Inspection Reports for
Milford Center

The complaint involved resident R1's family member expressing concerns about care issues and unresolved grievances. The grievance was escalated to a reportable event due to lack of resolution and absence of a written decision. The family member did not return calls from the facility after initial contact.

The facility failed to ensure prompt resolution and written decisions for grievances, failed to revise person-centered care plans addressing resident R1's refusal to obtain daily weights, and failed to maintain complete and accurate medical records for R1.

The facility failed to ensure food and beverages were stored, prepared, and served in a manner that prevents foodborne illness. Mold was observed on ceiling tiles in the dry food storage room and inside the tubing of the kitchen juice machine beverage dispenser.

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.

The complaint investigation was substantiated as the resident eloped on 6/13/25 due to an unsecured door left unlocked by a contractor. The immediate jeopardy was abated by 6/17/25 after corrective actions including door repairs, staff education, and elopement drills.

The facility failed to provide adequate supervision and assistive devices to prevent elopement for one resident, resulting in immediate jeopardy. The resident eloped through an unsecured sliding door, was missing for over an hour, and was found safely outside. The facility implemented corrective actions including securing doors, staff education, and elopement drills.

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

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.

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.

The inspection identified multiple deficiencies including failure to notify providers of resident dialysis refusal, unresolved resident grievances, delayed reporting of neglect allegations, incomplete PASARR screenings, inadequate care plan meetings, failure to provide necessary care for activities of daily living, pressure ulcer care deficiencies, inadequate continence care, failure to maintain resident hydration and nutrition, lack of psychotropic medication monitoring, delayed notification of lab results, failure to assist with dental services, and food safety violations in the kitchen.

The complaint investigation revealed multiple deficiencies including unresolved grievances, delayed neglect reporting, inadequate abuse investigations, poor ADL care, pressure ulcer treatment failures, fall risk management lapses, insufficient continence care, hydration and nutrition failures, and inaccurate clinical documentation.

The facility failed to promptly resolve resident grievances, timely report and investigate neglect allegations, provide adequate care for dependent residents including ADLs and pressure ulcers, assess and mitigate fall risks, implement individualized continence and toileting programs, ensure adequate hydration and nutrition, and maintain accurate clinical documentation.

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.

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 facility was found deficient in implementing the grievance process, accurately completing admission MDS assessments, providing discharge planning education to caregivers, and ensuring consistent monitoring and care of pressure ulcers for residents.

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.

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 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.

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 investigation was complaint-driven, focusing on issues such as failure to offer advance directives, inaccurate assessments, inadequate care provision, medication errors including insulin administration, and incomplete staff training. Immediate jeopardy was identified related to insulin administration errors for one resident.

The facility failed to offer residents the opportunity to formulate advance directives, ensure accurate assessments, provide necessary care and assistance with activities of daily living, monitor hydration for residents at risk, accurately review and administer insulin orders, complete required staff performance reviews and training, and maintain compliance with infection control and ethics training requirements.

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.

The facility had multiple deficiencies including failure to notify family of medication changes, inadequate resident accommodations, incomplete assessments, inaccurate care plans, expired medications, inadequate staff training, and food safety issues.

The investigation was complaint-driven, focusing on medication notification failures, environmental safety concerns, catheter care, and staff training compliance. The deficiencies were substantiated based on record reviews and interviews.

The facility failed to notify a resident's representative about medication changes, maintain a safe and homelike environment including adequate hot water and lighting, follow catheter care orders, and ensure nurse aides completed mandatory annual training. Multiple residents and staff interviews confirmed these deficiencies.

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

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 facility failed to prevent mold growth in high moisture areas and did not maintain food storage areas in a clean and safe condition. Observations included mold on shelving in the walk-in refrigerator and an unsealed floor seam allowing pest access and debris accumulation.

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.

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 involved six residents reviewed for abuse. One resident (R8) was involved in a physical altercation that was not reported timely. Another resident (R2) alleged sexual abuse by another resident (R1), but the investigation was found to be incomplete and unsubstantiated due to lack of evidence and missing staff interviews.

The facility failed to timely report an allegation of resident to resident physical abuse within two hours and failed to thoroughly investigate an allegation of sexual abuse. Additionally, the facility failed to protect a resident from further abuse for approximately 20.5 hours before initiating continuous supervision. The facility also failed to ensure required attendance at quarterly Quality Assurance Performance Improvement meetings.

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.

The inspection identified multiple deficiencies including inaccurate resident assessments, incomplete care plans, immediate jeopardy related to tracheostomy care and emergency preparedness, inadequate pain management, failure to accommodate food preferences, infection control lapses, and failure to monitor antibiotic use and COVID-19 testing protocols.

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.

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 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.

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 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.

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 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.

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.

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

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.