OC Milford Gardens LLC

In the surveyor’s words

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

• Actual harm, patternF684Dec 9, 2024

  Based on interview and record review, the facility failed to promote and manage the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice by failing to identify and address a change in condition and provide necessary care and treatment for one Resident (#65), out of a total sample of 18 residents. Specifically, the facility failed to implement treatment recommendations and orders to initiate a 40-day Vancomycin (antibiotic) taper due to a diagnosis of Enterocolitis due to Clostridium Difficile (C. […]

• Actual harm, isolatedF580Dec 9, 2024

  Based on observation, interview, and record review, the facility failed to notify the Physician and/or responsible party of recommendations or changes in condition for four Residents (#65, #13, #58, and #70), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #65, to notify the Physician of treatment recommendations and orders to initiate a 40-day Vancomycin (antibiotic) taper due to a diagnosis of Enterocolitis due to Clostridium Difficile (C. […]

• Actual harm, isolatedF686Dec 9, 2024

  Based on observations, interviews, and record review, the facility failed to ensure two Residents (#65, #68), out of a total sample of 18 residents, received care and treatment to promote healing of pressure injuries. Specifically, the facility failed: 1. For Resident #65, to implement wound care orders per physician recommendations for a stage IV pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) on the sacrum; and 2. […]

• No harm, potential for more than minimal, patternF760May 19, 2026

  Based on record reviews and interviews for one of three sampled residents (Resident #1), who was newly admitted to the facility, the Facility failed to ensure he/she was free from a significant medication error, when medications from his/her Hospital Discharge Summary were not accurately reconciled by Nursing and he/she was administered Buspirone (anxiolytic medication) and Benzonatate (cough suppressant) in error.Findings include:Review of the Facility Policy titled, Reconciliation of Medications on Admission, dated as revised 04/2025, indicated the following:-medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage,… […]

• No harm, potential for more than minimal, patternF565Mar 4, 2026

  Based on review of Resident Council Minutes, a resident group meeting, interviews, and document review, the facility failed to ensure grievances brought forward from the Resident Council were addressed and promptly resolved to ensure the residents felt their concerns were acted upon timely.Findings include:Review of the facility's policy titled Resident Council, undated, indicated but was not limited to the following:-the purpose of resident council is to provide a forum for residents to have input into the facility operation, discuss concerns, communication and dissemination of information-a resident council response form will be utilized to track issues, and their resolution will be discussed at the next meeting Review of the facility's policy titled: Grievances/Complaints, dated as… […]