Millville Center

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to thoroughly investigate an allegation of staff to resident abuse and take action to prevent further potential abuse for 1 of 10 residents (Resident [R] #3) R#3 reviewed for abuse. R2 alleged that a Certified Nurse Aide (CNA) abused R3. The facility failed to follow its abuse and neglect policy titled OPS300 Abuse Prohibition, conduct a thorough investigation of the incident, and failed to remove the CNA assigned to R3 on the shift identified in the allegation. On 03/04/26, an Immediate Jeopardy (IJ) was identified at S483.12(c)2 and 483.12(c)3 related to the facility's failure to ensure a thorough investigation was completed after an allegation of staff to resident abuse was made on 02/10/26 and to prevent further potential abuse. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure 1 of 3 residents (Resident [R] 1) reviewed for food allergies was not served foods to which the resident was allergic. R1 was noted to have food allergies to ketchup, vinegar, and mayonnaise. R1 was served two meals containing allergens. Serving residents foods to which they are allergic has the potential to lead to serious harm, injury, or death. The failure to follow its policy titled Allergies to ensure R1 was not served a food to which the resident was allergic placed this resident and all residents with food allergies at risk of serious harm, injury, or death. Immediate Jeopardy was identified on 03/03/26 at 12:20 PM when R1 was served mayonnaise and offered ketchup at the lunch meal. The Administrator was notified of the Immediate Jeopardy on 03/03/26 at 5:50 PM. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure the resident and/or the resident representative (RR) were given a transfer notice/discharge notice at the time the resident was transferred/discharged to the hospital for seven of seven residents (Residents (R) 180, R181, R21, R22, R42, R89, and R56) reviewed for hospitalization of 30 sample residents. This created the potential for the residents or their RR to have incomplete information, misunderstand the reason, and process for transfer or discharge, and the discharge appeal process.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to initiate a new PASARR [Pre-admission Screening and Resident Review] Level One for one of three residents (Resident (R) 22) reviewed for PASARR to reflect the admitting diagnosis of bipolar disorder of 30 sample residents. The failure to maintain a PASARR Level One that reflected the current diagnosis of R22 had the potential to delay or limit necessary assistance should R22 experience a bipolar episode that disrupted his daily life.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop a person-centered care plan related to dialysis when a resident started receiving hemodialysis for one of one resident (Resident (R)56) reviewed for dialysis of 30 sample residents. This had the potential for the residents to have unmet care needs.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to establish an antibiotic stewardship program to include protocols to monitor extended antibiotic use for one of two residents (Resident (R) 35) reviewed for antibiotics of 30 sample residents. This failure had the potential to affect resident safety related to antibiotic usage.

Inspectors wroteComplaint #: 181226 Based on interviews and medical record review (MR) and other pertinent facility documentation on 12/11/24 and 12/12/24, it was determined that the facility failed to implement their Abuse Prohibition policy due to staff not reporting an allegation of staff to resident verbal abuse. This deficient practice was evidenced by the following: 1. During an interview with the Surveyor on 12/11/24 at 11:57 A.M., Resident #3 stated that they were not able to remember the exact date, but about a week ago, Resident #3 asked CNA (Certified Nursing Assistant) #1 to wash their hair twice. They stated that CNA #1 yelled and stated that she does not have time for that. Resident #3 stated that they then began to cry. Resident #3 stated that they reported the incident to the Social Worker. [...]

Inspectors wroteComplaint #: 181226 Based on interviews and medical record review (MR) and other pertinent facility documentation on 12/11/24 and 12/12/24, it was determined that facility staff failed to report an allegation of staff to Resident abuse to facility Administration and New Jersey Department of Health (NJDOH) according to their Abuse Prohibition policy due to staff not reporting an allegation of staff to resident verbal abuse for 2 of 6 residents (Resident #3 and Resident #6). This deficient practice was evidenced by the following: 1. During an interview with the Surveyor on 12/11/24 at 11:57 A.M., Resident #3 stated that they were not able to remember the exact date, but about a week ago, Resident #3 asked CNA (Certified Nursing Assistant) #1 to wash their hair twice. They stated that CNA #1 yelled and stated that she does not have time for that. [...]

Inspectors wroteComplaint #: 181226 Based on interviews and medical record review (MR) and other pertinent facility documentation on 12/11/24 and 12/12/24, it was determined that facility failed to thoroughly investigate an allegation of verbal abuse for 2 of 6 residents (Resident #3 and Resident #6). This deficient practice was evidenced by the following: 1. During an interview with the Surveyor on 12/11/24 at 11:57 A.M., Resident #3 stated that they were not able to remember the exact date, but about a week ago, Resident #3 asked CNA (Certified Nursing Assistant) #1 to wash their hair twice. They stated that CNA #1 yelled and stated that she does not have time for that. Resident #3 stated that they then began to cry. Resident #3 stated that they reported the incident to the Social Worker. [...]

Inspectors wroteNJ00170135 Based on interview, record review, and review of the facility's policy, the facility failed to report an allegation of abuse to the State Survey Agency (SSA) immediately, but not later than two hours for one of 12 sampled residents reviewed for abuse/neglect and injuries of unknown origin (Resident (R)10). This deficient practice had the potential to allow residents of suspected abuse to go unreported to the SSA.

Inspectors wroteNJ00156215 Based on record review, and interview, and facility policy review, the facility failed to ensure a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) provided services according to accepted standards of clinical practice with medication administration for one resident (Resident (R) 2) out of 25 sampled residents.

Inspectors wroteNJ00171304 Based on observation, interview, record review, and facility policy review, the facility failed to ensure basic infection control practices were followed to prevent cross contamination for two residents of three residents reviewed for wound care (Resident (R) 2 and R24) out of a sample of 25 residents. The facility failed to ensure Enhanced Barrier Precautions were followed by wearing required PPE (Personal Protection Equipment) and wound supplies were placed on a protective barrier when performing wound care. These failures had the potential to cause the spread of infections.

Inspectors wroteBased on observation, interview, review of clinical records and other pertinent facility documentation it was determined that the facility failed to: a.) provide adequate supervision for a resident identified as a high risk for falls, b.) implement appropriate fall prevention interventions for a resident after sustaining multiple falls with a major injury, c.) update the resident's Care Plan in a timely manner, d.) perform neuro-checks (assess an individual's neurological functions, motor and sensory response, and level of consciousness) as per facility policy for a resident who had three falls resulting in head injuries. This deficient practice was identified for one of five residents, (Resident #193) reviewed for accidents. The resident had five (5) falls since 01/04/23, and three (3) out of 5 falls resulted in the resident sustaining head injuries. [...]

Inspectors wrote3.) On 01/23/23 at 12:03 PM, on the 300 unit, the surveyor inspected the back hall medication cart locked narcotic box with LPN #4 and observed that three Controlled Medication Utilization Records (CMURs) were not accurate. Resident #134's CMUR for Oxycodone (a pain reliever) revealed that there was documented a quantity of five pills and that the blister pack (a cardboard casing that stores the medication for dispensing) revealed a quantity of four pills. Resident #124's CMUR for Tramadol (a pain reliever) revealed that there was documented a quantity of 22 pills and that the blister pack revealed a quantity of 21 pills. Resident #58's CMUR for Percocet (a pain reliever) revealed that there was documented a quantity of 27 pills and that the blister pack revealed a quantity of 26 pills. [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent facility documents, it was determined that the facility failed to consistently document blood sugars and administer diabetic medications in accordance with the physician order. This deficient practice was identified for one (1) of two (2) residents, (Resident #10) reviewed for diabetic medication administration and was evidenced by the following: On 01/20/23 at 10:10 AM, the surveyor observed Resident #10 standing up looking out their room's window. Resident #10 stated he/she was feeling fine. The surveyor reviewed the electronic medical record (EMR) for Resident #10. A review of the resident's admission Record reflected that the resident was admitted to the facility August of 2022, with diagnoses which included: type two diabetes mellitus (DM) (high blood sugar), Alzheimer's disease, and chronic kidney disease. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to identify a significant weight loss and implement interventions related to the significant weight loss for one of one residents, (Resident #37) reviewed for nutrition. This deficient practice was evidenced by the following: On 01/20/23 at 11:48 AM, the surveyor observed Resident #37 in their room, laying in bed. The resident appeared thin. The resident told the surveyor that he/she, sometimes had an appetite. On 01/23/23 at 12:34 PM, the surveyor observed the resident in his/her room eating lunch. The surveyor observed that the resident could feed himself/herself independently. At the time of the observation the resident had consumed one third of their lunch and drank all of their whole milk that was on their lunch tray. [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent facility documents, it was determined that the facility failed to consistently complete the dialysis communication form for one (1) of two (2) residents, (Resident #23) reviewed for dialysis. This deficient practice was evidenced by the following: On 01/20/23 at 09:28 AM, during the initial tour, Licensed Practical Nurse (LPN #2) informed the surveyor that Resident #23 was out of the facility at dialysis. She stated that the resident went to dialysis on Monday, Wednesday, and Friday. On 01/20/23 at 10:44 AM, the surveyor observed the resident lying in their bed awake. Resident #23 stated that he/she just returned from dialysis. He/she further stated that the nurses woke him/her up around 4:00 AM and was picked up for dialysis at 5:00 AM. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to: a.) obtain an appropriate diagnosis for the use of a psychotropic medication, b.) create, document, and monitor target behaviors for the use of a psychotropic medication, c.) obtain a psychiatric consult for the use of a psychotropic medication, and d.) develop a Care Plan for the use of the psychotropic medication. This deficient practice was identified for one of five resident's, (Resident #2) reviewed for unnecessary medications. The deficient practice was evidence by the following: According to the admission Record dated [DATE], Resident #2 was admitted to the facility with diagnoses which included but not limited to dementia, anxiety, and unspecified dislocation of the right hip. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to: a.) store, label, and date potentially hazardous foods to prevent food-borne illness, b.) discard potentially hazardous foods past their date of expiration, and c.) maintain cleanliness in food storage areas. This deficient practice was evidenced by the following: 1.) On 01/20/23 at 9:38 AM, during the initial tour of the kitchen in the presence of the Assistant Food Service Director (AFSD) the surveyor observed in the dairy walk in refrigerator a 16-ounce container of beef base dated 12/17. The AFSD stated that the beef base was good for 30 days. There was no use by date on the container. 2.) At 9:41 AM, the surveyor observed in the walk in freezer that the floor was covered in debris and sticky upon walking on it. [...]

Inspectors wroteBased on observation, interview, and document review, it was determined that the facility failed maintain sanitation in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 10/30/20 at 09:40 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and observed the following: There were two stacks of six and eight steam table pans respectively on the second and third shelves of the dry rack wet nested. The FSD said pans should be completely dry on the drying racks before being stacked on the storage rack. The FSD immediately removed the two wet nested stacks from the storage rack. A review of the unsigned policy titled, Warewashing, with a revision date of 09/2017, revealed dishware should be air dried and properly stored. NJAC 8:39-17.2(g)