Inspection Reports for Milford Center

A desk review follow-up was conducted on December 23, 2025, of the Annual and Complaint survey ending September 23, 2025, which was delayed due to government shutdown.

The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as of December 5, 2025.

An unannounced Annual, Complaint and Emergency Preparedness survey was conducted at the facility from September 15, 2025 through September 23, 2025 to assess compliance with federal and state regulations for skilled and intermediate care nursing facilities.

The survey identified multiple deficiencies based on observations, interviews, and clinical record reviews. Deficiencies involved comprehensive care planning, ADL care, respiratory care, bowel/bladder incontinence management, dental services, food safety, and resident records. Corrective actions and education plans were outlined for each deficiency.

An unannounced Follow-up Survey to the Annual, Complaint and Emergency Preparedness Survey ending November 25, 2024, was conducted by the State of Delaware Division of Health Care Quality from January 24, 2025 through January 28, 2025.

The facility was found not to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care as of December 5, 2024. Deficiencies related to bowel/bladder incontinence, catheter, and urinary tract infections were identified, including failure to assess and implement measures to restore/maintain continence for one resident.

This was a follow-up survey to the Annual, Complaint and Emergency Preparedness Survey ending November 25, 2024.

An unannounced annual and complaint survey was conducted at the facility from November 12, 2024 through November 25, 2024, including an emergency preparedness survey.

The survey identified multiple deficiencies related to incident reporting, notification of changes, grievances, reporting of alleged violations, investigation of alleged violations, coordination of PASARR and assessments, care plan timing and revision, activities of daily living care, psychotropic medication monitoring, food safety, resident records confidentiality, and pressure ulcer treatment. The facility failed to meet several regulatory requirements and has plans for correction with compliance dates mostly set for January 9, 2025.

An unannounced complaint survey was conducted at the facility from May 16, 2024 through May 22, 2024 based on observations, interviews, and review of clinical records and other documentation.

The facility was found deficient in multiple areas including failure to implement the grievance process for pressure ulcers, inaccurate completion of admission assessments, inadequate discharge planning, and failure to ensure proper monitoring and treatment of pressure ulcers. Root cause analyses and corrective actions were planned for each deficiency.

The complaint investigation was substantiated as the facility failed to implement the grievance process for pressure ulcers and had deficiencies in assessment, discharge planning, and pressure ulcer care.

An unannounced follow-up and complaint survey was conducted from April 18 through April 22, 2024, to assess correction of previous deficiencies and investigate complaint allegations.

The survey found deficiencies related to accuracy of assessments and provision of ADL care to dependent residents. Corrective actions including re-education and audits were planned. No further errors were noted in MDS documentation after correction.

The visit was triggered by a complaint survey ending February 27, 2024, and included investigation of allegations related to resident care and documentation accuracy. The complaint was substantiated as deficiencies were found.

An unannounced Complaint and Extended survey was conducted from February 22, 2024 through February 27, 2024 to investigate complaints and assess compliance with regulatory requirements.

The survey identified multiple deficiencies related to residents' rights, nutrition and hydration, physician visits, medication administration, staff training, communication, resident rights, abuse prevention, quality assurance, infection control, and compliance and ethics training. The facility failed to meet several regulatory requirements, including failure to offer advance directives, monitor hydration status, ensure accurate insulin administration, and provide mandatory staff training.

The survey was complaint-driven and included an extended review based on allegations. Immediate Jeopardy was identified related to medication errors affecting a resident's health.

An unannounced annual, complaint, and emergency preparedness survey was conducted at Milford Center from December 12, 2023 through December 21, 2023 and January 3, 2024 through January 5, 2024 to assess compliance with state and federal regulations.

The facility was found noncompliant with multiple Delaware Code Chapters and federal regulations, including failure to maintain minimum staffing levels, inadequate emergency preparedness training, medication management errors, inadequate resident care planning, and environmental safety issues. Root cause analyses identified deficiencies in monitoring and staff education.

An unannounced complaint survey was conducted at the facility on August 30, 2023, triggered by concerns related to staffing levels and food safety.

The facility failed to maintain the minimum required staffing level of 3.28 hours of direct care per resident per day for six days out of 21 days reviewed. Additionally, food safety violations were found including mold in the walk-in refrigerator and improper sealing of seams allowing pest access.

The survey was complaint-driven and substantiation status is not explicitly stated in the report.

An unannounced Complaint Survey was conducted from April 21, 2023 through April 26, 2023 based on allegations of abuse and failure to protect residents.

The facility failed to report and investigate allegations of resident to resident abuse in a timely and thorough manner, failed to protect residents from abuse, and failed to ensure attendance of required members at Quality Assurance Performance Improvement (QAPI) meetings. The facility was unable to correct these deficiencies at the time of the survey.

The complaint investigation found substantiated allegations of failure to report and investigate resident to resident abuse, failure to protect residents, and failure to ensure proper QAPI meeting attendance.

An unannounced follow-up survey to the Annual and Complaint Survey ending June 28, 2022, was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection on August 23 through August 24, 2022.

The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care as of August 10, 2022. No deficiencies were identified at the time of the survey.

An unannounced Annual, Complaint and Extended Survey was conducted at the Milford Center from June 7, 2022 through June 28, 2022 to assess compliance with applicable federal and state regulations.

The facility was found to have multiple deficiencies including failure to meet minimum staffing levels, failure to provide emergency preparedness training to staff, failure to protect residents from verbal abuse, failure to ensure accurate assessments and care plans, failure to prevent and treat pressure ulcers, failure to ensure proper infection control and COVID-19 testing, and failure to ensure proper food safety and medication management. Corrective actions and plans of correction were documented for each deficiency.

An unannounced complaint survey was conducted at the facility from August 6, 2021 through August 11, 2021 to investigate complaints and assess compliance with regulatory requirements.

The facility failed to ensure dignity during dining for one resident, and failed to ensure timely and comprehensive care plan development and interdisciplinary team participation for sampled residents. Deficiencies were identified related to resident rights and care plan timing and revision.

The visit was complaint-related and unannounced, conducted over several days. The deficiencies cited were based on observations, interviews, and record reviews. The complaint was substantiated as evidenced by the findings.

An unannounced follow-up survey was conducted on April 5, 2021, by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection, following a complaint survey ending February 24, 2021.

The facility was found to be in compliance with 42 CFR, Part 483, Subpart B, Requirements for Long Term Care. No deficiencies were identified at the time of the survey.

The visit was a follow-up to a complaint survey ending February 24, 2021. No deficiencies were found, indicating compliance.

An unannounced Complaint Survey was conducted at the facility from February 17, 2021 through February 24, 2021 to investigate complaints and assess compliance with regulatory requirements.

The facility failed to ensure that appropriate assistive devices and supervision were used during resident transfers, resulting in harm to a resident who experienced pain and a broken leg. The facility lacked evidence of completed lift/transfer assessments prior to transfers and failed to provide adequate supervision and mechanical lift use.

The complaint investigation was substantiated based on record review and interviews showing that a resident (R2) was transferred twice without a mechanical lift and without adequate supervision, resulting in a broken leg and pain. The facility failed to complete lift/transfer assessments and did not follow safe resident handling policies.

An unannounced COVID-19 Focused Infection Control Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection from December 31, 2020 through January 5, 2021.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were identified at the time of the survey.

A COVID-19 Focused Infection Control Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection on October 22, 2020.

The facility was found to be in compliance with 42 CFR §483.80 and has implemented the CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were identified at the time of the survey.

An unannounced complaint survey was conducted at the facility from May 26, 2020 through June 2, 2020 based on interviews, review of resident clinical records, and other facility documentation.

The facility was found deficient in developing and implementing comprehensive care plans for dialysis residents and in ensuring dialysis care and communication of COVID-19 status to dialysis centers and transportation services. Infection prevention and control practices were also found inadequate, particularly in communication of infectious disease status to contracted agencies.

The complaint investigation was substantiated based on findings that the facility failed to develop care plans for dialysis residents, failed to communicate COVID-19 status to dialysis centers and transportation, and failed to implement adequate infection control policies.

An unannounced follow-up COVID-19 Focused Infection Control Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection on June 1, 2020.

The facility was found to have regained substantial compliance with 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices for COVID-19. No deficiencies were identified at the time of the survey.

A COVID-19 Focused Infection Control Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection from April 17, 2020 through April 22, 2020 to assess compliance with infection control regulations.

The facility was found to not be in compliance with 42 CFR §483.80 related to infection control. The survey identified failures in isolating and cohorting COVID-19 positive and presumptive positive residents, improper use of personal protective equipment (PPE), and inadequate infection prevention and control practices, placing residents at risk for contracting COVID-19.

An unannounced complaint survey was conducted at the facility from March 3, 2020 through March 5, 2020 to investigate complaints related to resident transfers, discharge requirements, bed hold policies, quality of care, competent nursing staff, and quality assurance activities.

The facility failed to ensure proper documentation and communication of resident care plan goals during transfers and discharges, failed to provide timely written notices to residents or their representatives, failed to complete neurological evaluations after falls, failed to ensure nursing staff competency and training, and failed to effectively implement quality assurance and performance improvement activities.

The survey was complaint triggered and substantiated as evidenced by multiple deficiencies cited related to transfer and discharge requirements, notice requirements, bed hold policy, quality of care, competent nursing staff, and quality assurance activities.

An unannounced complaint survey was conducted at the facility from January 16, 2020 through January 17, 2020 to investigate complaints related to resident care and facility compliance.

The facility failed to ensure residents' call bells were readily accessible, failed to properly manage pain medications including documentation and administration, and failed to properly manage psychotropic and antipsychotic medications with adequate monitoring and documentation.

The survey was complaint-driven and substantiated based on observations, interviews, and record reviews revealing multiple deficiencies in resident care and medication management.