Complete Care at Milford Manor LLC

In the surveyor’s words

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

• Actual harm, isolatedF697Mar 7, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Feb 18, 2023

  Based 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. Findings include: Observation on 02/16/23 at 11:50 AM of Cook (CK) and the Dietary Manager (DM) taking temperatures of food for the lunch meal revealed the CK took the temperature of the salisbury steak and wiped off the thermometer probe with a clean white towel and then took the temperature of the roasted chicken. […]

• No harm, potential for more than minimal, patternF803Mar 7, 2025

  Based 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. Findings include: A facility policy for menus was requested and not provided. Review of the facility policy titled Food: Quality and palatability, dated 02/02/03, provided by the facility revealed 1. The Dining Services Director and Cook(s) are responsible for food preparation. […]

• No harm, potential for more than minimal, patternF883Mar 7, 2025

  Based 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. Findings include: Review of the facility's policy titled, Pneumococcal vaccine (Series), dated 09/01/24 and reviewed 05/09/24 revealed, . It is our policy to offer residents and staff immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations. 1. Each resident will be assessed for pneumococcal immunization upon admission. […]

• No harm, potential for more than minimal, patternF945Mar 7, 2025

  Based 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. Findings include: 1. Review of CNA18's personnel files revealed CNA 18 had a date of hire (DOH) 05/23/22. Review of CNA18's personnel file revealed she had not received Infection Control training since her hire date at the facility. 2. Review of CNA19's personnel files revealed CNA 19 had a DOH of 11/27/23. […]