Oc Milford Gardens LLC

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents (Resident #2 and Resident #3), who had limited mobility and required staff assistance to complete Activities of Daily Living (ADLs), the facility failed to ensure their ADL Care Plans were individualized, with interventions that clearly identified the necessary number of staff assistance required to adequately and safely meet their needs.

Inspectors wroteBased 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.

Inspectors wroteBased on record reviews and interviews for one of three sampled residents (Resident #1), who was alert, oriented and newly admitted to the facility, the Facility failed to ensure that they obtained signed written informed consent for the administration of psychotropic medication, Buspirone, which include providing the resident with information related to the risks and benefits of the medication, prior to it being administered.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one Resident (#28), out of a total sample of 23 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed to obtain a physician's order and/or include a left heel boot in the plan of care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure one Resident (#59), out of a total sample of 23 residents, was provided an environment as free of accident hazards as possible and received adequate supervision and assistance to prevent accidents. Specifically, the facility failed to ensure person-centered interventions were developed and implemented related to the root cause of the falls to mitigate the risk of future falls and/or injury resulting in five falls in three months after he/she had sustained a fall with fracture and had a change in mobility and continence.

Inspectors wroteBased on observations and interviews, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#63), in a total sample of 23 residents. Specifically, the facility failed to ensure nail care was performed for Resident #63.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure staff provided appropriate care and services for one Resident (#12) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 23 sampled residents. Specifically, the facility failed to ensure enteral feedings (provide nutrition directly into gastrointestinal tract) were administered via G-tube in accordance with physician's orders.

Inspectors wroteBased on record review and interviews, the facility failed to ensure staff maintained accurate medical records for one Resident (#5), out of a total sample of 23 residents. Specifically, the facility failed to ensure nursing staff accurately documented the use of an as needed (PRN) medication on the medication administration record (MAR).

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensures staff consistently implemented and followed their abuse policy, when on 12/13/25 after Nurse #1 was made aware of an allegation that Resident #1 was abused by a staff member, and the following day the Nursing Supervisor was also made aware of the same allegation, however neither of them immediately reported it to facility administration, as required.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure that after being made aware of an allegation of abuse that staff immediately reported it to the administration, so it could then be reported to their state agency, timely as required. On 12/13/25, Nurse #1 became aware that Resident #1's family member was angry and alleged that he/she had been physically abused by a Certified Nurse Aide (CNA), however as a result of not immediately reporting the allegation to Administration, the allegation was not reported to the state survey agency until two days later.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure that Resident #1 and other residents on his/her unit were protected from potential further abuse by a staff member, when although Nurse #1 and the Nursing Supervisor were made aware of an allegation of physical abuse by a family member on 12/13/25 and 12/14/25, neither of them reported the allegation as required which resulted in the staff member continuing to care for and interact with the residents, and as well as a two day delay in facility initiating an investigation into the allegation.

Inspectors wroteBased 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. diff - an infection of the large intestine often resulting in diarrhea or loose stools) for 19 days after a hospitalization resulting a decline in the Resident's 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.

Inspectors wroteBased 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. diff - an infection of the large intestine often resulting in diarrhea or loose stools) for 19 days after a hospitalization resulting in a decline in the Resident's 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; 2. [...]

Inspectors wroteBased 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. For Resident #68, to implement orders for a change in treatment for the care of an unstageable pressure ulcer injury (full thickness tissue loss that is covered by a layer of dead tissue that prevents the stage from being determined) to the left heel.

Inspectors wroteBased on a resident group meeting, Resident Council Minutes, and interview, the facility failed to ensure staff promptly addressed and resolved grievances brought forward during Resident Council Meetings held on 9/29/24 and 10/18/24.

Inspectors wroteBased on grievance book review and interview, the facility failed to ensure that staff documented all the steps of the grievance resolution and/or reasonable attempts were made to provide a satisfactory resolution for five Residents' (#29, #278, #277, #47, and #72) grievances filed.

Inspectors wroteBased on observation, interview, and record review, for two Residents (#330 and #64), of 18 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: 1. For Resident #330, to maintain/secure the Resident's Foley catheter drainage bag away from contaminated surfaces; and 2. For Resident #64, to ensure his/her catheter drainage bag was positioned in a manner to prevent potential complications.

Inspectors wroteBased on document review and interview, the facility failed to ensure the monthly medication regimen review (MRR) for one Resident (#13), out of a total sample of 18 residents, was included in the medical record or readily available for review to indicate the Physician's response to the recommendations made by the Pharmacist.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. For Resident #41, ensure a portable nebulizer device (turns liquid medicine into a mist that can be inhaled to treat lung conditions) and a bottle of Tums (antacid that treats heartburn, indigestion, and upset stomach) were not left unsecured in the Resident's room; 2. Ensure that once opened, a Lantus (long-acting insulin) pen was labeled with the date opened/date to be discarded; and 3. Ensure that once opened, Liquid Protein supplements were labeled with the date opened and/or date to be discarded.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label and date food products as well as maintain safe and clean equipment in three of three nourishment kitchenettes.

Inspectors wroteBased on observation and interview, the facility failed to ensure one Resident's (#3) dignity was maintained, out of a total sample of 18 residents. Specifically, the facility failed to provide Resident #3 with a privacy bag for his/her indwelling suprapubic catheter (a tube inserted through the urinary tract into the bladder, connected to a drainage bag) drainage bag.

Inspectors wroteBased on document review and interview, the facility failed to accurately complete a Level 1 Preadmission Screening and Resident Review (PASARR) for one Resident (#18) with a severe mental illness, out of a total sample of 18 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for two Residents (#13 and # 58), out of a total sample of 16 residents. Specifically, the facility failed: 1. For Resident #58, to ensure medications were administered by a nurse and not by a Certified Nursing Assistant (CNA); and 2. For Resident #13, to ensure a physician's order for Trazodone (antidepressant) was complete and included the strength of the medication ordered.

Inspectors wroteBased on observation, document review, and interview, the facility failed to ensure it provided an environment free of potential safety hazards for two Residents (#38 and #18), out of a total sample of 18 residents. Specifically, the facility failed to: 1. For Resident #38, a. Ensure his/her emergency oxygen tank was stored in a holder to prevent it from potentially falling over and causing a hazard, and b. Provide him/her a lock box to secure his/her inhalers and keep them out of the reach of unauthorized users; and 2. For Resident #18, ensure his/her bedside inhaler, which he/she can self-administer, was secured and out of view or accessibility of other residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident's (#13) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 16 residents. Specifically, the facility failed to ensure the Physician or Nurse Practitioner documented a risk/benefit analysis for the continued use of the antidepressant medication Amitriptyline in response to the Pharmacist's recommendation to consider a safer alternative treatment.

Inspectors wroteBased on observation, interview, and record review, 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, the facility failed: 1. For Resident #65, to ensure staff wore appropriate personal protective equipment (PPE) while providing care for the Resident who was on contact precautions due to Enterocolitis due to Clostridium Difficile (C. diff- an infection of the large intestine often resulting in diarrhea or loose stools); and 2. For Resident #327, to ensure staff wore appropriate PPE for enhanced barrier precautions (EBP) when providing gastrostomy care.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to provide treatment and care to ensure the highest practicable mental and physical well-being for one terminally ill Resident (#76), out of 18 total sampled residents. Specifically, the facility failed to perform a dressing change according to professional standards of practice when Nurse #1 removed two primary dressings (protective covering provided directly to wounds or lesions) from open draining blisters on Resident #76's left lower extremity without implementing measures to reduce the risk for trauma when the dressings were adhered to the Resident's skin, which resulted in the Resident experiencing short-term pain.