Inspection Reports for
Arbors at Milford
5900 MEADOWCREEK DRIVE, MILFORD, OH, 45150
Back to Facility ProfileCitations (last 5 years)
Citations (over 5 years)
10.6 citations/year
Citations are regulatory findings recorded during state inspections.
130% worse than Ohio average
Ohio average: 4.6 citations/year
Citations per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Census: 72
Citations: 14
Date: Apr 9, 2025
Visit Reason
Complaint investigation triggered by allegations of neglect, abuse, and failure to follow care plans and regulatory requirements.
Complaint Details
The investigation was conducted under Complaint Numbers OH00162132 and OH00162508, involving allegations of neglect, abuse, failure to report incidents, and unsafe care practices.
Findings
The facility failed to ensure timely physician notification and assessment, proper abuse and neglect reporting, accurate PASRR screening, appropriate pressure ulcer care, fall prevention interventions, proper insulin storage and dating, adherence to menus, safe food handling, infection control practices, and maintenance of a safe environment.
Citations (14)
F578: The facility failed to ensure a resident's advance directive was fully completed and dated by the physician.
F580/F600: The facility failed to timely notify physician of a resident's change in condition, resulting in immediate jeopardy and resident death.
F600: The facility failed to protect a resident from neglect by not providing timely assessment, treatment, and notification, contributing to resident death.
F609: The facility failed to timely report allegations of neglect to the Administrator and State Survey Agency for multiple residents.
F610: The facility failed to respond appropriately to allegations of neglect and failed to thoroughly investigate neglect allegations.
F641: The facility failed to accurately code a resident's non-invasive mechanical ventilation status on the MDS assessment.
F656: The facility failed to develop and implement a care plan for dental care for a resident with dental concerns.
F686: The facility failed to thoroughly assess residents' skin and identify pressure ulcers until advanced stages, resulting in actual harm.
F689: The facility failed to implement fall prevention interventions as care planned for a resident at risk for falls.
F761: The facility failed to ensure insulin pens were properly dated and discarded after 28 days, affecting multiple residents.
F803: The facility failed to follow the posted menu for residents ordered a regular diet, omitting bacon and sausage without substitution.
F812: The facility failed to store and prepare foods to prevent spoilage and contamination, including undated food items and improper glove use.
F880: The facility failed to ensure proper personal protective equipment use, hand hygiene, and disposal of blood-contaminated materials.
F921: The facility failed to maintain a safe and clean environment, including holes in walls and unclean HVAC areas in resident rooms.
Report Facts
Facility census: 72
Blood glucose level: 583
Blood glucose level: 784
Pressure ulcer size: 1.5
Pressure ulcer size: 1
Pressure ulcer size: 0.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #122 | Licensed Practical Nurse | Confirmed missing physician date on advance directive form for Resident #65 |
| Previous DON #395 | Director of Nursing | Failed to notify physician of resident change and refusal of insulin; suspended and terminated |
| LPN #155 | Licensed Practical Nurse | Found Resident #70 unresponsive with advanced symptoms; called emergency code |
| NP #195 | Nurse Practitioner | Verified expectation for immediate notification of resident change in condition |
| CNA #145 | Certified Nurse Aide | Failed to provide timely care to residents, leaving them soiled; verbal counseling issued |
| Wound Nurse #150 | Wound Nurse Practitioner | Identified unstageable pressure ulcer on Resident #123's right shoulder |
| RN #98 | Registered Nurse | Verified fall mats missing for Resident #55 |
| MD #500 | Medical Director | Confirmed Resident #25 not assessed timely by physician after admission |
| LPN #155 | Licensed Practical Nurse | Observed insulin pens undated and expired in medication carts |
| Consulting Pharmacist #385 | Pharmacist | Verified insulin pens must be dated and discarded 28 days after removal from refrigeration |
| FSD #157 | Food Service Director | Verified undated food items and unclean kitchen conditions |
| DC #161 | Dietary Cook | Used same gloves for serving food and handling bread without changing gloves |
| LT #400 | Laboratory Technician | Failed to wear gown and perform hand hygiene between resident blood draws |
| LPN #130 | Licensed Practical Nurse | Improper disposal of blood glucose testing materials |
| DON | Director of Nursing | Verified environmental deficiencies including holes in walls and unpainted drywall |
| ADON | Assistant Director of Nursing | Verified towel stuffed in hole in wall behind resident's door |
Inspection Report
Complaint Investigation
Census: 62
Citations: 1
Date: Dec 4, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to administer appropriate respiratory care, specifically the failure to apply a ventilator at night as ordered for Resident #10.
Complaint Details
This deficiency represents noncompliance investigated under Complaint Number OH00159870.
Findings
The facility failed to apply the ventilator at night for Resident #10 as ordered, resulting in Immediate Jeopardy when the resident was found unresponsive and required CPR and hospitalization. The Immediate Jeopardy was removed after corrective actions including staff education, audits, and policy reviews were implemented, but the facility remained out of compliance at Severity Level 2 during ongoing monitoring.
Citations (1)
F 0695: The facility failed to provide safe and appropriate respiratory care by not applying the ventilator at night as ordered for Resident #10, resulting in Immediate Jeopardy and the resident requiring CPR and hospitalization.
Report Facts
Residents affected: 1
Residents reviewed for ventilator use: 5
Census: 62
Staff educated: 14
Staff educated: 7
Staff educated: 6
Audit frequency: 5
Audit duration: 4
Inspection Report
Citations: 0
Date: May 14, 2024
Visit Reason
The inspection was conducted as a regulatory survey of the nursing home facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Citations: 0
Date: Apr 9, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at the nursing home.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 76
Citations: 7
Date: Mar 19, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaints regarding resident dignity, activity provision, treatment and care, accident hazards, respiratory care, dialysis care, and infection control practices.
Complaint Details
This inspection was conducted under multiple complaint investigations including Complaint Numbers OH00150936, OH00151120, OH00151795, OH00151796, OH00152047, OH00151842, OH00151506, and OH00151053.
Findings
The facility was found non-compliant in several areas including failure to treat residents with dignity, failure to provide adequate activities, improper care of a nephrostomy tube causing actual harm, unsafe mechanical lift transfers, delayed response to ventilator alarms, delayed assessment and pressure application to a bleeding dialysis access site, and failure to implement proper infection control practices including COVID-19 precautions and hand hygiene during wound care.
Citations (7)
F 0550: The facility failed to ensure a resident was treated with respect and dignity, exposing Resident #1's back and incontinence brief in a public area.
F 0679: The facility failed to provide activities to meet residents' needs, affecting Residents #73 and #74 who were not offered scheduled activities or snacks.
F 0684: The facility failed to provide appropriate care for Resident #42's nephrostomy tube, resulting in accidental cutting of the tube and subsequent hospitalization.
F 0689: The facility failed to ensure safe transfers using mechanical lifts requiring two-person assistance, observed with one staff member transferring Resident #26 alone.
F 0695: The facility failed to timely respond to Resident #34's ventilator alarm which sounded for 11 minutes, risking resident safety.
F 0698: The facility failed to provide timely assessment and pressure to Resident #34's bleeding dialysis access site, delaying care for several hours.
F 0880: The facility failed to implement infection control practices, including improper use of PPE by staff caring for COVID-19 positive residents and inadequate hand hygiene during wound care.
Report Facts
Facility census: 76
Residents assigned to RN #119: 37
Popsicles in freezer: 50
Ventilator alarm duration: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #140 | Registered Nurse | Involved in accidental cutting of Resident #42's nephrostomy tube and wound care for Resident #73 |
| RN #119 | Registered Nurse | Worked while symptomatic with COVID-19, assigned to 37 residents on 02/19/24 |
| STNA #114 | State Tested Nursing Aide | Confirmed exposure of Resident #1's back and brief |
| AD #399 | Activity Director | Reported lack of help with activities and failure to offer activities to residents |
| LPN #26 | Licensed Practical Nurse | Verified unsafe mechanical lift transfer of Resident #26 |
| RT #144 | Respiratory Therapist | Responded to ventilator alarm for Resident #34 and provided care |
| DON | Director of Nursing | Interviewed regarding multiple findings including nephrostomy tube incident and ventilator alarm response |
| Administrator | Facility Administrator | Interviewed regarding ventilator alarm response and COVID-19 policies |
Inspection Report
Complaint Investigation
Citations: 3
Date: Mar 19, 2024
Visit Reason
The inspection was conducted as a complaint investigation into multiple non-compliance issues including improper care of a resident's nephrostomy tube, delayed response to bleeding at a dialysis access site, and failure to implement infection control practices.
Complaint Details
This inspection represents non-compliance investigated under Complaint Numbers OH00151795, OH00151796, OH00152047, OH00151842, OH00151506, and OH00151053.
Findings
The facility failed to provide appropriate care for a resident's nephrostomy tube resulting in actual harm, delayed assessment and pressure application to a bleeding dialysis access site, and failed to implement recommended infection control practices including proper hand hygiene and use of personal protective equipment. Multiple residents were affected by these deficiencies.
Citations (3)
F 0684: The facility failed to ensure appropriate treatment and care for a resident's nephrostomy tube, resulting in actual harm when a nurse accidentally cut the tube requiring surgical replacement and hospitalization.
F 0698: The facility failed to provide timely assessment and pressure to a resident's bleeding dialysis access site, resulting in minimal harm or potential for actual harm.
F 0880: The facility failed to implement infection prevention and control practices, including proper hand hygiene and use of eye protection, affecting multiple residents and staff.
Report Facts
Facility census: 69
Facility census: 76
Residents affected: 1
Residents affected: 1
Residents affected: 37
Residents affected: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #140 | Registered Nurse | Named in nephrostomy tube injury and infection control deficiencies |
| RN #119 | Registered Nurse | Worked while symptomatic for COVID-19 and involved in dialysis care deficiency |
| NP #118 | Nurse Practitioner | Provided orders related to nephrostomy tube injury |
| DON | Director of Nursing | Interviewed regarding nephrostomy tube injury and dialysis care deficiencies |
| MT #780 | Medication Technician | Observed not wearing eye protection in COVID-19 positive resident room |
| WN #125 | Wound Nurse | Observed improper sterile dressing change |
Inspection Report
Annual Inspection
Citations: 0
Date: Nov 1, 2023
Visit Reason
Annual inspection survey completed for regulatory compliance of the nursing home facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Citations: 0
Date: Sep 25, 2023
Visit Reason
Annual inspection survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 72
Citations: 1
Date: Mar 28, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to properly administer transdermal medication patches to residents.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00141340.
Findings
The facility failed to ensure proper administration and monitoring of transdermal medication patches for residents, including inadequate documentation and failure to verify patch placement every shift. This affected two residents reviewed for transdermal medications.
Citations (1)
F 0755: The facility failed to ensure transdermal medication patches were administered properly, including lack of monitoring and documentation of patch placement and presence on residents' bodies except on days when new patches were applied.
Report Facts
Facility census: 72
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to confirming standard of care for patch placement verification | |
| Nurse Practitioner | Named in relation to discontinuing Fentanyl patch order | |
| Licensed Practical Nurse #435 | Interviewed regarding patch placement and documentation for Resident #17 | |
| Licensed Practical Nurse #490 | Interviewed regarding patch application and removal for Resident #61 | |
| Regional Director of Clinical Operations #600 | Interviewed regarding proper patch removal timing and orders |
Inspection Report
Complaint Investigation
Census: 78
Citations: 17
Date: May 13, 2022
Visit Reason
Complaint investigations substantiating multiple complaints related to resident care, staffing, medication management, infection control, and facility operations.
Complaint Details
This citation substantiates Complaint Numbers OH00131752, OH00131761, OH00131479, OH00114337, OH00113490, and OH00131420.
Findings
The facility was found deficient in timely response to call lights, accurate resident assessments, care planning, assistance with activities of daily living, medication management, infection control, and food safety. Several residents experienced delayed care, medication errors, and inadequate infection precautions. Staffing shortages impacted care delivery.
Citations (17)
F 0558: The facility failed to answer call lights in a timely manner affecting seven residents. Response times ranged up to an hour.
F 0641: The facility failed to complete accurate comprehensive and quarterly assessments for two residents, including errors in hospice and dialysis service documentation.
F 0657: The facility failed to ensure routine care conferences were completed for three residents, with gaps in family involvement and documentation.
F 0677: The facility failed to provide timely feeding assistance and routine showers to dependent residents, affecting five residents.
F 0684: The facility failed to provide appropriate treatment for edema and failed to coordinate hospice services, affecting three residents.
F 0686: The facility failed to ensure weekly skin assessments and treatment orders for a pressure ulcer, resulting in progression from stage II to stage III in one resident.
F 0690: The facility failed to provide timely incontinence care for two residents, resulting in residents being left soiled and beds wet for extended periods.
F 0697: The facility failed to provide timely PRN pain medication to a resident experiencing chronic pain, resulting in actual harm.
F 0711: The facility failed to ensure physician orders were accurate and implemented, including failure to discontinue orders and complete required labs for two residents.
F 0725: The facility failed to provide enough nursing staff to meet resident needs, resulting in delayed call light responses, incontinence care, feeding assistance, and treatments for multiple residents.
F 0730: The facility failed to ensure annual performance evaluations for several State Tested Nurse Aides.
F 0756: The facility failed to ensure pharmacy recommendations were timely addressed and implemented by physicians for four residents.
F 0760: The facility failed to ensure insulin administration was performed correctly, with a nurse failing to expel air from the insulin pen before injection.
F 0790: The facility failed to ensure a resident received routine dental services despite documented dental needs and no dental visits since admission.
F 0803: The facility failed to follow menus and provide correct puree diet portions, serving less meat and incorrect bread portions to a resident.
F 0812: The facility failed to maintain a sanitary kitchen and acceptable food storage practices, including unlabeled food, lack of temperature logs, and improper ice machine sanitation.
F 0880: The facility failed to implement contact precautions for a resident with MRSA and failed to ensure newly hired employees received tuberculosis testing.
Report Facts
Residents affected by call light delay: 7
Residents affected by assessment inaccuracies: 2
Residents affected by care conference failures: 3
Residents affected by feeding and hygiene failures: 5
Residents affected by edema treatment failure: 1
Residents affected by pressure ulcer care failure: 1
Residents affected by incontinence care failure: 2
Residents affected by pain management failure: 1
Residents affected by physician order inaccuracies: 2
Residents affected by staffing shortages: 11
STNAs without annual performance review: 4
Residents affected by pharmacy recommendation failures: 4
Residents affected by insulin administration error: 1
Residents affected by lack of dental care: 1
Residents affected by menu and portion control failures: 1
Residents potentially affected by kitchen sanitation failures: 72
Residents affected by infection control failures: 1
Staff without required tuberculosis testing: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #330 | Registered Nurse | Verified delayed feeding assistance for Resident #5 |
| LPN #346 | Licensed Practical Nurse | Failed to wrap Resident #63's legs as ordered and falsified documentation |
| RN #328 | Registered Nurse/Wound Nurse | Verified pressure ulcer progression and lack of treatment for Resident #55 |
| STNA #392 | State Tested Nursing Assistant | Observed providing delayed incontinence care to Residents #26 and #33 |
| LPN #502 | Licensed Practical Nurse | Did not timely administer pain medication to Resident #277 |
| LPN #345 | Licensed Practical Nurse | Administered insulin without expelling air from pen; provided delayed pain medication |
| PT #501 | Physical Therapist | Observed Resident #277 in pain during therapy |
| RDM #422 | Regional Diet Manager | Verified incorrect puree diet portions served to Resident #31 |
| RT #358 | Respiratory Therapist | Failed to wear gown and gloves properly when caring for Resident #42 on contact precautions |
| Administrator | Facility Administrator | Verified missing annual evaluations and tuberculosis testing for staff |
Inspection Report
Complaint Investigation
Census: 87
Citations: 10
Date: Sep 26, 2019
Visit Reason
The inspection was conducted based on complaints regarding resident dignity, abuse prevention, care planning, fall prevention, staff performance evaluations, psychotropic medication use, food safety, medical record documentation, infection control, and pest control.
Complaint Details
The complaint investigation substantiated issues including failure to maintain resident privacy, incomplete background checks, inadequate care planning, fall prevention failures, lack of staff evaluations, improper psychotropic medication use, unsanitary conditions, incomplete medical records, infection control breaches, and pest control deficiencies.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy, incomplete background checks, inadequate care plans, failure to implement fall prevention interventions, lack of staff performance evaluations, improper use of psychotropic medications, unsanitary ice machine, incomplete medical record documentation, failure to follow isolation precautions, incomplete tuberculosis testing for staff, and ineffective pest control in the kitchen.
Citations (10)
F 0550: The facility failed to ensure privacy was maintained for a resident during incontinent care, exposing the resident's buttocks to the public.
F 0607: The facility failed to complete a Bureau of Criminal Investigation background check on one staff member, potentially affecting 47 residents.
F 0656: The facility failed to develop and implement care plans for a resident's stoma care, vision needs, and fall prevention interventions affecting three residents.
F 0689: The facility failed to ensure a wheelchair alarm was in place as care planned, resulting in a resident falling and sustaining facial fractures.
F 0730: The facility failed to provide 90-day and annual performance reviews for four State Tested Nursing Assistants.
F 0758: The facility failed to limit as needed psychotropic medication to 14 days and did not attempt gradual dose reductions for psychotropic drugs for one resident.
F 0812: The facility failed to maintain the ice machine in a sanitary manner, with black substance observed inside the machine.
F 0842: The facility failed to document a resident's hospital discharge and fall assessments in the medical record.
F 0880: The facility failed to ensure staff followed isolation precautions and did not complete two-step Mantoux testing on newly hired staff.
F 0925: The facility failed to maintain an effective pest control program, with gnats observed in the kitchen and food storage areas.
Report Facts
Facility census: 87
Residents potentially affected by background check failure: 47
STNA files reviewed: 4
Residents reviewed for care planning: 19
Residents reviewed for unnecessary medications: 5
Residents reviewed for infections: 6
Staff files reviewed for Mantoux testing: 7
Gnats observed in kitchen: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager #46 | Business Office Manager | Named in background check deficiency and Mantoux testing deficiency |
| Payroll/Human Resources Director #77 | Payroll/Human Resources Director | Interviewed regarding background check and performance evaluations |
| State Tested Nursing Assistant #30 | STNA | Named in resident privacy deficiency |
| Director of Nursing | Director of Nursing | Interviewed regarding care planning, psychotropic medication use, and medical record documentation |
| Administrator | Administrator | Interviewed regarding fall incident |
| Payroll Coordinator #77 | Payroll Coordinator | Interviewed regarding staff performance evaluations and Mantoux testing |
| Maintenance Director #52 | Maintenance Director | Interviewed regarding ice machine sanitation |
| Dietary Manager #800 | Dietary Manager | Interviewed regarding pest control issues |
| Licensed Practical Nurse #92 | Licensed Practical Nurse | Named in fall documentation deficiency |
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