1/25/2025.This citation relates to Intake 2654973 and 2658962.3.1-45(a)
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