Complete Care at Middlebury

In the surveyor’s words

From the most serious findings on record at Complete Care at Middlebury, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 19, 2025

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident who required staff assistance for mobility, had leg rests applied on the wheelchair prior to pushing the wheelchair. The failure resulted in a fall with injury. The findings include: Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident who required staff assistance for mobility, had leg rests applied on the wheelchair prior to pushing the wheelchair. The failure resulted in a fall with injury. […]

• Actual harm, isolatedF689Mar 26, 2021

  Based on review of the clinical record, facility documentation, facility policy and/or procedures and interviews for 1 of 6 residents reviewed for accidents (R#1), the facility failed to provide adequate supervision or assistance to prevent to prevent an accident. The findings included: 1a) Resident #1 ' s diagnoses included [CONDITION(S)], anxiety disorder, abnormal posture, [CONDITION(S)], left hand contracture and a history for displaced fracture of the left femur 5/11/2019. A quarterly assessment dated [DATE] identified the resident as severely impaired for decision-making skills, requiring total assistance of two staff for bed mobility, transfers and as having impaired functional the limitation in ROM to LLE the (left lower extremity). […]

• No harm, potential for more than minimal, widespreadF880Sep 25, 2023

  Based on review of facility documentation, review of facility policy, and interview, the facility failed to review the infection prevention control program policies and procedures at least annually, and failed to have a current list of communicable diseases that are reportable to the local and state health authorities and failed to maintain appropriate tracking for Multi-Drug Resistant Organisms (MDRO). The findings include: a. Review of the facility's Infection Control Program Policies and Procedure Manual on 9/21/23 at 10:57 AM identified the policies and procedures were last reviewed on 2/2/22. […]

• No harm, potential for more than minimal, widespreadF882Sep 25, 2023

  Based on review of facility policy, and interviews, the facility failed to have a designated Infection Preventionist responsible for the Infection Control Program. The findings include: Interview with the DNS on 9/21/23 at 10:57 AM identified that the person that was hired for the infection preventionist position was in the process of going through the infection prevention and control program training to obtain their Infection Preventionist (IP) certification; however, the person has not assumed the position because she is currently functioning in the position of day shift nursing supervisor. The DNS further identified the IP position was still open. The DNS further noted that she was overseeing the infection control program. […]

• No harm, potential for more than minimal, patternF757Sep 25, 2023

  Based on clinical record review, and interviews for one of five sampled resident (Resident #33) reviewed for unnecessary meds, the facility failed to ensure that physician ordered monitoring for orthostatic blood pressures and for bleeding were implemented. The findings include: Resident #33's diagnoses included dementia, bipolar disorder, anxiety disorder, adjustment disorder, depression, hypertension, and a history of a coronary vascular accident. A quarterly MDS assessment dated [DATE] identified Resident #33 had intact cognition, did not display behavior symptoms, and required extensive assistance with bed mobility, transfers, ambulation, dressing, toilet use, and personal hygiene. […]