Cycle 1
Health 2025-07-28 · Fire 2025-07-28
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Rossville, IN
Milner Community Health Care
3-star overall rating with 4-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
370 E Main St, Rossville, IN
(765) 379-2112
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
50
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Major Hospital
Operator or chain grouping
Approved since
2000-08-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.74
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.87
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.22
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.87
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.85
CMS adjusted RN staffing hours
Adjusted total hours
4.84
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
42%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,718
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.11
Composite VBP score used to determine payment impact.
Payment multiplier
1.0018
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
1.63
Performance 7.35% · Measure score 1.63 · Achievement 1.63 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
4.14
Baseline 50.00% · Performance 46.75% · Measure score 4.14 · Achievement 4.14 · Improvement 0.79
Adjusted total nurse staffing
8.66
Baseline 3.96 hours · Performance 5.54 hours · Measure score 8.66 · Achievement 8.66 · Improvement 8.18
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.5% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 14% · Lower 95% interval 7.59% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.24% |
95.27%
About the same
|
Numerator 20 · Denominator 21 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 21 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.35% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 7.41% · Lower 95% interval 3.88% |
| Staff COVID-19 vaccination coverage | 5.68% |
8.2%
2.5 pts worse
|
Numerator 5 · Denominator 88 |
| Staff flu vaccination coverage | 25.47% |
42%
16.5 pts worse
|
Numerator 27 · Denominator 106 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.2 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
93.6%
5.3 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 95.7% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.8%
1 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 2.2% · Q3 2.4% · Q4 2.1% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
24.6%
23.4 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 2.6% · Q4 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
5.6%
3 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 8.1% · Q4 0.0% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.8% |
23.5%
2.7 pts better
|
19.6%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 20.0% · Q3 18.9% · Q4 23.7% · 4Q avg 20.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.2% |
14.8%
3.6 pts better
|
16.7%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 11.8% · Q3 9.4% · Q4 9.1% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.6% |
13.3%
3.3 pts worse
|
16.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.5% |
11.7%
16.8 pts worse
|
14.9%
13.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 32.4% · Q3 31.2% · Q4 30.0% · 4Q avg 28.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.2% |
0.4%
3.8 pts worse
|
1.0%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.0% · Q3 2.5% · Q4 9.2% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
1.2%
1.1 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 2.4% · Q4 2.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.1% |
24.2%
3.9 pts worse
|
19.8%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 38.0% · Q3 25.2% · Q4 33.9% · 4Q avg 28.1% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
4.1%
1.7 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.6% · Q3 2.5% · Q4 2.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
81.6%
12.2 pts better
|
81.7%
12.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 95.7% · Q3 88.5% · 4Q avg 93.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.6% |
79.0%
3.6 pts better
|
79.7%
2.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-16 · Fire 2024-08-16
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-06-05 · Fire 2023-06-05
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-07-28
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-09-05
F · Potential for more than minimal harm
2025-07-28
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-09-12
E · Potential for more than minimal harm
2025-07-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-05
E · Potential for more than minimal harm
2025-07-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-09-27
E · Potential for more than minimal harm
2025-07-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-09-12
E · Potential for more than minimal harm
2024-08-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-08-16
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-08-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-08-16
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-08-16
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-08-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-08-16
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-08-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-08-16
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-10-31
F · Potential for more than minimal harm
2023-06-05
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-07-24
F · Potential for more than minimal harm
2023-06-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-15
F · Potential for more than minimal harm
2023-06-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
E · Potential for more than minimal harm
2023-06-05
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-07-24
E · Potential for more than minimal harm
2023-06-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-07-24
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-28
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-08-29
E · Potential for more than minimal harm
2024-08-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-16
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-16
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-08-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-09-09
G · Actual harm
2023-06-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-01
F · Potential for more than minimal harm
2023-06-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-01
E · Potential for more than minimal harm
2023-06-05
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-06-05
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-06-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-06-05
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-06-05
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-07-01
Penalties and ownership
What sits behind the stars
Ownership
Major Hospital
5% Or Greater Direct Ownership Interest · Organization
Claxton, Ryan
Operational/Managerial Control · Individual
Claxton, Ryan
Corporate Officer · Individual
Jackson, Richard
Operational/Managerial Control · Individual
Li, William
Operational/Managerial Control · Individual
Milner Community Health Care, Inc.
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Mulberry Health & Rehabilitation Center
Mulberry, IN
4-star overall rating with 5-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Wesley Manor Health Center
Frankfort, IN
3-star overall rating with 3-star inspections with $20,826 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Clinton House Rehabilitation And Healthcare Center
Frankfort, IN
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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