Crystal Lake Healthcare And Rehabilitation

Based on interviews, record review, and review of facility documents, it was determined that the facility failed to act upon the recommendations made by the Consultant Pharmacist in a timely manner. This deficient practice was identified for 1 of 35 residents (Resident #135) reviewed for medications and was evidenced by the following:On 1/16/26 at 12:52 PM, the surveyor observed Resident #135 ambulating independently in the hallway without an assistive device. At that time, the surveyor attempted to interview the resident who appeared to be confused and was unable to answer the surveyor's questions appropriately. On 1/20/26 at 11:54 AM, the surveyor reviewed the medical record for Resident #135. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: morbid (severe) obesity due to excess calories, schizophrenia, unspecified (a serious mental health condition), anxiety disorder, unspecified, depression, Acute and Chronic Respiratory Failure, Unspecified whether with Hypoxia (deficiency in the amount of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to properly store and secure medication left at a resident's bedside (Resident #13). This deficient practice was identified on 1 of 5 nursing units (5th Floor) and was evidenced by the following:On 1/20/26 at 10:36 AM, the surveyor in the presence of another surveyor, observed Resident #13 lying in bed, with their eyes closed, fully dressed with a blanket over their legs. On the bedside table there was a clear plastic cup containing a clear liquid and a plastic medicine cup with two round pills, one pink-colored pill, and one slightly smaller light orange pill. The resident had their privacy curtain pulled to the side of their footboard on the bed, inhibiting access to the nightstand. The resident did not respond to surveyor inquiry.At that time, the surveyor did not observe any residents ambulating independently near the resident's room without staff present.On 1/20/26 at 10:37 AM, surveyor #2 went to find the nurse and the Certified Nursing Aide (CNA)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to properly dispose of garbage and refuse in one of one garbage disposal areas.This deficient practice was evidenced by:On 1/15/26 at 10:25 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the facility's garbage disposal area. The surveyor observed container tops, food waste, plastic utensils, pieces of wood and cardboard boxes, as well as used gloves and face masks discarded on the ground adjacent to the garbage disposal containers. The surveyor also observed low-lying black tubing and additional black tubing running along the ground in the garbage disposal area. During the tour, the surveyor interviewed the FSD regarding the facility's garbage disposal practices and the presence of black tubing in the garbage disposal area. The FSD stated that maintenance of the facility's garbage disposal areas was a shared responsibility between the dietary and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the required members were present during the quarterly Quality Assurance and Performance Improvement (QAPI) Committee Meetings. This deficient practice occurred during 2 of 4 meetings reviewed and was evidenced by the following:On 1/15/26 at 11:39 AM, the surveyor requested to view the last four quarters of the QAPI meeting sign-in sheets.On 1/20/26 at 10:13 AM, the surveyor was provided with the QAPI Committee Quarterly Meeting Sign-In Sheets that were dated 1/23/25, 4/24/25, July 2025, and October 2025. A review of the 4/24/25 Sign-In Sheet revealed that LOA (Leave of Absence) was documented in the signature panel of a mandatory participant, the Infection Control Preventionist (ICP). Further review of the July 2025 QAPI Meeting Sign-In Sheet revealed that the signature panel that was allotted for the ICP's signature was not filled in with any data to indicate the status of the ICP's attendance at the quarterly QAPI Meeting.On 1/23/2026 at 3:04…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the arbitration agreement and admission agreement specifically provides for the selection of a venue that is convenient to both parties, specifically by stating in the admission Agreement a specific location where binding arbitration will be settled. This deficient practice was identified for all residents in the facility. The deficient practice was evidenced by the following: Review of a copy of the facility's undated admission Agreement revealed in section 9. Miscellaneous Category G, Disputes, Any controversy, dispute or disagreement arising out of or in connection with this Agreement, the breach thereof, or the subject matter thereof including Facility's obligation thereof shall be settled by binding arbitration, which shall be conducted in Jersey City, New Jersey in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Arbitration, and which to the extent of the subject matter of the arbitration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to complete the Comprehensive Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 23 of 59 residents (Residents #2, #108, #69, #125, #90, #57, #111, #100, #60, #21, #165, #177, #136, #134, #132, #172, #83, #104, #174, #96 ,#54, and #19) reviewed for Resident Assessment and was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. At a minimum, facilities are required to complete a comprehensive assessment for each resident within 14 calendar days after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to complete the Quarterly Minimum Data Set (QMDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 54 of 59 residents (Residents # 129,#51, #42, #8, #2, #108, #69, #5, #1, #125, #58, #48, #111, #100, #3, #60, #21, #159, #46, #169, #75, #138, #71, #165, #107, #177, #67, #181, #176, #136, #147, #74, #134, #132, #126, #172, #18, #23, #83, #38, #104, #13, #96, #54, #78, #19, #105, #155, #116, #182, #135, #99, #39, and #52) reviewed for Resident Assessment and was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined the facility failed to complete and transmit a Minimum Data Set death in facility tracking record in accordance with federal guidelines and that the facility failed to transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 5 of 59 residents reviewed for resident assessment (Resident #34, #129, #58, #26 and #48 ). This deficient practice was evidenced by: The MDS is a comprehensive federal mandated process for clinical assessment of all residents that should be completed and submitted to the Quality Measure System. The facility must electronically transmit the MDS no later than 14 days after the assessment being completed. After transmission of the MDS, it will generate a quality measure to enable a facility to monitor the residents decline and progress. The following residents were identified that the MDSs were not transmitted timely: 1. Resident #34: the resident expired on [DATE]. There was no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner designed to prevent food borne illness. This deficient practice was evidenced by the following: On 04/30/2025 from 09:33 to 9:58 AM the surveyor, accompanied the by the facility Registered Dietitian Nutritionist (RDN), observed the following in the kitchen: 1. In the dry storage room, a can of pear halves on 1of 4 mobile, multi-tiered storage racks had a significant dent on the bottom seam of the can. The RDN removed the dented can to the designated dented can area and told the surveyor that he noticed the dent. 2. On an upper shelf of a multi-tiered storage shelf, two (2) previously opened packages of dry pasta had no open or use by dates. The RDN removed the opened bags of dry pasta to the trash. The pasta consisted of fine noodles and rigatoni noodles. When asked what the facility practice was for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to a.) ensure the infection control practices for residents on enhanced barrier precautions (EBP) were implemented in accordance with facility policy and accepted national standards, b.) follow appropriate hand hygiene practices during wound treatment, and c.) follow appropriate hand hygiene practices during incontinence rounds to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice. This deficient practice was identified in 2 of 4 resident's reviewed for transmission-based precautions (Resident's #30 and #88), 1 of 1 resident (Resident #30) observed for wound treatment, and 10 of 10 residents (Resident #30, #40, #48, #52, #81, #132, #167, #169, #187, and #187) observed during incontinence rounds. The deficient practice was evidenced by the following: Reference: Hand hygiene should be performed immediately before touching a patient; before…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY F548 Based on observation, interview and review of other facility documentation, it was determined that the facility failed to ensure residents received a homelike environment during dining by removing the food from the tray and providing tablecloths. This deficient practice was identified for 1 of 6 dining rooms, the main dining room, and was evidenced by the following: 1. On 05/01/2025 at 11:50 AM during the lunch meal in the main dining room [ROOM NUMBER] residents were in attendance by surveyor count. 30 dining tables were available by surveyor count and numbered table cards. 30 tables were observed without tablecloths. The first lunch meal tray was delivered at 12:01 PM. Staff brought the meal tray into the dining room and placed the tray on the table in front of the resident. Staff removed the top pellet and then proceeded to exit the dining room. Staff proceeded to distribute resident lunch meal trays from a meal cart to residents in attendance for the lunch meal. 43 of 43 residents in attendance at the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to develop and implement a baseline care plan (BCP) within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident. This deficient practice was identified for 3 of 35 sampled residents (Resident #185, Resident #187 and #293) and was evidenced by the following: 1.)1. According to the admission record, Resident #185 was admitted to the facility in January 2025 with the following but not limited to diagnoses: paranoid schizophrenia, diabetes mellitus and heart failure. A review of the [facility name] Baseline Care Plan - V 2 revealed that there were five (5) sections to the baseline care plan and were as follows: 1. General Information and Initial Goals 2. Functional Status 3. Health Conditions 4. Dietary, Therapy and Social Services 5. BCP Summary and Signatures A review of Resident #185's base line care plan revealed that Section 1, Section…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, review of the medical record, and other facility documentation, it was determined that the facility failed to ensure that a resident who was identified as having a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity or rigidity of joints) received services to prevent further decreased range of motion (ROM) after discharge from therapy. This deficient practice was identified for 1 of 2 residents reviewed for limited ROM, (Resident #33) and was evidenced by the following: On 4/30/2025 at 9:49 AM, during the initial tour of the facility, the surveyor observed Resident #33 sitting in the wheelchair in the hallway. The resident's left thumb and 4th finger were noted curled inward towards the palm. When the resident was asked if they could extend their left fingers, the resident stated that they could not and that their fingers were stiff. The fingernails on both hands were trimmed and buffed. There was no skin opening on the left palm. The resident was not wearing any brace or splint. There…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident received appropriate care and sufficient services based upon current standards of practice for a urinary catheter. The deficient practice was identified for 1 of 2 residents (Resident # 118) investigated under the Urinary Catheter investigation. This deficient practice was evidenced by the following: On 04/30/2025 at 09:48 AM, during the initial tour of the facility, the surveyor observed Resident # 118 in bed in their room. At that time, the resident told the survey that his urinary catheter was connected to a leg bag. A review of Resident # 118's Electronic Medical Record (EMR) revealed under, Orders that there was a Physician's Order that indicated, Monitor urine output. The order was started on 01/31/2025. There were no other orders related to a urinary catheter. A review of Resident # 118's Minimum Data Set (MDS) dated [DATE] revealed in section H…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to a.) obtain a physician order for the use of oxygen b.) obtain a physician order for the use of a suction catheter (a flexible plastic tube used to remove fluid from the airway). This deficient practice was identified for 2 of 2 residents reviewed for respiratory care (Resident #185 and Resident #68) and was evidenced by the following: During the initial tour of the facility on 4/30/2025 at 10:45 AM, the Surveyor #1 observed Resident # 185 in the dayroom receiving oxygen via nasal cannula (a device used to deliver supplemental oxygen). On 5/1/2025 at 11:36 AM, the surveyor observed the resident in the dayroom receiving oxygen via nasal cannula. On 5/5/2025 at 1:58 PM, the surveyor observed the resident in the dayroom receiving oxygen via nasal cannula. The surveyor reviewed the medical record for Resident #185. A review of the admission Record reflected Resident #185 was admitted to the facility with diagnoses which included but were notlimited…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, it was determined that the facility failed to effectively accommodate the needs and preferences of residents during dining. This deficient practice was identified for 2 residents (Residents #14 and #85) on 1 of 6 dining rooms, who were included in the review of the dining observation and was evidenced by the following: 1. On 05/01/2025 at 12:12 PM the surveyor observed Resident #85 seated alone in the main dining room eating the lunch meal. The lunch meal consisted of baked ziti, green beans, and garlic bread. Resident #85 consumed 100%of baked ziti and garlic bread. Resident #85 did not eat the green beans received. Resident #85 stated to the surveyor that the lunch was excellent. The surveyor asked Resident #85 why he/she did not eat their green beans and Resident #85 responded that he/she did not like green beans. Observation of Resident #85's meal ticket for the lunch meal on Thursday 05/01/25 revealed the following DISLIKES: Green Beans Resident #85 was provided green beans at the lunch meal when his/her meal ticket clearly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Complaint #: NJ185153 Based on interviews and review of other pertinent facility documentation on 4/23/25, it was determined that the facility failed to maintain documentation and demonstrate evidence of its Quality Assurance and Performance Improvement (QAPI) program. On 4/23/25 at 10:47 AM, the surveyor requested the facility's QAPI plan and most recent meeting minutes from the Licensed Nursing Home Administrator (LNHA). On 4/23/25 at 11:05 AM, the surveyor interviewed the LNHA who stated she was unable to retrieve the QAPI plan and meeting minutes due to not having internet access. The LNHA stated she kept the QAPI plan and meeting minutes on her computer. She further stated she would try to email the surveyor the QAPI plan and meeting minutes. On 4/23/25 at 12:06 PM, the surveyor conducted a follow up interview with the LNHA who stated No, I am unable to print my QAPI meeting minutes. Since we don't have internet, I am unable to access it. The LNHA further indicated that the QAPI should have been readily accessible to the surveyors when requested. A review of the facility's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Complaint #: NJ182091 Based on interviews and review of other pertinent facility documentation on 4/10/25, it was determined that the facility failed to ensure that a staff member assigned the position of Monitor was not performing direct resident care. This deficient practice was identified for 1 of 3 monitors reviewed and was evidenced by the following: According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with an event date of 1/1/25 revealed the Physical Therapist Aide (PTA) was approached by Resident #4 who stated the aide hit Resident #3. The PTA went to the residents' room, where the aide (Monitor #1) was performing Activities of Daily Living (ADLS) with Resident #3. According to the admission Record (AR), Resident #3 was admitted to the facility in July 2024 with diagnoses which included but were not limited to: dementia, schizoaffective disorder, and major depressive disorder. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 10/25/24, Resident #3 had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ181767, NJ181768, NJ181846 Based on observations, interviews, and review of facility documentation, it was determined that the facility failed to ensure a resident's right to privacy and confidentiality were not violated when a video of a resident (Resident #1) being hit with a broom by the Director of Nursing (DON) was recorded by a staff member and sent to their friend who posted the video on a social media website. This deficient practice was identified for 1 of 1 resident (Resident #1) who was reviewed for privacy and confidentiality and was evidenced by the following: According to the admission Record (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Major Depressive Disorder, Dementia, and Epilepsy (seizures). According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 11/02/2024, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ181767, NJ181768, NJ181846 Based on observations, interviews, medical record review, and review of other pertinent facility documents on 12/23/2024, it was determined that the facility failed to report an allegation of witnessed staff to resident physical and verbal abuse toward a resident (Resident #1) to the Department of Health and to the local Police Department when the incident occurred on 06/20/2023. This deficient practice was identified for 1 of 3 residents (Resident #1) who were reviewed for abuse and was evidenced by the following: The Surveyors and the Assistant Director of Nursing (ADON) reviewed a video on 12/23/2024 at 10:41 A.M. found on a social media website, that revealed a staff member hitting at a resident with a broom. Several other staff members observed the incident and did not intervene. The ADON identified the resident in the video as Resident #1. The ADON identified the staff member holding the broom throughout the video as the DON. The DON was heard asking the staff that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ178766, NJ178770 Based on interviews, medical record review, and review of other pertinent facility documents on 10/22/2024, 10/23/2024, and 10/24/2024, it was determined that the facility failed to update the care plan (CP) with interventions for 2 of 7 residents (Resident #3 & #4) for making an abuse allegation about staff to the local authorities. The facility also failed to follow its policy titled Care Plan. This deficient practice was evidenced by: According to the Facility Reportable Events (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents dated 10/18/2024, with an event date of 10/17/2024 and a time of event of 12:30 P.M., pertaining to Resident #3: Local authorities came to the facility stating they were investigating an anonymous call stating, the resident was being abused by staff. An investigation was immediately started in the presence of the local authorities. A body check was completed with the local authorities present in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Complaint #: NJ172203 Based on interviews, record review, and facility policy review, the facility failed to honor the rights to have in their possession a personal cell phone for 1 (Resident #1) of 3 sampled residents reviewed for resident rights. Findings included: The facility policy titled, Personal Property, revised in September 2012, revealed Residents are permitted to retain and use personal possessions and appropriate clothing, as space permits. A review of Resident #1's admission Record revealed the facility admitted the resident on 02/09/2024 with diagnoses that included heart failure, hyperlipidemia, and depression. A review of Resident #1's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/16/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. A review of Resident#1's care plan, initiated on 02/22/2024, revealed the resident had a potential for alteration in psychosocial well-being due to the resident called 911 instead of a nurse for chest…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure allegations of physical and sexual abuse and injury of unknown origin were reported to the State Survey Agency (SSA) timely for three of seven residents (Resident (R)191, R79 and R116) reviewed for physical and sexual abuse and one of one resident (R79) reviewed for injury of unknown origin. Findings include: 1. Review of R168's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including restlessness and agitation, schizoaffective disorder, bipolar disorder, schizophrenia, anxiety disorder and dementia with behavioral disturbance. Review of R191's admission Record, located in the Profile tab of the EMR revealed she was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnosis including schizophrenia. Review of a Nurse's Note in the EMR under the Notes tab written by Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure resident-to- resident abuse and injury of unknown origin were investigated thoroughly for two of seven residents reviewed for resident-to-resident abuse (Resident (R)191 and R79) and for one of one injury of unknown origin (R79). Findings include: 1. Review of R168's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including cerebral infarction, restlessness and agitation, schizoaffective disorder, bipolar disorder, schizophrenia, anxiety disorder and dementia with behavioral disturbance. Review of R191's admission Record, located in the Profile tab of the EMR revealed she was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnosis of schizophrenia. Review of the facility's Reportable Event provided by Director of Nursing (DON) revealed the incident occurred on 05/05/23 at 8:49…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete the quarterly Minimum Data Set (MDS) assessment in a timely manner for 14 of 35 sampled residents (Resident (R) 11, R12, R24, R38, R47, R53, R76, R80, R85, R99, R116, R145, R157 and R171). Findings include: Review of the CMS's RAI 3.0 User's Manual Version 1.18.11, dated 10/01/23, revealed . Chapter 2: Assessment for the RAI . 05. Quarterly Assessment (A0310A = 02) The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The ARD (A2300) must be not more than 92 days after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and policy review, the facility failed to provide care and services in a manner that maintained and promoted dignity for two of three sampled residents (Resident (R157 and R88) reviewed for dignity in a sample of 35 residents. Specifically, staff stood while assisting residents with their meals. This failure placed residents at risk for diminished self-worth, self-esteem, and feelings of embarrassment. Findings include: 1 Review of R88's admission Record found in the electronic medical record (EMR) under the Profile tab documented R88 was admitted to the facility on [DATE] and had diagnoses that included adjustment disorder and major depression. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/06/23 documented R88 had a Brief Interview of Mental Status (BIMS) score of five out of 15 indicating severe cognitive impairment and required maximal assistance with eating. Review of the Care Plan found in the EMR under the Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, document review and policy review, the facility failed to ensure one resident (Resident (R) 46) of 35 sampled residents were maintained in a manner to ensure resident privacy, in that the computer screen on the medication cart was left open revealing R46's medications. This failure placed residents at risk of loss of the right to personal privacy and confidentiality of medical information. Findings include: Review of R46's admission Record located in the Electronic Medical Record (EMR) under the Profile tab documented R46 was admitted to the facility on [DATE]. During an observation on 02/04/24, at 3:55 PM, the computer screen was on the top of the fourth-floor medication cart left open and was displaying R46's medications. The cart was locked and there were no staff member at the medication cart. During an interview on 02/05/24 at 3:58 PM, Licensed Practical Nurse (LPN) 3 acknowledged the computer screen had displayed R46's name and medications while she was away…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review, the facility failed to ensure that a new Preadmission Screening and Resident Review (PASARR) Level I assessment was submitted after a new mental illness diagnosis for one (Resident (R)168) out of 3 residents reviewed for PASARR. Findings include: Review of R168's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including cerebral infarction, restlessness and agitation, schizoaffective disorder, bipolar disorder, schizophrenia, anxiety disorder and dementia with behavioral disturbance. Review of R168's quarterly Minimum Data Set (MDS) assessment under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 12/10/23 and the Brief Interview for Mental Status (BIMS), score of three out of 15 which indicated severe cognitive impairment. Review of R168's Initial Assessment PASARR located under the Resident Documents tab…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure medical records included accurate advance directives for one (Resident (R) R88) of three residents reviewed for advance directives, of a total sample of 35 residents. Findings include: Review of the admission Record found in the Electronic Medical Record (EMR) under the Profile tab documented R88 was admitted to the facility on [DATE] and had diagnoses that included adjustment disorder and major depression. Review of the quarterly Minimum Data Set (MDS) assessment found in the EMR under the MDS tab with an Assessment Reference Date (ARD) of [DATE] documented R88 had a Brief Interview of Mental Status (BIMS) score of five out of 15, indicating severe cognitive impairment. Review of R88's Physician Order for Sustaining Treatment (POLST) located in the EMR under the Miscellaneous tab dated [DATE] revealed, Attempt resuscitation/CPR .Do not intubate . Review of the Physician Orders located in the EMR under the Orders tab revealed R88…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to maintain the cleanliness of the oxygen concentrators for two out of two residents (Resident (R) 38 and R12) of 35 sample residents. Findings include: 1. Observation on 02/05/24 at 12:05 PM, revealed R38's oxygen concentrators was dirty with debris. Review of R38's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted to on 11/19/22 with diagnosis of pneumonia. Review of the Physician Orders under the Orders tab of the EMR revealed the resident had an order dated 03/23/23 for Oxygen via nasal cannula @ [at] 4 L/min [liters per minute] continuously every shift for SOB [shortness of breath]. 2. Observation on 02/06/24 at 12:18 PM revealed R12's oxygen concentrator filter and machine were dirty with debris. Further observation on 02/08/24 at 9:41 AM, the outside of R12's oxygen concentrator machine was dirty with debris. Record review of the admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to attempt to use appropriate alternatives prior to installing a side rail and failed to complete quarterly assessments for the continued use and safety of the side rail for one of one resident reviewed for side rails out of 35 sampled residents (Resident (R) 80). Findings include: Review of the facility's policy titled Side Rails, revised 10/01/17, revealed Purpose To determine the appropriateness of bed rail use for individual residents. Procedure I. The Assessment of whether to use bed rails should include an evaluation of the alternatives to the use of bed rail that were attempted and how these alternatives failed to meet the resident's assessed needs. II. If side rails are to be used, the assessment form, Side Rail Utilization Assessment, by a licensed nurse and/or the IDT . i. Before installing a side rail, the Facility must: a. Assess the risk resident for risk of entrapment from side rails; and b. Ensure the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, policy review and manufacturer's guidelines review, the facility failed to prevent the potential spread of infection and cross-contamination between residents in that the nurses did not disinfected the glucometer after completing R76's accu chek per the facility's policy prior to storage of the glucometer and the nurse failed to sanitize the top of the medication cart and residents' beside table after placing the unclean glucometer directly on the two surfaces for two residents (Resident (R) 76 and R4) of three residents in the sample of 35. In addition, one of one Certified Nursing Assistant (CNA10) staff failed to sanitize their hands between direct contact with residents, R22 and R88. Findings include: 1 Review of R76's admission Record found in the Electronic Medical Record (EMR) under the Profile tab documented R76 was admitted to the facility on [DATE] and had a diagnosis of type 2 Diabetes Mellitus. During an observation on 02/05/23 at 4:08 PM, Licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ 151371 Based on interview, record review, and policy review, the facility failed to notify one (Resident (R) 12)'s representative, out of a survey sample of 17, when the resident sustained a change in her condition and had to be transported to a local hospital. Findings include: Review of a policy provided by the facility titled Notification of Change of Condition: Responsible Party/Guardian, dated 09/21/21 indicated .The responsible party or guardian is to be notified of changes in condition or occurrences to ensure that the resident's responsible party or guardian is notified of changes and/or occurrences and action and pertinent information are documented. When any one of the following instances occurs, the resident's responsible party or guardian will be notified.There is a significant change in the resident's physical, mental or psychosocial status, weight loss. Review of R12's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one (Resident (R) 17) out of 17 sampled residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the resident. Findings include: Review R17's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R17's EMR titled annual MDS with an Assessment Reference Date (ARD) of 04/08/23 indicated the resident had a Brief Interview for Mental Status (BIMS score of three out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident had no obvious broken teeth. During an interview on 08/16/23 at 1:44 PM, R17 stated he lost weight and when asked about dental care the resident opened his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ 155008 Based on interviews, record reviews, and facility policy review, the facility failed to ensure that narcotic pain medication was ordered and available in a timely manner for one resident (Resident (R) 7) out of 17 sampled residents. Findings include: Review of the facility policy titled, 4.0 Schedule II Controlled Substance Medication, revised 09/2020 stated, . B. If a medication shortage is noted during normal pharmacy hours: a. A licensed nurse notifies the pharmacy and speaks to a registered pharmacist to determine the status of the order. If not ordered, place the order or re-order to be sent with the next scheduled delivery. 2. If the next available delivery results in a delay or missed dose in the customer's medication schedule . If ordered medication is not available in the emergency stock supply, notify the pharmacist that an emergency delivery is requested .C. If a medication shortage is noted after normal pharmacy hours: . 2. If the ordered medication is unavailable in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ 155008 Based on record review, interviews, and policy review, the facility failed to ensure that clinical records related to the administration of narcotic medication was complete and contained accurate documentation for one resident (Resident (R) 7) out of 17 sampled residents. Findings include: Review of the facility policy titled, 4.0 Schedule II Controlled Substance Medication, revised 09/2020 stated, . 3. A declining inventory sheet will be provided with each dispensed prescription for controlled dangerous medications. The form will contain the following information: customer name, medication name, medication strength, dosage form, name of prescribing physician, amount dispensed, prescription number and date dispensed .5. When a CDS (controlled dangerous substance) is administered, in addition to following proper procedure for the charting of medications, the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.