Milford Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 26, 2025

  Based on observation, interview, and record review and review of other facility documentation it was determined that for one (R1) out of three residents reviewed for accidents and supervision the facility failed to provide adequate supervision and assistive devices to prevent elopement. This put R1 in immediate jeopardy and at risk of a serious adverse outcome. R1 was able to elope from the facility on 6/13/25 through an unsecured sliding door in the conference room. R1 wandered across a busy roadway approximately 0.6 miles away from the facility and was found asleep on the grass. R1 was missing for 1 hour and 23 minutes. An immediate jeopardy (IJ) was identified starting on 6/13/25. […]

• Immediate jeopardy, isolatedF760Feb 27, 2024

  Based on observation, interview, and record review, it was determined that for one (R1) out of three residents reviewed for medications, the facility failed to ensure that R1 was ordered and received necessary insulin for a diagnosis of insulin dependent diabetes upon her admission to the facility from 2/14/24 to 2/19/24. The facility's failure placed R1 in a severe adverse outcome, hyperglycemia, and diabetic ketoacidosis. Due to this significant medication error R1 became unresponsive and was emergently transferred to a hospital and received emergent treatment for hyperglycemia, diabetic ketoacidosis, and acute kidney injury resulting in harm to the resident. […]

• Immediate jeopardy, isolatedF678Jun 28, 2022

  Based on record review, interview and review of other facility documentation as indicated, it was determined that for three (R37, R89 and R105) out of 25 initial pool residents reviewed for Advance Directives in relation to code status, the facility failed to ensure that code status' were accurate and congruent in all facility documents. For R37, his electronic medical records (EMR) failed to match the Resident Healthcare Instructions Checklist filed in the advance directive tab of the paper chart located in the Memory Care nursing station. For two residents (R89 and R105), their EMRs failed to match the staff generated shift report that R89's staff nurse in the Memory Care unit and R105's staff nurse in the East unit use as a reference in determining the code status. […]

• Immediate jeopardy, isolatedF695Jun 28, 2022

  Based on observation, clinical record review, interviews, review of the facility's policies and procedures, and review of other facility documentation as indicated, it was determined that the facility failed to ensure that emergency equipment was available for potential accidental dislodgement for two (R7 and R67) out of two active residents in the facility reviewed for [CONDITION(S)] ([CONDITION(S)]) related care. The lack of available emergency equipment, in addition to the lack of competent trained staff in [CONDITION(S)] care posed an immediate jeopardy (IJ) situation to the residents with tracheostomies. The IJ was identified on 6/8/22 at 6:05 PM and was abated on 6/9/22 at 1:55 PM. […]

• Actual harm, isolatedF689Nov 25, 2024

  Based on interview and record review, it was determined that for one (R89) out of two residents reviewed for falls, the facility failed to assess for and implement interventions to reduce R89's risk for falling. R89 sustained twelve falls which included two falls resulting in head trauma that required transfer to an acute care hospital. Findings include: A facility policy titled Falls Management effective 9/15/01 (last revised 3/15/24) included: Patient will be assessed for risk of falling as part of the nursing assessment process. Interventions to reduce risk and minimize injury will be implemented as appropriate. 1. All patients will be assessed for risk of falls upon admission, with reassessments (e.g. […]