Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Oc Milford Gardens Llc during CMS and state inspections, most recent first.
A newly admitted resident with multiple chronic conditions received two medications in error after admission because the Unit Manager transcribed the EMAR during multiple simultaneous admissions and interruptions. The hospital discharge summary did not include Buspirone or Benzonatate, yet both were entered on the EMAR and administered multiple times without documentation that the discrepancy was clarified with the provider. The facility's review identified the Buspirone error but missed the additional Benzonatate error.
A resident who was alert, oriented, and his/her own decision maker was given Buspirone HCL, an antianxiety psychotropic medication, without documented signed informed consent. The MAR showed multiple doses were administered, but the record contained no consent form. The nurse said she administered the medication as ordered and did not check for consent, the Unit Manager said she did not obtain it, and the DON could not locate documentation supporting informed written consent.
Resident Council grievances were not promptly resolved or clearly communicated back to residents. Residents repeatedly reported that staff and agency staff were speaking a non-English language in resident areas, and most said they felt unheard and believed the facility only responded with in-services that did not fix the issue. The Activity Director and Administrator acknowledged the concern remained ongoing, and the grievance record did not show a resolution date or clear communication of the plan back to the council.
A resident with CVA, left-sided hemiplegia/hemiparesis, and a fractured heel was observed wearing a soft heel boot in bed, but the boot was not supported by a physician order or included in the care plan. The resident said the boot was used daily in bed and had been given by OT, while staff stated they relied on orders and documentation to guide brace and splint use. Rehab and nursing staff could not produce documentation for the soft boot, and OT notes did not show a treatment plan for it.
A resident with cognitive impairment, a prior hip fracture, and a history of repeated falls continued to fall during toileting and self-transfers. Although the care plan and therapy notes showed the resident needed supervision or staff assistance with toileting and transfers, documentation often coded the resident as independent, and staff were observed allowing the resident to self-propel, stand without locking the wheelchair, and use the bathroom alone. The falls care plan interventions did not consistently address the toileting and transfer-related causes of the resident’s falls.
Failure to provide nail care for a dependent resident. A resident with weakness and degenerative disc disease was cognitively intact but dependent on staff for ADLs. The resident reported staff took personal nail clippers and did not return them, and multiple nurses and CNAs did not trim the nails despite repeated requests. Surveyors observed the resident’s fingernails long and dirty with dark substance underneath on several occasions, while staff stated nail care should be done on shower days and as needed.
A resident with a G-tube, cerebral infarction, aphasia, and moderate cognitive impairment did not receive enteral feedings as ordered. Staff delayed hanging the feeding, failed to verify tube placement before use, and administered the feeding at incorrect rates, with the pump and bottle labels not matching the physician’s order. The DON stated feedings should be given at the ordered time and orders should be double checked before setup.
Inaccurate documentation of PRN oxycodone administration was identified for a resident with osteoarthritis and a sacral pressure ulcer. The MAR did not match the narcotic book, with multiple oxycodone doses signed out in the narcotic book but not documented on the MAR. A UM stated she administered the medication and forgot to document it, and the DON stated PRN narcotic doses should be documented on both records.
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.
Medication Reconciliation Error Led to Unordered Buspirone and Benzonatate Administration
Penalty
Summary
Resident #1 was newly admitted to the facility in March 2026 with diagnoses including acute renal failure on chronic kidney disease, benign prostatic hyperplasia with lower urinary tract symptoms, hyponatremia, hypomagnesemia, hypocalcemia, atrial fibrillation, hyperlipidemia, hypertension, chronic gout due to renal impairment, and Wegener's granulomatosis with renal involvement. The facility policy required medication reconciliation by comparing the hospital discharge medications to the post-discharge medication list, obtaining a medication history, reviewing the discharge summary carefully, and resolving any discrepancies with the referring facility and admitting physician. Resident #1's hospital discharge summary listed multiple medications, but the facility physician's orders and EMAR also included Buspirone HCL 10 mg three times daily and Benzonatate 100 mg three times daily, even though those medications were not on the hospital discharge summary. The medical record contained no documentation that nursing clarified these discrepancies, reconciled them, or obtained new orders from the physician regarding either medication. The NP documented that the admission medications were reviewed with the Unit Manager and that everything looked appropriate, and later noted that the hospital had issues confirming medication dosing and that the resident confirmed the dosing in the discharge paperwork. The MAR showed that Resident #1 received Buspirone and Benzonatate in error, each administered three times daily from 3/11/26 through 3/16/26 for a total of 16 doses. Nursing stated that the Unit Manager completed the medication reconciliations for three admissions at the same time and entered the medications into the EMAR, and the Unit Manager stated she was interrupted multiple times and mixed up Resident #1's medication list with another resident's list. The facility's internal investigation identified the Buspirone transcription error, but did not identify that Benzonatate had also been transcribed and administered in error. The DON later stated she reviewed the discharge summary and verified listed medications were on the EMAR, but did not check for additional medications on the EMAR and did not notice the extra medications.
Failure to Obtain Written Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain signed written informed consent before administering Buspirone HCL, an antianxiety psychotropic medication, to a newly admitted resident who was alert, oriented, and his/her own decision maker. The resident’s admission MDS dated 03/16/26 indicated a BIMS score of 15/15, and the medical record showed physician’s orders for Buspirone HCL 10 mg by mouth three times daily beginning 03/11/26. The March 2026 MAR documented 16 administered doses of Buspirone HCL between 03/11/26 and 03/16/26. Review of the medical record found no documentation that a written informed consent for Buspirone HCL had been obtained. The facility policy required informed written consent before administration of any psychotropic medication, including antianxiety medications, and required the prescriber to discuss the purpose, dosage, and known effects or side effects with the resident before administration. During interviews, the nurse said she administered the medication as ordered and did not check the record for consent, the Unit Manager said she did not obtain the consent and was unaware it had not been obtained, and the DON said she could not locate documentation supporting informed written consent for the medication.
Resident Council Grievances Not Timely Resolved
Penalty
Summary
The facility failed to ensure grievances brought forward from the Resident Council were addressed and promptly resolved. Review of Resident Council minutes showed a repeated concern beginning with staff on the 3-11 shift not speaking English on the units or in resident areas, followed by ongoing reports that agency nursing staff and other staff continued to speak a non-English language in resident areas over multiple council meetings. The corresponding departmental response forms repeatedly documented only ongoing in-servicing and audits, with the concern continuing to be raised at subsequent Resident Council meetings. During a group meeting with 11 residents, 9 residents said staff were still not speaking English on the units or in resident areas and that they felt staff were speaking negatively about them and trying to be sneaky. Ten residents said they felt unheard by the facility when they repeatedly brought forward concerns, and 9 residents said they did not feel the facility tried to resolve the issues or provide a plan to resolve them. Residents stated the concern had remained unresolved since September 2025 and that the only response they had received was in-servicing, which they felt was ineffective. The Activity Director said she managed the Resident Council minutes and completed departmental response forms, and that repetitive or severe issues were supposed to go directly onto a grievance form. She stated the ongoing concern about staff not speaking English had been placed into grievance status a few months earlier, but residents continued to voice it as an ongoing concern. Review of the grievance book showed the concern was investigated with a plan to provide in-services and survey the Resident Council at the next meeting, but the grievance form did not indicate the grievance was resolved, did not include a date of resolution, and did not show that the plan was communicated within the facility's stated timeframe. The Administrator stated he was the grievance official, acknowledged the concern may never be resolved because it involved behavior change, and said he should have communicated more detailed interventions and attempts to resolve the concern with the Resident Council.
Missing Order and Care Plan for Soft Heel Boot
Penalty
Summary
The facility failed to ensure that one resident received care and treatment in accordance with professional standards because a left heel boot was not supported by a physician's order and was not included in the care plan. The resident was admitted with diagnoses including CVA/stroke, left-sided hemiplegia/hemiparesis, and a fractured left heel, and the MDS indicated the resident was cognitively intact and at risk for pressure ulcers. The physician's orders included a left CAM boot for transfers and when out of bed, and the care plan addressed limited mobility, ADL deficits, and skin breakdown risk, but there was no order or care plan entry for the soft left heel boot that staff observed the resident wearing in bed. Survey observations showed the resident lying in bed with a soft left heel boot on on multiple occasions. During interview, the resident stated the CAM boot was worn when out of bed and the soft boot was worn in bed every day, and said the boot had been given by OT. The resident also stated staff never put the soft boot on correctly and that OT had provided education on how to apply it, but staff still did not do it right. Review of OT treatment notes did not show a soft heel boot or any treatment plan for it. Staff interviews confirmed there was no written communication tool for CNAs regarding braces or splints, and CNAs were expected to ask the nurse if they had questions. Nursing staff stated they relied on physician orders to know when devices should be applied and removed, and rehab staff stated that if OT provided a splint or brace, the order would be entered in the computer and nursing would obtain physician approval. However, rehab and nursing staff could not produce documentation showing a soft boot order, care plan entry, or education record for the resident, and multiple staff members stated the soft boot was not documented in the orders or care plan.
Repeated falls linked to toileting and transfer supervision failures
Penalty
Summary
The facility failed to ensure a resident with a history of repeated falls received an environment free of accident hazards and adequate supervision related to toileting and transfers. The resident was admitted with diagnoses including mild cognitive impairment, protein calorie malnutrition, spinal stenosis, repeated falls, and a right femur fracture. After a fall on 10/8/25 that resulted in a hip fracture, the resident’s mobility and continence changed, and subsequent assessments showed the resident used a wheelchair, was occasionally incontinent, was not on a toileting program, and required supervision or touching assistance with transfers and toileting. The resident experienced five additional falls after the fracture, and each incident was tied to toileting or self-transferring. The falls occurred when the resident attempted to get to the bathroom, transfer off the toilet, slide from the wheelchair during a transfer, or move from the bed to the wheelchair without locking the brakes. The incident reports showed that after each fall, the care plan was updated with interventions such as diverting the resident with activities, repositioning items, obtaining resident input, adding therapy evaluation, and briefly adding floor mats, but the documented interventions did not address the repeated toileting and transfer-related causes identified in the falls. The care plan and therapy records showed the resident required staff participation or supervision with toileting, transfers, and other ADLs, yet the toilet transfer and bed/chair transfer documentation from 2/1/26 through 3/3/26 frequently coded the resident as independent. During observations, the resident was seen self-propelling in the wheelchair, standing at the nurses’ station without locking the brakes, and going to the bathroom without staff assistance. On one occasion, the resident remained in the bathroom alone for 55 minutes while barefoot and handling clothing items, and no staff entered to assist with toileting, dressing, or cleanup. Staff interviews confirmed the resident should have been assisted with toileting and transfers and that the interventions in the care plan did not address the actual causes of the repeated falls.
Failure to Provide Nail Care for a Dependent Resident
Penalty
Summary
The facility failed to ensure ADL care was provided to maintain good personal grooming for one resident, specifically nail care for Resident #63. The resident was admitted with diagnoses including intervertebral disc degeneration and weakness, and the MDS dated 2/16/26 indicated a BIMS score of 15 out of 15, showing the resident was cognitively intact and dependent on staff for ADL assistance. The care plan identified an ADL self-care performance deficit related to weakness and degenerative disc disease. During interview, the resident stated staff had taken a pair of toenail clippers that he/she used for fingernails and had not returned them, and that multiple nurses and CNAs had been asked to cut the nails but had not done so. Surveyor observations showed the resident’s fingernails were long and dirty with dark substance underneath on multiple occasions from 2/25/26 through 2/27/26. The shower schedule showed the resident was scheduled for a weekly shower on Thursdays, and staff interviews indicated nail care should be provided on shower days and as needed when nails were long, dirty, or when requested. A CNA stated every resident is showered weekly and the nurse does the rest, while a nurse, unit managers, and the DON all stated nail care should be done on shower days and when needed. One unit manager recalled the resident’s nail clippers being locked in the cart but was unsure where they were after the resident moved units. By 3/3/26, the resident’s nails were observed clean and trimmed.
Incorrect G-tube Feeding Administration and Failure to Verify Tube Placement
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident with a G-tube by not administering enteral feedings in accordance with physician’s orders. Resident #12 was admitted with diagnoses including cerebral infarction and aphasia, had a BIMS score of 10 indicating moderate cognitive impairment, and was receiving nutrition and fluids through a feeding tube. The resident’s orders included NPO status, continuous Jevity 1.5 Cal via pump at 150 mL/hr from 12:00 P.M. to 10:00 P.M., free water at 80 mL/hr while tube feeding was running, and checking tube placement prior to each use. During observation on 2/26/26, the resident’s enteral feeding pump was present at the bedside without feeding, water, or tubing attached. The nurse later stated she had not hung the tube feeding yet because she was running late and had been interrupted during medication pass, and said the feeding ran slowly so the delay should not be a problem. When she later set up the feeding, she programmed the pump at 150 mL/hr and the water flush at 80 mL/hr, but did not check residual aspirate or verify tube placement before starting the feeding, despite the physician’s order to check placement prior to use. On 3/2/26, the surveyor observed the resident receiving enteral feeding with a bottle labeled with a rate of 50 mL/hr, while the pump was programmed at 80 mL/hr and the water flush was also set at 80 mL/hr. The Unit Manager later stated she had prepared and administered the feeding, confirmed the physician’s order called for 150 mL/hr, and said she did not check the order before administering the feeding. She also stated she was not sure why she wrote a different rate on the bottle than what she set on the pump, and said both rates were incorrect. The nurse later stated she did not check tube placement because she was not required to do so and did not realize the resident had an order for placement checks. The DON stated enteral feeding should be given at the ordered time and that physician’s orders should be double checked prior to setting up the feeding.
Inaccurate Documentation of PRN Oxycodone Administration
Penalty
Summary
The facility failed to ensure staff maintained accurate medical records for one resident in a sample of 23 when nursing staff did not accurately document the administration of a PRN opioid on the MAR. The facility policy titled Administering Medications stated that the individual administering medication initials the MAR after giving each medication and records the date and time a PRN medication is administered in the resident's medical record. Resident #5 was admitted with diagnoses including osteoarthritis and a pressure ulcer of the sacral region, and the MDS indicated a BIMS score of 15 of 15, showing the resident was cognitively intact. The physician's order was for oxycodone 5 mg by mouth every 4 hours as needed for pain, with one tablet for moderate pain and two tablets for severe pain. Review of the MAR showed the resident received oxycodone 21 times from 2/7/26 to 3/3/26, while the narcotic book showed 38 administrations during the same period. The MAR did not document 17 of those 38 administrations, and a UM stated she administered oxycodone, got busy, and forgot to document it on the MAR, acknowledging the documentation did not match and was inaccurate. The DON stated it was her expectation that all narcotic PRN administrations be documented on both the MAR and in the narcotic book.
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.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 975 citations issued within 25 miles in the last 12 months — including the 12 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.