Civita Care Center at Milford

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #91) reviewed for elopement, the facility failed to ensure when the receptionist unlocked the front doors a resident identified at risk for elopement was not able to elope from the facility.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on review of the clinical record, facility documentation, policy, and interviews for nineteen (18) of twenty nine (29) sampled residents (Residents #3, 4, 8, 9, 10, 11, 15, 16, 17, 18, 20, 22, 24, 26, 27, 28, 29, 30) reviewed for omitted medications, the facility failed to notify the provider immediately after omitted medications were identified. As a result, affected residents were not assessed timely and providers were not notified until the next day.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for seven (7) of eighteen (18) sampled residents (Residents #6, 11, 13, 23, 26, 27 and 30) reviewed for neglect, the facility failed to ensure Resident Care Conferences (RCCs) were completed at least quarterly.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews 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, 30) reviewed for neglect, the facility failed to ensure that the residents were provided social services support timely after alleged neglect occurred within the facility. Specifically, LPN #1 repeatedly left the assigned unit for long periods without notifying staff, and failed to ensure resident medications and treatments were administered per physician's orders resulting in significant medication errors.

Inspectors wroteBased on a review of the clinical record, facility documentation, facility policies, and interviews, the facility failed to complete a thorough investigation following an incident in which a licensed nurse left the first floor long hall unit multiple times for long periods during the shift, resulting in omitted medications. Specifically, the facility did not interview all 29 residents on the unit to determine whether they received their medications as scheduled, experienced any signs or symptoms related to missed doses or observed any unusual behavior from the licensed nurse.

Inspectors wroteBased on a review of clinical records, facility documentation, facility policy, and staff interviews for two (2) of four (4) sampled residents (Residents #1 and #30) reviewed for pain management, the facility failed to ensure pain was adequately assessed, pain medications were administered and documented as ordered, and required post administration pain re evaluations were completed. Specifically, the facility failed to ensure as needed (PRN) opioid pain medication was documented as administered, monitored for effectiveness, and that pain reevaluations were completed for Resident #1 and failed to ensure scheduled pain medication was administered and accurately documented for Resident #30. These failures resulted in inadequate pain management, inaccurate medication documentation, missed reassessments, and increased risk for adverse outcomes.

Inspectors wroteBased on review of the clinical record, facility policy and interviews for eighteen (18) of twenty-two (22) sampled residents (Residents #1, 3, 4, 8, 10, 11, 13, 14, 17, 18, 20, 22, 23, 24, 26, 27, 28 and 30) reviewed for comprehensive assessments, the facility failed to ensure the resident comprehensive assessments were completed within fourteen (14) days of the Assessment Reference Date (ARD) as required.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who had sustained a fall with major injury, the facility failed to administer pain medication at the time the injury was identified and after prior to transfer to the Emergency Department (ED) to ensure the resident was kept comfortable.

Inspectors wroteBased on clinical record reviews, facility documentation, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for falls with major injury, the facility failed to follow through with obtaining the x-ray reports when the diagnostic provider failed to notify the facility immediately of a positive finding which resulted in a delay of care.

Inspectors wroteBased on clinical record review and resident and staff interviews for Resident #1, reviewed for a change in condition, the facility failed to ensure that licensed staff informed the provider that an alternative method of oxygen delivery was implemented to maintain adequate oxygenation.

Inspectors wroteBased on observations, clinical record review and staff interviews, the facility failed to ensure that staff used an oxygen mask appropriately and failed to ensure staff followed a physician's order for the flow of oxygen.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #2) reviewed for abuse, the facility failed to ensure the resident was free from verbal mistreatment.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one (Resident #1) reviewed for quality of care, the facility failed to ensure the resident was free from a medication error.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who had a history of elopement, refused to wear a wander guard bracelet, and wandered throughout the facility, the facility failed to ensure the resident did not leave the facility unsupervised.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for the misappropriation of personal property, the facility failed to ensure the resident's controlled medication was not removed from the facility.

Inspectors wroteBased on clinical record reviews, review of facility documentation and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for the misappropriation of personal property, the facility failed to ensure shift to shift count of the controlled medications was conducted by two (2) licensed nurses.

Inspectors wrote5. Resident #62 was admitted to the facility on [DATE] with diagnoses that included fracture of unspecified part of the neck of the left femur, hypertension, seizures, acute embolism and thrombosis of unspecified deep veins of the lower extremity, vascular dementia, and pain disorder with related psychological factors. The admission MDS dated [DATE] identified Resident #62 had intact cognition and in the past 7 days had taken medications from the following pharmacological classifications: antianxiety, antidepressant, anticoagulant, opioid, and antiplatelet. The care plan dated 12/5/24 identified Resident #62 was on antibiotics for prophylaxis status post orthopedic surgery. Interventions included administering medications as ordered and updating the physician and responsible party, as needed. Physician's orders dated 11/21/24 directed to administer the following medications: [...]

Inspectors wroteBased on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure food temperatures were logged prior to serving meals, temperatures were logged for refrigeration, beard restraints worn as appropriate, refrigerated and frozen items were dated when opened, and ensure the refrigerator, and food storage shelves were free of personal employee items.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to provide appropriate education to its staff for Covid 19 during a recent outbreak, and for 1 of 5 residents (Resident #47) reviewed for hospitalizations, the facility failed to ensure infection control standards during lunch when staff placed a lunch tray on the residents overbed table next to 2 urinals containing urine.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #25 and 83) reviewed for medications, the facility failed to ensure the resident and/or resident representative were offered to attend quarterly resident care plan conferences.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 4 residents (Resident #31 and 87) reviewed for advance directives, the facility failed to ascertain the resident/representative wishes and the necessary documentation regarding Code status (code status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops).

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #50), reviewed for nutrition and weight loss, the facility failed to notify the physician and resident representative after a significant weight loss was identified, and for 1 of 2 residents (Resident #103) reviewed for opioid medications, the facility failed to notify the resident representative when a new medication was initiated.

Inspectors wroteBased on review of the clinical record, facility documentation, and interview for 2 residents (Resident #53 and 78) who reside on a locked unit, the facility failed to identify the clinical criteria for placing the residents on the locked unit, failed to provide the method of opening doors independently to the residents, failed to involve the resident/representative in discussions regarding the decision for placement on a locked unit, and failed to ensure the clinical record included documentation according to 483.12(a)(1) to ensure the residents were free from involuntary seclusion.

Inspectors wrote2. Resident #96 was admitted to the facility in February 2024 with diagnoses that included malignant neoplasm of the breast, cerebrovascular disease, and anxiety. Notice of PASARR Level I Screen Outcome dated 2/2/24 identified no Level II was required. The Level I screen did not identify the presence of a serious mental illness or an intellectual/developmental disability. No further Level I screening was required unless the resident was suspected of having a serious mental illness or an intellectual or developmental disability and exhibit a significant change in treatment. The quarterly MDS dated [DATE] identified Resident #96 had intact cognition and had the following psychiatric/mood disorder: anxiety. The psychiatric evaluation and consultation note dated 8/2/24 identified the following diagnoses: anxiety disorder and mild neurocognitive disorder. [...]

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 6 residents (Resident #75) reviewed for PASARR, the facility failed to ensure that a PASARR rescreen was completed following admission to the facility for a resident who had documented major mental illness that required treatment.

Inspectors wroteBased on review of the clinical record, facility policy, and interviews for 1 of 6 residents (Resident #96) reviewed for PASARR, the facility failed to ensure a comprehensive care plan was developed for a new psychiatric diagnosis.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policies, and interviews for 2 of 3 residents (Resident #47 and 89) reviewed for care planning, the facility failed to hold quarterly resident care conferences and failed to ensure the resident/resident representative were invited.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 8 residents (Resident #265 and 104) reviewed for smoking, for Resident #265, the facility failed to put smoking interventions in place prior to the resident being found smoking in his/her room on 10/8/24 and failed to ensure every 15-minute checks were completed subsequent to the incident, and for Resident #104 the facility failed to ensure the resident was free of smoking contraband.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 of 3 residents (Resident #30, 265 and 89) reviewed for respiratory care, the facility failed to ensure oxygen tubing and humidifier were changed and dated per the physician order and that a physician's order for CPAP was followed.

Inspectors wroteBased on observation, review of facility documentation, facility policy, and interviews, the facility failed to provide education on the use of a smoking blanket to staff responsible for monitoring the smoking process.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #27) reviewed for nutrition, the pharmacy failed to identified a medication irregularity, and failed to ensure that pharmacy recommendations were addressed per facility policy.

Inspectors wroteBased on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure the medication cart was secured when unlocked and unattended and that expired medications were discarded.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #74) reviewed for dental, the facility failed to follow a recommendation from the APRN for dental services in a timely manner and failed to ensure routine dental services were rendered annually.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #265) reviewed for quality of care, the facility failed to ensure a complete and accurate medical record for meal intake.

Inspectors wroteBased 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. The RCP directed treatments as ordered and diet as ordered. [...]

Inspectors wroteBased on clinical record review, facility documentation review, and staff interviews for two of four residents reviewed for abuse (Resident #1, and #3), the facility failed to ensure the residents were free from abuse.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #4) reviewed for ambulation, the facility failed to ensure treatment and services were provided to the resident to maintain ambulation status.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #5) reviewed for accidents, the facility failed to ensure that a resident identified at risk for elopement did not leave the facility unescorted.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #3) who had a stage four (4) pressure ulcer to the coccyx, the facility failed to maintain a complete and accurate clinical record that demonstrated the wound was assessed weekly and wound care was done per the physician's orders.

Inspectors wroteBased on review of the clinical record, facility documentation, and interviews for 1 of 3 residents (Resident #1) reviewed for medication administration, the facility failed to administer medications as ordered by a provider, and failed to notify a provider of medication administration omissions, and failed to follow the facility's system for ordering medications resulting in borrowing of medications.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one sampled resident (Resident #1) who required staff assistance with self-care needs, the facility failed to be respectful and ensure the resident did not overhear staff using foul language.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for two (2) of three (3) residents (Resident #1 and Resident #2) reviewed for abuse, the facility failed to ensure the comprehensive care plan reflected a consensual relationship between two residents with the capacity to consent.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #3) who were reviewed for nutrition and weight loss, the facility failed to ensure Resident #3, who had known weight decrease, was weighed monthly per facility policy.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, review of the clinical record, facility policy and interviews for 1 of 2 residents (Resident #5), reviewed for respiratory care, the facility failed to complete a self-administration of medications assessment prior to allowing the resident to self-administer medications.

Inspectors wroteBased on observation, review of facility documentation, facility policy, and interviews the facility failed to ensure the environment was maintained in a clean, sanitary, and homelike manner.

Inspectors wroteBased on observation, review of the clinical record, facility policy and interviews for 1 resident (Resident #53) reviewed for ADL's, the facility failed to ensure feeding assistance was offered and provided to a dependent resident.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #5, 6 and 78), reviewed for skin and respiratory care, for Resident #5 the facility failed to follow the physician's order for a Continuous Positive Airway Pressure (CPAP) device; for Resident #6 the facility failed follow recommendations for pressure relief for a resident with vascular ulcers, and for Resident #78 the facility failed to obtain a physician's order for monitoring skin integrity during the utilization of a leg immobilizer.

Inspectors wroteBased on review of the clinical record, facility documentation and interview for 1 resident, (Resident #4) reviewed for tube feeding and nutrition, the facility failed to follow standards of care when the resident had a significant weight loss.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #5 and 247) reviewed for respiratory care, for Resident #5, the facility failed to maintain oxygen tubing in a sanitary manner and for Resident #247 who had a tracheostomy, the facility failed to ensure tracheostomy care was performed in accordance with physician's orders and professional standards.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to ensure that visitor/staff screening was completed prior to entering a resident care area.

Inspectors wroteBased on clinical record reviews, review of facility documentation, review of facility policy and interviews for 3 of 3 sampled residents (Residents #2, #3 & #4) reviewed for resident assessment, the facility failed to transmit the residents' quarterly Minimum Data Set (MDS) assessments to CMS within regulatory parameters.

Inspectors wroteBased on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for one of three sampled residents (Resident #24) reviewed for accidents, the facility failed to revise and implement care plan interventions on a consistent basis in order to prevent further falls.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 of 3 sampled residents (Resident #50, #93 and #308) reviewed for dining and catheter care, the facility failed to maintain dignity for a urinary appliance and for the dining experience.

Inspectors wroteBased on observation, review of the clinical record, review of facility documentation, review of facility policy and interviews for 1 sampled resident (Resident #2) reviewed for choices, and for 1 of 3 sampled residents (Resident #308) observed for dining in the small assistive dining room on the second floor, the facility failed to provide a meal according to the posted and selective menus and failed to ensure that an item of clothing was applied on a daily basis per resident/family request.

Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #22) who had a change in bladder functioning, the facility failed to notify the APRN of a non-functioning bladder scanner.

Inspectors wroteBased on review of the clinical record, review of facility documentation, review of facility policy and interviews for one of two sampled residents (Resident #91) reviewed for mistreatment, the facility failed to protect the resident's right to be free from mental anguish.

Inspectors wroteBased on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #24) reviewed for restraints, the facility failed to ensure a restraint assessment was completed for a seatbelt and failed to ensure that an ambulatory resident with a seatbelt was able to remove the device on request.

Inspectors wroteBased on review of the clinical record, interviews, review of facility documentation and review of facility policy for one of two sampled residents (Resident # 91) reviewed for abuse, the facility failed to report an allegation of mistreatment to the state agency.

Inspectors wroteBased on review of the clinical record, interviews, review of facility documentation, and review of facility policy for one of two Residents reviewed for abuse (Resident # 91) the facility failed to initiate and conduct a thorough investigation after an allegation of mistreatment.

Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy and interviews for 1 sampled resident (Resident #50) reviewed for Pre-admission Screening and Resident Review (PASARR), the facility failed to ensure a referral was made to the state designated authority when a new psychiatric diagnosis was identified.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident # 88) reviewed for pressure ulcers, the facility failed ensure a resident with a pressure ulcer had his/her heels off loaded per physician orders.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 sampled residents (Resident #50 and #93) reviewed for indwelling catheter devices, the facility ensure the device was positioned appropriately to prevent the occurrence of infection.

Inspectors wroteBased on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for two of two sampled residents (Residents #11 & #49) reviewed for dialysis, the facility failed to appropriately monitor the hemodialysis access site.

Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and interviews for 2 of 5 sampled residents (Resident #24 and #68) reviewed for unnecessary medications, the facility failed to ensure appropriate monitoring of a psychotropic medication.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 sampled residents (Resident # 50 and #84) reviewed for precautions, the facility staff failed to follow the infection control policy.