Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Milford Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Failure to Develop Individualized Dementia Behavior Care Plan: A resident with dementia and severe cognitive impairment had repeated aggressive, sexually inappropriate, and unsafe behaviors, including striking staff and residents, wandering into restricted areas, pulling a fire alarm, and attempting to access med carts. The care plan only listed general supervision and behavior logging, and the record did not show an individualized, person-centered plan based on the resident’s history, routines, triggers, or effective approaches to manage the behaviors.
Failure to Implement Scabies Precautions and EBP: A resident with a progressive pruritic rash was later confirmed to have scabies, but infection control surveillance was incomplete and the resident left the facility without additional precautions. A second resident, identified as a close contact, was kept in quarantine despite no scabies symptoms, and staff were uncertain about the need for isolation. In addition, an order for EBP due to an indwelling catheter was not followed when two CNAs transferred a resident without gowns and gloves.
Incomplete Care Plans for Enhanced Barrier Precautions: Two residents had care plans that did not identify their EBP status or include appropriate interventions. One resident had severe cognitive impairment, a Stage 3 pressure wound on the right heel, and EBP signage and PPE in the room; the other had acute respiratory failure with hypoxia and an order for EBP due to an indwelling catheter.
Failure to revise a fall-risk care plan after repeated falls. A resident with primary generalized osteoarthritis and a BIMS score of 15 had a preexisting care plan for fall risk, but after falling from bed while reaching for an item and later falling while attempting to transfer into bed, the plan was not updated to reflect the interventions used, including a call-for-assistance sign and a chair clip alarm.
Delayed assessment and treatment of burn injury: A resident with severe cognitive impairment and a prior hip fracture sustained a hot coffee burn in the dining room when coffee spilled onto her thighs. The injury was not documented at the time, no immediate provider order was obtained, Silvadene was not started until several days later, and the record lacked evidence of additional skin assessment or wound care specialist evaluation.
Failure to Provide Adequate Supervision and Fall Prevention: A resident with dementia, PTSD, impaired judgment, poor safety awareness, and declining mobility had repeated falls with injuries, including skin tears and a closed head injury. The resident’s care plan identified fall risk and included assistance with ambulation and close observation, but staff did not consistently prevent recurrent falls, did not timely complete PT/OT evaluation after a hospital return, and did not revise the care plan to reflect worsening gait and mobility. The resident was later found on the floor multiple times, including after attempting to rise from a chair and striking the head.
A resident with CHF had a physician-ordered 1500 mL/day fluid restriction, but staff did not document daily fluid intake or monitor adherence in the EMR as required by facility policy. The resident said he was unaware of the restriction and was drinking available fluids, and surveyors observed water and orange soda at the bedside. The ADON confirmed there was no documentation of intake, hydration status, bedside fluid availability, or compliance with the ordered restriction.
Failure to Address Pharmacist Review of Psychoactive Medications: A resident with anxiety disorder was receiving Lexapro and Klonopin, and the consultant pharmacist noted the need for periodic review of psychoactive meds and consideration of GDR if clinically appropriate. The clinical record did not show that the attending physician reviewed, acknowledged, or responded to the recommendation, and there was no documentation of a GDR attempt or a clinical contraindication.
Expired and improperly dated medications were found in the first-floor med room, including Geri-Lanta, two bottles of naproxen sodium, and an opened multi-dose vial of Tuberculin PPD with no opening date. An RN confirmed the items were expired or undated and available for resident use, and the NHA acknowledged the facility failed to follow medication storage and dating requirements.
The facility permitted RNs to access and administer IV antibiotics through an implanted port-a-cath for a resident with colon cancer and pneumonia without documented specialized training or demonstrated competency. Policy required additional training and proven competency for personnel accessing implanted venous ports, and state nursing regulations prohibit RNs from engaging in highly specialized practice without adequate knowledge and skills. When staff could not obtain a peripheral IV, a physician authorized use of the resident’s port with a Huber needle, and three RNs documented IV antibiotic administration via the port on the MAR. The facility could not produce any evidence of initial or ongoing competency validation, skills checklists, return demonstrations, or formal education specific to port access, and the DON confirmed that such documentation was not maintained.
Surveyors observed multiple unsanitary practices in the dietary department, including undated and improperly stored food items, cleaning equipment stored among food supplies, and a lack of proper sanitizing procedures for kitchen equipment. Staff demonstrated inadequate knowledge of sanitation protocols, and food service staff handled food containers after improper glove use, all of which increased the risk of food contamination.
A resident with dementia and lactose intolerance did not receive a prescribed enzyme medication with meals on over thirty occasions due to the medication being unavailable for several weeks. The MAR lacked documentation explaining the missed doses, and the DON later notified the physician of the ongoing unavailability.
The facility did not ensure that a licensed pharmacist conducted monthly medication regimen reviews for two residents with diagnoses such as dementia, anxiety, and PTSD, as required by policy. This lapse was confirmed through record review and DON interview, showing missing reviews for two consecutive months.
Surveyors found that the facility failed to discontinue an unnecessary antibiotic for a resident without infection symptoms, did not provide clinical justification for duplicate antidepressant use in another resident, and administered PRN antianxiety medication beyond 14 days without proper documentation or attempted non-pharmacological interventions. The facility also lacked sufficient clinical rationale for the continued use of multiple psychoactive medications.
A resident reported that a staff member failed to administer prescribed Xanax and exhibited unprofessional behavior. The facility did not notify the resident of the grievance resolution within the required timeframe, violating its policy. Additionally, a grievance filed by the resident's daughter lacked documentation of an investigation or communication of the resolution. Interviews confirmed the lack of timely follow-up and documentation.
The facility was found to have improperly disposed of garbage and refuse. During an inspection, it was observed that the dumpster was not fully covered, with one lid open, and food containers and debris were scattered around it. The food service director confirmed that the dumpster lid should be closed and the area kept sanitary.
A resident with dementia and a risk of elopement was given a wanderguard bracelet without specific placement instructions or routine skin checks. The bracelet caused a skin tear on the resident's shin, which worsened due to lack of monitoring. The facility did not assess the bracelet's placement after the injury, leading to further skin damage.
A resident with a Midline catheter experienced dislodgement and removal of the catheter, but the facility failed to promptly notify the attending physician and the resident's representative. The incident was documented on August 12, but the physician was not informed until two days later, and there was no evidence that the resident's representative was notified at all. This lack of timely communication violated the facility's policy and regulatory requirements.
A resident with multiple diagnoses, including congestive heart failure and rheumatoid arthritis, had a skin condition that was not addressed in their care plan. Despite receiving treatment for moisture-associated skin damage (MASD) on the sacrum, the care plan lacked documentation of the condition and specific interventions to prevent recurrence, as confirmed by the DON.
A resident with multiple health issues, including amputations and diabetes, developed a pressure ulcer in the left groin area. The facility failed to accurately assess and manage the wound, leading to discrepancies in wound evaluation and delayed appropriate treatment. The wound care consultant later identified the wound as full-thickness, requiring a change in treatment.
A resident with a urinary tract infection and sepsis did not receive a timely dose of a prescribed IV antibiotic due to a delay in pharmacy delivery. The facility failed to administer the first dose of Ceftazidime as scheduled and did not notify the attending physician of the missed dose, as confirmed by the DON.
A facility failed to ensure the availability of necessary emergency supplies for a resident receiving hemodialysis. The resident, with end-stage renal disease, had a care plan requiring emergency clamps at the bedside, but none were found during an observation. Interviews with staff confirmed the absence of these supplies, indicating a failure to adhere to the care plan.
A resident with unspecified dementia exhibited suicidal ideations, but the facility failed to update her care plan to address these behavioral health needs. Despite recommendations for continued psychological services, the care plan did not reflect these needs, and social services were not informed of the resident's statements. The NHA could not provide evidence of psychological services being provided.
A resident with a urinary tract infection and sepsis did not receive a timely dose of the prescribed antibiotic, Ceftazidime, due to a delay in delivery from the facility's pharmacy. The medication was scheduled for administration but was unavailable, as confirmed by the DON.
The facility failed to comply with EPA and state requirements for drinking water testing, resulting in violations for not monitoring/reporting routine samples for 30 contaminants. The SOC testing was overdue due to non-payment, with the last tests conducted in 2021. The facility's COO confirmed payments were being made for outstanding balances, but no additional payment was submitted for the required tests.
The facility failed to store food items under sanitary conditions in both the kitchen and resident pantry areas. Observations revealed multiple unlabeled and undated food items in the kitchen's prep cooler and the first-floor nurses' station pantry. On the second floor, dietary staff were observed attempting to date opened items, but several items remained unlabeled and undated. The Dietary Manager confirmed that food and beverage items should be labeled and dated per policy and discarded once expired or beyond their use-by date.
The facility failed to provide physician-ordered nutritional supplements as prescribed to three residents. Observations revealed that supplements were not administered as documented in the MAR, and interviews confirmed inconsistencies in following physician orders.
The facility failed to store and maintain oxygen equipment in a safe, functional, and sanitary manner. Observations revealed improper storage of oxygen cylinders in the medication/pantry area and a designated storage area outside the building, where both empty and full tanks were mixed together. Additionally, the storage area was located near a staff smoking area, posing a safety risk.
The facility failed to ensure adherence to use by/expiration dates of pharmaceutical products in the central supply room. Observations revealed expired Hydrogen Peroxide bottles and IV starter kits. Interviews with the DON and Nursing Home Administrator confirmed that these expired supplies should have been discarded.
The facility failed to provide written notices of facility-initiated transfers to the hospital in a language that was easily understood for three residents. The notices were written in medical terms, which may not be easily understood by the residents and their representatives.
The facility failed to notify a resident's representative of a significant change in condition and the need for a new treatment. The resident, diagnosed with dementia, had a dermatology consult and a biopsy for a cancerous lesion, but the representative was not informed. The DON confirmed this failure.
The facility failed to ensure that licensed nurses accurately administered prescribed medications to a resident. Despite specific instructions to hold Metoprolol Tartrate if the resident's systolic blood pressure was less than 100 or heart rate was less than 60, the medication was administered on multiple occasions when these conditions were not met. The DON confirmed the non-compliance.
The facility failed to provide sufficiently detailed written notices of facility-initiated transfers to the resident and the residents' representative for three residents. The written transfer notices lacked the reason for the transfer and only indicated that the residents needed a higher level of care. The facility did not provide documented evidence of the provision of written transfer notices that identified the reasons for the move in writing and in a language and manner the residents and their representatives understand.
Failure to Develop Individualized Dementia Behavior Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan to address the dementia-related behaviors and cognitive decline of Resident 36. The resident was admitted with diagnoses including dementia, cerebral infarction, and communication deficit disorder, and a Quarterly MDS dated April 11, 2026, identified the resident as severely cognitively impaired. The existing care plan, initially dated March 24, 2026, identified a potential for physical aggression related to dementia and poor impulse control and included general interventions such as modifying the environment, maintaining constant visual observation when out of the room, and documenting behaviors and interventions in a behavior log. Nursing documentation and facility investigative records showed repeated dementia-related behaviors from December 2025 through May 2026. These included verbal aggression, physical aggression toward staff and residents, sexually inappropriate behaviors, unsafe attempts to stand and ambulate, wandering into restricted areas and other residents’ rooms, pulling the fire alarm, attempting to access medication carts, and behaviors that did not consistently respond to staff redirection. Documented incidents included shouting profanities, making threats, becoming combative when redirected, blocking a bathroom door with a wheelchair and linen cart, falling after attempting to stand from a wheelchair, and repeated episodes of agitation and aggression during care and routine interactions. The record also documented multiple incidents involving other residents and staff, including touching another resident’s exposed breast, striking staff members, grabbing staff inappropriately, attempting to punch staff, throwing a chair toward another resident, and pulling a fire alarm cover. The resident’s behaviors continued despite close supervision and increases in Seroquel from 25 mg daily to 25 mg twice daily and later to 50 mg twice daily. The facility’s documentation did not show an individualized, person-centered plan based on the resident’s preferences, social and past life history, customary routines, interests, triggers, or effective approaches to manage or decrease the dementia-related behavioral symptoms. During interview, the Nursing Home Administrator confirmed the facility was unable to provide evidence of development and implementation of an individualized, person-centered dementia care plan for Resident 36.
Failure to Implement Scabies Precautions and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement infection prevention practices and follow its policy for identifying, treating, and preventing transmission of scabies for two residents, and failed to implement enhanced barrier precautions for one resident. CDC guidance cited in the report stated that residents with confirmed or suspected scabies should be placed on contact precautions with gowns and gloves, and the facility policy required residents with scabies to remain on contact precautions for 24 hours after treatment, with roommates assessed and monitored as indicated. Resident 72 was admitted with congestive heart failure and a rash, and the admission MDS showed the resident was cognitively intact. The resident continued to report intense itching, worse at night, and had a rash that progressed from the shoulders to the arms, legs, torso, back, sacrum, chest, abdomen, and bilateral arms. Hospital records documented chronic pruritic dermatitis and topical treatment, and a specialty wound care evaluation later confirmed scabies by dermoscopy. The record also showed the resident left the facility for an outside appointment without additional infection control precautions, and the infection control surveillance documentation did not include the rash identified on admission; the revised McGeer surveillance checklist was incomplete, undated, and did not include completed scabies criteria. Resident 16 was admitted with acute respiratory failure with hypoxia and was cognitively intact. The resident reported being quarantined because of the roommate’s skin condition but denied rash or itching, and nursing documentation showed a full skin assessment with no evidence of scabies. The resident received permethrin treatment, but the record reflected uncertainty about the duration and necessity of isolation. In addition, a physician order required enhanced barrier precautions because of an indwelling catheter, yet observation showed the resident was transferred by two nursing assistants without gowns and gloves, and the nursing home administrator and infection control nurse acknowledged that enhanced barrier precautions were not implemented during the care.
Incomplete Care Plans for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop a comprehensive care plan to meet the individualized needs of two residents. Facility policy required a comprehensive, person-centered care plan for each resident that described the services necessary to help residents attain or maintain their highest practicable physical, mental, and psychosocial well-being and be revised as new information became available or as the resident's condition changed. Resident 13 was admitted with a fracture to the neck of the left femur and had an admission MDS showing severe cognitive impairment with a BIMS score of 5. The clinical record also showed a Specialty Physician Wound Evaluation & Management Summary dated May 7, 2026, documenting a Stage 3 pressure wound on the right heel. During an observation on May 14, 2026, gowns and gloves for Enhanced Barrier Precautions were available in the room and a sign indicated the need for gowns and gloves during high-contact care, but the resident's current care plan did not identify Enhanced Barrier Precaution status or include appropriate interventions. Resident 16 was admitted with acute respiratory failure with hypoxia, had an admission MDS showing cognitive intactness with a BIMS score of 14, and had a physician order dated April 17, 2026, for Enhanced Barrier Precautions due to an indwelling catheter. The resident's current care plan also failed to identify Enhanced Barrier Precaution status or include appropriate interventions.
Failure to Revise Fall Care Plan After Repeated Falls
Penalty
Summary
The facility failed to review and revise Resident 11’s comprehensive plan of care after the resident experienced two falls. Resident 11 was admitted with a diagnosis of primary generalized osteoarthritis and had a quarterly MDS assessment dated February 20, 2026, showing the resident was cognitively intact with a BIMS score of 15. The resident’s care plan, initiated on November 25, 2025, identified fall risk related to impaired cognition, impaired coordination, and medication side effects and included a goal of reducing fall risk. Facility investigative documentation showed that on May 6, 2026, Resident 11 fell from the bed in the room while reaching for an item, and the immediate action documented was placing a sign instructing the resident to call for assistance. On May 10, 2026, the resident fell again in the room while attempting to transfer into bed, and the immediate fall prevention measure documented was the use of a chair clip alarm. The resident’s plan of care was not revised to include the interventions implemented after these falls. The Nursing Home Administrator acknowledged the concerns identified with resident care plans during an interview on May 14, 2026.
Delayed assessment and treatment of burn injury
Penalty
Summary
The facility failed to provide nursing services in accordance with professional standards of quality for a resident admitted with a fracture of the neck of the left femur and documented as cognitively impaired with a BIMS score of 5. While seated in the dining room for lunch, the resident self-propelled her wheelchair to a coffee cart, and hot coffee spilled onto her clothing and upper legs. Nursing documentation noted wet garments were removed, mild redness to both thighs, and a flattened blister measuring 2 cm by 2 cm on the mid-left thigh; a cool compress was applied, and the nurse practitioner who was present in the facility evaluated the resident and recommended continued cool compresses and Silvadene cream. The incident was not documented in the clinical record at the time it occurred, and there was no physician order for burn treatment obtained on the date of the injury. A physician order for Silvadene 1% cream was not written until three days later, and the eMAR showed the cream was not started until four days after the burn occurred. The facility record also referenced use of Silvadene from stock medication on two earlier days, but the eMAR did not show administration during that period. In addition, the clinical record did not show additional assessments or a skin evaluation by a wound care specialist after the burn injury, and there was no documentation of a comprehensive assessment of the burn.
Failure to Provide Adequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to provide adequate supervision and effective fall prevention interventions for a resident with a history of recurrent falls. The resident had diagnoses including PTSD and Alzheimer’s disease, was unable to complete the Brief Interview for Mental Status because of cognitive impairment, and required partial/moderate assistance and supervision or touching assistance for walking. The resident’s care plan identified fall risk related to sensory deficits and antipsychotic use, with interventions including assistance with transfers and ambulation, reinforcement to request assistance, and standby/contact guard assistance with a wheeled walker when unsteady. A physician order also directed staff to maintain close observation during ambulation. The resident experienced multiple falls and related injuries over a short period. One fall occurred when the resident tripped over a tray table near the nursing station and sustained a skin tear. Another incident occurred when staff responded to a noise in the resident’s room and found the resident on the floor bleeding from the forehead, requiring transfer to the ER and later return with staples to the forehead. The resident was identified as high fall risk on a Morse Fall Scale assessment due to poor recall, impaired judgment, impaired safety awareness, decreased muscular coordination, prior falls, dementia, and wandering behaviors. After the resident returned from the hospital, the facility did not document timely PT or OT evaluation as planned, and the care plan was not revised to reflect the resident’s decline in mobility or increased fall risk. PT later documented decline in functional ambulation, mobility, dynamic balance, gait mechanics, and posture, with a shuffled gait and rounded kyphotic posture. Nursing notes then described the resident as weak, hunched over, and unable to maintain gait while ambulating. The resident later became too weak to continue ambulating, was lowered to the floor because no wheelchair or additional staff assistance was immediately available, and sustained another skin tear. The resident then fell again while attempting to rise from a chair, struck the right side of the head, and was transferred to the ER, where diagnoses included closed head injury, right shoulder abrasion, and right shoulder contusion.
Failure to Monitor Fluid Restriction
Penalty
Summary
The facility failed to monitor and document hydration status for a resident with a physician-ordered 1500 mL daily fluid restriction related to congestive heart failure. The resident was admitted with diagnoses of congestive heart failure and rash, and the admission MDS showed he was cognitively intact with a BIMS score of 15. A physician order dated April 24, 2026 specified the fluid restriction, including set amounts for meals, day shift, evening shift, and nursing care/medication administration. The resident’s nutritional risk care plan identified the fluid restriction and included monitoring for signs and symptoms of excess fluid intake. During an interview, the resident stated he was unaware of the fluid restriction and reported thirst and consuming available liquids. Observation of the bedside area showed a Styrofoam cup containing water and a clear plastic bottle of orange soda accessible to the resident. The clinical record included a nutrition evaluation acknowledging the fluid restriction, but there was no evidence that adherence to the restriction was monitored or documented in the electronic medical record as required by facility policy. The ADON confirmed there was no documentation of the resident’s daily fluid intake from admission through the time of survey and acknowledged the facility failed to monitor and document fluid intake, hydration status, bedside fluid availability, and compliance with the ordered fluid restriction.
Failure to Address Pharmacist Review of Psychoactive Medications
Penalty
Summary
The facility failed to ensure that the attending physician reviewed and addressed a consultant pharmacist’s identified irregularities in Resident 3’s medication regimen. Resident 3 was admitted with a diagnosis that included anxiety disorder and was prescribed Lexapro 10 mg daily and Klonopin 0.5 mg daily, both psychoactive medications. In a consultant pharmacist report dated December 7, 2025, the pharmacist noted that Resident 3 required periodic review of psychoactive medications and consideration of a gradual dose reduction if clinically appropriate. Review of Resident 3’s clinical record did not reveal documentation that the attending physician reviewed, acknowledged, or responded to the pharmacist’s recommendation. The record also did not show that a gradual dose reduction was attempted or that there was documentation supporting a clinical contraindication to prevent a gradual dose reduction. During an interview on May 14, 2026, at 1:00 PM, the NHA confirmed the facility could not provide documentation showing the attending physician reviewed or acted on the consultant pharmacist’s recommendation.
Expired and Undated Medications Found in Medication Room
Penalty
Summary
The facility failed to follow its medication labeling and storage policy in the first-floor medication room by keeping expired and improperly dated medications available for resident use. The policy required medications and biologicals to be stored in locked compartments, expired items to be handled through the dispensing pharmacy, and multi-dose vials to be dated when opened and discarded within 28 days unless otherwise specified. During an observation of the first-floor medication room, surveyors found one bottle of Geri-Lanta with an expiration date of August 2025, one opened multi-dose vial of Tuberculin Purified Protein Derivative with no opening date, and two bottles of All-Relief Naproxen Sodium with an expiration date of December 2025. An RN confirmed that the medications were expired and that the Tuberculin vial was undated while stored in the medication room and available for resident use. The NHA later reviewed and acknowledged that the facility had failed to adhere to medication storage requirements, including proper dating, monitoring, and removal of expired medications and biologicals from use.
Lack of RN Competency Validation for Implanted Venous Port Access
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality by allowing RNs to access and administer IV medications through an implanted venous port without documented specialized training and demonstrated competency. Facility policy on implanted venous port accessing, last reviewed April 23, 2025, required that medical personnel who access or de-access an implanted venous port complete additional training and demonstrate proven clinical competency prior to performing the procedure. Pennsylvania Code Title 49, State Board of Nursing, 21.11(c) states that an RN may not engage in areas of highly specialized practice without adequate knowledge and skills in the practice area involved. Clinical record review showed that one resident, admitted with malignant neoplasm of the colon and with a surgically placed port-a-cath in the upper chest, required IV antibiotics. A nursing progress note documented that staff were unable to establish a peripheral IV, and the physician authorized nursing staff to access the port-a-cath with a Huber needle to administer IV antibiotics. Physician orders directed daily IV Ceftriaxone for five days for pneumonia, and the MAR showed that three RNs administered the IV antibiotic through the implanted port over that period. The facility was unable to provide documentation that these RNs had completed additional training or competency validation specific to accessing an implanted venous port with a Huber needle, including lack of skills checklists, return demonstrations, formal education records, or internal training. The DON confirmed that the facility did not maintain evidence of education, specialized training, or competency validation for RNs administering medications through a port-a-cath.
Deficient Food Storage and Sanitation Practices in Dietary Department
Penalty
Summary
The facility failed to maintain proper food storage and service practices in the dietary department, as evidenced by multiple unsanitary conditions and improper procedures observed during a survey. Open bottles of chocolate and caramel syrup in the cook's reach-in cooler were not dated, and pre-portioned cold cereals in the dry storage room also lacked dates. Gallon jugs of water were stored directly on the floor, and an open package of brown gravy mix was found without an open date. Additionally, a bulk bag of thickener powder was left unsealed with an uncovered ladle resting on top. Cleaning equipment, such as a dirty hand broom and dusters, was stored among food items and pots, and a corroded, dust-laden ceiling fan was present in the dish room. In the janitor's closet, mop buckets with dirty water and mops were stored with brooms placed across the tops, further contributing to unsanitary conditions. During the survey, dietary staff demonstrated a lack of knowledge regarding proper sanitizing procedures for the 3-compartment sink, as litmus strips to test sanitizer strength could not be located and the sanitizer concentration was measured at 0 ppm, indicating no sanitizer was present. Additionally, a server was observed dipping gloved hands into a sanitizer bucket and then handling food containers before changing gloves, which was not in accordance with safe food handling practices. These findings were confirmed by the Nursing Home Administrator, who acknowledged the need for the dietary department to be maintained in a sanitary manner to prevent food contamination and foodborne illness.
Failure to Timely Acquire and Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure the timely acquisition and administration of a prescribed medication for one resident. According to the clinical record, a resident with dementia and lactose intolerance was prescribed Lactaid Fast oral tablets to be given with meals. The medication administration record (MAR) showed that the Lactaid was not administered on multiple occasions, specifically thirty-three times between early and late June, with no documented reason for the omissions. The MAR was marked to indicate 'other/see progress note,' but no explanation was found in the clinical record for the missed doses. A nursing progress note later indicated that the DON informed the physician that the Lactaid had been unavailable for several weeks. It was also noted that the resident did not receive milk on meal trays due to their intolerance. Staff interviews confirmed the findings related to the failure to ensure the timely acquisition and administration of the prescribed medication, as required by facility policy and physician orders.
Failure to Complete Required Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed monthly medication regimen reviews (MRR) for two out of five sampled residents, as required by facility policy and state regulations. The policy, last reviewed in April 2025, mandates that the consultant pharmacist conduct a thorough monthly review of each resident's medical record to identify, report, and resolve medication-related problems, errors, and irregularities. However, a review of clinical records for two residents revealed no evidence that the pharmacist had conducted these reviews for the months of February and March 2025. One resident had diagnoses including dementia and anxiety, while the other had post-traumatic stress disorder (PTSD) and dementia. The absence of documented monthly MRRs for these residents was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the required reviews had not been completed as stipulated by facility policy and regulatory requirements.
Failure to Ensure Residents' Drug Regimens Were Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications in several instances. For one resident with dementia and chronic kidney disease, an antibiotic (Bactrim DS) was administered for a urinary tract infection despite the absence of urinary symptoms and without laboratory confirmation of infection. The McGreer Criteria Checklist, reviewed by the medical doctor, DON, and infection control preventionist, indicated that the resident did not meet criteria for antibiotic use, yet the resident received twenty doses of the medication without supporting documentation. Another resident with dementia and anxiety was prescribed two antidepressant medications, Trazodone and Remeron, concurrently. The clinical record lacked documentation justifying the use of duplicate antidepressant therapy. The DON confirmed that there was no clinical justification available for this medication regimen. A third resident with PTSD and dementia received an as-needed (PRN) antianxiety medication, Ativan, on multiple occasions over several months. The facility did not limit the PRN order to 14 days as required, nor did it provide documentation of physician assessment or clinical justification for continued use. Additionally, there was no evidence that non-pharmacological interventions were attempted prior to administration of the medication. The consultant pharmacist had recommended a review and possible gradual dose reduction of psychoactive medications, but the physician's response did not provide sufficient clinical rationale for continued use. The facility was unable to provide documentation supporting the ongoing use of multiple psychoactive medications for this resident.
Failure to Resolve Resident Grievances Timely and Adequately
Penalty
Summary
The facility failed to demonstrate timely and adequate efforts to resolve a grievance filed by a resident, which is a violation of the facility's grievance policy. The resident, who was admitted with a history of falls, anxiety, and a need for rehabilitation therapy services, reported that a staff member failed to administer their prescribed Xanax when requested and exhibited unprofessional behavior. The grievance was documented by staff, noting previous complaints about the staff member's behavior, but there was no evidence that the resident was notified of the grievance resolution within the required timeframe. The facility's policy requires that grievances be addressed promptly, with both verbal and written communication of the findings and actions taken within five working days. However, the resident was only verbally notified by phone after discharge, and no written documentation was provided. Additionally, a grievance filed by the resident's daughter regarding concerns about the resident's care lacked documentation of an investigation or communication of the resolution to the family. Interviews with facility staff, including the Director of Nursing and the Nursing Home Administrator, confirmed the lack of timely follow-up and documentation. The facility did not provide evidence of evaluating whether its efforts effectively resolved the grievances, further violating the resident's rights as outlined in the facility's policy and state regulations.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed on August 13, 2024. During an inspection at 10:20 AM, it was noted that the facility's dumpster, which contained bags of garbage, was not fully covered, with one of the two lids left open. Additionally, food containers and debris were scattered on the ground surrounding the dumpster. An interview with the food service director confirmed that the dumpster lid should have been kept closed and the area around the dumpster should have been maintained in a sanitary condition.
Failure to Monitor Wanderguard Placement Leads to Resident Injury
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident diagnosed with dementia. The resident was admitted with a risk of elopement, necessitating the use of a wanderguard bracelet. However, the physician's order did not specify the placement of the bracelet or the need for routine skin checks beneath it. An incident report noted a skin tear on the resident's right shin, which later worsened due to swelling and the bracelet digging into the skin. The facility did not assess the appropriateness of the wanderguard's placement after the skin tear was identified, leading to further injury. The lack of monitoring and evaluation of the resident's skin condition where the bracelet was placed resulted in the deterioration of the wound. This deficiency was confirmed through interviews with the Nursing Home Administrator and the Director of Nursing.
Failure to Notify Physician and Representative of Catheter Dislodgement
Penalty
Summary
The facility failed to promptly notify the attending physician and the resident's representative of a significant change in the resident's condition, specifically the dislodgement and removal of a Midline catheter. Resident 115, who had been readmitted to the facility with a urinary tract infection, cerebral infarction, and seizures, had a Midline catheter in place upon readmission. On August 12, 2024, a nurse's note documented that the Midline catheter was dislodged and subsequently removed after leaking was observed around the dressing. However, the physician was not notified of this incident until two days later, as indicated by a late entry nurse's note dated August 14, 2024. Additionally, there was no documented evidence that the resident's representative was informed about the dislodgement and removal of the Midline catheter. An interview with the Director of Nursing confirmed the lack of timely notification to both the physician and the resident's representative. This failure to communicate promptly with the necessary parties is a violation of the facility's policy on notifying changes in a resident's condition, as well as a breach of the regulatory requirements under 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services.
Failure to Address Skin Condition in Care Plan
Penalty
Summary
The facility failed to address a resident's skin condition in the comprehensive care plan, which is a deficiency identified during the survey. Resident 23, who was admitted with diagnoses including congestive heart failure, cerebrovascular accident, and rheumatoid arthritis, had a physician's order to apply Zinc to the buttocks every shift as a skin protectant. Despite this, the care plan did not include the resident's moisture-associated skin damage (MASD) or the specific interventions required to manage and prevent recurrence of the condition. The deficiency was confirmed through a review of clinical records and an interview with the Director of Nursing. The records showed that the resident's sacrum had MASD, which was being treated with Zinc ointment and other interventions such as limiting sitting time and repositioning. However, these treatments and preventative measures were not documented in the resident's care plan, indicating a failure to comprehensively address the resident's skin condition and associated risks.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to consistently provide care and services to prevent the development and/or worsening of pressure sores and promote healing for a resident. The resident, who was admitted with diagnoses including end-stage renal disease, diabetes, and bilateral leg amputations, was identified as being at risk for skin integrity issues. Despite having a care plan in place with interventions such as repositioning and preventative skin care, a wound was discovered in the resident's left groin. The initial assessment of the wound was inaccurate, and there was no evidence that the wound was properly evaluated by the treatment team. Further observations revealed discrepancies in the wound's condition, with the wound being larger and having visible depth compared to initial reports. The wound care consultant later assessed the wound as a full-thickness wound with moderate drainage and recommended a change in treatment. The Director of Nursing confirmed that the facility failed to properly assess the pressure area and implement timely interventions to prevent worsening and promote healing.
Failure to Administer IV Antibiotic Timely
Penalty
Summary
The facility failed to ensure the timely administration of a physician-ordered intravenous antibiotic for a resident, identified as Resident 115, who was readmitted with a Midline Catheter and diagnosed with a urinary tract infection and sepsis. The physician's order, dated August 8, 2024, prescribed Ceftazidime 1000 MG to be administered intravenously twice daily for three days, with the first dose scheduled for 10:00 PM on the same day. However, the Medication Administration Record indicated that the first dose was not administered as prescribed. A nurse's progress note on August 8, 2024, documented that the 10:00 PM dose was missed due to awaiting delivery from the pharmacy. The Director of Nursing confirmed that the facility did not administer the first dose of the IV antibiotic therapy on time and failed to notify the attending physician about the missed dose. This oversight was identified during a review of clinical records, facility policy, and interviews with staff and residents.
Failure to Provide Emergency Dialysis Supplies
Penalty
Summary
The facility failed to ensure the ready availability of necessary emergency supplies for a resident receiving hemodialysis. Resident 6, who was admitted with end-stage renal disease and dependent on renal dialysis, had a care plan that required emergency clamps to be kept at the bedside for the dialysis access site. However, during an observation conducted on August 13, 2024, it was noted that there were no emergency supplies available in the resident's room or on the resident's wheelchair. Interviews with a registered nurse and the Director of Nursing confirmed the absence of the required emergency supplies at the resident's bedside. The Director of Nursing acknowledged that the facility failed to ensure the availability of these supplies, which were part of the care plan for the resident's dialysis access site in case of an emergency. This deficiency was identified for one of the 16 residents sampled during the survey.
Failure to Provide Timely Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as Resident 59, who was admitted with a diagnosis of unspecified dementia. The resident exhibited behaviors including suicidal ideations, which were documented in the clinical record. Despite these documented behaviors, the resident's care plan, initiated on May 18, 2024, did not address these specific behavioral problems or symptoms. A psychological evaluation conducted on June 6, 2024, recommended continued psychological services for the resident, but the care plan was not updated to reflect these needs. On August 13, 2024, a nursing progress note indicated that the resident expressed suicidal thoughts to her daughter. Although the physician was informed, social services and psychological services were not notified of these statements. During an interview on August 15, 2024, the Nursing Home Administrator was unable to provide evidence that the resident was receiving psychological services to maintain her mental and psychosocial well-being. This oversight resulted in a failure to update the resident's care plan to address her mental health needs adequately.
Failure to Provide Timely Antibiotic Administration
Penalty
Summary
The facility failed to provide timely pharmacy services for a resident who was readmitted with diagnoses including a urinary tract infection and sepsis. A physician ordered Ceftazidime, an intravenous antibiotic, to be administered twice daily for three days. The first dose was scheduled for administration on the evening of the same day the order was made. However, the medication was not administered as prescribed because it was not available in the facility. The director of nursing confirmed that the delay was due to the facility's pharmacy not delivering the antibiotic on time.
Failure to Conduct Required Drinking Water Testing
Penalty
Summary
The facility failed to comply with the Environmental Protection Agency (EPA) and Pennsylvania Department of Agriculture and Pennsylvania Drinking Water Information System (PADWIS) requirements, as well as Title 25 Pa. Code Chapter 109 Subchapter C Monitoring Requirements relating to Title 40, Code of Federal regulations 40 CFR. The deficiency was identified through a review of the facility's water testing results and interviews with laboratory and facility staff. The facility received violations for failing to monitor and report routine samples for 30 types of contaminants, resulting in a violation for each contaminant on July 23, 2024. The Certified Water Systems Operator/Laboratory Director revealed that the facility was required to conduct synthetic organic chemical (SOC) testing of their drinking water every three years during the second quarter. However, the SOC testing was not completed because the facility did not submit payment for the tests. The last SOC tests were performed on April 20, 2021, and as of July 26, 2024, the facility was overdue for the required 2024 SOC testing. The facility's Chief Operating Officer confirmed that payments were being made for outstanding balances, but no additional payment was submitted for the required tests, leading to non-compliance with federal, state, and local laws regarding drinking water safety.
Failure to Store Food Items Under Sanitary Conditions
Penalty
Summary
The facility failed to store food items under sanitary conditions in both the kitchen and resident pantry areas on the first and second floors. Observations revealed multiple food items in the kitchen's prep cooler that were not labeled or dated, including containers of mandarin oranges, cupcakes, lemon juice, sandwiches, turkey base, liquid egg whites, sandwich thins, a protein shake, and chopped garlic. Employee 4, a cook/dietary aide, confirmed that these items should have been labeled and dated when first opened, put into use, or received. Additionally, the first-floor nurses' station pantry contained a bag of salad in a shopping bag with no name or date, a Ready Shake with no thaw date, a package of sliced cheese with a resident's name but no date, a half-consumed container of chocolate ice cream with no date, and a box of Hot Pockets that was not kept frozen as per manufacturer directions. Employee 3, the Dietary Manager, confirmed that these items should have been labeled and dated per policy and discarded once expired or beyond their use-by date. On the second floor, dietary staff were observed attempting to date opened items in the refrigerator with a red marking pen. The refrigerator contained two bottles of Boathouse Farms berry juice and a bottle of nectar thick apple juice, all dated with the same date, making it impossible to determine the actual date of opening. Additionally, an opened jar of jam and a container of fresh blueberries were found without labels or dates. Employee 3 confirmed that food and beverage items should be labeled and dated per policy and discarded once expired or beyond their use-by date. The facility's failure to adhere to its food storage policies resulted in unsanitary conditions and potential health risks for the residents.
Failure to Provide Physician-Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide physician-ordered nutritional supplementation as prescribed to three out of 11 sampled residents (Residents A4, A5, and A6). For Resident A4, the clinical record showed an order for Ensure to be administered daily at 2:00 PM, with Boost allowed as a substitution. However, during an observation, it was found that the supplements labeled for March 15, 16, and 17 were still in the medication room, despite documentation indicating that the resident had received them on March 15 and 16 and refused them on March 17. Similarly, Resident A5 had an order for Glucerna to be administered at 2:00 PM for weight loss, with Boost Glucose Control as a substitution. Observations revealed that the supplements for March 17, 21, and 22 were still in the medication room, although the MAR indicated that the resident had received them on those dates. Resident A5 also reported inconsistencies in receiving the supplement daily. For Resident A6, an order for Ensure at 2:00 PM with a straw was noted, but a Boost supplement dated March 21 was found in the medication room, despite documentation showing it was provided as ordered on that date. Interviews with the Dietary Manager and the DON confirmed that the physician orders for nutritional supplements were not consistently followed. The Dietary Manager explained that the date on the supplement indicates when it should be consumed, and the presence of these supplements in the medication rooms indicated they were not provided to the residents as ordered. The DON confirmed that staff had documented the provision or refusal of the supplements, which were still observed in the medication rooms, indicating a failure to follow physician orders consistently.
Improper Storage and Maintenance of Oxygen Equipment
Penalty
Summary
The facility failed to store and maintain oxygen equipment in a safe, functional, and sanitary manner on the second floor nursing unit and in the general storage area. During an observation, four oxygen cylinders were found in the medication/pantry area, with two cylinders having regulators attached, indicating they were used or empty. An LPN interviewed at the time was unaware of the proper storage procedures, and an RN confirmed that used oxygen tanks should be taken outside to a designated storage area. However, the RN also mentioned that a few new tanks are stored in the medication/pantry for immediate use if needed. Further inspection of the designated oxygen storage area revealed that it was located outside the building in a caged area near the boiler room and laundry area, which was also a staff smoking area. More than 40 oxygen tanks were stored in this caged area, with both empty and full tanks mixed together, indicating improper segregation of used and clean tanks. The facility's failure to maintain oxygen cylinders in a safe and sanitary manner was evident from the improper storage practices and the proximity of the storage area to a heat source, such as the staff smoking area.
Expired Pharmaceutical Products in Central Supply Room
Penalty
Summary
The facility failed to ensure adherence to use by/expiration dates of pharmaceutical products in the central supply room. Observations revealed 35 bottles of Hydrogen Peroxide and 10 IV starter kits that were expired. An interview with the Director of Nursing confirmed that the expired pharmacy supplies should have been discarded. Additionally, the Nursing Home Administrator confirmed that expired pharmacy products should have been removed from the storage room and discarded.
Failure to Provide Easily Understandable Transfer Notices
Penalty
Summary
The facility failed to provide written notices of facility-initiated transfers to the hospital in a language that was easily understood for three residents. Resident CR1 was transferred to the hospital due to respiratory distress and did not return to the facility. Resident A7 was transferred to the hospital due to tachycardia and hypotension and later returned to the facility. Resident A8 was transferred to the hospital due to respiratory distress and remained in the hospital. The notices of transfer or discharge letters for these residents were written in medical or diagnosis terms, which may not be easily understood by the residents and their representatives. During an interview with the Nursing Home Administrator and Director of Nursing, it was confirmed that the reasons for the residents' transfers were written in medical terms. This failure to provide easily understandable notices was identified as a deficiency under 28 Pa. Code 201.14(a) Responsibility of Licensee.
Failure to Notify Resident's Representative of Significant Change in Condition
Penalty
Summary
The facility failed to timely notify a resident's representative of a significant change in condition and the need to potentially commence a new form of treatment. Resident 1, who was admitted with a diagnosis of dementia and was moderately cognitively impaired, had a dermatology consult ordered for a cancerous lesion on the left side of the face. However, there was no documentation that the resident's representative was informed about this change in condition or the dermatology consult. Further review revealed that the resident had a biopsy completed during a dermatology appointment to rule out cancer, but again, there was no documented evidence that the resident's representative was informed about the appointment or the biopsy. An interview with the Director of Nursing confirmed that the facility failed to notify the resident's representative of these significant changes in the resident's condition.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring that licensed nurses accurately administered prescribed medications to one of the sampled residents. Specifically, Resident 4, who was admitted with diagnoses including hypertension, congestive heart disease, and orthopedic aftercare following a left hip fracture, had a physician order for Metoprolol Tartrate 50 mg to be administered twice daily. The order included instructions to hold the medication if the systolic blood pressure was less than 100 or the heart rate was less than 60. However, the medication administration record for February 2024 showed that the medication was administered on multiple occasions despite the resident's heart rate or blood pressure being below the specified thresholds. For instance, on February 6, 2024, the medication was given when the resident's heart rate was 59, and on February 7, 2024, it was administered with a blood pressure of 98/43. Similar non-compliance was noted on February 20, 2024, when the medication was given with a heart rate of 58. An interview with the Director of Nursing on March 5, 2024, confirmed that the facility's licensed nurses did not consistently follow the prescribed instructions for administering the antihypertensive medication to Resident 4. This failure to adhere to the physician's orders and professional standards of nursing conduct, as outlined in the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, resulted in a deficiency in the quality of care provided to the resident.
Failure to Provide Detailed Written Transfer Notices
Penalty
Summary
The facility failed to provide sufficiently detailed written notices of facility-initiated transfers to the resident and the residents' representative for three residents. The clinical records of these residents revealed that they were transferred to the hospital and returned to the facility on different dates. However, the written transfer notices lacked the reason for the transfer and only indicated that the residents needed a higher level of care. During an interview with the Nursing Home Administrator and Director of Nursing, it was confirmed that the facility did not provide documented evidence of the provision of written transfer notices that identified the reasons for the move in writing and in a language and manner the residents and their representatives understand.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 53 citations issued within 25 miles in the last 12 months — including the 2 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| Delaware Valley Skilled Nursing & Rehabilitation C | 5.2 mi | ★★★★★ | 14 | 0 |
| St Josephs Place | 6.3 mi | ★★★★★ | 3 | 0 |
| Homestead Rehabilitation & Health Care Center | 14.2 mi | ★★★★★ | 5 | 2 |
| Valley View Rehabilitation And Healthcare Ctr | 18.7 mi | ★★★★★ | 0 | 0 |
| Complete Care At Barn Hill | 18.7 mi | ★★★★★ | 12 | 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.