Above average — CMS composite of the measures below.
The next survey window likely opens around September 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 S.e.m. Haven Health Care Center during CMS and state inspections, most recent first.
A facility delayed lab processing and treatment for symptomatic residents with suspected UTIs by routinely requiring repeated urine dipstick testing and waiting for specimen pickup, including weekend delays and a mislabeled specimen that was not promptly recollected. Residents had symptoms such as burning, foul-smelling or dark urine, mucus, hallucinations, and abdominal discomfort, and cultures later grew significant organisms including Proteus mirabilis, Pseudomonas aeruginosa, and Citrobacter koseri.
Dignified Dining Assistance Not Provided to Dependent Residents: Two residents with severe cognitive impairment and dysphagia were dependent on staff for eating, but observations showed food placed in front of them while no staff assisted for several minutes. An RN and CNAs intermittently stopped feeding one resident to help other residents or tasks in the dining room, and one resident was brought to the table and left unassisted while staff served others. Staff interviews confirmed that dependent diners were sometimes assisted only after delays, despite expectations that feeding assistance should remain focused on the resident being served.
Failure to Notify Physicians of UTI Changes and Delayed Orders: Staff did not promptly notify the MD/NP when residents developed UTI symptoms, had abnormal urine/lab findings, or when ordered antibiotics were not started. One resident had recurrent UTI symptoms, abnormal urine, and a delayed/mislabeled specimen; another had dysuria and a ciprofloxacin order that was not initiated; and a third had foul-smelling cloudy urine with a positive culture. Interviews confirmed the physician notifications were not documented and, in some cases, were not made.
Failure to Initiate Ordered Antibiotics for Symptomatic UTI Two residents with urinary symptoms, abnormal urine testing, and positive cultures did not receive timely antibiotic therapy as ordered by the NP and MD. One resident with recurrent UTIs had hallucinations, dysuria, foul-smelling urine, and a culture showing Citrobacter koseri, yet suppressive Trimethoprim was not transcribed or started. Another resident with bladder issues and CKD had cloudy, foul-smelling urine, burning, and a culture showing Klebsiella pneumoniae, but ciprofloxacin orders were not initiated when prescribed. Staff stated orders were held because of facility protocol and were not always communicated back to the provider.
Uncovered food items were found stored in a satellite kitchen refrigerator in 1 of 4 satellite kitchens. A metal container with sliced tomatoes, cucumbers, and eggs, plus a plate of sliced meat, were left uncovered. Staff gave conflicting explanations about whether prepped or immediate-use food had to be covered, while the facility policy stated all refrigerated foods should be covered, labeled, and dated.
Failure to perform hand hygiene between resident dining tasks. An RN assisted one resident with eating, then cut up food for another resident using that resident’s cutlery, and returned to the first resident without hand hygiene in between. The first resident had severe cognitive impairment and dysphagia, and the second resident had moderate cognitive impairment and needed setup or clean-up help with eating. Facility policy required staff to follow hand hygiene procedures between resident contact and after handling potentially contaminated items.
Delayed Urine Testing and Treatment for Symptomatic Residents
Penalty
Summary
The facility failed to provide laboratory services in a timely and efficient manner for residents with symptoms of urinary tract infections, resulting in delays in obtaining urine cultures and starting treatment for four residents reviewed for UTIs. Facility policy stated that diagnostic and clinical laboratory services were available 24 hours a day, seven days a week, and that urine cultures were to be ordered when clinical indications met McGeer's criteria. The policy also directed nursing staff to document symptoms, notify the provider, perform urine dipstick testing, encourage fluids, repeat testing, and then obtain a culture when criteria were met. One resident had a history of BPH, bladder disorder, and prior UTI. When the resident complained of urinary pain, burning, foul-smelling cloudy urine, mucus, and blood clots, nursing performed a dipstick that was positive for leukocytes and nitrites, but the urine was not sent to the lab until later. The specimen was refrigerated for pickup, and the culture later showed mixed flora on one occasion and then Proteus mirabilis and Pseudomonas aeruginosa on another. The resident was not started on antibiotics until after the later culture results were available. The same resident again developed urinary symptoms with burning, frequency, dark concentrated urine, and a positive dipstick, but the specimen was again held for weekend pickup and the culture was not received by the lab until days later; antibiotics were ordered after the culture results. Another resident with a history of urinary tract infections and moderate cognitive impairment developed hallucinations, facial flushing, foul-smelling dark urine with mucus, burning with urination, and abdominal grimacing. Nursing performed dipstick testing twice, both showing leukocytes, before a straight-catheter specimen was finally sent to the lab. The first specimen was rejected because it was mislabeled, and a replacement specimen was not obtained until several days later. The later culture grew Citrobacter koseri. Staff interviews showed that the facility routinely waited for two positive dipstick tests before sending a specimen to the laboratory, encouraged fluids between tests, and often delayed collection or transport because the laboratory did not pick up specimens on weekends or because staff believed culture and sensitivity testing could not be done on weekends. The DON, ED, Medical Director, and nursing staff all described this practice, and the MD stated the multiple urine tests delayed treatment for symptomatic residents.
Dignified Dining Assistance Not Provided to Dependent Residents
Penalty
Summary
The facility failed to provide dining services in a dignified manner for two dependent residents who required staff assistance with eating. One resident was admitted with diagnoses including Alzheimer's disease and dysphagia, had severe impairment in cognitive skills, and was dependent on staff for eating. The other resident was admitted with diagnoses including unspecified dementia with behavioral disturbances and dysphagia, had a BIMS score of 00 indicating severe cognitive impairment, and was also dependent on staff for eating. Both residents had care plans directing staff to assist or supervise them with eating. During observation in the dining room, one resident was seated at a table with food in front of them while no staff were assisting with eating, even though another resident at the same table was being fed by an RN. The RN stopped feeding the dependent resident to retrieve a beverage for another resident and later stopped again to assist another resident with cutting food, while the first resident remained with food in front of them and no assistance. On another observation, the same resident sat with two bowls of pureed food in front of them for several minutes before a CNA began assisting. Later that meal, the second dependent resident was brought to the table, served food and beverages, and remained unassisted while staff passed food to other residents in the dining room until a CNA eventually sat down to assist. Staff interviews confirmed that the unit had two residents who required full assistance with meals and that residents were usually served at the same table at the same time. Staff stated that feeding assistance was sometimes interrupted to attend to other residents or tasks in the dining room, and one CNA stated that one dependent resident was sometimes served last. The DON stated staff assisting a resident with a meal should only be engaged in assisting that resident and expected the resident to be assisted within a few minutes of receiving food. The ED stated she would not expect residents who needed assistance with eating to have food sitting in front of them while other residents were eating.
Failure to Notify Physicians of UTI Changes and Delayed Orders
Penalty
Summary
The facility failed to ensure physicians were notified of changes in residents’ medical conditions and failed to notify physicians when delays occurred in initiating ordered treatment for 3 residents reviewed for UTIs. The report states that facility policy required prompt notification of the resident, attending physician, and responsible party for changes in condition, and that notifications were to be made within 24 hours except in emergencies. It also required nursing staff to obtain and transcribe orders in a timely manner, monitor for side effects, and notify the physician, with documentation completed as care occurred or as timely as possible. For one resident with a history of recurrent UTIs, moderate cognitive impairment, and incontinence, nursing notes documented abnormal urine findings, hallucinations, burning with urination, foul-smelling urine, mucus, lethargy, and later a culture showing greater than 100,000 CFU/ml of Citrobacter koseri. The record showed a delay when a urine specimen was mislabeled and another specimen was needed, and staff also did not notify the physician when the resident’s suppressive Trimethoprim order from the provider was not transcribed or initiated. Interviews with the RN, DON, Medical Director, NP, and MD confirmed the physician was not notified of the delay in obtaining the lab, the abnormal symptoms, or the failure to start the ordered prophylactic antibiotic, and the chart contained no documentation of those notifications. For another resident admitted with overactive bladder and intact cognition, the provider documented dysuria, urinary frequency, an abnormal urinalysis, and an order for ciprofloxacin, but the medication was not initiated as ordered. The record showed the resident remained symptomatic for several days, and the physician later noted concern that the resident had gone six full days with an acute UTI without treatment. Staff interviews confirmed the facility did not notify the physician when the antibiotic was not started on the original order date, and the DON acknowledged the missed orders were medication errors and that the doctor, pharmacy, and family should have been notified, but the medical record did not document those notifications. For a third resident with obstructive and reflux uropathy, moderate cognitive impairment, and frequent bowel and bladder incontinence, nursing notes documented dark yellow foul-smelling urine, urinary pain and burning, cloudy urine with sediment, and a urine culture later showing greater than 100,000 CFU/ml of Escherichia coli. The report states that when the first specimen did not yield culture results because the lab did not perform culture and sensitivity on weekends, another specimen was collected. The DON later acknowledged that notifications to the physicians were not documented for this resident, and antibiotics were not ordered until after the later lab results were received and reviewed.
Failure to Initiate Ordered Antibiotic Therapy for Symptomatic UTI
Penalty
Summary
The facility failed to ensure timely and appropriate treatment and services related to urinary tract infections for two residents with symptomatic urinary complaints. Facility policies required physician orders to be entered into the medical record within a clinically appropriate period and described a process for evaluating suspected UTIs, including notifying the provider, completing infection screening, and obtaining urine testing. The antibiotic stewardship policy also required antibiotic orders to include a specific prescribing order with dose and duration and to be reviewed when they did not follow standards of practice. One resident had a history of recurrent UTIs, was incontinent of bowel and bladder, and had impaired cognition and dependence for toileting care. The resident developed hallucinations, facial flushing, foul-smelling dark urine with mucus, burning with urination, and abdominal tenderness. Staff completed infection screening and dipstick testing, which triggered suspected UTI criteria, but the urine specimen was initially mislabeled and had to be recollected. After the culture later showed greater than 100,000 CFU/ml of Citrobacter koseri and the resident continued to have cloudy, foul-smelling urine and lethargy, antibiotic therapy was ordered. Later, the primary care provider documented that suppressive Trimethoprim therapy had been recommended for recurrent UTI, but the order was neglected and was not transcribed into the medical record or started. A second resident was admitted with overactive bladder, occasional bladder incontinence, and chronic kidney disease. The resident developed foul-smelling, cloudy urine, burning with urination, and polyuria. Staff obtained urine dipsticks that showed leukocytes and protein, and a urine culture later showed turbid urine, nitrates, 4+ leukocytes, and greater than 100,000 CFU/ml of Klebsiella pneumoniae. The nurse practitioner and later the physician both wrote orders for ciprofloxacin for the symptomatic UTI, but the record showed the resident was not on the antibiotic therapy when the physician documented the treatment plan. The report also included staff statements that antibiotic orders were not transcribed or started because of facility protocol and that providers were not always notified when orders were not followed.
Uncovered Food Stored in Satellite Kitchen Refrigerator
Penalty
Summary
The facility failed to ensure food items stored in the refrigerator were covered in 1 of 4 satellite kitchens, Ripple Ridge. During a concurrent observation and interview, a refrigerator in the Ripple Ridge satellite kitchen contained a metal container with approximately 12 tomato slices, 12 cucumber slices, and 12 sliced eggs, along with a dinner plate holding several slices of light brown meat, and these items were uncovered. The Dietary Director stated that, in her view, it was acceptable for items not to be covered if they were used within a reasonable timeframe, which she described as about one hour. Interviews with staff showed differing expectations about refrigerator food storage. Homemaker #3 stated she was responsible for covering all food items in the satellite kitchen refrigerator, but said the uncovered items were left out because they were intended for the lunch meal and she had been told immediate-use food did not have to be covered. The Kitchen Manager stated everything stored in a refrigerator, including prepped items, should be covered and that this applied to all refrigerators, including satellite kitchen refrigerators. The Dietary Director, Registered Dietitian, and Executive Director each described exceptions or staging practices for prepped food, but the facility policy stated that all foods should be covered, labeled, and dated while refrigerated.
Failure to Perform Hand Hygiene Between Resident Dining Tasks
Penalty
Summary
The facility failed to implement an effective infection prevention and control program by not ensuring staff performed hand hygiene during one of three meal services observed, affecting two residents. Facility policies titled Infection Control Plan/Program and Hand Washing/Hand Hygiene stated that hand hygiene was to be followed by all employees and that handwashing or hand sanitizer use was the most important means of preventing the spread of infection. The hand hygiene policy also required personnel to follow established handwashing and sanitizer procedures and identified handwashing after handling items potentially contaminated with blood, body fluids, excretions, or secretions. Resident #38 had diagnoses including moderate unspecified dementia with other behavioral disturbance and oral phase dysphagia, and a quarterly MDS showed a BIMS score of 00 with dependence on staff for eating. Resident #76 had a diagnosis of type 2 diabetes mellitus with diabetic neuropathy, and a quarterly MDS showed a BIMS score of 9 with setup or clean-up assistance needed for eating. During a dining room observation, RN #12 assisted Resident #38 with a meal, then stopped to cut up food for Resident #76 using Resident #76's cutlery, and then returned to assist Resident #38 without performing hand hygiene between the tasks. RN #12 stated she was taught to perform hand hygiene between resident contact, before feeding a resident, and before touching resident food items, but said she did not complete hand hygiene because she did not know she touched anything that required it. The DON and Administrator stated they expected staff to perform hand hygiene between tasks in the dining room and between assisting more than one resident with dining.
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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) |
|---|---|---|---|---|
| The Laurels Of Milford | 2.2 mi | ★★★★★ | 11 | 0 |
| Arbors At Milford | 2.9 mi | ★★★★★ | 11 | 0 |
| Florentine Gardens | 3.5 mi | ★★★★★ | 0 | 0 |
| Madeira Healthcare Center | 3.8 mi | ★★★★★ | 1 | 0 |
| Forest Hills Healthcare Center. | 3.8 mi | ★★★★★ | 16 | 0 |
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