Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Blaire House Of Milford during CMS and state inspections, most recent first.
A resident with TBI, depression, anxiety, and behavioral disturbances had a court-appointed guardian who requested, and a physician ordered, that PRN Ativan be tried first for agitation and aggressive behaviors before using PRN Trazodone. Facility policies required honoring resident/representative participation in care and administering medications per prescriber orders. However, MAR reviews over multiple weeks showed repeated administration of PRN Trazodone without a prior trial of Ativan, or with Trazodone given before Ativan, contrary to the order. In interviews, nurses acknowledged awareness of the guardian’s request and the order but admitted giving Trazodone first, with one stating she believed it was more effective, demonstrating failure to follow the established medication sequence.
A resident with a traumatic brain injury and a court-appointed guardian lost upper and lower partial dentures and was evaluated twice by a dentist, who documented that replacement dentures were needed and instructed staff to obtain the guardian’s signed consent so dentures could be made. Despite these written recommendations and the facility’s policy requiring dental treatment orders and documentation, nursing staff did not secure the required consent, and the medical record contained no evidence of a signed dental consent form. The resident and guardian reported the dentures had been missing for a long time, CNAs confirmed the dentures had been lost for an extended period, and the DON stated she was unaware the dentures were missing, resulting in a prolonged delay in fabricating new dentures.
Three residents experienced deficiencies in care, including failure to reconcile and administer critical medications upon admission, lack of required documentation for healthcare proxy activation, and failure to discontinue medications as ordered by a physician. These lapses resulted from incomplete admission processes, missing documentation, and failure to update electronic health records.
A resident with cognitive impairment and multiple diagnoses was struck in the face and side with a pillow by a roommate during an altercation. Staff separated the residents but did not recognize the incident as potential abuse, failed to notify law enforcement, and did not update the care plan or implement interventions to prevent recurrence. Facility policies for reporting and investigation were not followed, and required documentation was not completed.
A resident with moderate cognitive impairment and multiple diagnoses was struck with a pillow by their roommate, and although the incident was documented and facility leadership was notified, it was not reported to the state agency as required. The Administrator initially did not report the event, believing no physical contact had occurred, resulting in a 26-day delay before the incident was entered into the required reporting system.
A resident with chronic anemia and heart failure had critically low hemoglobin and hematocrit results that were not promptly reported to the provider, despite multiple attempts by the lab to notify staff. The provider was not informed until two days later, after the resident became lethargic, leading to a delayed hospital transfer and necessary interventions.
Surveyors found that staff did not consistently label or date food items in all kitchenettes, including opened thickened liquids, yogurt cups, soda, salad dressing, and other ready-to-eat foods. Multiple items were observed without required labels, dates, or were stored past expiration, in violation of facility policy and FDA Food Code. The Food Service Director confirmed that labeling and dating procedures were not always followed.
The facility failed to maintain accurate infection surveillance and proper hand hygiene practices. The IP used outdated McGeer criteria, resulting in incomplete and inaccurate documentation of HAIs for several residents. Staff did not consistently perform hand hygiene during meal service or assist residents in cleaning their hands before meals, and the facility lacked a policy addressing these practices. These deficiencies led to a failure in providing a safe and sanitary environment.
Two residents who were eligible for updated pneumococcal vaccines (PCV20 or PCV21) were not screened, educated, or offered these immunizations as required by current CDC guidance. The facility relied on outdated protocols, resulting in a lack of documentation and shared decision-making regarding the newer vaccines.
The facility failed to inform residents of their right to not sign a binding arbitration agreement upon admission. Despite adding options to accept or decline, the agreement's wording led to confusion, resulting in residents signing agreements they intended to decline.
The facility failed to address and resolve grievances from residents through the Resident Council over several months. Despite policies requiring prompt action, grievances such as delayed staff assistance, medication issues, and noise disturbances were repeatedly raised but remained unresolved. The Activity Director documented grievances, but responses were incomplete, and the former DON did not address issues in her department. Residents expressed frustration over unresolved grievances, and the Administrator and current DON acknowledged the need for a more effective process.
The facility failed to transcribe physician's orders for GDR of antipsychotic medications for residents, did not follow manufacturer's instructions for administering Metamucil, and neglected to obtain pathology results for a resident post-surgery. Additionally, a diabetic resident was self-administering blood sugar tests without a physician's order or assessment.
The facility failed to secure medication and treatment carts, leaving them unlocked and unattended across three units. Observations showed carts were left accessible in areas like nurses' stations and dining areas, contrary to the facility's policy. Interviews with nursing staff and the DON confirmed the expectation for carts to be locked when unattended.
A resident with a history of stroke and limited mobility was found to have their call light consistently out of reach, contrary to facility policy. Despite staff acknowledging the need for the call light to be accessible, it was repeatedly observed on the floor, highlighting a failure to accommodate the resident's needs.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical needs. A resident with an indwelling Foley catheter did not have a care plan, confirmed by staff interviews. Another resident with dementia also lacked a care plan for their catheter. Additionally, a resident self-administering blood sugar tests and with an implantable cardiac device had no care plans for these aspects of care, as confirmed by staff.
A resident was discharged without a complete recapitulation of their stay, including their course of illness and treatment. The discharge paperwork lacked essential information such as Admission Diagnosis and Summary of Course of Stay. Staff interviews revealed that each department was responsible for completing sections of the discharge paperwork, but the summary section was not completed. The DON confirmed this oversight.
A resident with a history of a brain tumor and epilepsy fell from a wheelchair and hit their head in the dining room. Contrary to the facility's Falls Policy, a dietary aide moved the resident back into the wheelchair before a nurse could assess them. The aide was unaware of the policy, and the Director of Nursing was not informed of the premature move. The resident was sent to the hospital and returned with no injuries.
A resident with an indwelling catheter was observed multiple times with the catheter drainage bag lying on the floor, contrary to CDC guidelines and facility policy. Staff interviews confirmed that the bag should be hanging from the bed, highlighting a failure in infection control practices.
A facility failed to conduct timely AIMS assessments for a resident receiving Olanzapine, an antipsychotic medication, as part of their drug regimen. The AIMS assessment, crucial for monitoring tardive dyskinesia, was last completed in September 2023, contrary to the expected every six-month interval. The Director of Nursing confirmed the lapse, highlighting a deficiency in adhering to standards of practice for monitoring adverse effects of psychotropic medications.
A facility failed to implement proper contact precautions for a resident with MDRO and VRE infections. Despite physician's orders, an incorrect precaution sign was posted, leading to staff not wearing appropriate PPE. A nurse was observed without a gown while performing tasks requiring contact precautions. The DON confirmed the error and acknowledged the need for correct PPE use.
A facility failed to administer a pneumococcal vaccine to a resident despite obtaining consent, as per CDC guidelines and facility policy. The resident, with diabetes and dementia, consented to the vaccine, but there was no record of administration. The DON confirmed the oversight during an interview, highlighting a lapse in the facility's vaccination process.
A resident, eligible for an updated COVID-19 vaccine, did not receive the vaccination despite having signed consent. The DON confirmed that while consent was obtained, there was no documentation of the vaccine being administered in the MIIS.
The facility failed to complete and transmit MDS discharge assessments within the required timeframe for four residents. Despite the CMS RAI Manual's requirement for completion within 14 days post-discharge, assessments for these residents were not completed, as confirmed by an MDS nurse. The DON acknowledged the expectation for timely completion and submission, highlighting a lapse in adherence to submission timeframes.
The facility failed to accurately complete MDS assessments for four residents, leading to deficiencies in documenting their care. A resident with dementia and weakness had multiple falls, but only one was recorded in the MDS. Another resident's fall was not documented, and a third resident's hospice status was omitted. Additionally, a resident's fall with a major injury was not recorded. MDS Nurse #2 confirmed the inaccuracies, and the DON stated that MDS assessments should accurately reflect residents' status.
Failure to Honor Guardian’s Request and Physician Order for PRN Psychotropic Medication Sequence
Penalty
Summary
The deficiency involves the facility’s failure to honor a court-appointed guardian’s request and a physician’s order regarding the sequence of administering PRN psychotropic medications for a resident with a traumatic brain injury, depression, anxiety, and behavioral disturbances. The guardian, based on her observations, preferred that PRN Ativan be administered first for the resident’s aggressive and yelling behaviors, and only if ineffective, that PRN Trazodone be used, as Trazodone made the resident appear sleepier rather than improving behavior. This preference was communicated to the DON on 02/05/26, documented in a nurse’s progress note, and relayed to the physician, who issued an order specifying that Ativan should be tried first before Trazodone. Facility policies stated that residents or their legal representatives have the right to participate in care planning, that medications must be administered in accordance with prescriber orders, and that psychotropic medication management is an interdisciplinary process involving the resident and representative. Despite the guardian’s request and the explicit physician’s order to try Ativan first, MAR reviews for February and March 2026 showed multiple instances where PRN Trazodone was administered without a prior trial of PRN Ativan, or where Trazodone was given earlier in the day and Ativan only later, contrary to the ordered sequence. Specific dates documented repeated administration of Trazodone alone or before Ativan. In interviews, two nurses acknowledged they were aware of the guardian’s request and the order to use Ativan first, yet they administered Trazodone prior to Ativan, with one nurse stating she believed Trazodone was more effective. The DON confirmed that the expectation was for all nurses to follow physician orders, including directions, but the documented medication administration patterns and staff interviews demonstrated that the order and the guardian’s expressed preferences were not consistently followed.
Failure to Obtain Guardian Consent Delaying Denture Fabrication
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely signed dental consent from a court-appointed guardian, which delayed fabrication of new dentures for a resident. The resident, admitted in August 2023, had diagnoses including traumatic brain injury related to a motor vehicle accident, depression, anxiety, and behavioral disturbances, and had a legal guardian appointed by court order. A dental evaluation dated 10/14/25 documented that the resident had lost upper and lower partial dentures and that replacement dentures would aid in mastication. The dentist’s form directed nursing home staff to have the responsible party (guardian) sign a consent for dentures so the dentist could make the partial plates. A subsequent dental evaluation dated 02/05/26 again documented the resident’s desire for upper and lower partial dentures and repeated the instruction for staff to obtain the guardian’s signed consent. Review of the medical record showed no documentation that nursing staff obtained the signed dental consent form from the guardian, despite these written recommendations. During interviews, the guardian stated the resident had been without dentures for some time and did not know when they went missing, and the resident reported not knowing how long they had been without dentures but expressed a desire to have them. CNAs reported that the resident previously had dentures but that they had been lost for a very long time. The DON stated she was not aware the resident’s dentures were missing and acknowledged that the facility’s expectation is to promptly follow up on outside provider recommendations and obtain consent to treat as needed. The facility’s own policy on dental services required written, signed, and dated treatment orders from the dentist to be charted and made part of the medical record and care plan, but the necessary guardian consent for denture fabrication was not obtained, resulting in a delay of several months before new dentures could be made.
Failure to Meet Professional Standards in Medication Reconciliation, Documentation, and Order Implementation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for three residents. For one resident newly admitted with multiple complex diagnoses, including heart failure and dementia, the facility did not complete medication reconciliation or physician notification at the time of admission. The resident's family brought in topical antifungal medications and a list of home hospice medications, but many of these, including critical cardiac and dementia medications, were not ordered or administered. The admission checklist, which required reconciliation of medications and physician approval, was not completed by the admitting nurse, resulting in the omission of 17 medications from the resident's regimen. Another resident with severe cognitive impairment had a healthcare proxy (HCP) activated prior to admission, with the HCP making all medical decisions. Despite this, the required HCP invocation/activation form, which documents the physician's determination of incapacity, was not completed or present in the medical record. Interviews with facility staff and the physician confirmed that the form was missing and should have been completed at the time the HCP was activated. A third resident with dementia and heart failure had a physician's telephone order to discontinue two dementia medications. However, the DON did not discontinue these medications in the electronic health record, and the resident continued to receive them for several days after the discontinuation order. This failure to implement physician orders in a timely manner was confirmed through record review and staff interviews.
Failure to Implement Abuse Policy After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its abuse prevention policy following a resident-to-resident altercation involving a resident with a history of sciatica, Parkinsonism, and bipolar disorder, who was moderately cognitively impaired. The incident occurred when the resident's roommate rummaged through their belongings, leading to a verbal exchange and the roommate throwing a pillow that struck the resident in the face and left side. Staff intervened and separated the residents, but the event was not recognized or treated as potential abuse at the time. Despite facility policies requiring prompt reporting of suspected abuse to local law enforcement and the implementation of interventions to prevent future incidents, these steps were not taken. The nursing note documented the altercation but incorrectly stated that no physical contact was made, and there was no indication that law enforcement was notified or that any follow-up interventions were put in place. The resident's care plan was not updated to reflect the incident or to include measures to prevent recurrence. Interviews with staff, including the social worker, DON, and administrator, revealed a lack of understanding and misinterpretation of what constitutes physical contact and abuse. The administrator acknowledged being aware of the incident but did not implement the abuse protocol, and the nurse on duty did not complete an incident report or notify authorities. The required investigational forms were not completed, and the facility's abuse policy and procedures were not followed, resulting in a failure to protect the resident and ensure appropriate reporting and intervention.
Failure to Timely Report Resident-to-Resident Altercation as Potential Abuse
Penalty
Summary
The facility failed to report a resident-to-resident altercation as potential abuse in accordance with its abuse prevention policy and state requirements. The incident involved a resident with moderate cognitive impairment and diagnoses including sciatica, Parkinsonism, and bipolar disorder, who was struck in the face and left flank area with a small pillow by their roommate. The event was documented in the nursing notes, and the Administrator, DON, NP, and the resident's POA were notified. However, the incident was not reported to the State Agency as required by the facility's policy and state regulations. The Administrator was aware of the incident and conducted an investigation but did not submit the required report to the Healthcare Facility Reporting System (HCFRS) at the time, as he initially believed no physical contact had occurred. It was later acknowledged by the Administrator that the incident should have been reported in accordance with the facility's investigation guidance and abuse policy. The failure to report was confirmed during interviews and review of the HCFRS, which showed the incident was not reported until 26 days after it occurred.
Failure to Timely Report and Act on Critical Lab Results
Penalty
Summary
The facility failed to ensure that laboratory results were reported and acted upon in a timely manner for one resident with chronic iron deficiency anemia and congestive heart failure. On 4/1/25, the resident's CBC results showed a critically low hemoglobin (Hgb) level of 7.2 g/dL and a low hematocrit (Hct) of 21.9%. The laboratory made two attempts to notify the facility by phone on the same day, but there was no documentation that the provider was notified of these critical results on 4/1/25 or 4/2/25. Nursing progress notes did not indicate any provider notification until 4/3/25, when the resident was found to be very lethargic with decreased verbal responsiveness. At that time, a nurse practitioner evaluated the resident, reviewed the lab results, and ordered a transfer to the hospital. Interviews with nursing staff and providers confirmed that neither the nurse practitioner nor the covering physician was made aware of the critical lab results prior to 4/3/25. Both providers stated they would have taken action had they been notified earlier. The facility's policy required immediate provider notification and documentation for critical lab results, but this was not followed. The DON confirmed that the expectation was for critical results to be called in to the provider immediately. The failure to notify the provider resulted in a delay in the resident's evaluation and transfer to the hospital, where the resident ultimately received a blood transfusion and had anticoagulant medication stopped.
Failure to Label and Date Food Items in Kitchenettes
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation by not properly labeling and dating food items in all three kitchenettes. Observations revealed multiple instances of opened and ready-to-eat food items, such as thickened liquids, yogurt cups, soda, salad dressing, garden salad, cake, and mandarin oranges, that were either undated, unlabeled, or stored beyond their expiration dates. The facility's own policies require that all resident food and beverage items stored in unit kitchenettes be clearly marked with the resident's name and the date the item was placed in storage, and that foods brought in from outside be labeled and dated by staff. Additionally, the FDA Food Code mandates that refrigerated, ready-to-eat, time/temperature control for safety foods held for more than 24 hours be clearly marked with a consume-by date. Despite posted reminders in each kitchenette, staff did not consistently label or date food items, as confirmed by the Food Service Director. Items such as thickened liquids were not dated upon opening, and several food items were found in refrigerators past their manufacturer’s expiration dates. The lack of proper labeling and dating of food items represents a failure to follow both facility policy and federal food safety standards, increasing the risk of foodborne illness among residents who are considered high risk.
Deficient Infection Surveillance and Hand Hygiene Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by inaccurate and incomplete infection surveillance and inadequate hand hygiene practices. The Infection Preventionist (IP), who also served as the Director of Nursing (DON), was responsible for infection surveillance using the McGeer criteria. However, the facility's surveillance documentation for several residents was found to be incomplete or inaccurate, with missing or insufficient signs and symptoms to meet the criteria for healthcare-associated infections (HAIs). Additionally, the facility was using outdated McGeer criteria from 2013, despite a more recent revision being available, leading to further inaccuracies in infection reporting. Specific examples included residents being counted as having HAIs without sufficient documentation of required symptoms or diagnostic evidence, such as chest x-rays for pneumonia or detailed signs for skin infections. In some cases, surveillance forms were left blank or lacked critical information, and the IP acknowledged errors and lack of awareness regarding updated surveillance criteria. The facility's infection control report sheets and surveillance records did not align with the most current standards, resulting in misclassification and under-documentation of infections. Observations by surveyors revealed that staff did not consistently perform hand hygiene when entering or exiting resident rooms, between meal tray passes, or when assisting residents with meals. Residents were not offered or encouraged to clean their hands before meals, and staff used regular napkins instead of designated hand wipes, which were reportedly out of stock. Staff interviews confirmed that hand hygiene protocols were not being followed, and the facility lacked a policy specifically addressing hand hygiene during meal pass and meal assistance. These lapses contributed to an environment that did not meet infection prevention and control standards.
Failure to Screen, Educate, and Offer Updated Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that two residents were properly screened for eligibility, educated about, and offered the recommended PCV20 or PCV21 pneumococcal vaccinations in accordance with current CDC guidance. Both residents had previously received PCV13 and PPSV23 vaccinations several years prior, making them eligible for the newer vaccines. However, their medical records did not indicate that they or their responsible parties were informed about or offered the PCV20 or PCV21 vaccines, nor was there documentation of shared decision-making regarding these immunizations. The facility's policy required informed consent, physician orders, education, and documentation for vaccine administration, but the process was not followed for these residents. During an interview, the Infection Preventionist acknowledged that the facility was using outdated guidance from 2015 and was unaware of the updated CDC recommendations to offer PCV20 or PCV21 to eligible residents. As a result, the necessary steps to assess, educate, and offer the vaccines were not completed for the two residents in question.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to fully inform all residents of their right to not sign a binding arbitration agreement upon admission. The facility's Resident and Facility Arbitration Agreement, last revised in February 2022, indicated that any legal disputes would be resolved exclusively by binding arbitration, and residents were waiving their right to a court trial. The agreement also stated that signing it was not a precondition for receiving services and could be rescinded within 30 days. However, during the entrance conference, the Administrator stated that every resident had signed the agreement, suggesting a lack of proper communication regarding the residents' rights to decline. Interviews with the Business Office Manager (BOM) revealed that the arbitration agreements were included in the admission packet and reviewed with residents or their representatives. In 2023, the facility began asking all residents to sign the agreement, adding handwritten options to accept or decline. Despite this, the Administrator and BOM admitted that the agreement was confusing, as it implied that signing indicated both understanding and agreement to enter into the contract. They provided copies of signed agreements, many of which had 'Declined' circled, yet were still signed, indicating a misunderstanding of the agreement's implications.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to address and resolve grievances brought forward by residents through the Resident Council from September 2023 to March 2024. The facility's policies require the Grievance Officer, either the Executive Director or the Director of Nursing (DON), to oversee the grievance process, ensuring grievances are tracked and resolved promptly. However, the review of Resident Council Minutes revealed multiple grievances, such as delayed staff assistance, medication issues, and noise disturbances, that were repeatedly raised by residents but remained unresolved. Interviews with the Activity Director, who coordinates Resident Council Meetings, indicated that grievances were documented and communicated to the relevant departments using Interdisciplinary Communication Forms. Despite this process, the Activity Director found incomplete and unsigned responses for grievances from the February 2024 meeting, and noted that the former DON did not address grievances related to her department. This lack of follow-up and resolution was confirmed by the Administrator and the current DON, who acknowledged the absence of documented responses in the grievance book. Residents expressed frustration during a surveyor-led Resident Group meeting, stating that their grievances were acknowledged but not resolved, with some issues persisting over several months. The Administrator and DON admitted the need for a more effective process to ensure grievances are addressed and resolved in a timely manner, ideally before the next Resident Council Meeting.
Failure to Transcribe Orders and Follow Protocols
Penalty
Summary
The facility failed to transcribe and implement physician's orders for gradual dose reduction (GDR) of antipsychotic medications for several residents. For one resident with severe cognitive deficits, the physician agreed with a psychiatric nurse practitioner's recommendation to decrease the dosage of Haloperidol, but the order was not transcribed into the resident's record. Similarly, another resident with bipolar disorder and dementia was supposed to have their Olanzapine dosage reduced, but the order was not transcribed, and a re-evaluation of the medication was not conducted as required. Additionally, the facility did not adhere to the manufacturer's instructions for administering Metamucil to a resident with hemiplegia. The nurse administered the medication with only 5 ounces of water instead of the recommended 8 ounces. This deviation from the manufacturer's guidelines was acknowledged by the nurse, who cited the lack of appropriate cup sizes as the reason for the error. The facility also failed to follow up on pathology results for a resident who underwent surgical intervention for osteomyelitis. Despite a physician's order to obtain the pathology results to determine the need for further antibiotic treatment, there was no documentation of follow-up. Furthermore, a resident with diabetes was self-administering finger stick blood sugar tests without a physician's order or assessment of their ability to do so, which was acknowledged by the Director of Nursing.
Medication and Treatment Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely as required by their policy. Specifically, medication and treatment carts were observed to be unlocked and unattended on multiple occasions across three different units. These observations were made by surveyors on various dates, with carts being left unlocked in areas accessible to residents, such as in front of nurses' stations and along walls between nurses' stations and dining areas. The facility's policy mandates that all medications and biologicals should be securely stored in locked cabinets or carts, which was not adhered to in these instances. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the expectation was for all medication and treatment carts to be locked when unattended. Nurse #4 and Nurse #3 acknowledged that the carts should have been locked when not supervised. The DON reiterated the facility's policy that all carts must be locked when not in use, highlighting a clear deviation from the established procedures. This deficiency was identified through a combination of direct observation, staff interviews, and a review of the facility's storage policy.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was accessible, which is a violation of their policy on answering call lights. The resident in question was admitted with a history of cerebral infarction, hemiplegia affecting the right side, and aphasia, making them dependent on staff for self-care and mobility. Observations by the surveyor on multiple occasions revealed that the call light was consistently out of reach, either on the floor or clipped to the mattress in a manner that left it inaccessible to the resident. Interviews with staff, including a CNA and nurses, confirmed that the resident's call light should have been within reach at all times. Despite this, the call light was repeatedly found on the floor, and staff acknowledged the oversight. The Director of Nurses also stated that the expectation was for call lights to be accessible at all times, indicating a lapse in adherence to facility policy and staff awareness regarding the resident's needs.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their individual medical needs. Resident #14, who was admitted with diagnoses including hypertensive urgency and urinary retention, had an indwelling Foley catheter inserted but did not have a corresponding care plan developed. This oversight was confirmed during interviews with Nurse #5 and the Director of Nursing (DON), who acknowledged the absence of a care plan for the catheter, despite the facility's policy requiring one. Similarly, Resident #22, admitted with dementia, also had an indwelling Foley catheter inserted without a care plan being developed. The lack of a care plan was noted during interviews with Nurse #4 and Nurse #3, who confirmed that the care plan should have been updated to reflect the change in the resident's care needs. The DON reiterated the expectation for a care plan to be in place for residents with indwelling catheters, which was not met in this case. Resident #51, with diagnoses including atrial fibrillation and diabetes mellitus type 2, was found to be self-administering finger stick blood sugar testing and had an implantable cardiac device, yet no comprehensive care plans were developed for these aspects of care. Interviews with Nurse #2 and the DON revealed that the facility failed to create care plans for the resident's self-administration of blood sugar testing and the use of the implantable cardiac device, despite the facility's policy requiring care plans to reflect all aspects of a resident's care needs.
Incomplete Discharge Documentation
Penalty
Summary
The facility failed to document the recapitulation of a resident's stay, including their course of illness and treatment, at the time of a planned discharge. The resident was admitted with a partial amputation of the left great toe and discharged home at the end of January 2024. Upon review, the discharge paperwork, specifically the Discharge Plan, was found incomplete, with sections such as Admission Diagnosis, Summary of Course of Stay, Final Diagnosis, and other observations left blank. Interviews with staff revealed that each department was responsible for completing a section of the discharge paperwork, but the summary section was not completed as required. The Director of Nurses confirmed that the summary section should have been filled out, indicating a lapse in the discharge documentation process.
Failure to Follow Falls Policy After Resident's Unwitnessed Fall
Penalty
Summary
The facility failed to adhere to its Falls Policy & Procedure by not ensuring that a resident who sustained an unwitnessed fall with a head strike was assessed by a nurse before being moved. The incident involved a resident with a history of a malignant brain tumor and epilepsy, who was unable to complete a mental status assessment and had severely impaired cognitive skills. On the day of the incident, the resident fell from a wheelchair in the dining room and hit their forehead on the floor. Despite the facility's policy to leave the resident as found until a nurse could assess them, a dietary aide moved the resident back into the wheelchair before a nurse's assessment. Interviews revealed that the dietary aide, unaware of the policy, moved the resident after hearing them call for help and finding no staff nearby. The Director of Nursing was not aware of the resident being moved before a nurse's assessment. The incident report and staff statements confirmed that the resident was moved before being assessed, which was against the facility's policy. The resident was later sent to the hospital for evaluation and returned with no injuries from the fall.
Improper Catheter Care and Infection Control
Penalty
Summary
The facility failed to provide proper care for a resident with an indwelling catheter, which is a flexible tube inserted into the bladder to drain urine. The deficiency was identified through observations, interviews, and record reviews. The resident, who was admitted with conditions including hypertensive urgency, cognitive communication deficit, and urinary retention, had a Foley catheter inserted in April 2024. The facility's policy and CDC guidelines specify that catheter drainage bags should not rest on the floor to prevent infections. However, on multiple occasions, the surveyor observed the resident's catheter drainage bag lying on the floor, sometimes in a privacy bag and sometimes not. Interviews with facility staff, including a CNA and a nurse, confirmed that the catheter drainage bags should be hanging from the bed and not placed on the floor. The Director of Nursing also stated that the expectation is for catheter drainage bags to be kept in a privacy bag and off the floor. Despite these guidelines and expectations, the facility did not adhere to proper infection control practices, as evidenced by the repeated observations of the catheter bag on the floor.
Failure to Conduct Timely AIMS Assessment for Psychotropic Medication Monitoring
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic medications by not completing an Abnormal Involuntary Movement Scale (AIMS) assessment in a timely manner. The AIMS assessment is a clinical tool used to monitor for tardive dyskinesia, a condition characterized by abnormal involuntary movements, and should be conducted every three to six months according to the National Library of Medicine. However, the facility's policy on antipsychotic medication use did not specify the intervals for conducting AIMS assessments. The resident in question was admitted with diagnoses of bipolar disorder and dementia with agitation and was receiving regular doses of the antipsychotic medication Olanzapine. The resident's records indicated that the last AIMS assessment was completed in September 2023, and subsequent assessments were not conducted every six months as expected. Interviews with the Director of Nursing confirmed that the psychiatric practitioner was expected to complete the AIMS assessment every six months, but this was not done for the resident. This oversight resulted in a failure to adhere to standards of practice for monitoring the adverse effects of psychotropic medications, specifically the development of tardive dyskinesia.
Failure to Implement Contact Precautions for Resident with MDRO
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident diagnosed with sepsis and infection with Multi-Drug Resistant Organisms (MDRO). The resident was admitted with physician's orders for contact precautions due to MDRO and Vancomycin Resistant Enterococcus (VRE) infections. However, the facility did not implement these precautions correctly. Instead of a contact precaution sign, an enhanced barrier precaution sign was posted on the resident's door, which led to improper use of personal protective equipment (PPE) by the staff. During observations, a nurse was seen in the resident's room without wearing a gown while performing tasks that required contact precautions, such as applying skin prep and repositioning the resident. The nurse incorrectly believed that a gown was only necessary when dealing directly with the wound, despite the posted sign indicating otherwise. The Director of Nurses confirmed that the wrong precaution sign was posted and acknowledged that staff should have adhered to contact precautions, including wearing a gown and gloves, as per the facility's policy for residents with MDROs.
Failure to Administer Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to administer pneumococcal vaccinations to Resident #46 in accordance with the Centers for Disease Control and Prevention (CDC) recommendations and the facility's own policy. Resident #46, who was admitted in January 2021 with diagnoses of diabetes mellitus and dementia, had consented to receive the pneumococcal vaccination on August 25, 2021. The facility's policy required that residents be assessed for eligibility and offered the vaccine series within thirty days of admission unless contraindicated or already completed. Despite the consent being obtained, there was no documented evidence that the vaccination was administered. The Director of Nurses (DON), who also served as the Infection Prevention Nurse, confirmed during an interview that Resident #46 was eligible for the pneumococcal vaccine any time after December 31, 2021, following the administration of the PCV 13 vaccine on December 31, 2020. However, the DON acknowledged that there was no record of the vaccine being administered, despite the consent being in place. This oversight indicates a failure in the facility's process to ensure that vaccinations are administered as per policy and CDC guidelines.
Failure to Administer COVID-19 Vaccine to Eligible Resident
Penalty
Summary
The facility failed to provide education, assess eligibility, and offer COVID-19 vaccinations to a resident in accordance with CDC recommendations and facility policy. A resident, who was admitted in January 2024 and was of eligible age, had previously received COVID-19 vaccinations in 2021 and 2022. Despite having signed consent to receive an updated COVID-19 vaccination in January 2024, there was no documented evidence that the vaccine was administered. The Director of Nurses, who also served as the Infection Prevention Nurse, confirmed during an interview that while the consent was obtained, the vaccination was not recorded as administered in the Massachusetts Immunization Information System (MIIS).
Failure to Complete MDS Discharge Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) discharge assessments were completed within the required timeframe for four residents. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, a discharge assessment must be completed no later than 14 calendar days after the discharge date. However, the facility did not adhere to this requirement for Residents #5, #12, #11, and #59, as their discharge assessments were not completed and transmitted within the specified period. Resident #5 was discharged on February 28, 2024, Resident #12 on January 18, 2024, Resident #11 on December 19, 2023, and Resident #59 on November 21, 2023. Despite these discharge dates, the assessments for these residents were not completed, as confirmed by MDS Nurse #2 during a telephonic interview. The Director of Nurses (DON) acknowledged that the expectation was for MDS assessments to be completed and submitted as required, indicating a lapse in the facility's adherence to federal and state submission timeframes.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for four residents, leading to deficiencies in the documentation of their care. Resident #47, who was admitted with dementia and weakness, experienced multiple falls between January and April 2024, but the MDS assessment dated April 11, 2024, only recorded one fall since the previous assessment. Similarly, Resident #58, admitted with weakness and repeated falls, had a fall on April 4, 2024, which was not documented in the MDS assessment of the same date. MDS Nurse #2 confirmed that the MDS assessments for both residents did not accurately reflect their fall history. Additionally, Resident #22, admitted with dementia and weakness, was on hospice care since December 6, 2023, but this was not indicated in the MDS assessment dated March 7, 2024. Resident #46, who had dementia and multiple fractures, was hospitalized after a fall in February 2024 and returned with a rib fracture. However, the MDS assessment dated March 11, 2024, failed to document the fall with a major injury. MDS Nurse #2 acknowledged the inaccuracies in the MDS assessments, and the Director of Nurses stated that the expectation was for MDS assessments to accurately reflect the residents' status.
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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) |
|---|---|---|---|---|
| Oc Milford Gardens Llc | 1 mi | ★★★★★ | 13 | 0 |
| Countryside Health Care Of Milford | 2.1 mi | ★★★★★ | 5 | 0 |
| Medway Country Manor Skilled Nursing & Rehabilitat | 5.7 mi | — | 9 | 0 |
| Timothy Daniels House | 6.5 mi | ★★★★★ | 1 | 0 |
| Adviniacare At Northbridge | 7 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.