Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oc Milford Gardens Llc during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, and dependence on staff for care was allegedly handled roughly by a CNA, resulting in bruising to the resident’s arms, according to the resident’s family. A nurse heard the family member loudly accuse the CNA of abuse but did not report the allegation to a supervisor or administration. The weekend Nursing Supervisor was later informed by the same family member that the CNA had not properly cleaned the resident and was believed to be responsible for the bruising, yet she did not immediately notify the administrator or DON as required by the facility’s abuse policy, instead leaving a written statement under the administrator’s door. As a result, the administrator did not learn of the alleged abuse until informed by police, demonstrating a failure to follow the facility’s mandated immediate abuse reporting procedures.
A resident with dementia, severe cognitive impairment, and generalized muscle weakness, who was dependent on staff for care, was the subject of a family member’s allegation that a CNA had been rough during care and caused bruising on the resident’s arms. A nurse heard the family member loudly accuse the CNA of abuse but did not report the allegation to a supervisor or administration, and there was no documentation of any report at that time. A nursing supervisor later received related concerns from the family but also did not immediately notify administration. As a result, the administrator did not learn of the abuse allegation until informed by police, and the allegation was not reported to the state agency within the facility’s required 2-hour timeframe.
A resident with dementia and severe cognitive impairment, fully dependent on staff for care, was allegedly handled roughly by a CNA, causing bruising to the arms, as reported by a family member. A nurse heard the family member accuse the CNA of abuse but did not report the allegation to supervisory or administrative staff. The nursing supervisor later learned that the family member believed the CNA caused the bruising but did not immediately notify administration or initiate an investigation, and did not remove the CNA from duty at that time. This inaction resulted in the CNA continuing to work with residents and delayed the start of the facility’s abuse investigation.
A facility failed to implement a 40-day Vancomycin taper for a resident with C. diff, leading to worsening of a stage IV pressure ulcer. Despite clear hospital discharge recommendations, the treatment was not initiated for 19 days, during which the resident experienced frequent diarrhea. Interviews revealed a communication breakdown among staff, resulting in the delay of necessary care.
The facility failed to notify the physician and/or responsible party of significant changes in condition for four residents, leading to deficiencies in care. One resident experienced a delay in treatment for C. diff, resulting in worsening of a pressure ulcer. Two residents had significant weight loss without physician notification, and another resident's guardian was not informed of a fall and hospital transfer. These failures highlight inadequate communication and documentation.
Two residents in a facility did not receive appropriate wound care for their pressure ulcers. One resident with a stage IV sacral ulcer did not receive the recommended Santyl treatment, and a Vancomycin taper for C. diff was not initiated. Another resident with unstageable heel ulcers did not have their treatment plan updated as recommended by the wound NP. Staff interviews revealed lapses in communication and implementation of wound care orders.
The facility failed to address grievances from Resident Council Meetings regarding evening snacks and non-English speaking agency staff. The Administrator signed off on response forms without follow-up, and the Activities Director did not include unresolved issues in subsequent meetings. Residents reported these issues remained unresolved months later.
The facility failed to properly document and resolve grievances from residents, including issues with staff responsiveness, missing personal items, roommate disturbances, and care needs. Grievance forms lacked investigation details, findings, and confirmation of resolutions, as required by the facility's policy. The Administrator acknowledged these documentation gaps.
Two residents in the facility experienced improper catheter care, leading to deficiencies in infection control. A resident with severe cognitive deficits had their catheter drainage bag repeatedly observed on the floor, contrary to guidelines. Another resident, also severely cognitively impaired, had their drainage bag on the floor and above bladder level, risking complications. Staff interviews confirmed the failure to follow proper procedures, resulting in a deficiency in infection control practices.
A facility failed to document the physician's response to a pharmacist's medication regimen review (MRR) recommendations for a resident with dementia and other conditions. Despite multiple recommendations for medication adjustments and lab tests, the facility could not provide documentation of the physician's review, except for one instance. The Director of Nurses confirmed that these forms should have been retained in the resident's medical record.
The facility failed to properly store and label drugs and biologicals. A resident had unsecured medications in their room, including a nebulizer and Tums, without proper assessments for self-administration. Additionally, a Lantus insulin pen and Liquid Protein supplements were found unlabeled with the date opened. Staff acknowledged these oversights, which contravened facility policies.
The facility failed to follow food safety and sanitation standards, risking foodborne illness among residents. Observations showed improper labeling and storage of food items in nourishment kitchenettes, with missing resident identification and use-by dates. Additionally, microwaves were found unclean, with food splatter and dark substances. The Food Service Director confirmed that dietary and nursing staff are responsible for labeling and checking expiration dates, but these duties were not consistently fulfilled.
A resident with a suprapubic catheter was observed multiple times with the catheter drainage bag visible from the hallway, without a privacy bag, compromising their dignity. Staff interviews confirmed the expectation for privacy bags to be used, but the facility was out of stock, leading to the deficiency.
A facility failed to accurately complete a Level 1 PASARR for a resident with severe mental illness, including bipolar disorder and PTSD. The PASARR, completed by the MDS nurse, incorrectly indicated no serious mental illness diagnoses, despite these being documented in the resident's hospital discharge summary and MDS assessment. This error was confirmed by the Director of Social Services and the MDS nurse, resulting in the absence of a necessary Level 2 PASARR.
A facility failed to follow professional standards when a CNA administered a medicated cream to a resident, which should have been done by a nurse. Additionally, a physician's order for Trazodone for another resident was incomplete, lacking the medication's strength. These actions were against the facility's policies and state regulations.
Two residents in an LTC facility were found to have deficiencies related to safety and medication storage. One resident's emergency oxygen tank was not secured, posing a safety hazard, and their inhalers were left unsecured at the bedside. Another resident's rescue inhaler was also left unsecured. Staff interviews confirmed that these practices were against the facility's policies, which require medications to be stored securely.
A facility failed to document a risk/benefit analysis for the continued use of Amitriptyline in a resident with severe cognitive impairment, despite a pharmacist's recommendation for a safer alternative. The physician acknowledged the recommendation but did not provide the required documentation, leading to a deficiency in compliance with the facility's psychoactive medication policy.
A facility failed to maintain an effective infection prevention and control program, as staff did not adhere to PPE protocols for two residents on contact precautions. One resident with C. diff was assisted by a CNA without gloves or a gown, despite clear signage. Another resident with a feeding tube did not receive proper gown usage during gastrostomy care. Interviews revealed staff misunderstandings about PPE requirements, confirmed by the DON.
Failure to Immediately Report Alleged Abuse as Required by Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed its abuse policy requiring immediate reporting of alleged abuse to administration. The facility’s abuse policy, revised March 2023, stated that alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property, must be reported immediately to the administrator and DON using the chain of command, with a two-hour requirement to report allegations to the Department of Public Health and local law enforcement. Resident #1, admitted in December 2025 with dementia and generalized muscle weakness, had a comprehensive MDS dated 12/10/25 indicating severe cognitive impairment and dependence on staff for care needs. On 12/13/25, Nurse #1 heard a family member yelling and swearing at CNA #1, accusing him of abusing the resident and causing bruises on the resident’s arms. Nurse #1 stated she stepped away from the situation because of the yelling and did not want to be involved, and there was no documentation that she notified her supervisor or administrative staff of the altercation or the abuse allegation at that time. The next day, the weekend Nursing Supervisor reported that the family member initially complained that CNA #1 had not properly cleaned the resident, and later told her that she believed CNA #1 was responsible for bruises on the resident’s arms and wanted to speak with him. The Nursing Supervisor did not immediately contact the administrator or DON as required by policy, but instead placed a written statement under the administrator’s door that day. The DON stated that facility policy requires all staff to immediately report any suspicion or allegation of abuse to their supervisor or administration and confirmed that the weekend Nursing Supervisor, who was aware of the allegation on 12/14/25, did not immediately report it to her or the administrator. The administrator reported that he was not made aware of the allegation of staff abuse involving the resident until 12/15/25, when police arrived and informed him that the resident’s family had reported rough handling by CNA #1 that allegedly caused bruising on the resident’s arm. This sequence of events shows that staff who became aware of the allegation on 12/13/25 and 12/14/25 did not follow the facility’s abuse reporting policy.
Failure to Timely Report Allegation of Abuse to Administration and State Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an allegation of abuse was immediately reported to administration so it could be reported to the state survey agency within the required timeframe. Facility policy, revised March 2023, required that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown origin, misappropriation of resident property, and exploitation, be reported immediately to the administrator and DON using the chain of command, and that all abuse allegations require immediate action with notification to the Department of Public Health and local law enforcement no later than two hours after an abuse allegation is received. The resident involved had dementia, generalized muscle weakness, severe cognitive impairment, and was dependent on staff to meet care needs, as documented in a comprehensive MDS assessment dated 12/10/25. On 12/13/25, a nurse heard the resident’s family member yelling and swearing at a CNA, accusing the CNA of abusing the resident and causing bruises on the resident’s arms. The nurse stated she stepped away because the family member was yelling and she did not want to be involved, and she did not take any action or notify a supervisor or administration; there was no documentation that she reported the allegation. The nursing supervisor reported that on 12/13/25 the family member only complained that the CNA had not properly cleaned the resident, and that it was not until the next day that the family member linked the CNA to bruises on the resident’s arms; the supervisor also did not immediately notify administration. The administrator and DON both stated that staff are expected to report any suspicion or allegation of abuse immediately so that administration can report to DPH and police within two hours. However, the administrator did not become aware of the allegation until 12/15/25 when police arrived with the family and reported the allegation of rough care and bruising, and the HCFRS report was submitted that same day, resulting in the allegation being reported to the state agency two days after staff were first made aware of the abuse allegation.
Failure to Immediately Report and Act on Abuse Allegation Against CNA
Penalty
Summary
The deficiency involves the facility’s failure to respond appropriately to an allegation of physical abuse involving a resident with severe cognitive impairment who was dependent on staff for care. The resident, admitted in December 2025 with dementia and generalized muscle weakness, had an MDS assessment indicating severe cognitive impairment and total dependence on staff. The facility’s abuse policy, revised March 2023, required that when abuse is observed, reported, or suspected, residents must be immediately protected from the alleged abuse and the employee immediately suspended pending investigation. On 12/13/25, a nurse heard the resident’s family member yelling and swearing at a CNA, accusing him of abusing the resident and causing bruises on the resident’s arms. The nurse stated she removed herself from the situation because of the yelling and did nothing further, and there was no documentation that she notified a supervisor or administrative staff of the altercation or the abuse allegation. On the same date, the nursing supervisor reported that the family member only complained that the CNA had not properly cleaned the resident and did not mention abuse. The next day, the family member told the nursing supervisor she wanted to talk to the CNA because she believed he was responsible for bruises on the resident’s arms. The nursing supervisor did not immediately report this allegation to administration, and there was no documentation that she initiated an investigation or had the CNA removed from the schedule at that time. The DON later stated that any time an allegation of abuse is made against a staff member, the staff member must be suspended immediately to protect the resident and other residents, and acknowledged that the nursing supervisor should have reported the allegation immediately. The administrator reported first learning of the allegation on 12/15/25, at which time the CNA was not working, and he then obtained a statement and suspended the CNA. As a result of the nurse’s and nursing supervisor’s inaction, the CNA continued to work and interact with residents, and there was a two-day delay in the facility initiating an investigation into the abuse allegation.
Failure to Implement Antibiotic Treatment for C. diff
Penalty
Summary
The facility failed to manage and deliver safe nursing care by not implementing treatment recommendations for a resident diagnosed with Enterocolitis due to Clostridium Difficile (C. diff). The resident, who was admitted with diagnoses including C. diff, a stage IV pressure ulcer, and chronic kidney disease, returned from a hospital stay with a recommendation for a 40-day Vancomycin taper. However, this recommendation was not reviewed or implemented by the facility's in-house physician or nursing staff for 19 days following the resident's discharge from the hospital. During this period, the resident experienced frequent episodes of diarrhea, which were documented by the Certified Nursing Assistant (CNA) on multiple occasions. The resident's stage IV pressure ulcer on the sacrum worsened, as noted by the wound consultant, who reported increased wound measurements, odor, and drainage. The physician and wound consultant both acknowledged that the resident's loose stools and C. diff infection negatively impacted the wound healing process. Interviews with the facility's staff, including the physician, unit manager, and director of nursing, revealed a breakdown in communication and procedure. The hospital discharge summary clearly indicated the need for a Vancomycin taper, but this was not communicated effectively to the physician or nurse practitioner for implementation. The director of nursing confirmed that the discharge summary should have been reviewed and clarified with the physician, and acknowledged the delay in starting the necessary antibiotic treatment for the resident.
Failure to Notify Physician and Guardian of Changes in Resident Conditions
Penalty
Summary
The facility failed to notify the physician and/or responsible party of significant changes in condition for four residents, leading to deficiencies in care. For one resident, the facility did not inform the physician of treatment recommendations for a 40-day Vancomycin taper following a diagnosis of C. diff after hospitalization. This oversight resulted in a delay of 19 days before the treatment was initiated, during which time the resident experienced worsening of a stage IV pressure ulcer due to recurrent diarrhea. Another resident experienced significant weight loss, but the facility did not notify the physician or document such notification in the medical record. The resident had lost approximately 99 pounds since admission, and although the dietitian was aware, there was no system in place to ensure the physician was informed of the weight loss, which is a critical aspect of the resident's care. Additionally, a third resident also experienced significant weight loss without the physician being notified. The facility's care plan required notification of the physician for any significant weight changes, but this was not followed. Lastly, a resident who suffered a fall and was transferred to the hospital did not have their guardian notified of the incident, as required by the facility's policy. These failures highlight a pattern of inadequate communication and documentation regarding changes in residents' conditions.
Deficiencies in Wound Care Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate wound care for two residents, leading to deficiencies in the treatment of pressure ulcers. Resident #65, who was admitted with a stage IV pressure ulcer on the sacrum, did not receive the recommended wound care treatment as prescribed by the Consulting Wound Nurse Practitioner (NP). The physician's orders and the Treatment Administration Record (TAR) did not include the use of Santyl, a critical component of the treatment plan, and there was a lack of clarity regarding the use of Dakin's solution and alginate dressing. Additionally, a 40-day Vancomycin taper for the treatment of C. diff was not initiated upon the resident's return from hospitalization, which could have impacted the healing process of the pressure ulcer. Resident #68, who had unstageable pressure ulcers on both heels, also did not receive the updated treatment plan recommended by the Wound Care Nurse Practitioner. The physician's orders continued to reflect an outdated treatment plan, failing to incorporate the new recommendations made on 11/22/24. This oversight was attributed to a lapse in communication and implementation of the wound NP's recommendations, as the staff member responsible for updating the orders was not present during the NP's rounds. Interviews with facility staff, including the Unit Manager and Director of Nursing, revealed a breakdown in the process of updating and implementing wound care orders. The staff acknowledged the discrepancies between the NP's recommendations and the actual orders in the residents' medical records. The failure to follow through with the recommended treatment plans for both residents highlights a significant deficiency in the facility's wound care management practices.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to address and resolve grievances brought forward during Resident Council Meetings held on 9/29/24 and 10/18/24. During these meetings, residents complained about not being offered evening snacks and the presence of too many agency staff who did not speak English. The facility's policy requires the use of a Resident Council Response Form to track issues and their resolution, with the responsible department addressing the concerns. However, the Administrator signed off on the forms without providing follow-up to the Resident Council regarding the efforts made to address these grievances. During a resident group meeting on 12/4/24, residents reported that the issues raised in September and October remained unresolved. The Activities Director, who facilitates the Resident Council meetings, admitted to not following up on the residents' concerns and failing to include them in the discussion of old business at subsequent meetings. The Administrator, who is the grievance official, acknowledged that he did not provide documented evidence of resolutions to the complaints and confirmed that the grievances should have been reviewed at the next month's meetings, but they were not.
Inadequate Documentation and Resolution of Resident Grievances
Penalty
Summary
The facility failed to ensure proper documentation and resolution of grievances filed by residents, as evidenced by the review of the grievance book and interviews with the Administrator and Consultant Staff. The facility's policy requires that grievances be documented with all steps of the resolution process, including investigation findings, conclusions, and whether the grievance was confirmed or not. However, for several residents, these steps were not adequately documented, leading to incomplete grievance records. For instance, Resident #29 reported that a Certified Nursing Assistant ignored a request, but the grievance form lacked documentation of an investigation or resolution. Similarly, Resident #278's grievance about missing cheese packages was not followed up with documentation of reimbursement or satisfaction with the resolution. Resident #277's complaint about a noisy roommate was not thoroughly investigated, and the grievance form did not include a summary of findings or staff interviews. Additionally, Resident #47's grievances regarding a bed sore and the need for a two-person assist were not fully documented, lacking confirmation of the grievances and satisfaction with the resolutions. Resident #72's grievances about colostomy bag changes and a wet bed were also inadequately documented, with missing investigation details and resolution satisfaction. The Administrator acknowledged these documentation gaps, indicating a failure to adhere to the facility's grievance policy.
Improper Catheter Care and Infection Control Deficiency
Penalty
Summary
The facility failed to provide proper indwelling catheter care for two residents, leading to deficiencies in infection control prevention. For Resident #330, the catheter drainage bag was repeatedly observed in direct contact with the floor, which is against the guidelines set by the Centers for Disease Control and Prevention and the facility's own policy. Despite having severe cognitive deficits and requiring an indwelling catheter, the resident's catheter care was not maintained according to professional standards, as evidenced by multiple observations of the drainage bag on the floor over two days. Similarly, Resident #64, who was severely cognitively impaired and had a history of cerebral infarction and obstructive uropathy, also experienced improper catheter care. The resident's catheter drainage bag was observed on the floor and positioned above the bladder level, which could lead to potential complications. The facility's staff, including CNAs and nurses, acknowledged that the drainage bags should be kept off the floor and below the bladder level to prevent infection and backflow of urine. Interviews with various staff members, including CNAs, nurses, the unit manager, and the infection preventionist, confirmed that the facility's procedures for catheter care were not followed. The staff recognized the importance of maintaining the drainage bags off the floor and below the bladder level to prevent infection and other complications. However, the observations made by the surveyor indicated a failure to adhere to these procedures, resulting in a deficiency in the facility's infection control practices.
Failure to Document Medication Regimen Review
Penalty
Summary
The facility failed to ensure that the monthly medication regimen review (MRR) for a resident was properly documented and included in the medical record. The facility's policy requires that the consulting pharmacist's observations and recommendations be made available to the Director of Nursing and other relevant staff, and that these recommendations be addressed before the next MRR. However, for one resident, the facility did not provide documentation of the physician's response to the pharmacist's recommendations for several months, despite the pharmacist making multiple recommendations regarding medication adjustments and laboratory tests. The resident in question was admitted with diagnoses including dementia, a fracture of the second cervical vertebra, and mild cognitive impairment. The pharmacist made several recommendations over a period of months, including re-evaluating the use of certain medications and conducting specific laboratory tests. Despite these recommendations, the facility was unable to provide documentation showing that the physician had reviewed and responded to these recommendations, except for one instance. This lack of documentation was confirmed during an interview with the Director of Nurses, who acknowledged that the completed forms should have been retained in the resident's medical record.
Deficiencies in Drug Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, as observed in several instances. For Resident #41, a portable nebulizer device and a bottle of Tums were found unsecured in the resident's room. Despite the resident's cognitive intactness and a self-administration assessment for inhaled medications, there was no assessment for oral medications like Tums. The facility's policy requires medications to be stored securely, yet the nebulizer and Tums were repeatedly found unsecured, and staff were unaware of the resident's possession of these items. Additionally, during a review of the medication cart on the Elm Unit, a Lantus insulin pen was found opened but not labeled with the date it was opened or the date it should be discarded. This oversight was acknowledged by Nurse #5, who confirmed that the insulin pen should have been labeled according to the facility's policy, which mandates that insulin be discarded 28 days after opening. Furthermore, the facility failed to label Liquid Protein supplements with the date opened. Nurse #6 administered Liquid Protein to a resident without the bottle being marked with the date it was opened, despite the product having a three-month shelf life from the date of opening. This issue was also observed on the medication cart, where an opened bottle of Liquid Protein was not dated. Nurse #5 admitted to not being informed about the requirement to label the Liquid Protein with the date opened, and the DON confirmed that it should have been marked.
Food Safety and Sanitation Deficiencies in Facility Kitchenettes
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, which could potentially lead to foodborne illness among residents. Observations revealed that food products in the nourishment kitchenettes across three units were not properly labeled with resident identification or use-by dates. Specifically, items such as Premier Protein Shakes, V8 Juice, and various frozen food packages lacked resident identification, and some items were past their expiration dates. Additionally, Tupperware containers with food products had ice buildup and were missing use-by dates, indicating improper storage practices. The facility's policy requires that food brought in by family or visitors be labeled with the resident's name and the date it was brought in, and that it should be discarded after three days. However, the surveyor found multiple instances where these guidelines were not followed. For example, a bottle of Coffee Milk was found with a use-by date that had already passed, and several Tupperware containers were stored without proper labeling. These lapses in protocol suggest a lack of oversight in ensuring that food safety standards are consistently met. Furthermore, the cleanliness of the equipment in the nourishment kitchenettes was substandard. Microwaves in the Elm Unit were observed to have food splatter and a dark brown/black substance on the inside, indicating inadequate cleaning practices. The Food Service Director acknowledged that dietary staff are responsible for checking labels and expiration dates during stocking, while nursing staff should label items brought in by families. However, the observed deficiencies indicate a breakdown in these responsibilities, contributing to the potential risk of foodborne illness among residents.
Failure to Maintain Resident Dignity Due to Lack of Privacy Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident with a suprapubic catheter by not providing a privacy bag for the catheter drainage bag. The resident, who was admitted in June 2021 with neuromuscular dysfunction of the bladder and diabetes mellitus with neuropathy, was observed multiple times with the catheter drainage bag visible from the doorway and hallway, without any cover to ensure privacy. The resident was moderately cognitively impaired, scoring 8 out of 15 on the Brief Interview for Mental Status. Interviews with various staff members, including nurses and certified nurse aides, confirmed that the catheter drainage bag should have been kept in a privacy bag at all times to prevent visibility and maintain the resident's dignity. The Unit Manager acknowledged that the facility was out of privacy bags and was awaiting a delivery, but stated that the drainage bag should have been positioned in a way that it was not visible from the hallway. The Staff Development Coordinator also confirmed that the staff are responsible for ensuring that catheter drainage bags are not in plain view to preserve residents' dignity and privacy.
Inaccurate PASARR Completion for Resident with Severe Mental Illness
Penalty
Summary
The facility failed to accurately complete a Level 1 Preadmission Screening and Resident Review (PASARR) for a resident with severe mental illness. The resident, admitted in October 2023, had diagnoses including bipolar disorder and PTSD, which were documented in the hospital discharge summary and the Minimum Data Set (MDS) assessment. However, the PASARR completed by the facility's MDS nurse prior to admission incorrectly indicated that the resident did not have any serious mental illness diagnoses, such as bipolar disorder or PTSD. The discrepancy was identified during a review of the PASARR and confirmed through interviews with the Director of Social Services and the MDS nurse. The Director of Social Services acknowledged that the PASARR was completed incorrectly and did not reflect the resident's mental illnesses as it should have. The MDS nurse also admitted that the PASARR did not match the resident's known active diagnoses as reflected on the MDS at the time of admission or currently. This error resulted in the resident not having a Level 2 PASARR completed, which would typically be required for someone with the resident's psychiatric history and diagnoses.
Medication Administration and Order Completeness Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of practice in two specific instances involving residents. For one resident, a Certified Nursing Assistant (CNA) improperly administered a medicated cream, Lidocaine Pain Relief Cream Plus Menthol, which is considered a medication. The resident, who was cognitively intact and experiencing frequent pain, requested the CNA to apply the cream to their lower back. The CNA complied, unaware that administering medicated creams is outside their scope of practice, as confirmed by interviews with the nursing staff and the Director of Nursing (DON). In another instance, the facility did not ensure that a physician's order for Trazodone, an antidepressant, was complete. The order for the resident, who had severe cognitive impairment and was receiving psychotropic medication daily, lacked the strength of the medication. This omission occurred when the order was renewed, and it was noted by both a nurse and the DON during a review of the resident's medical record. These deficiencies highlight a lack of adherence to established protocols regarding medication administration and order completeness. The facility's policies and state regulations clearly outline the responsibilities of nursing staff and the requirements for medication orders, which were not followed in these cases.
Deficiencies in Safety and Medication Storage
Penalty
Summary
The facility failed to ensure a safe environment free from potential safety hazards for two residents, leading to deficiencies in the storage and security of medical equipment and medications. For one resident, the facility did not properly secure an emergency oxygen tank, which was observed multiple times standing unsecured in the resident's room. This failure to secure the oxygen tank was acknowledged by both the Unit Manager and the Director of Maintenance, who confirmed that the tank should have been stored in a cylinder stand or attached to the wall to prevent it from falling and causing a safety hazard. Additionally, the same resident was allowed to keep inhalers at the bedside without a lock box or any means of securing them, contrary to the facility's policy on medication storage. The resident, who was cognitively intact and permitted to self-administer medications, kept the inhalers on the overbed table, accessible to others. Interviews with nursing staff and the Unit Manager confirmed that the inhalers should have been secured in a locked compartment to prevent unauthorized access, but this was not done. Another resident also kept a rescue inhaler at the bedside without any means of securing it. Despite being cognitively intact and having permission to self-administer the inhaler, the resident's inhaler was left unsecured on the overbed table. Interviews with nursing staff and the Director of Nurses revealed that the facility's process for self-administration of medications was not fully implemented, as the inhaler was not secured in a lock box as required by the facility's policy.
Failure to Document Risk/Benefit Analysis for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility did not document a risk/benefit analysis for the continued use of the antidepressant medication Amitriptyline, despite a recommendation from the pharmacist to consider a safer alternative. The resident, who was admitted in September 2023, had diagnoses including major depression, dementia with psychotic disturbance, and anxiety. The Minimum Data Set assessment indicated severe cognitive impairment, and the resident received psychotropic medication daily. The pharmacist's Medication Regimen Review highlighted that Amitriptyline should be avoided in elderly patients due to its anticholinergic properties and potential side effects, suggesting alternatives such as SSRIs and SNRIs. Although the physician acknowledged the pharmacist's recommendation by checking a pre-printed response, there was no documented risk/benefit analysis in the resident's medical record. Interviews with the Unit Manager and Physician confirmed the absence of such documentation, indicating a failure to comply with the facility's policy on psychoactive medication use.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents on contact precautions. For Resident #65, who was admitted with diagnoses including C. diff and a stage IV pressure ulcer, staff did not adhere to the required personal protective equipment (PPE) protocols. Despite the presence of a Contact Precautions Plus sign outside the resident's room, a Certified Nursing Assistant (CNA) was observed assisting the resident with their lunch without wearing gloves or a gown. Interviews with the CNA, a nurse, and the unit manager revealed a misunderstanding of the PPE requirements, with some staff believing that gowns and gloves were only necessary during direct care, contrary to the facility's policy. In the case of Resident #327, who was admitted with severe protein-calorie malnutrition and diabetes mellitus, and had a feeding tube, staff also failed to follow enhanced barrier precautions (EBP). The resident's room had an EBP sign indicating the need for gloves and a gown during high-contact care activities, including gastrostomy care. However, a nurse was observed administering medications and enteral feeding via the gastrostomy tube without donning a gown, although gloves were worn. Interviews with the nurse and unit manager confirmed a lack of clarity regarding the necessity of wearing a gown for these procedures. The Director of Nursing (DON) confirmed that both residents were on specific precautions and that staff were expected to adhere to the facility's infection control policies. The observations and interviews highlighted a gap in staff understanding and implementation of the required PPE protocols, leading to the deficiencies noted by the surveyors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Milford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blaire House Of Milford | 1 mi | — | 2 | 0 |
| Countryside Health Care Of Milford | 2.7 mi | — | 5 | 0 |
| Medway Country Manor Skilled Nursing & Rehabilitat | 4.8 mi | — | 9 | 0 |
| Timothy Daniels House | 5.4 mi | — | 1 | 0 |
| Waterview Lodge Llc, Rehabilitation & Healthcare | 6.7 mi | — | 15 | 0 |
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