A list of the most recent deficiencies for Complete Care at Milford Manor LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2024-01-05 | 2024-01-26 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-02-18 | 2023-04-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-18 | 2023-04-19 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-02-18 | 2023-03-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-18 | 2023-03-31 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-02-18 | 2023-03-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-18 | 2023-03-31 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-18 | 2023-03-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-18 | 2023-03-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-18 | 2023-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-18 | 2023-03-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-18 | 2023-03-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-18 | 2023-03-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-18 | 2023-03-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-18 | 2023-03-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-18 | 2023-03-31 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-02-18 | 2023-03-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-08 | 2021-04-06 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-03-08 | 2021-03-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-08 | 2021-03-19 | N |
