Civita Care Center at Milford: Oxygen Dosing Failures - CT
The resident, identified in inspection records only as Resident 1, had a physician's order dated October 1, 2025, directing continuous oxygen at 2 liters per minute through a nasal cannula. When a state inspector observed the resident at 11:00 that morning, the oxygen concentrator was running at 2.5 liters per minute. When the inspector returned at 2:45 that afternoon, it had climbed to 4 liters per minute.
Neither setting matched the order.
LPN 3, the nurse responsible for the resident's care, explained what had happened in an interview that afternoon. He said he had received a verbal report suggesting the resident should be on 4 liters per minute. He had lowered the flow overnight because the higher rate was irritating the resident's nostrils. Then, at noon on October 2, he increased it back to 4 liters per minute — because he believed 4 liters was the ordered rate.
It was not. The order said 2.
LPN 3 acknowledged that the resident's oxygen saturation levels were stable when he made the decision to increase the flow. He wasn't responding to a clinical change. He increased the oxygen because he thought that was what the order required, based on a verbal report he had received from someone else, without checking the written order himself.
By 3:00 PM, LPN 3 had spoken with an advanced practice registered nurse, identified as APRN 1, who clarified that the resident should be ordered for 2 to 3 liters of continuous oxygen via nasal cannula, targeting an oxygen saturation above 90 percent.
What the inspection revealed wasn't just one nurse's error. It was a policy framework that left staff without basic clinical guidance.
The facility's oxygen administration policy required nurses to verify and review the physician's order before administering oxygen. LPN 3 did not do that. But inspectors also reviewed the policy itself and found it didn't specify appropriate liter flow rates for a nasal cannula, or for any other type of oxygen delivery device. A facility training session held on July 22, 2025, covered oxygen tank handling. It said nothing about flow rates or the differences between mask types.
A nasal cannula, which delivers oxygen through two small prongs positioned at the nostrils, operates at different flow rates than a face mask or a partial rebreather mask. Administering oxygen at the wrong rate — too high or too low — carries clinical consequences. The inspection report classified the harm level as minimal or potential. But the gap between what LPN 3 thought he was doing and what the order actually said was not a narrow one. He was running the concentrator at double the prescribed rate.
The facility's physician order policy stated that orders for medications and treatments should be consistent with the principles of safe and effective order writing. Oxygen is a treatment. The order existed. It was not followed, and no one caught it until an inspector arrived and observed the concentrator settings hours apart.
Resident 1 was on continuous oxygen, meaning the concentrator ran without interruption. The incorrect settings were not a momentary mistake corrected within minutes. The 2.5-liter setting was in place when the inspector arrived at 11:00 AM. The 4-liter setting was running when the inspector returned nearly four hours later.
LPN 3 said he had asked for the flow to be lowered overnight because of nostril irritation. That means the resident had been on a higher-than-ordered flow rate long enough that the physical discomfort of it had become a factor in the nurse's decision-making, and the response was to adjust the flow based on a verbal report rather than return to the written order.
The inspection was conducted as a complaint investigation. The report does not identify who filed the complaint or what prompted it.
Civita Care Center at Milford did not receive a correction to Resident 1's oxygen order until an advanced practice nurse was contacted on the afternoon of October 2, after the inspector had already documented both incorrect readings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Civita Care Center At Milford from 2025-11-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 24, 2026 · Our methodology
CIVITA CARE CENTER AT MILFORD in MILFORD, CT was cited for violations during a health inspection on November 24, 2025.
When a state inspector observed the resident at 11:00 that morning, the oxygen concentrator was running at 2.5 liters per minute.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.