Little Brook Nursing And Convalescent Home

Based on observation, interview, and record review, it was determined that the facility failed to notify the resident's representative and the Office of the Ombudsman in writing for an emergency transfer to the hospital. This deficient practice was identified for 1 of 1 resident, Resident #9, reviewed for hospitalization. On 10/23/24 at 9:28 AM, the surveyor reviewed the electronic medical record for Resident #9. A review of the physician's progress note dated 4/20/24, revealed that the resident had a recent hospitalization. A review of the Discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 4/15/24, reflected that Resident #9 was discharged to the hospital with a return anticipated to the facility. On 10/23/24 at 12:06 PM, the surveyor interviewed the Director of Nursing (DON), who stated she reviewed the book of letters which contained a report to the Office of the Ombudsman and to the residents' representatives but was unable to find them. The DON further stated that in May 2024, she started to do the notification because there had…

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 record review, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) to reflect the resident status in accordance with federal guidelines. This deficient practice was identified for 1 of 12 residents (Resident #7) reviewed. The deficient practice was evidenced by the following: The MDS is a comprehensive tool that is federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. 1. On 10/23/24 at 10:10 AM, the surveyor observed Resident #7 seated in the wheelchair inside the room, watching television. The resident was able to answer the surveyor's inquiry. On 10/24/24 at 11:15 AM, the surveyor reviewed the hybrid (paper and electronic) medical record (HMR) of Resident #7, which revealed the following: A review of the admission Record (AR) (an admission summary) reflected that Resident #7 was admitted to the facility with diagnoses that included, but were not limited…

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 ensure residents with significant weight changes (a weight change of 5% in 30 days and/or 10% in 180 days) were addressed by the Registered Dietitian (RD) in a timely fashion. This deficient practice was identified for 2 of 2 residents reviewed for significant weights changes (Resident #3 and #14), and was evidenced by the following: 1. On 10/22/24 at 10:30 AM, the surveyor observed Resident #3 seated in their wheelchair on the outside deck of the facility. Resident #3 stated they had weight gains and losses but was not sure of their current weight. A review of Resident #3' admission Record (AR) (admission summary) revealed that the resident was admitted to the facility with diagnosis that included but were not limited to paranoid schizophrenia, gastro-esophageal reflux disease, and muscle wasting and atrophy. A review of the Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate the management of care, dated 9/15/24 reflected a Brief Interview for Mental Status (BIMS)…

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 follow acceptable standards of clinical practice for accurately administering medications according to the physician's order (PO). This deficient practice was identified in 1 (one) of 12 (twelve) residents (Resident #20) observed during the medication observation pass. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice…

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 record review, it was determined that the facility failed to properly label, store, and dispose medications in one (1) of two (2) medication carts inspected. This deficient practice was evidenced by the following: On [DATE] at 11:35 AM, the surveyor inspected medication cart #1 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened vial of Fiasp insulin with an opened date of [DATE] and was expired. The surveyor also observed two opened bottles of Pro-Stat AWC (protein supplement), one bottle had an opened date of [DATE] and a second bottle with an opened date of [DATE]. Both bottles of Pro-Stat AWC were expired. At that time, the surveyor interviewed LPN#1 who acknowledged that both the Fiasp insulin vial and the two bottles of Pro-Stat AWC were expired and should have been removed from the medication cart. A review of the manufacturer's specifications for the following medications revealed that the Fiasp insulin had an expiration date of 28…

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 facility policy, it was determined that the facility staff failed to ensure a resident received liquids in the appropriate consistency at meals in accordance with physician orders for 1 of 1 resident (Resident #1). This deficient practice was evidenced by the following: On 12/26/24 at 11:37 AM, during the kitchen inspection, the surveyor observed Resident #1's lunch tray with tray card listing the resident's diet, diet consistency and liquid consistency. The surveyor further observed Resident #1's tray card which revealed the current diet order was Regular diet, mechanical soft consistency (mechanical soft diet consists of any foods that can be blended, mashed, pureed, or chopped using a kitchen tool such as a knife, a grinder, a blender, or a food processor) and nectar thick liquids (nectar thick liquids are thicker than water, fall slowly from a spoon, and are sipped through a straw or from a cup). The surveyor observed a cup with a clear liquid labeled nectar on Resident #1's tray. A review of the Resident Face Sheet…

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, it was determined that the facility failed to maintain complete and readily accessible medical records. This deficient practice was identified for (1) one of (5) five residents (Resident #28) reviewed for unnecessary medication. This deficient practice was evidenced by the following: On 10/23/24 at 10:15 AM, the surveyor observed Resident #28 in bed, awake, covered with a blanket, and unable to answer the surveyor's inquiry. On 10/23/24 at 11:23 AM, the surveyor reviewed the hybrid (paper and electronic) medical record of Resident #28, which revealed the following: A review of the admission Record (an admission summary) reflected that Resident #28 was admitted to the facility with diagnoses that included but were not limited to unspecified dementia (memory loss), unspecified severity, with other behavioral disturbances. A review of the recent annual Minimum Data Set (An/MDS), an assessment tool used to facilitate the management of care, dated 9/8/24, reflected that Resident #28 had a Brief Interview for Mental Status score (BIMS) score…

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 NJ#173220 Based on interview and record reviews, it was determined that the facility failed to report an allegation of Abuse/Neglect to the New Jersey Department of Health (NJ DOH) in the required timeframe for 2 of 2 sampled residents, (Residents #29 and Resident #81). This deficient practice was evidenced by the following: On 10/28/24 at 10:30 AM, the surveyor reviewed a Reportable Event Record/Report Form (RER/RF) provided by the facility. The form was dated 4/24/24 and documented an event that occurred on 4/20/24 at 3:30 PM involving Resident #81 and Resident #29. The report documented Resident #81 touched Resident #29's face and attempted to remove the resident's glasses from Resident #29's face. Resident #29 who was startled and reacted by swatting Resident #81's hand away. The facility's activity director was present during the time of the incident and was able to separate both residents and notified the nurse. Further review of the REF/RF form revealed an event date of 4/20/24 at 3:30 PM and the NJ DOH was notified by the facility via a phone call on 4/24/24 at…

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#: NJ00171484 Based on interviews, review of electronic medical records (EMR), and other pertinent facility documentation on 03/04/24, it was determined that the facility staff failed to maintain a complete and accurate medical record by having an incomplete smoking assessment for 1 of 2 residents (Resident #1) reviewed. This deficient practice was evidenced by the following: According to the admission Record, Resident #1 was admitted to the facility with diagnoses which included but were not limited to edema (swelling caused by too much fluid trapped in the body's tissues), anxiety disorder, and Type 2 Diabetes. Review of Resident #1's 10/10/23 admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care revealed, that the resident did use tobacco. Review of Resident #1's 01/07/24 Quarterly MDS revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that the resident's cognition was moderately impaired. Review of Resident #1's Smoking- Safety Screen, (Smoking Assessment), dated…

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 C #: NJ167461, NJ169331, and NJ169500 Based on interview, medical records (MR) review, and review of pertinent facility documents on 12/7/23, 12/11/23, and 12/12/23, it was determined that the facility failed to report four allegations of resident to resident abuse to the New Jersey Department of Health (NJDOH) and follow their facility policy on Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property Prevention for 4 of 6 sampled residents (Resident #1, Resident #2, Resident 4, and Resident #6) reviewed for incident and accident, investigation and reporting. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to; Dementia and Macular Degeneration The Minimum Data Set (MDS), an assessment tool dated 9/27/23, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 4 which indicated the resident's cognition was severely impaired. A Care Plan…

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 C #: NJ167461, NJ169331, and NJ169500 Based on interview, medical records (MR) review, and review of pertinent facility documents on 12/7/23, 12/11/23, and 12/12/23, it was determined that the facility failed to provide documented evidence that four allegations of resident to resident abuse were thoroughly investigated according to their facility's policies on Reporting Accident and Incident and Resident Abuse Prohibition Policy for 4 of 6 sampled residents (Resident #1, Resident #2, Resident 4 and Resident #6) reviewed for incident and accident investigation and reporting. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to; Dementia and Macular Degeneration. The Minimum Data Set (MDS), an assessment tool dated 9/27/23, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 4 which indicated the resident's cognition was severely impaired. A Care Plan (CP),…

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 C #: NJ167461, NJ169331, and NJ169500 Based on interview, medical records (MR) review, and review of pertinent facility documents on 12/7/23, 12/11/23, and 12/12/23, it was determined that the facility failed to revise residents care plans (CP) for 4 of 6 sampled residents (Resident #1, Resident #2, Resident #4, and Resident #6) reviewed for CP revision. The deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to: Dementia and Macular Degeneration. The Minimum Data Set (MDS), an assessment tool dated 9/27/23, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 4 which indicated cognition was severely impaired. The MDS further revealed that Resident #1 had a fall prior to the MDS assessment. A Care Plan (CP), initiated on 12/20/21, reflected that Resident #1 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to memory…

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 ensure that three (3) Licensed Practical Nurses (LPN #1, #2, #3) had competencies to assess nursing care for residents' needs. The deficient practice was evidenced by the following: On 6/01/23 at 3:25 PM, the surveyor reviewed the requested nurse competencies for LPN #1 provided by the Director of Nursing (DON). The competencies were for handwashing, covid antigen nasal swab testing, enteral nutrition feedings, and personal protective equipment donning and doffing. The competencies were done between 9/2022 and 11/2022. On 6/1/23 at 3:30 PM, the surveyor asked the DON if LPN #1 had completed other competencies. The surveyor also requested competencies for the other two (2) LPNs (LPN #2 and #3) who worked at the facility. The DON stated that no other nurse competencies were found. She stated she would call the former DON to see where they were filed. No additional nurse competencies were provided to the surveyor. Additionally, the facility did not have a policy for nurse competencies.…

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 record review and interview with the Licensed Nursing Home Administrator (LNHA), it was determined that the facility failed to complete the annual Nurse Aide performance appraisals for 4 of 4 Certified Nursing Assistants (CNA) reviewed and was evidenced by the following: On 6/5/23 at 9:36 AM, the surveyor requested the annual Nurse Aide performance appraisals for CNA #1, 2, 3, and 4. The LNHA referred the surveyor to the Director of Nursing (DON). On 6/5/23 at 12:12 PM, the DON told the surveyor that the performance appraisals were not done. The DON stated, I will begin them now. On 6/5/23 at 1 PM, the surveyor requested the facility policy regarding employee annual performance appraisals. The policy was not provided to the surveyor. NJAC 8:39-43.17(b)

Based on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure that medications were administered and accurately signed in the electronic medication administration record (eMAR). This deficient practice was identified for 13 of 13 residents (Residents #4, #11, #13, #17, #18, #19, #20, #22, #26, #79, #179, #229, and #230) reviewed for medication management. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated,…

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 the interview and record review, it was determined that the facility failed to ensure that the Infection Preventionist (IP), Director of Nursing (DON), Medical Director (MD), or designee attended the quarterly Quality Assurance (QA) meetings. This was identified for 2 of the 3 quarterly QA meetings reviewed. This deficient practice was evidenced by the following: The surveyor reviewed the QA meeting sign-in sheets for the last three (3) quarters dated April 26, 2023, January 25, 2023, and September 30, 2022. Reviewing the sign-in sheets for those 3 quarters revealed no DON signatures to show that the DON was in attendance for September 30, 2022 and January 25, 2023 QA meetings. There were no IP signatures to show that the IP was in attendance for January 25, 2023, and September 30, 2022, QA meetings, and there were no MD signatures to show that the MD attended the QA meeting on September 30, 2022. On 5/25/23 at 10:30 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who confirmed the abovementioned concerns. The LNHA stated that she knows 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, and record review, it was determined that the facility failed to treat each resident with respect and dignity in a manner that promotes his/her quality of life during lunch. This deficient practice was identified for one (1) of three (3) residents (Resident #11) who required assistance to eat and were not being assisted while the other residents at the same table were either eating or being assisted. This deficient practice was evidenced by the following: On 5/24/23 at 12:20 PM, during lunch in the dining area, the surveyor observed Resident #11 seated in a geri-chair (a chair that can fully recline with wheels to provide a portable, spacious seat) at a table with two (2) unsampled residents. All three residents had their lunch trays in front of them, and Resident #11's lunch tray remained covered. One of the unsampled residents could eat independently, and a Certified Nursing Assistant (CNA) assisted the other unsampled resident at a hospice company (HCNA). The HCNA was seated between the unsampled resident she was feeding and Resident #11. On…

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 the interview and review of pertinent facility documents, it was determined that the facility failed to obtain current and past-employer reference checks prior to hiring in accordance with the facility's abuse policy and procedure for screening newly hired employees. This deficient practice was identified for 3 of 5 newly hired employees and was evidenced by the following: On 6/5/23, the surveyor reviewed pre-screening for five (5) newly hired employees. Three of the 5 employees listed below had no reference checks performed before starting work at the facility. a) A Dietary Aide (DA) who began working at the facility on 5/12/22. b) A Certified Nursing Assistant (CNA) who began working on 3/13/23. c) A Registered Nurse (RN) who began working on 3/10/23. On 6/5/23 at 9:20 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated the DA, CNA, and RN did not have pre-employment reference checks done. The LNHA stated the facility's policy is to perform them before hiring. The LNHA did not give a reason for the omissions. The LNHA provided 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, and record review, it was determined that the facility failed to document the circumstances of the resident change of condition leading to emergency transfer and the resident's readmission to the facility post-hospitalization. The deficient practice was identified for 2 of 5 residents (Residents #26, #4) reviewed for hospitalization. The evidence is as follows: 1. The surveyor observed Resident #26 sitting in bed on 5/24/23 at 10:45 AM. The alert and oriented resident discussed her various medical conditions with the surveyor. A review of the resident's Electronic Medical Record (EMR) revealed the following information: The admission Record (AR) listed diagnoses of displacement of nephrostomy catheter, irritable bowel syndrome, diabetes mellitus, hypotension, kidney failure, and urinary tract infection. The 3/19/23 admission Minimum Data Set (MDS) assessment tool indicated the resident scored 12 out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. A Social Service (SS) Progress Note written on 4/14/2023…

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 policy review, it was determined that the facility failed to: a.) assess a weight change for 1 of 1 resident reviewed for nutritional status, which did not contribute to weight loss, Resident #229, and b.) follow the physician's order (PO) for medication used to raise blood pressure for 1 of 1 resident, Resident #26. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states, The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. On 5/30/23 at 12:20 PM,…

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 maintain the necessary respiratory care and services for 1 of 1 residents (Resident #4) reviewed for respiratory care. The deficient practice was evidenced by the following: On 5/24/23 at 10:11 AM, the surveyor observed the resident in bed receiving oxygen therapy through a nasal cannula from an oxygen concentrator at two (2) liters per minute (lpm). The oxygen tubing was not labeled to indicate when the tubing had been changed. On 5/25/23 at 10:10 AM, the surveyor observed the resident in bed with eyes closed, receiving oxygen. The tubing was not dated. On 5/25/23 at 10:17 AM, the Certified Nursing Assistant (CNA) told the surveyor the resident always used oxygen, She needs it. The CNA stated nurses and CNAs encourage the resident to use oxygen. The CNA revealed the nurse changes the oxygen tubing once a week. On 5/25/23 at 11:10 AM, the Licensed Practical Nurse (LPN) told the surveyor that the resident used oxygen continuously. She stated the nurse routinely changed the tubing weekly…

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 ensure that all medications were administered without error of 5% or more. During the medication observations on 5/25/23 and 5/26/23, the surveyors observed one (1) nurse administer medications to five (5) residents. There were twenty-seven (27) opportunities, and two (2) errors were observed, calculated to a medication administration error rate of 13.5%. This deficient practice was identified for one (1) of five (5) residents observed (Resident #18) that were administered medications by one (1) nurse. The deficient practice was evidenced by the following: 1. On 5/25/23 at 8:46 AM, during the morning medication pass, the surveyor observed the Licensed Practical Nurse (LPN #1) preparing eight (8) medications which included one (1) Aspirin Enteric Coated (EC) 81 milligram (MG) tablet for Resident #18. On 5/25/23 at 9:01 AM, the surveyor observed LPN #1 preparing thickened water and stated that she would administer the eight (8) medications to Resident #18. At that time, the surveyor…

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 observations, interviews and review of documentation provided by the facility, it was determined that the facility failed to maintain proper kitchen sanitation practices to prevent the development of food borne illnesses. The deficient practice was observed and was evidenced by the following: On 05/18/21 at 10:27 AM, during the tour of the kitchen in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. Inside the reach-in freezer: -An opened clear bag of chicken nuggets. The bag did not have an identifier label, a received on date, or an opened on date. The FSD confirmed that the bag contained chicken nuggets. -An opened clear bag of unidentifiable white pieced items. The bag did not have an identifier label, a received on date, or an opened on date. The FSD stated the bag contained frozen diced chicken -An opened blue bag of frozen white and brown items. The bag did not have an identifier label, a received on date, or an opened on date. The FSD stated that the bag contained stuffed potatoes. -Frozen hot dogs contained in clear wrap. 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, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility's Administrator failed to ensure that the facility was in compliance by following their policy and procedures. The Administrator did not: a.) maintain or have readily accessible facility policies and procedures; b.) maintain life-saving medical equipment; c.) store resident care supplies in a sanitary manner to prevent infection, and d.) maintain an Antibiotic Stewardship Program. Refer to: F689; F880; F881 A review of the Administrator's job description dated [DATE] included the primary purpose of the Administrator's job position is to direct the day to day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to the residents at all times. The Administrator is delegated the administrative authority, responsibility,…

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 facility documentation, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to: a.) perform proper hand hygiene and perform a wound treatment in a safe and sanitary manner for 1 of 1 nurse observed providing a wound care treatment, to 1 of 1 resident, (Resident #6); b.) maintain and store sterile and non-sterile resident care equipment in a safe and sanitary manner; c.) follow appropriate hand hygiene practices for 2 of 2 nurses who administered medications to 3 of 6 residents (Resident #20, #24, and #26) during the medication pass; d.) implement a handwashing policy that adheres to the Centers for Disease Control and Prevention (CDC) guidelines; and, f) ensure that their Infection Control Policies and Procedure (ICPP) manual was reviewed annually; and, g) ensure proper storage of respiratory equipment for 2 of 2 residents reviewed for respiratory equipment. (Residents #13 and #28). This deficient practice was evidenced…

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 a.) report to the New Jersey Department of Health (NJDOH) an allegation of abuse for injuries of unknown origin and b.) follow the facility's Resident Abuse Prohibition Policy. This deficient practice was identified for 2 of 2 residents reviewed for injuries of unknown origin (Resident #17 and #20). This deficient practice was evidenced by the following: 1. On 05/18/2021 at 11:05 AM, the surveyor observed Resident #20 seated in a high back wheelchair with a chair alarm to the back of the chair, doing puzzles and eating snacks in the dining area. The surveyor reviewed the medical records for Resident #20. According to the admission Record, Resident #20 was admitted to the facility on 10/2020. Review of the Discharge Minimum Data Set (MDS), an assessment tool dated 02/11/2021, reflected the resident was hospitalized . Review of the Significant change MDS dated [DATE], indicated…

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 investigate injuries of unknown origins in accordance with the facility's Resident Abuse Prohibition Policy. This deficient practice was identified for 2 of 2 residents reviewed for injuries of unknown origin (Resident #17 and #20) and was evidenced by the following: On 05/18/2021 at 11:05 AM, the surveyor observed Resident #20 seated in a high back wheelchair with chair alarm to the back of the chair, doing puzzles and eating snacks in the dining area. The surveyor reviewed the medical records for Resident #20. According to the admission Record, Resident #20 was admitted to the facility on 10/2020. Review of the Discharge Minimum Data Set (MDS) an assessment tool dated 02/11/2021, reflected the resident was hospitalized . Review of the Significant change MDS dated [DATE], indicated the resident had a medical diagnoses that included but was not limited to: Hypertension (high…

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, medical record review and review of other pertinent facility documentation, it was determined that the facility failed to ensure a.) an assessment and evaluation for restraint use was performed and b.) obtain a consent with disclosure of risk versus benefits for use the of a restraint for 1 of 1 residents reviewed for restraints. (Resident #28) This deficient practice was evidenced by the following: According to the facility admission Record, Resident #28 was admitted to the facility in 4/2021 with diagnoses which included but were not limited to; down syndrome and pneumonitis (inflammation of lungs) due to inhalation of food and vomit. Review of the admission Minimum Data Set (MDS) an assessment tool dated 4/20/21, revealed that the resident had short and long term memory impairments, required total care with activities of daily living, was receiving oxygen therapy, and limb restraint was used daily. Review of the Universal Transfer form from the hospital dated 04/13/21, revealed that the resident had a diagnosis of pneumonia, was receiving oxygen…

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, interviews, review of medical records and other facility documentation, it was determined that the facility failed to update and revise a comprehensive person-centered care plan in a timely manner for 1 of 15 residents reviewed. (Resident #21) This deficient practice was evidenced by: On 05/18/21 at 09:58 AM, the surveyor observed Resident #21 in bed pointing to his/her head sutures. The resident stated a few days ago he/she was walking to the kitchen and fell backwards striking his/her head on the floor. Resident stated he/she was using the walker at the time. According to the admission Record, Resident #21 was admitted in 4/2020 with diagnoses which included by were not limited to: dementia, cerebral infarction (stroke), and altered mental status. Review of the resident's Annual Minimum Data Set (MDS) an assessment tool dated 4/8/21, revealed the resident had a Brief Interview for Mental Status (BIMS) of 13 which indicated that the resident's cognition was intact. Review of the resident's care plan (CP) initiated on 4/10/2020 with a revision on 4/14/2020,…

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 facility documents, it was determined that the facility failed to follow professional standards of clinical practice with medication administration for 1 of 6 residents (Resident #24) observed for medication pass. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing a medical regimen as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: The practice of nursing as a licensed practical nurse is defined as…

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 a.)ensure the implementation of physician orders for bilateral heel boot for a resident at risk for skin breakdown for 1 of 1 residents reviewed for position and mobility (Resident #15) b.) obtain a physician's order for oral suctioning for 1 of 1 resident reviewed (Resident #28) and c.) ensure suction machine equipment was available and in working order for 1 of 1 resident reviewed, (Resident #28). 1. During the initial tour of the facility on 05/18/21 at 10:00 AM, the surveyor observed Resident #15 in bed resting with both eyes closed. The surveyor observed a pair of heel boots on the dresser next to the resident's bed. Review of the quarterly Minimum Data Set (MDS), an assessment tool dated 03/21/2021, indicated the resident was admitted to the facility in 12/2020 with medical diagnoses that included but not limited to: hypertension (high blood pressure), non-Alzheimer dementia and depression. The residents Brief Interview Mental Status (BIMS) was 00 which indicated the resident 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 Based on observation, interview, and review of facility documentation, it was determined that the facility failed to ensure that emergency medical equipment was maintained and stored in a safe and sanitary manner for 1 of 1 nursing units reviewed for emergency equipment. This deficient practice was evidenced by the following: On [DATE] at 12:45 PM, the surveyor entered the facility's Therapy room. The Therapy room, which was used for storage, included a staff bathroom. The surveyor observed the emergency response kit (backup medication box) was unlocked, lying directly on the floor in the staff's bathroom under the handwashing sink. At that time, the surveyor interviewed the Acting Director of Nursing (ADON), who stated that she did not know that it was there or when the lock was removed. She stated that the pharmacy should have been notified when a medication was removed so that it could have been replaced and another lock would have been issued to secure the emergency response kit. She stated that it should…

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 record review, it was determined that the facility failed to order as needed psychotropic medications for a 14-day period for 1 of 5 residents reviewed (Residents #3) for medications. This deficient practice was evidenced by the following: According to the admission Record, Resident #3 was admitted to the facility in May of 2019 with medical diagnosis which included but were not limited to: dementia with behavioral disturbance, generalized anxiety disorder and depressive episodes. The surveyor reviewed the medical record of Resident #3 for PRN (as needed) psychotropic medications (any drug capable of affecting the mind, emotions, and behavior). Review of the Physician's Order Sheet revealed a physician's order dated 01/25/21 for alprazolam (generic for Xanax) 0.5 mg (milligram) one tablet by mouth every 6 hours as needed for severe anxiety. The physician's order did not contain a stop date of 14 days as required. The facility was unable to provide complete and documented evidence of Resident #3's Medication Administration Records for January through March 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.