Civita Care Center at Milford

In the surveyor’s words

From the most serious findings on record at Civita Care Center at Milford, in the surveyor’s own words.

• Immediate jeopardy, widespreadF760Jun 24, 2026

  Based on clinical record review, facility policy and interviews, the facility failed to ensure medications were administered as ordered and failed to prevent significant medication errors for nineteen (19) of twenty-nine (29) sampled residents (Residents #3, 4, 8, 9, 10, 11, 13, 15, 16, 17, 18, 20, 22, 24, 26, 27, 28, 29, and 30). This resulted in missed doses of high risk medications, unsafe controlled substance handling, and a lack of timely assessment or provider notification. Specifically, LPN #1 repeatedly left the unit without notifying supervisory staff, was unavailable to administer scheduled and PRN medications, and was later found unresponsive in an employee restroom with drug paraphernalia present. […]

• Immediate jeopardy, isolatedF805Nov 4, 2024

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #5) reviewed for dining, the facility failed to ensure staff provided the correct diet texture and failed to ensure staff knew or verified what the diet orders were, resulting in a choking episode. The failures resulted in a finding of Immediate Jeopardy. Resident #5 was admitted with diagnoses that included dysphagia (difficulty swallowing), dementia and end stage renal disease. The nursing admission note dated 10/4/2024 at 9:26 PM identified Resident #5 was oriented to person. The Resident Care Plan (RCP) dated 10/4/2024 identified a potential for alteration in kidney function due to dialysis and nutritional status. […]

• Actual harm, isolatedF686May 12, 2022

  Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 of 6 residents (Resident #6, 67 and 78) reviewed for pressure ulcers, the facility failed to ensure offloading devices were in place prior the development of a pressure ulcer, failed to ensure a registered nurse completed a skin assessment on admission and ongoing for a resident admitted with a pressure ulcer, and the facility failed to consistently monitor the resident 's Circulation, Motion and Sensory (CMS) and skin integrity during the utilization of bilateral knee immobilizers for potential skin impairment and pressure ulcer development. […]

• Actual harm, isolatedF684Mar 25, 2021

  Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for one of six residents (Resident # 1) reviewed for abuse, the facility failed to ensure a resident with cognitive impairment was free from non-consensual sexual contact to ensure the resident's highest practicable psychosocial wellbeing was maintained The findings include: Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment and was independent with ambulation but required supervision at times. The Resident Care Plan (RCP) dated 3/4/21 identified Resident #1 to be at risk for wandering due to being oblivious to safety. […]

• Actual harm, isolatedF600Feb 24, 2021

  Based on clinical record reviews, review of facility documentation, review of the facility policies and procedures, and interviews for one of three sampled residents (Resident #1) who was reviewed for an allegation of abuse, the facility failed to ensure a staff member was not verbally abusive, yelling and using profound language, when speaking to the resident. The findings include: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented, had some memory recall problems, had not exhibited behavioral symptoms in the past seven (7) days and requiried extensive to total one (1) to two (2) person assistance with activities of daily living. […]