Inspection Reports for
Milford Health & Rehabilitation Center

The complaint investigation found that the facility did not report Resident #1's injury of unknown origin within the required 2-hour reporting timeline. The injury was a right hip fracture confirmed by X-ray on 9/11/24. The facility initiated a reportable event 8 days later on 9/19/24 and rescinded it on 9/23/24, then re-initiated a Class B reportable event 11 days after the fracture confirmation. The DNS acknowledged the failure to report timely and could not explain the delay.

The facility failed to report Resident #1's acute right hip fracture of unknown origin to the state agency within the required 2-hour timeframe. The fracture was identified on 9/11/24, but the reportable event was not initiated until 9/19/24 and later corrected on 9/23/24.

The facility failed to consistently label opened dry food with the date opened and expiration date, and canned goods had expiration dates in codes that could not be deciphered. The Food Service Director was unable to provide documentation verifying expiration dates on canned items.

The facility was found deficient in multiple areas including failure to notify providers of significant weight loss, failure to promptly notify state mental health authorities of new psychiatric diagnoses, inadequate fingernail care, failure to address abnormal lab results, incomplete nurse aide performance reviews, improper storage and reconciliation of discontinued controlled substances, and inconsistent labeling and dating of dietary food products.

Complaint CT #'s 33247, 35965, 36931, 39271 were part of the investigations.

The report details multiple violations of Connecticut State Agencies regulations identified during the visits, including failures in notifying providers of weight loss, incorrect coding of discharge assessments, failure to notify mental health authorities promptly, inadequate maintenance of residents' fingernails, failure to address abnormal lab results, incomplete yearly performance reviews for staff, and improper medication storage and reconciliation. Plans of correction were submitted for each violation.

The facility was found deficient in timely completion and submission of quarterly resident assessments, failure to provide diabetic education and teaching prior to discharge, inadequate provision of personal hygiene care including showers, and lack of physician orders for oxygen use for a resident.

Complaint Investigation #30210 was substantiated with violations identified. The complaint involved Resident #1 signing out Against Medical Advice (AMA) without proper involvement of the Conservator, and failure to notify police prior to discharge. The facility also failed to clarify and document the conservatorship status in the clinical record.

Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified during the inspection. The report includes details of a resident's discharge against medical advice and failure to properly document conservatorship status in clinical records.

Complaint #30210 triggered the investigation. The complaint involved Resident #1 signing out AMA with a spouse who was not the appointed conservator. The facility failed to clarify conservatorship status and did not notify the conservator or police promptly. Protective services and other authorities were notified after the event.

The investigation identified violations of Connecticut State regulations, including failure to include legal documentation clarifying the status of a resident's conservatorship in the clinical record. The resident signed out Against Medical Advice (AMA) without proper authorization, and the facility failed to prevent the discharge without notifying the conservator or police in a timely manner.

The facility failed to ensure that the responsible party was notified once a medication was discontinued for Resident #1. The findings included documentation and interviews showing that the Percocet medication was discontinued without proper notification to the resident's family member, despite the resident having chronic pain and a history of medication orders.

The facility was found deficient in notifying resident representatives about changes in resident conditions, administering unnecessary medications, and infection control practices during wound care. Deficiencies involved failure to notify family of IV therapy initiation, application of a nicotine patch without indication causing adverse effects, and improper hand hygiene during dressing changes.

Complaint #24011 triggered the investigation and inspection.

The report identifies multiple violations related to failure to notify resident representatives of condition changes, unnecessary medication administration, and inadequate infection control practices. Plans of correction include staff in-service training, audits, and policy reviews to address these deficiencies.