Complete Care at Milford Manor LLC

Inspectors wroteComplaint #: NJ187267 Based on observation, interviews, review of medical records, and review of other pertinent facility documents on 6/24/2025, it was determined that the facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice by failing to follow a Physician's order for a Stat (immediate ) x-ray. This deficient practice was identified for 1 of 5 residents reviewed (Resident #2), as evidenced by the following: A review of the medical record according to the admission sheet, Resident #2 was admitted with diagnoses that included but were not limited to: Type 2 Diabetes Mellitus Without Complications. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure methadone (an opioid pain medication) was ordered in a timely manner to provide a resident with chronic pain their methadone for three days (03/01/25 through 03/03/25) which caused the resident to miss six doses of the pain medication that resulted in the resident experiencing withdrawal symptoms including; mental pain and physical pain all over their body. This deficient practice was identified for 1 of 38 residents reviewed for pain (Resident #1), and was evidenced by the following: On 03/03/25 at 11:19 AM, Resident #1 was observed awake in bed and stated they did not feel well enough to talk, but wanted to talk later. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to plan menus for two of 46 residents (Resident (R #1 and R #80) reviewed for menus and for puree and mechanical soft diets. This deficient practice could cause residents to choke on food and/or lose weight.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents had accurate vaccine records and were current with their pneumococcal vaccines for five of five residents (Resident #1, #7, #39, #45, and #91 reviewed for pneumonia vaccinations out of a total sample of 38 residents. This practice had the potential to increase the risk for these residents to contract pneumonia.

Inspectors wroteBased on interview, personnel files review, and document review, the facility failed to ensure four of five Certified Nurse Aides (CNA #7, #18, #19, and #14) whose personnel files were reviewed received training on the facility's infection control program, including standards, policies, and procedures of the program. This had the potential to affect all 107 residents in the facility related to Infection Control.

Inspectors wroteBased on interview, personnel files review, and document review, the facility failed to ensure five of five Certified Nurse Aides (CNA #7, #18, #19, #12, and #14) received education related to the facility's Compliance and Ethics program. This had the potential to affect 107 residents who resided at the facility.

Inspectors wroteBased on interview, personnel files review, and document review, the facility failed to ensure five of five Certified Nurse Aides (CNA #7, #18, #19, #12, and #14) received mandatory Behavior Health training. This had the potential to impact all 107 residents in the facility.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to: 1.) notify the physician of a hypoglycemic event that required medication intervention for one of one resident (Resident (R) 40) reviewed for diabetic management out of a total sample of 38. This placed R40 at risk of harm related to hypoglycemia; and 2.) notify the Responsible Party (RP) of an alteration in treatment for one of one (Resident (R) 76) reviewed for notification out of a total sample of 38. R76 was started on a prophylactic regime of Tamiflu without the RP's notification. This prevented the RP from having input into R76's treatment.

Inspectors wroteBased on observation, interviews, and policy review, the facility failed to protect a resident's right to privacy during care for one of 38 sampled residents (Resident (R) 8). This failure had the potential to have a negative impact on the residents' psychosocial well-being.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure pressure relieving interventions were consistently implemented and weekly skin assessments were completed for one (Resident (R)37) of two residents reviewed for pressure ulcers out of a total sample of 38 residents. This failure increased the risk of existing pressure ulcers worsening and/or the development of new pressure ulcers.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to implement interventions to prevent weight loss for two of five residents (Resident (R) 85 and R80) reviewed for nutrition out of a total sample of 38. This had the potential to cause harm to R85 and R80 related to unaddressed weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor for side effects of an anticoagulant (blood thinner) for one of five residents (Resident #98) reviewed for unnecessary drugs out of a total sample of 38. The deficient practice could potentially result in unnoticed bleeding.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate and complete medical record for one (Resident (R) 40) of 38 sampled residents. R40 suffered a hypoglycemia incident requiring medication intervention. The clinical record contained no documentation of the event.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to: 1. Ensure staff appropriately donned and doffed gloves and perform hand hygiene during care for three of three residents (Resident (R) 3, R62, and R37) out of a total sample of 38 residents and 2. Ensure five of five staff observed (Certified Nurse Aide) (CNA #1), and CNA #5, (Licensed Practical Nurse) (LPN #1) and (Registered Nurse) (RN #1) and RN #4 wore face masks as indicated. This had the potential to affect all 107 residents who resided at the facility.

Inspectors wroteComplaint #s: NJ00154300, NJ00164616, NJ00164923, NJ00166227, NJ00167635, and NJ00169867. Based on observations, policy review, and interviews, the facility failed to ensure that staff changed gloves when going from a dirty area to a clean area during incontinent care for two of two residents (Resident (R)9 and R4) observed out of a total sample of 11 residents. Failure to appropriately change gloves increases the risk of infection.

Inspectors wroteBased on observation, interview, review of the Food and Drug Administration website (www.fda.gov) food guide, and facility policy review, the facility failed to ensure proper cleaning of the food thermometer between taking temperatures of different food items. This had the potential to create foodborne illness for 107 of 109 residents who consume food from the kitchen.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure the electronic medical record (EMR) reflected the resident's code status and failed to completed a Physician's Orders for Life Sustaining Treatment (POLST) form for one (Resident (R)31) of 28 residents reviewed for code status.

Inspectors wroteBased on record review and interview, the facility failed to develop comprehensive plan of care that included a plan of care for pain for one (Resident (R)305) of two residents reveiwed for a plan of care for pain.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure two of three sampled residents (Resident (R)153 and R305) reviewed for discharge planning had a plan of care related to discharge to the community.

Inspectors wroteBased on record review and interview, the facility failed to ensure one resident (Resident (R)306) of one reviewed for elopement with a history of wandering and risk for elopement was provided supervision and a monitoring system in place to potentially prevent an elopement.

Inspectors wroteBased on observations, record review, staff interview, and facility policy review, the facility failed to ensure one of 28 sampled residents (Resident (R) 69) reviewed for pain received appropriate pain assessments, pain medication, and pain evaluations. This had the potential for an increase in the resident's risk for pain.

Inspectors wroteBased on record review, interview, observation, and review of facility policy, the facility failed to ensure medications were available for administering as ordered to meet the needs of one (Resident (R)83) of 11 residents observed during medication pass observation.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure the medication error rate was less than 5 percent (%). Observation of medication administration revealed out of 26 opportunities two errors were observed resulting in a medication error rate of 7.69%. Specifically, medications were not available for two residents (Resident (R) 69 and (R) 83) out of 11 residents observed during medication pass.

Inspectors wroteBased on observation, interview and review of facility documentation, it was determined that the facility failed to a.) date eye drops bottle when opened and discard unused eye drops and b.) failed to utilize the medication refrigerator solely to store appropriate medications. The deficient practice was observed in 1 of 5 medication carts inspected and 1 of 2 medication refrigerators inspected and evidenced by the following: On 3/02/21 11:45 AM, the surveyor inspected the medication cart on the short hall of Unit two in the presence of the Licensed Practical Nurse Unit Manager (LPNUM) who was also the medication nurse. The surveyor observed three bottles of Timolol Maleate 0.5% eye drops used to treat Glaucoma for Resident #7. The first bottle had an open date of 12/29/20 and had approximately one drop in the bottle. [...]

Inspectors wroteBased on observation, interview, record review and policy review, it was determined that the facility failed to a.) failed to sanitize and air dry steam table pans in a manner to prevent microbial growth and b.) failed to maintain the kitchen environment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: The surveyor reviewed the facility's policy titled, Dietary Pot Washing Procedure and Emergency Manual Dishwashing Procedure dated 1/2021. The policy indicated that items are to be air dried on drying rack. On 3/2/2021 at 10:00 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that two nurses, a Licensed Practical Nurse (LPN) and Registered Nurse (RN), observed during a medication pass observation failed to perform hand hygiene in a manner to reduce the transmission of infection. The deficient practice was evidenced by the following: On 3/4/2021 at 8:15 AM, the surveyor observed the LPN perform handwashing prior to administering oral medications to a resident. The LPN wet her hands, applied soap, lathered outside of running water for 8 seconds, rinsed under running water, dried her hands with a paper towel, and closed the faucet with a dry paper towel. When questioned by the surveyor, the LPN stated she should sing the Happy Birthday song twice while lathering outside of running water. [...]