Inspection Reports for Complete Care At Milford Manor Llc

69 Maple Road, NJ, 07480

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Deficiencies per Year

20 15 10 5 0
2021
2022
2023
2024
2025
Severe High Moderate Low Unclassified

Census Over Time

88 96 104 112 120 Feb '21 Aug '21 Feb '23 Jan '24 Jul '24
Census Capacity
Notice Deficiencies: 0 Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
NameTitleContext
Devon L. GrafDirector, Office of Legal and Regulatory ComplianceListed as NJDHSS Privacy Officer contact for questions about the notice
Inspection Report Complaint Investigation Census: 103 Deficiencies: 1 Jul 31, 2024
Visit Reason
The inspection was conducted based on complaints NJ00171980, NJ00172632, and NJ00170194 to investigate compliance with federal and state regulations regarding staffing ratios and care standards.
Findings
The facility was found to be in substantial compliance with federal requirements but was not in compliance with New Jersey state staffing regulations, specifically failing to meet minimum staff-to-resident ratios on 14 of 28 day shifts. The facility submitted a plan of correction to address staffing deficiencies.
Complaint Details
Complaint investigation based on complaints NJ00171980, NJ00172632, and NJ00170194. The facility was found substantially compliant with federal requirements but deficient in state staffing requirements.
Deficiencies (1)
Description
Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratio as mandated by the State of New Jersey for 14 of 28 day shifts.
Report Facts
Census: 103 Day shifts deficient in CNA staffing: 14 Sample Size: 5 Staffing ratios required: 8
Inspection Report Complaint Investigation Census: 105 Deficiencies: 2 Jan 5, 2024
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health due to multiple complaint numbers listed, to investigate compliance with long term care facility regulations.
Findings
The facility was found not in substantial compliance with infection prevention and control requirements, specifically failing to ensure staff changed gloves appropriately during resident care, increasing infection risk. Additionally, the facility failed to maintain required minimum staffing ratios for certified nurse aides (CNAs) on multiple shifts over several months.
Complaint Details
The complaint investigation involved multiple complaint numbers and found the facility not in substantial compliance with 42 CFR Part 483, Subpart B, based on observed infection control deficiencies and staffing shortages.
Severity Breakdown
SS=D: 1
Deficiencies (2)
DescriptionSeverity
Failure to ensure staff changed gloves when moving from dirty to clean areas during care for residents, increasing risk of infection.SS=D
Failure to maintain required minimum staff-to-resident ratios as mandated by New Jersey law on multiple day, evening, and night shifts.
Report Facts
Survey Census: 105 Sample Size: 11 Staffing Deficiencies: 43 Staffing Deficiencies: 1 Staffing Deficiencies: 4 Deficiency Counts: 1
Employees Mentioned
NameTitleContext
Infection Preventionist NurseConducted in-service and competency evaluations related to infection control deficiencies.
Certified Nursing Assistant (CNA) 1Observed failing to change gloves appropriately during resident care.
Director of Nursing (DON)Interviewed and confirmed glove changing policy.
Assistant Director of Nursing (ADON)Interviewed and confirmed glove changing policy.
Inspection Report Abbreviated Survey Census: 115 Deficiencies: 0 Oct 18, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 7
Inspection Report Annual Inspection Census: 109 Capacity: 109 Deficiencies: 17 Feb 18, 2023
Visit Reason
A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health to assess compliance with federal and state regulations.
Findings
The facility was found not to be in substantial compliance with multiple regulatory requirements including advance directives documentation, comprehensive care planning, discharge planning, accident prevention, pain management, medication availability and administration, food safety, staffing ratios, and life safety code violations related to emergency lighting, fire alarm system testing, sprinkler system installation and maintenance, smoke barrier integrity, corridor door functionality, fire drills, and portable space heater use.
Severity Breakdown
SS=D: 7 SS=E: 5 SS=F: 4
Deficiencies (17)
DescriptionSeverity
Failed to ensure electronic medical record reflected resident's code status and completion of POLST form.SS=D
Failed to develop and implement a comprehensive care plan including plan of care for pain for one resident.SS=D
Failed to develop and implement an effective discharge planning process for two residents.SS=D
Failed to ensure adequate supervision and monitoring system to prevent elopement for one resident.SS=D
Failed to provide appropriate pain assessments, medication, and evaluations for one resident.SS=D
Failed to ensure medication was available for administration as ordered for one resident.SS=D
Medication error rate exceeded 5% due to unavailable medications for two residents during medication pass observation.SS=D
Failed to properly clean food thermometer between taking temperatures of different food items.SS=F
Failed to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Failed to provide emergency lighting for the generator transfer switch.SS=F
Failed to complete smoke detection sensitivity test for all photo electric smoke detectors in the past two years.SS=F
Failed to ensure two sunrooms were protected with automatic sprinkler systems.SS=E
Failed to inspect and test the 10,000 gallon exterior sprinkler water tank in accordance with NFPA 25.SS=F
Failed to ensure two corridor doors were capable of resisting the passage of smoke and one door lacked functional latching hardware.SS=E
Failed to ensure penetrations in smoke barriers were protected and smoke barriers were continuous from floor to ceiling.SS=E
Failed to ensure fire drills included transmission of fire alarm signal and simulation of emergency fire conditions.SS=F
Failed to ensure space heaters used in offices did not exceed temperatures of 212 degrees Fahrenheit.SS=E
Report Facts
Survey Census: 109 Sample Size: 28 Medication error rate: 7.69 Staffing Deficiencies: 13 Staffing Deficiencies: 8 Fire drills reviewed: 12 Smoke detectors: 99 Sprinkler water tank capacity: 10000 Sunroom dimensions: 33 Sunroom dimensions: 15 Sunroom dimensions: 27 Sunroom dimensions: 9 Corridor door damage: 1.25 Corridor door damage: 12 Smoke barrier gap: 6 Smoke barrier gap: 8 Smoke barrier gap: 6 Smoke barrier gap: 24 Smoke barrier gap: 36 Unsealed smoke barrier openings: 3 Fire drills missing alarm transmission: 6
Employees Mentioned
NameTitleContext
Maintenance DirectorNamed in multiple findings related to fire safety, emergency lighting, sprinkler system, smoke barriers, and space heater observations
Director of NursingNamed in findings related to medication availability, pain management, and space heater policy
Licensed Practical Nurse 2LPNNamed in medication administration and pain management findings
Licensed Practical Nurse 5LPNNamed in medication administration findings
Inspection Report Routine Census: 110 Deficiencies: 0 Jul 7, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Inspection Report Routine Census: 109 Deficiencies: 0 Aug 19, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report Routine Census: 94 Deficiencies: 3 Mar 8, 2021
Visit Reason
Routine standard survey conducted on 3/8/21 to assess compliance with 42 CFR Part 483, Subpart B for long term care facilities.
Findings
The facility was found not in substantial compliance due to deficiencies in medication labeling and storage, food safety and sanitation practices, and infection prevention and control, including improper hand hygiene by nursing staff.
Severity Breakdown
SS=D: 3
Deficiencies (3)
DescriptionSeverity
Failure to date eye drop bottles when opened and improper storage of medications in the medication refrigerator.SS=D
Failure to sanitize and air dry steam table pans properly and maintain a sanitary kitchen environment.SS=D
Failure to establish and maintain an infection prevention and control program including improper hand hygiene by nursing staff.SS=D
Report Facts
Sample Size: 21 Deficiency Correction Completion Date: Mar 19, 2021 Deficiency Correction Completion Date: Apr 6, 2021
Employees Mentioned
NameTitleContext
Licensed Practical Nurse Unit Manager (LPNUM)Present during medication cart and refrigerator inspection; involved in medication labeling deficiency.
Food Service Director (FSD)Present during kitchen inspection; involved in food safety deficiency.
AdministratorInterviewed regarding medication labeling and food safety concerns.
Director of NursingProvided in-service training and corrective action plans related to medication labeling, hand hygiene, and infection control.
MDS CoordinatorInterviewed regarding hand hygiene policy and competencies.
Inspection Report Abbreviated Survey Census: 96 Deficiencies: 2 Feb 3, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found not in compliance with 42 CFR §483.80 infection control regulations, specifically failing to ensure adequate screening of staff and visitors and appropriate infection control practices during rapid COVID-19 testing, including improper use of personal protective equipment and lack of disinfection procedures.
Severity Breakdown
SS=D: 2
Deficiencies (2)
DescriptionSeverity
Failure to adequately and thoroughly screen staff and visitors/vendors prior to entrance to the facility.SS=D
Failure to follow appropriate infection control practices during rapid COVID-19 testing, including not wearing gowns or gloves, not disinfecting the testing table, and lack of a facility policy and procedure for rapid COVID-19 testing.SS=D
Report Facts
Census: 96 Sample size: 5
Employees Mentioned
NameTitleContext
Licensed Practical Nurse (LPN)Conducted rapid COVID-19 testing observed not following proper infection control protocols.
AdministratorAcknowledged deficiencies in screening questionnaire and could not explain improper PPE use during testing.
Director of NursingDirector of NursingProvided counseling and re-in-service to LPN on proper rapid test protocol.

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