Blaire House of Milford

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP), the Facility failed to ensure nursing promptly notified his/her Health Care Agent (HCA), when 1) he/she had a change in condition and 2) had a decline in functional status.

Inspectors wroteBased on record reviews and interviews for one of three sampled residents (Resident #1) who had a Legal Guardianship (person designated by the court to make health care decisions on behalf of a person determined to not be able to make those decisions) in place, the Facility failed to ensure nursing honored his/her Guardian's request and Physician's Order regarding the administration of his/her as needed (PRN) psychotropic medications used to help treat his/her mood and behavior.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had lost his/her upper and lower dentures and had been seen by the Dentist to have new dentures made, the Facility failed to ensure they obtained a signed consent in a timely manner from his/her Legal Guardian, resulting in a delay of several months before his/her new dentures could be fabricated.

Inspectors wrote2. Resident #111 was newly admitted to the facility from home in 5/2025 with diagnoses which included hypertensive heart disease with heart failure, combined systolic and diastolic (congestive) heart failure, atrial fibrillation, and unspecified dementia with other behavioral disturbance. The Resident had been living at home with his/her family and received services from a home Hospice agency. Review of the nursing policy for new admissions, revised in 10/2024, indicated that an admission Checklist (CN-011) was to be completed for each admission. Upon completion of the First Day tasks from the checklist, the nurse was to return the checklist to the Director of Nursing/Executive Director. First Day tasks included, but were not limited to the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy when one Resident (#162), was involved in a resident to resident altercation, in a total sample of 16 residents. Specifically, the facility failed to ensure staff, who were aware of the incident and notified the Administrator, implemented their abuse protocol by notifying the local authorities of the potential abuse or implemented a system of follow up with interventions to prevent potential future incidents.

Inspectors wroteBased on interview and record review, the facility failed to report a resident to resident altercation as potential abuse in which one Resident (#162) was struck with a pillow by their roommate, in a total sample of 16 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure laboratory results were reported and acted on timely for one Resident (#262), out of a total sample of 16 residents. Specifically, the facility failed to report Resident #262's 4/1/25 critically low hemoglobin (Hgb, a protein in red blood cells that carries oxygen from the lungs to the body's tissues and returns carbon dioxide from the tissues back to the lungs) level result to the Resident's provider until 4/3/25.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure food items were properly labeled and dated in three of three kitchenettes.

Inspectors wroteBased on observation, document review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Specifically, the facility failed to: 1. Maintain an accurate surveillance system that reflected potential illnesses and infections in the facility in accordance with the most up to date pre-defined McGeer criteria; and 2. Ensure hand hygiene was performed by staff and residents during meals and tray pass.

Inspectors wroteBased on record review and interview, the facility failed to ensure two Residents (#14 and #28), out of a total sample of five residents reviewed for immunizations, were screened for eligibility to receive the recommended PCV20 or PCV21 pneumococcal vaccination, the residents/residents' representatives were educated on the benefits and potential side effects of the vaccine, and were offered and administered (if applicable) the vaccine in a timely manner. Specifically, the facility failed: to identify that the Residents were eligible for the PCV20 or PCV21 pneumococcal vaccinations and were offered the opportunity through shared decision making to receive the vaccination if warranted and desired in accordance with Centers for Disease Control and Prevention (CDC) guidance.

Inspectors wroteBased on document review and interview, the facility failed to fully inform all residents of their right to not sign a binding arbitration agreement upon admission.

Inspectors wroteBased on interviews, policy review, and review of Resident Council Minutes, the facility failed to ensure that grievances brought forward through Resident Council from 9/21/23 through 3/29/24 were addressed and promptly resolved as required.

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to follow professional standards for five Residents (#46, #27, #62, #17, and #51), out of a total sample of 16 residents. Specifically, the facility failed: 1. For Resident #46, to transcribe a physician's order for a gradual dose reduction (GDR, the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for Haloperidol (antipsychotic medication); 2. For Resident #27, a. to transcribe a physician's order for a GDR for Olanzapine (antipsychotic medication), and b. to follow a physician's order to re-evaluate a GDR for Olanzapine; 3. For Resident #62, to follow manufacturer's instructions for administering Metamucil (used to treat constipation); 4. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required. Specifically, the facility failed to ensure all medication and treatment carts were locked when unattended and unsupervised on three of three units in the facility.

Inspectors wroteBased on observations, interviews, and record review, for one Resident (#28) of 16 sampled residents, the facility failed to ensure his/her call light was accessible so he/she was able to call for assistance.

Inspectors wroteBased on observations, interviews, policy review, and records reviewed, for three Residents (#14, #22, and #51), out of 16 sampled residents, the facility failed to develop and implement comprehensive care plans to reflect the individual needs of the residents. Specifically, the facility failed: 1. For Resident #14, to develop and implement a care plan for an indwelling Foley catheter (tube placed in the body to drain and collect urine from the bladder); 2. For Resident #22, to develop and implement a care plan for an indwelling Foley catheter; and 3. For Resident #51, failed to a. develop a comprehensive care plan for self-administration of finger stick blood sugar testing (FSBS), and b. develop a comprehensive care plan for an implantable cardiac device. Findings Include: [...]

Inspectors wroteBased on record review and staff interview, for one Resident (#66), of three closed records reviewed, the facility failed to document the recapitulation of the Resident's stay that included his/her course of illness/treatment.

Inspectors wroteBased on record review and interviews, the facility failed to promote and manage the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice for one Resident (#26), out of a total sample of 16 residents. Specifically, the facility failed to ensure a dietary aide did not move a resident off the floor and into a wheelchair after the Resident sustained an unwitnessed fall with a head strike, prior to having a nurse assess the Resident.

Inspectors wroteBased on observation, interview, and record review, for one Resident (#14), of 16 sampled residents, the facility failed to provide indwelling catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care consistent with professional standards related to infection control prevention. Specifically, the facility failed to maintain/secure the Resident's Foley catheter drainage bag away from contaminated surfaces.

Inspectors wroteBased on records reviewed and interviews, the facility failed to ensure for one Resident (#27), out of a total sample of 16 residents, that each Resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS) assessment (a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body) was completed timely in accordance with standards of practice.

Inspectors wroteBased on observation, interview, and record review for one Resident (#16), of 16 sampled residents, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, for Resident #16, the facility failed to ensure transmission-based precautions (TBP) were implemented per physician's order for contact precautions.

Inspectors wroteBased on record review, policy review, and interview, for one Resident (#46), of five residents reviewed, the facility failed to provide the pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy. Specifically, for Resident #46, the facility failed to ensure that pneumococcal vaccinations were administered after consent was obtained.

Inspectors wroteBased on record review, policy review, and interview for one Resident (#63), of five sampled residents, the facility failed to provide education, assess for eligibility, and offer COVID-19 vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy.

Inspectors wroteBased on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to ensure an MDS assessment was completed timely as required for four Residents (#5, #12, #11, and #59), out of four records reviewed and 16 sampled residents. Specifically, the facility failed to ensure MDS discharge assessments were completed within the required timeframe.

Inspectors wroteBased on record review and interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for four Residents (#47, #58, #22, and #46), out of 16 sampled residents. Specifically, the facility failed: 1. For Resident #47, to ensure falls were accurately coded on the MDS; 2. For Resident #58, to ensure falls were accurately coded on the MDS; 3. For Resident #22, to accurately code his/her hospice status on the MDS; and 4. For Resident #46, to accurately code a fall with fracture.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was physician's orders included the administration of an antipsychotic medication (clozapine) and an antianxiety medication (clonazepam), the Facility failed to ensure that Resident #1 was free from the use of unnecessary psychotropic medications, when although the dosages of his/her psychotropic medications were successfully titrated down while he/she was in the hospital, upon readmission to the Facility he/she was restarted on his/her previous higher dosages, Resident #1 became lethargic, was transferred to the Hospital Emergency Department for evaluation for mental status changes and required readmission related to drug-induced fever related to the rapid dose increase of clozapine.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a physician's order, dated 2/13/24, for a stat (immediate) x-ray of his/her left lower leg, the Facility failed to ensure nursing promptly notified the Physician when although they received Resident #1's x-ray results on 2/14/24 which indicated he/she had left distal tibia and fibula (lower leg bones, near the ankle) fractures, the physician was not made aware of the results until 2/16/24, resulting in a delay in treatment.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was provided with quality of care that met professional standards of practice, when Resident #1 developed swelling, with redness and tenderness to his/her left ankle area which was later identified as a left fibula (lower leg) fracture, and he/she was not monitored for worsening or a change in condition and was not assessed for pain by nursing on the days following the injury.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #2), the Facility failed to ensure staff completed all sections of the annual Minimum Data Set Assessment (MDS) no later than 14 calendar days after the Assessment Reference Date (ARD).

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Health Care Proxy had been activated, the Facility failed to ensure that nursing staff notified Resident #1's Physician and Health Care Agent (HCA) in a timely manner, when on 8/27/23 nursing was made aware that the pinky finger on Resident #1's right hand was red and swollen, but the Physician and the HCA were not notified until more than 24 hours later.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had developed redness and swelling of his/her right pinky finger, the Facility failed to ensure Resident#1 was provided nursing care and treatment in accordance with professional standards of practice, after he/she experienced a change in condition on 8/27/23, and nursing was made aware that Resident #1's pinky finger on his/her right hand was red and swollen, however he/she was not assessed by nursing until approximately 24 hours later, at which point the Physician was notified and new orders were obtained for an X-ray of his/her right hand.

Inspectors wroteBased on interview, policy review, and document review, the facility failed to maintain and consistently implement an infection prevention and control program during a current COVID-19 outbreak in the facility. Specifically, the facility failed to implement a system for resident surveillance of COVID-19 within the facility to: a. ensure staff consistently documented an assessment of symptoms of COVID-19 during each shift for three Residents (#1, #2, and #3), out of a total sample of three residents reviewed; and b. maintain resident COVID-19 infection surveillance line listings to include symptomatic residents.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to provide education, assess for eligibility, and offer pneumococcal vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for one Resident (#1), out of a total sample of five residents reviewed for immunizations.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to provide education, assess for eligibility, and offer COVID-19 vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for two Residents (#1 and #2), out of a total sample of five residents reviewed for immunizations.

Inspectors wroteBased on interview and record review, the facility failed to provide timely medical care resulting in the development of an infection requiring oral and intravenous antibiotics, a seven-day hospitalization, and recommendation for a third toe amputation for one Resident (#20), out of a total sample of 20 residents. Specifically, the facility failed to: a. Notify the physician and/or physician assistant immediately once the Resident reported the right third toe injury to staff, which delayed physician evaluation and treatment for over 48 hours, and b. Provide ongoing assessment for latent injuries and/or signs of infections of the right third toe wound over the course of 48 hours (Saturday and Sunday).

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure staff identified, addressed, and monitored gradual unplanned significant weight loss for one Resident (#20), out of a total sample of 20 residents. Specifically, the facility failed to: a. Assess nutritional interventions put in place on 10/7/22 for their effectiveness to prevent continued weight loss through 12/7/22, and b. Identify in a timely manner the Resident's food and flavor preferences to optimize the Resident's caloric intake to prevent continued weight loss.

Inspectors wroteBased on interviews and record review, the facility failed to allow residents to make individualized meal choices prior to meal service, and ensure residents were offered a choice and variety.

Inspectors wroteBased on interview, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, care, and services to residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify residents, resident representatives, and families of positive COVID-19 cases (staff or resident) by 5:00 P.M. the following day as required.

Inspectors wroteBased on interview, policy review, and record review, the facility failed to manage COVID-19 in a manner consistent with professional standards of practice. Specifically, the facility failed to: 1. Perform contact tracing for 12 positive staff members to include all resident and staff exposures and subsequently failed to perform outbreak testing, and 2. Perform surveillance testing for COVID-19 as indicated in the facility's policy.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure that drugs and biologicals were stored in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 2 medication rooms.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Roger's Treatment Plan (court approved treatment plan for the administration of antipsychotic medications) was active and current for administration of an antipsychotic medication for one Resident (#13), out of a total sample of 20 residents.

Inspectors wroteBased on interview, record review, and review of an investigation, the facility failed to implement interventions to prevent a resident-to-resident altercation for one Resident (#53), in a total sample of 10 residents. Specifically, following a resident-to-resident altercation between Resident #53 and Resident #2A, the facility failed to implement interventions to prevent an additional resident-to-resident altercation.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#53), out of a total sample of 20 residents. Specifically, the facility failed to follow their policy and ensure an allegation of abuse was thoroughly investigated, an alleged staff member was removed pending an investigation, and the incident/allegation was reported to the Department of Public health within two hours.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#53), out of a total sample of 20 residents. Specifically, the facility failed to report the alleged allegation of abuse to the state agency within two hours.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#53), out of a total sample of 20 residents. Specifically, the facility failed to fully investigate the allegations of abuse.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that for one Resident (#52), out of a total sample of 20 residents, that the Resident, and/or family were provided with a Discharge Notice upon discharge to an acute care hospital.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that for one Resident (#10), out of a total sample of 20 residents, that the plan of care was revised following a change in the Resident's dental status. Specifically, Resident #10's plan of care was not revised following the loss of her/his dentures and reported difficulty chewing and swallowing.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the nursing staff followed professional standards of practice during medication administration and observed the resident's consumption of the medication for one Resident (#10), out of a total sample of 20 residents.

Inspectors wroteBased on interview, policy review, and record review, the facility failed to follow their policy and investigate a fall and implement interventions to decrease the risk for future falls for one Resident (#35), out of a total sample size of 20 residents.

Inspectors wroteBased on record review and interviews, the facility failed to have an effective communication system in place between the facility and the dialysis center for one Resident (#20), out of a sample size of 20 residents. Specifically, the facility did not document in the dialysis communication book changes in medication including new or held medications, vital signs, laboratory values, or nutritional concerns.

Inspectors wroteBased on interview and employee record review, the facility failed to ensure that agency nursing staff was provided an orientation to the facility's day-to-day operations including emergency services to ensure resident safety.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to ensure that each Resident's drug regimen was free of unnecessary psychotropic medications. Specifically, the facility failed to ensure targeted behaviors and signs and symptoms of side effects were adequately monitored to evaluate the effectiveness of psychotropic medication to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for two Residents (#13 and #52), out of a total sample of 20 residents.

Inspectors wroteBased on Minimum Data Set (MDS) assessment review and staff interview, the facility failed to encode and electronically transmit MDS data to the Centers for Medicare and Medicaid Services (CMS) processing system, for one Resident (#12), out of one resident assessment reviewed.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that for one Resident (#10), out of a total sample of 20 residents, that the Resident's Minimum Data Set (MDS) assessment accurately reflected the Resident's Oral/Dental Status.