Deficiency Records for Milford Healthcare and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Milford Healthcare and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2023-09-28 | 2023-11-10 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-09-28 | 2023-11-10 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-09-28 | 2023-11-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-28 | 2023-11-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-09-28 | 2023-11-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-28 | 2023-11-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-28 | 2023-11-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-28 | 2023-11-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-28 | 2023-11-10 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-09-28 | 2023-11-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-28 | 2023-11-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-14 | 2023-10-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-14 | 2023-10-31 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-09-14 | 2023-10-31 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-09-14 | 2023-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-14 | 2023-10-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-14 | 2023-10-31 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-09-14 | 2023-10-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-14 | 2023-10-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-14 | 2023-10-31 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-09-14 | 2023-10-31 | Y |
| Keep all essential equipment working safely. | Health | 2023-09-14 | 2023-10-31 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-14 | 2023-10-31 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-16 | 2023-09-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-16 | 2023-09-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-16 | 2023-09-06 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-08-16 | 2023-09-06 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-05-04 | 2023-05-31 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-04 | 2023-05-31 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-05-04 | 2023-05-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-04 | 2023-05-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-04 | 2023-05-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-04 | 2023-05-31 | Y |
| Report COVID19 data to residents and families. | Health | 2023-05-04 | 2023-05-31 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2023-05-04 | 2023-05-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-29 | 2023-05-04 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-02 | 2022-12-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-02 | 2022-12-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-02 | 2022-12-19 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-12-02 | 2022-12-19 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-02 | 2022-12-19 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-02 | 2022-12-19 | Y |
| Keep all essential equipment working safely. | Health | 2022-12-02 | 2022-12-19 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-12-02 | 2022-12-19 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-09-27 | 2022-12-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-27 | 2022-12-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-27 | 2022-12-19 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-09-27 | 2022-12-19 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-06 | 2022-12-19 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-09-27 | 2022-12-02 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-09-27 | 2022-12-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-27 | 2022-12-02 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-09-27 | 2022-12-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-27 | 2022-12-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-27 | 2022-12-02 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-27 | 2022-12-02 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-09-27 | 2022-12-02 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-09-27 | 2022-12-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-27 | 2022-12-02 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-09-27 | 2022-12-02 | Y |
| Post nurse staffing information every day. | Health | 2022-09-27 | 2022-12-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-27 | 2022-12-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-27 | 2022-12-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-27 | 2022-12-02 | Y |
| Implement a program that monitors antibiotic use. | Health | 2022-09-27 | 2022-12-02 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-09-27 | 2022-12-02 | Y |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-09-27 | 2022-12-02 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-09-27 | 2022-12-02 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-09-27 | 2022-12-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-06 | 2022-12-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-06 | 2022-12-02 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-10-06 | 2022-12-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-06 | 2022-12-02 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-10-06 | 2022-12-02 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-10-06 | 2022-12-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-06 | 2022-12-02 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2022-10-06 | 2022-12-02 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-10-06 | 2022-12-02 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-10-06 | 2022-12-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-06 | 2022-12-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-06 | 2022-12-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-10-06 | 2022-12-02 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-10-06 | 2022-12-02 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-10-06 | 2022-12-02 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-10-06 | 2022-12-02 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-10-06 | 2022-12-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-06 | 2022-12-02 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-10-06 | 2022-12-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-10-06 | 2022-12-02 | N |
| Report COVID19 data to residents and families. | Health | 2022-10-06 | 2022-12-02 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-10-06 | 2022-12-02 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-10-06 | 2022-12-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-06 | 2022-12-02 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-10-06 | 2022-12-02 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-10-06 | 2022-12-02 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-10-20 | 2022-11-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-20 | 2022-11-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-20 | 2022-11-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-20 | 2022-11-03 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-26 | 2022-06-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-17 | 2022-05-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-12 | 2022-01-11 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-11-22 | 2022-01-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-11-22 | 2022-01-11 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-11-22 | 2022-01-11 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-11-22 | 2022-01-11 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-11-22 | 2022-01-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-22 | 2022-01-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-22 | 2022-01-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-22 | 2022-01-11 | N |
| Post nurse staffing information every day. | Health | 2021-11-22 | 2022-01-11 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-11-22 | 2022-01-11 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-11-22 | 2022-01-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-22 | 2022-01-11 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-11-22 | 2022-01-11 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-11-22 | 2022-01-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-22 | 2022-01-11 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-11-22 | 2022-01-11 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-11-22 | 2022-01-11 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-11-22 | 2022-01-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-11-30 | 2022-01-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-30 | 2022-01-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-30 | 2022-01-07 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-10-12 | 2021-11-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-12 | 2021-11-22 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-10-12 | 2021-11-22 | Y |
| Report COVID19 data to residents and families. | Health | 2021-10-12 | 2021-11-22 | Y |
| Keep all essential equipment working safely. | Health | 2021-10-12 | 2021-11-22 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-12 | 2021-11-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-02 | 2021-06-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-03 | Not Fixed | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-03 | Not Fixed | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-03 | Not Fixed | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-06-27 | Not Fixed | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-05-04 | Not Fixed | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-04 | Not Fixed | Y |
| Post nurse staffing information every day. | Health | 2023-05-04 | Not Fixed | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-05-04 | Not Fixed | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-05-04 | Not Fixed | Y |
