NEW MILFORD, NJ - A federal inspection of Care One At New Milford nursing home uncovered serious safety violations, including a cognitively impaired resident who walked out of the facility undetected and was found at their former home four miles away. The March 2025 survey also documented failures in wound care management, medication administration, and basic physician oversight that placed residents at risk.
Resident With Dementia Walks Out Undetected
The most serious violation involved a resident with documented dementia and a known history of elopement who left the facility on July 29, 2023, without staff knowledge. The resident, who had severe cognitive impairment with a Brief Interview for Mental Status score of 7 out of 15, was last seen at 5:30 PM in the television room.
When staff couldn't locate the resident at 6:00 PM, they initiated a facility-wide search and contacted local police. The resident was eventually discovered at their previous home address approximately four miles from the nursing home after police conducted a wellness check. The resident returned to the facility at 9:40 PM, reporting back pain from the incident.
Hospital records from the resident's admission clearly documented a history of elopement requiring staff supervision. Despite this critical information, the facility's elopement risk assessment completed on July 14, 2023, incorrectly determined the resident was not at risk. Investigation revealed a nurse had initially assessed the resident as being at elopement risk but then edited the assessment to change it to "not at risk."
The third-floor unit where the resident lived had minimal security measures at the time. While there was a wanderguard alarm system for the elevator, the unit lacked electromagnetic locks on the double doors. After reviewing available camera footage from the lobby, back exit, and first-floor stairway, facility staff could not determine how the resident exited the building.
This incident created an immediate jeopardy situation - a finding reserved for violations that pose likelihood of serious harm or death. Federal surveyors determined the facility failed to provide adequate supervision for a cognitively impaired resident with documented elopement history.
Critical Wound Care Failures
Inspectors identified multiple failures in pressure ulcer prevention and treatment that compromised resident safety. In one case, a resident developed pressure ulcers on both heels that weren't properly investigated or treated with appropriate preventive measures.
The resident developed the wounds on January 13, 2025, but no incident report was filed until January 16 when the wound consultant physician examined them. During those three critical days, no additional interventions were implemented to prevent further skin breakdown. The care plan wasn't updated with new preventive measures until January 27 - two weeks after the wounds first appeared.
When wounds develop in nursing homes, immediate action is essential. Pressure redistributing surfaces, heel elevation devices, and frequent repositioning should be implemented immediately, not weeks later. Every day of delayed intervention increases the risk of wound progression and complications.
The facility also failed to follow wound consultant recommendations. When the specialist ordered specific dressing changes twice weekly with foam dressings, staff instead applied treatments once daily - a completely different frequency than prescribed. When the consultant later changed orders to twice-daily skin prep application, staff continued applying it only once per day.
Another resident with a sacral pressure ulcer received multiple conflicting wound treatments simultaneously. Electronic records showed nurses signed off on administering two or three different topical medications to the same wound on the same days, without any clarification about which treatment was actually being used or whether they were meant to be combined.
Medication Administration Violations
The inspection revealed systemic problems with medication availability and administration. Multiple residents went without prescribed medications for days at a time, with no physician notification or alternative arrangements made.
One resident on dialysis repeatedly missed critical medications because administration times weren't adjusted for dialysis days. The resident left for treatment at 11:00 AM and returned around 5:00 PM, but medications remained scheduled for noon when the resident was absent. This included Midodrine for low blood pressure and Velphoro, a phosphorus binder that must be taken with meals.
Insulin administration and blood sugar monitoring were also scheduled during dialysis absence. Missing these medications can cause dangerous blood pressure fluctuations, elevated phosphorus levels leading to bone and cardiovascular complications, and uncontrolled blood sugar levels.
Another resident went without Risperidone, an antipsychotic medication, for five consecutive days in February 2025. Electronic records showed blank entries from February 18-22 with no documentation explaining the omission or physician notification about the missing doses. Abrupt discontinuation of antipsychotic medications can trigger withdrawal symptoms, behavior changes, and symptom recurrence.
A resident with glaucoma didn't receive prescribed eye drops for four days. While one notation indicated the physician was notified on day one, no further physician contact was documented for the remaining days. Untreated glaucoma can lead to permanent vision loss, making timely medication administration critical.
Physician Oversight Failures
Federal regulations require physicians to personally review each resident's care monthly, document their assessments, and respond to significant changes in condition. At Care One At New Milford, inspection findings revealed physicians weren't meeting these basic requirements.
One resident's physician hadn't documented any progress notes between February 2024 and the March 2025 inspection - over a year without required documentation. When notes finally appeared in the medical record, many were created months after the purported visit dates. Multiple entries dated August through January weren't actually written until February 2025.
These backdated notes contained concerning patterns. Six consecutive monthly notes all contained identical language about changing Seroquel to Trazodone and contacting psychiatry - suggesting copy-paste documentation rather than actual monthly assessments. The resident had experienced two falls, including one that resulted in blood pressure of 205/125, yet physician notes showed no evidence these incidents were ever assessed.
Additional Issues Identified
Beyond these major violations, surveyors documented numerous other deficiencies affecting resident care and safety. Staff failed to properly document and investigate falls, omitting required pain and fall risk evaluations after incidents. Care plans weren't updated when residents' conditions changed, leaving staff without current guidance for providing appropriate assistance.
The facility demonstrated inadequate monitoring of psychoactive medications. Required behavioral assessments weren't completed regularly, making it impossible to determine if medications were effective or necessary. Monthly nursing summaries meant to evaluate psychotropic medication effectiveness were completed sporadically - some residents had gaps of several months without required reviews.
Infection control practices were also problematic. A nurse was observed washing hands by scrubbing them under running water rather than following proper technique. The same nurse used contaminated gloves to check blood pressure after disinfecting equipment, then prepared medications without performing hand hygiene.
Basic security measures were lacking. Surveyors found an unlocked, unattended medication cart on a nursing unit - a serious breach that could allow unauthorized access to controlled substances and other medications.
The facility also failed to report the elopement incident to state authorities within the required two-hour timeframe. While the incident occurred on July 29, 2023, at 5:30 PM, the state wasn't notified until July 31 at 11:05 AM - over 40 hours later. Documentation showed police, not facility staff, notified the Ombudsman's office about the elopement.
These violations represent fundamental failures in nursing home care. Proper wound care protocols exist to prevent minor skin issues from becoming serious infections. Medication management systems are designed to ensure residents receive prescribed treatments consistently. Physician oversight requirements ensure medical conditions are properly monitored and treated.
When these systems break down, residents face unnecessary suffering and preventable complications. The patterns documented at Care One At New Milford suggest systemic problems requiring comprehensive corrective action to ensure resident safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Care One At New Milford from 2025-03-06 including all violations, facility responses, and corrective action plans.
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