Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Civita Care Center At West River during CMS and state inspections, most recent first.
The facility failed to ensure the Infection Preventionist (IP) completed the necessary specialized training. The IP, who had served for 10 months, did not pass the final test required for certification, despite completing the training course. This oversight was discovered during a survey, leading to the Assistant Director of Nursing Services temporarily overseeing infection control duties.
The facility failed to timely administer COVID-19 vaccines to residents who had consented, due to miscommunication and lack of awareness among staff about vaccine availability. Despite having vaccines in stock, several residents received their vaccinations only after surveyor inquiry.
A resident with severe cognitive impairment was left unsupervised during a meal, contrary to a physician's order for 1:1 feeding assistance. The resident attempted to self-feed in an undignified manner, highlighting a failure to provide proper care and adhere to facility policies on dignified dining experiences.
A facility failed to align a resident's advance directive choice of DNR with the physician's orders, which incorrectly listed the resident as full code. Despite the resident's representative signing a DNR form, the discrepancy persisted, and the clinical record lacked a care plan related to the advance directive. Interviews with staff revealed uncertainty about the inconsistency, and the facility could not provide a policy for maintaining accurate records.
Two residents in a facility experienced deficiencies in care due to the facility's failure to notify physicians and relevant parties of significant changes in their conditions. One resident with end-stage renal disease exceeded their fluid restriction for most days over two months without the physician or dialysis center being informed. Another resident experienced significant weight loss over four months, yet the physician, APRN, and dietitian were not notified in a timely manner. The facility's policies for monitoring and notifying changes in residents' conditions were not followed, leading to a lack of appropriate interventions.
A facility failed to notify the State-designated authority when a resident was diagnosed with and later had a mental health condition discontinued. The resident was initially admitted with anxiety, depression, and dysthymic disorder, later diagnosed with schizoaffective disorder, and the facility did not update the PASARR Level 1 screen. The Director of Social Services was not informed of these changes, leading to non-compliance with PASARR requirements.
A facility failed to maintain proper air mattress settings for a resident with a pressure ulcer, did not provide required meal supervision for a resident with dementia, and inaccurately documented weights for a resident with specific physician orders. Staff interviews revealed lapses in following physician orders and facility policies, leading to deficiencies in resident care and supervision.
A resident with Alzheimer's and recurrent pressure ulcers did not receive weekly Braden Scale assessments or the recommended zinc oxide-based barrier cream due to staff oversight. Upon readmission after hospitalization, the facility failed to conduct a thorough RN assessment of the resident's pressure ulcers, as indicated in the hospital discharge paperwork.
A resident experienced significant weight loss over several months, but the facility failed to notify the physician or dietitian in a timely manner, as required by policy. Despite a physician's order to report weight loss, the staff did not document or communicate the changes, leading to a delay in addressing the resident's nutritional needs. The dietitian was not informed until a quarterly assessment, missing earlier opportunities for intervention.
A facility failed to monitor and manage the fluid intake of a resident with end-stage renal disease on peritoneal dialysis, who had a physician-ordered fluid restriction of 1000 ml per day. The resident exceeded this restriction on most days over two months, and the facility did not notify the physician or provide education to the resident. Interviews revealed a lack of adherence to policies for monitoring fluid intake and notifying medical personnel.
A facility failed to implement gradual dose reductions for a resident's antipsychotic medication after the diagnosis of schizoaffective disorder was discontinued. Despite recommendations for a GDR trial, the resident continued receiving Abilify throughout 2024. The social worker was unaware of the diagnosis change, and the APRN was not informed, leading to continued medication use based on an outdated diagnosis.
A resident with dementia and a stroke did not receive required adaptive eating equipment, such as a scoop plate and sippy cup, due to miscommunication among staff and an EMR transition glitch. Nursing aides failed to verify meal trays, assuming it was the kitchen's responsibility, while the new EMR system did not correctly transfer adaptive equipment orders.
Infection Preventionist Lacked Required Certification
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP), RN #1, completed the necessary specialized training in infection prevention. RN #1 was hired on November 30, 2015, and had been serving as the facility's IP for 10 months. During a survey conducted on January 26, 2024, it was discovered that RN #1 had not completed the final test required to obtain the Infection Preventionist certification, despite having completed the Nursing Home Infection Preventionist Training Course on April 23, 2024. The facility was unable to provide documentation that RN #1 had been awarded the certification with contact hours, which is a requirement for the role. Interviews with RN #1 and the Director of Nursing Services (DNS) revealed a misunderstanding regarding the certification requirements. RN #1 believed that completing the training course fulfilled all the necessary requirements for the IP role. It was only after the surveyor's inquiry that RN #1 realized a final test was required for certification. Although RN #1 attempted to take the test, she did not pass. Consequently, RN #1's last day as the full-time IP was January 27, 2025, and the Assistant Director of Nursing Services (ADNS), who had been certified since September 4, 2020, was to oversee infection control duties until a new IP was hired.
Delayed COVID-19 Vaccination for Consented Residents
Penalty
Summary
The facility failed to ensure that residents who consented to receive the COVID-19 vaccine were vaccinated in a timely manner. Several residents, including Resident #2, #18, #79, #87, #88, and #100, had consented to receive the vaccine, but there were delays in administration. The facility's Preventative Health Care Report indicated that these residents received their vaccinations only after surveyor inquiry, highlighting a lapse in the timely administration of vaccines. The Infection Preventionist (RN #1) was unable to provide surveillance data on resident COVID-19 vaccinations and indicated that vaccines were dispensed in quantities of 10 at a time by the pharmacy. However, the pharmacy manager clarified that there was no policy limiting the number of vaccines supplied and that more could be provided if needed. Despite this, RN #1 and the DNS were unaware of the available vaccines in the facility's refrigerator, which contributed to the delay in vaccinating consented residents. Interviews with facility staff, including the Administrator and DNS, revealed a lack of awareness and communication regarding the availability and administration of COVID-19 vaccines. The DNS was unaware of the multiple residents who had consented to the vaccine but had not yet received it, and the ADNS was unaware of the available vaccines in the facility. This lack of coordination and oversight led to the deficiency in ensuring timely vaccination for residents who had consented to receive the COVID-19 vaccine.
Failure to Provide 1:1 Feeding Assistance
Penalty
Summary
The facility failed to provide feeding assistance according to the physician's order for a resident with severe cognitive impairment, resulting in a lack of dignified dining experience. The resident, who was admitted with diagnoses including dementia and cognitive communication deficit, had a physician's order for 1:1 feeding assistance with all meals due to cognitive decline. Despite this order, a nursing assistant left the resident unsupervised with a meal tray, leading to the resident attempting to self-feed in an undignified manner. During the observation, the nursing assistant placed a meal tray in front of the resident, opened a yogurt container, and then left the resident to assist another resident, leaving the resident unsupervised. The resident attempted to self-feed by inserting fingers into the yogurt and using a spoon without proper assistance. This was contrary to the care plan and physician's order, which required a staff member to sit with the resident throughout the meal to provide necessary prompts and assistance. Interviews with staff, including the LPN and dietitian, confirmed the resident's need for 1:1 feeding assistance due to cognitive deficits. The facility's policies on resident rights and assistance with meals emphasized the importance of providing dignified care and meeting individual needs, which were not adhered to in this instance. The deficiency highlights a failure to ensure the resident's right to a dignified existence and proper feeding assistance as per the physician's directive.
Inconsistency in Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that the physician's orders were consistent with Resident #48's advance directive choice of do not resuscitate (DNR). Upon admission, the resident's representative signed a health care instruction form indicating a DNR status, but the physician's order incorrectly listed the resident as full code. This discrepancy persisted even after the resident was hospitalized and returned to the facility, with the physician's order still not reflecting the resident's DNR choice. The clinical record did not contain a care plan related to the resident's advance directive choice, and the facility was unable to provide a policy related to maintaining a clear and accurate clinical record. Interviews with facility staff revealed a lack of clarity and responsibility in reconciling the resident's advance directive choices with the physician's orders. The admitting nurse and regional nurse both acknowledged the inconsistency but were unsure why the physician's order did not match the resident's documented wishes. The facility's policy on advance directives stated that the resident's treatment preferences should be prominently displayed in the clinical record and that the care plan should align with these preferences, which was not adhered to in this case.
Failure to Notify Physician of Fluid Restriction and Weight Loss
Penalty
Summary
The facility failed to notify the physician and specialized treatment center regarding a resident with end-stage renal disease who consistently exceeded their prescribed fluid restriction. The resident, who required peritoneal dialysis, had a physician's order limiting fluid intake to 1000 ml per day. However, records showed that the resident exceeded this limit on 54 out of 59 days, and there was no documentation indicating that the physician or dialysis center had been informed. Interviews with staff revealed that the responsibility for monitoring and notifying the physician lay with the night supervisor, but this protocol was not followed, and the facility lacked a specific policy for dialysis residents on fluid restrictions. Another resident, admitted with diagnoses including stroke, dysphasia, and dementia, experienced significant weight loss without appropriate notification to the physician, APRN, or resident representative. The resident's weight dropped from 156 lbs to 138 lbs over four months, with a notable 12 lbs loss in one month. Despite a physician's order to notify the physician if weight loss exceeded certain thresholds, there was no record of such notifications or dietitian consultations until much later. Interviews confirmed that the dietitian was unaware of the weight loss until reviewing the clinical record months later, and the facility's policy required nursing to notify the dietitian of significant weight changes. The facility's failure to adhere to its policy of promptly notifying relevant parties of significant changes in residents' conditions resulted in deficiencies in care. The lack of documentation and communication regarding the residents' fluid intake and weight loss highlights a breakdown in the facility's processes for monitoring and responding to changes in residents' medical conditions. This oversight could potentially impact the residents' health and well-being, as timely interventions were not initiated.
Failure to Notify State Authority of Mental Health Diagnosis Changes
Penalty
Summary
The facility failed to notify the State-designated authority when a resident was diagnosed with a new mental health condition and when the diagnosis was later discontinued. The resident, who was initially admitted with anxiety, depression, and dysthymic disorder, was later diagnosed with schizoaffective disorder by a psychiatric evaluation. This diagnosis was added on 10/20/21, but the facility did not update the PASARR Level 1 screen to reflect this change. Furthermore, when the diagnosis of schizoaffective disorder was discontinued on 10/13/23, the facility again failed to notify the State-designated authority. The Director of Social Services, responsible for overseeing PASARRs, indicated that she was not informed of the changes in the resident's diagnosis. The facility's policy requires coordination with the PASARR program to ensure that any significant changes in a resident's mental health status are promptly reported to the appropriate state authority. This oversight resulted in a failure to comply with the PASARR requirements, as the facility did not update the necessary documentation or notify the state authority of the changes in the resident's mental health diagnosis.
Deficiencies in Resident Care and Supervision
Penalty
Summary
The facility failed to ensure proper settings for an air mattress for a resident with a stage 4 pressure ulcer. The resident was readmitted with diagnoses including stroke and was dependent on staff for personal care. A physician's order specified the air mattress should be set at 210 lbs, but observations on multiple occasions revealed it was set at 270 lbs. Interviews with staff confirmed the discrepancy, and it was noted that the setting should be checked every shift, but this was not adhered to. Another deficiency involved a resident with dementia who required close supervision during meals. The resident was observed with an untouched breakfast tray and was not visible from the doorway due to a privacy curtain. Staff interviews revealed a misunderstanding of the supervision requirements, with aides leaving the resident unsupervised and planning to return later. The facility's policy required visual supervision during meals, which was not followed, leading to the resident being left unattended. The third deficiency concerned a resident who required weights to be obtained as per physician's orders. The clinical record lacked documentation of weights on specified dates, despite being signed off as completed. An LPN admitted to signing off weights without actually obtaining them, intending to do so later. This practice was against the facility's policy, which required weights to be documented in the resident's medical record immediately after being obtained.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to adhere to the physician's order to complete the Braden Scale weekly for Resident #37, who was admitted with diagnoses including Alzheimer's dementia, muscle weakness, and anemia. The initial Braden Scale assessment on 11/14/22 indicated that the resident was not at risk for pressure ulcers, but subsequent weekly assessments were not documented. Additionally, the care plan identified the resident as at risk for skin breakdown due to incontinence, yet the necessary interventions were not fully implemented. The facility also did not implement the wound care physician's recommendation to apply Dermaseptin, a zinc oxide-based barrier cream, to protect the resident's skin from moisture and breakdown. This oversight was attributed to the wound care nurse's overwhelming workload and failure to enter the order into the clinical record. Consequently, the resident did not receive the prescribed treatment, which was crucial given their history of recurrent pressure ulcers. Upon the resident's readmission to the facility following a hospitalization for a gastrointestinal bleed, the facility failed to conduct a thorough RN assessment of the resident's pressure ulcers. The hospital discharge paperwork indicated a stage IV pressure ulcer and a deep tissue injury, but these were not properly assessed or documented by the facility staff. The RN supervisor did not review the hospital discharge paperwork adequately, resulting in incomplete documentation and assessment of the resident's wounds upon readmission.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to address a significant weight loss for a resident, identified as Resident #84, according to professional standards and facility policy. Resident #84, who was admitted with diagnoses including stroke, dysphasia, and dementia, experienced a weight loss of 18 lbs. over four months. Despite a physician's order to notify the physician or APRN if the resident lost more than 2 lbs. in a day or 5 lbs. in 7 days, the facility did not notify the physician or dietitian of the weight loss in a timely manner. The resident's weight records showed a loss of 12 lbs. in one month, yet there was no documentation indicating that the physician or dietitian was informed of this significant change. The facility's policy required that any weight change of 5% or more be retaken the next day for confirmation, and if verified, the dietitian should be notified immediately. However, the dietitian was not informed of the weight loss until the quarterly MDS assessment, despite being present in the facility four days a week. Interviews with the dietitian and medical staff revealed that the lack of communication and documentation prevented timely intervention. The dietitian indicated that had she been notified earlier, she would have conducted a complete evaluation to determine the cause of the weight loss. The deficiency was further highlighted by the facility's failure to follow its own Weight Assessment and Intervention Policy, which mandates immediate notification of the dietitian and physician upon verification of significant weight loss. The nursing staff did not document the notification of the physician or dietitian, and the LPN responsible for weighing the resident was unaware of the weight loss due to limitations in the computer system. This lack of communication and adherence to policy resulted in a delay in addressing the resident's nutritional needs.
Failure to Monitor Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to consistently monitor and manage the fluid intake of a resident with end-stage renal disease who required peritoneal dialysis and had a physician-ordered fluid restriction of 1000 ml per day. Despite the care plan and physician's orders, the resident exceeded the fluid restriction on 28 out of 31 days in December 2024 and 26 out of 28 days in January 2025. The facility's documentation and interviews revealed that the nursing staff did not notify the physician, APRN, or the resident about these exceedances, nor was there any documentation of education provided to the resident regarding the fluid restriction. Interviews with facility staff, including LPNs and RNs, indicated a lack of adherence to the facility's policy for monitoring fluid intake and notifying appropriate medical personnel when the fluid restriction was exceeded. The Director of Nursing Services (DNS) confirmed that the night supervisor was responsible for calculating daily fluid totals and informing the day supervisor to notify the APRN or physician. However, there was no evidence that these notifications or educational interventions occurred. Additionally, the facility did not provide a specific policy for managing dialysis residents on fluid restrictions, further contributing to the deficiency.
Failure to Implement Gradual Dose Reductions for Antipsychotic Medication
Penalty
Summary
The facility failed to implement gradual dose reductions (GDR) and non-pharmacological interventions for a resident who was receiving antipsychotic medication, Abilify, after the diagnosis of schizoaffective disorder had been discontinued. The resident was initially diagnosed with anxiety, depression, and dysthymic disorder upon admission and was later prescribed Abilify for schizoaffective disorder. However, a psychiatric evaluation in October 2023 recommended discontinuing the schizoaffective disorder diagnosis and suggested a GDR trial of antipsychotics. Despite this recommendation, the facility did not attempt further GDRs after reducing the Abilify dosage from 5mg to 2mg in November 2023. The resident continued to receive Abilify for schizoaffective disorder throughout 2024, as documented in psychiatric notes. The social worker was unaware that the diagnosis had been discontinued and did not ensure a comprehensive care plan was developed for the use of the antipsychotic medication. Interviews revealed a lack of communication among staff regarding the discontinuation of the schizoaffective disorder diagnosis. The APRN responsible for the resident's care was not informed of the change and continued to prescribe Abilify based on the outdated diagnosis. The facility's policy on antipsychotic medication use was not followed, as the medication was not reviewed or adjusted according to the updated diagnosis and professional standards.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment to a resident, as per the physician's orders and care plan. The resident, who was admitted with dementia and a stroke affecting the right side, required a scoop plate, built-up utensils, and a two-handled sippy cup with every meal. Despite these requirements being documented in the resident's care plan and physician's orders, observations on multiple occasions revealed that the resident's meal trays lacked the necessary adaptive equipment. This deficiency was noted during breakfast and lunch meals, where the resident was observed without the required scoop dish and sippy cup. Interviews with nursing assistants and dietary staff revealed a lack of awareness and responsibility regarding the provision of adaptive equipment. Nursing assistants admitted to not reading meal tickets and assumed it was the kitchen's responsibility to ensure the trays were correct. The dietary staff, including the Director of Dietary and the Dietitian, indicated that while the kitchen staff was responsible for preparing accurate trays, the nursing aides were expected to verify the trays before serving them to residents. This miscommunication and lack of accountability contributed to the resident not receiving the necessary adaptive equipment. The transition to a new electronic medical record (EMR) system in August 2024 further complicated the situation. The Chief Nursing Officer identified an importing glitch during the system changeover, which resulted in the adaptive equipment orders not being transferred correctly. This oversight meant that the resident's need for adaptive equipment was not reflected in the new system, leading to the continued absence of necessary items on meal trays. The facility acknowledged the issue and recognized the need for a comprehensive audit to ensure no other residents were affected by similar discrepancies.
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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) |
|---|---|---|---|---|
| Civita Care Center At Milford | 1.2 mi | ★★★★★ | 6 | 0 |
| Milford Health And Rehabilitation Center | 2.3 mi | ★★★★★ | 8 | 0 |
| Lord Chamberlain Nursing & Rehabilitation Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Lord Chamberlain Manor Nursing & Rehabilitation Ce | 2.6 mi | ★★★★★ | 5 | 1 |
| Orange Health Care Center | 4 mi | ★★★★★ | 0 | 0 |
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