Milcrest Nursing Center

In the surveyor’s words

From the most serious findings on record at Milcrest Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jun 13, 2024

  Based on review of the facility's Self-Reported Incident (SRI) and investigation, review of the facility's video surveillance, closed medical record review, review of the hospital records, staff interviews, and review of the facility policy, the facility failed to ensure a resident was free from neglect when the Director of Nursing (DON) and License Practical Nurse (LPN) #21 failed to adequately assess, monitor, and timely notify the physician of the resident's condition in accordance with professional standards of practice. […]

• Immediate jeopardy, isolatedF678Jun 13, 2024

  Based on closed medical record review, review of the facility's video surveillance, staff interviews, review of the facility's Self-Reported Incident (SRI) and investigation, review of the Emergency Medical Services (EMS) run report, review of the facility policy, and review of the American Heart Association (AHA) guidelines, the facility failed to timely initiate Cardiopulmonary Resuscitation (CPR) or contact EMS timely for one resident (#15), who was found unresponsive, without a pulse or respirations, and who was identified as a Full Code status. In addition, once initiated, the facility failed to provide adequate CPR techniques for Resident #15. […]

• No harm, potential for more than minimal, widespreadF812Apr 10, 2025

  Based on observations, staff interviews, and policy review, the facility failed to ensure safe storage of food in the kitchen. This had potential to affect all facility residents as they all ate food from the kitchen. The facility census was 44. Findings include: Observation and interview on 04/07/25 at 10:21 A.M. of the freezer with Kitchen Manager (KM) #66 revealed a bag of tater tots and a bag of crinkle fries were open and left undated. A bag of hot dogs had a hold in it and was left open to air. A box of garlic bread was left open to air and uncovered. In the fridge two undated carry out boxes with leftovers were present. One contained cake and another had breakfast food. […]

• No harm, potential for more than minimal, widespreadF880Mar 8, 2021

  Based on medical record review, observations, staff interview, review of facility policy and review of Centers for Disease Control and Prevention (CDC) guidance to nursing homes, the facility failed to implement Personal Protection Equipment (PPE) properly to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This had the potential to affect all 47 resident residing in the facility. The facility's census was 47. Findings included: 1. Medical record review for Resident #15 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #15's physician orders [REDACTED].#15 was ordered to be on a 14 days isolation due to a hospital stay. 2. Medical record reviewed for Resident #13 revealed an admission date of [DATE]. […]

• No harm, potential for more than minimal, patternF689Oct 17, 2022

  Based on observation, staff and resident interview, the facility failed to ensure wires in the ceiling were contained in the ceiling area and not hanging down from the ceiling within reach of visitors or residents. This affected 21 residents (#02, #06, #07,#09, #11, #12, #14, #16, #17, #18, #20, #21, #29, #31, #36, #38, #40, #43, #44, #45, and #46) out of 21 residents who reside in the front hallway. The facility census was 48. Findings include: Observations during the initial tour of the facility on 10/12/22 at 8:30 A.M. revealed ceiling tiles on the left side of the entire front hallway from room number one to room [ROOM NUMBER] were missing ceiling tiles exposing wires and electrical connections where residents resided. […]