Alaris Health At Cedar Grove

Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to ensure licensed staff credentials were verified upon hire. This deficient practice was identified for three (3) of five (5) newly hired licensed staff reviewed, (Staff #5, #8 and #10). This deficient practice was evidenced by the following: 1. On On 6/27/24 at 12:00 PM, the surveyor reviewed five of ten randomly selected new employee files. The review for license verification for one of the new licensed employees revealed the following: Staff #5, a Social Worker, hired 8/21/23, had a New Jersey Division Consumer Affairs license verification printout was dated 10/02/23. The verification was completed after the staff member was hired. There was no documented evidence that Staff #5's license was verified prior to the date of hire (doh). On 6/28/24 at 10:00 AM, the surveyor interviewed the Business Office Manager (BOM) regarding license verification. The BOM stated that she would check the license and print a copy and that it had to be done before orientation.…

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 interviews, and record review, it was determined that the facility failed to ensure that the responsible physician supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every sixty days from January 2024 through June 2024 according to the facility's policy and procedure. This deficient practice was identified for one (1) of 28 residents, Resident #134 was reviewed for physician visits and was evidenced by the following: On 6/24/24 at 11:39 AM, the surveyor observed Resident #134 seated in a wheelchair in the Therapy room (also known as the dining area) with other five residents for early lunch. The surveyor reviewed the hybrid (combination of paper and electronic) medical record for Resident #134. Resident #134's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to hypotension unspecified (low blood pressure), traumatic subdural hemorrhage (caused by a traumatic head injury) without loss of consciousness, cerebral infarction (also…

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 pertinent facility documents, it was determined that the facility failed to maintain a safe and sanitary environment. This deficient practice was identified in behavioral unit for four (4) of six (6) residents rooms, one (1) of one (1) shower room, and one (1) of two (2) unit rooms. This deficient practice was evidenced by the following: On 6/25/24 at 10:08 AM through 10:49 AM, the surveyor conducted a Behavioral Unit (BU) tour with the Licensed Nursing Home Administrator (LNHA) and Registered Nurse/Unit Coordinator (RN/UC) in the presence of a second surveyor. The following was observed during the tour: 1. At 10:08 AM, the surveyor entered into room [ROOM NUMBER] and observed a gray-black colored substance on the air vent cover on the ceiling of the room. The LNHA stated, the gray/black substance was an accumulation of dust. The LNHA was unable to state when the air vent was last cleaned. The surveyor observed one ceiling tile near the window area with a large…

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 provide full visual privacy when providing wound care treatment, for one (1) of 28 residents, Resident #103. The deficient practice was evidenced by the following: On 6/27/24 at 10:15 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform a treatment to the sacral wound of Resident #103. The Certified Nurse Aide (CNA) was assisting the LPN with the positioning of Resident #103 during the wound treatment. On 6/27/24 at 10:31 AM, during the wound treatment, Resident #103 with the assistance of the CNA was lying on their left side on the bed facing away from the door. The back of the resident's body was exposed. The privacy curtain was partially pulled, around the foot of the resident's bed. The resident's bed was visible to the door of the room, which was closed. The LPN after cleansing the resident's wound, removed her gloves and went to the door of the room. LPN #1 fully opened the door, went to the treatment cart positioned in front of the door to get gloves from the box…

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 other pertinent facility documents, it was determined that the facility failed to provide the resident and the resident's representative written notification of the reason for transfer to the hospital and also send a copy to a representative of the Office of the State Long-Term Care Ombudsman (LTCO) for two (2) of three (3) resident's (Resident #195 and #41) reviewed for hospitalization. This deficient practice was evidenced by the following: 1. A review of Resident #195's electronic medical record included the following: Resident #195's discharge return anticipated Minimum Data Set's (DRAMDS), an assessment tool used to facilitate the management of care, for the three DRAMDS, reflected that the resident was transferred to the hospital. A review of Resident #195's hybrid (a combination of paper, scanned, and computer-generated records) medical record did not include a written notification of the reason for transfer to the resident or resident representative (RR) and a copy to the LTCO for each transfer to the hospital. 2. 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 interview, record review and review of pertinent facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for one (1) of three (3) residents, Resident #142 reviewed for closed records. This deficient practice was evidenced by the following: On 6/26/24 at 12:58 PM, the surveyor reviewed the closed medical chart for Resident #142 whose discharge MDS was coded for discharge (dc) to an acute hospital. Review of Resident #142's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included but were not limited to unspecified atrial fibrillation (an irregular and often very rapid heart rhythm), anxiety disorder, unspecified, and essential (primary) hypertension (high blood pressure). Review of A section of the 4/27/24 Discharge MDS for Resident #142 revealed that section A2105 DC Status documented, 04. Short-Term General Hospital. The Order Summary Report (OSR)…

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 pertinent facility documents, it was determined that the facility failed to follow the physician's orders for medications with parameters for two (2) of 28 residents, Residents #44 and #134, reviewed for physician orders according to standards of clinical practice. 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 regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. 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 interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that a discharge summary was completed for two (2) of two (2) residents, Residents #13 and #142 reviewed for discharge to home, according to the facility policy and procedure . This deficient practice was evidenced by the following: 1. On 6/26/24 at 10:10 AM, the surveyor reviewed the hybrid (combination of paper and electronic) closed record of Resident #13 and revealed the following: The admission Record (AR, or face sheet, an admission summary) showed that the resident was admitted to the facility with a diagnosis that included but was not limited to urinary tract infection (UTI, an infection) site not specified, hypothyroidism (underactive thyroid), chronic obstructive pulmonary disease with acute exacerbation (COPD, group of lung diseases that block airflow and make it difficult to breathe), depression unspecified, anxiety disorder unspecified, and fibromyalgia (long-term condition that involves widespread body pain and tiredness). A review 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 the medical record and other facility documentation, it was determined that the facility failed to ensure that residents with decreased range of motion and mobility received consistent daily treatment of a hand splint to prevent contractures or further contraction for one (1) of two (2) residents reviewed for position and mobility (Resident #94). This deficient practice was evidenced by the following: On 6/24/24 at 10:45 AM, the surveyor observed Resident #94 seated in a wheelchair and wore a splint on their left hand. Resident #94 stated that he/she wore the splint during the day. On 6/25/24 at 11:48 AM, the surveyor reviewed Resident #94's electronic medical record. Resident #94's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to flaccid hemiplegia affecting left nondominant side (affected extremity exhibits decreased muscle tone and cannot be actively moved by the patient), type 1 diabetes mellitus (lifelong condition where…

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 pertinent facility documentation, it was determined that the facility failed to ensure that the incontinence care plan was developed according to the resident's assessment to provide appropriate treatment and services for the care of the resident who had frequent urine and occasional bowel incontinence according to the facility's policy and procedure, for one (1) of one (1) resident, Resident #134, reviewed for bowel and bladder incontinence. This deficient practice was evidenced by the following: On 6/24/24 at 11:39 AM, the surveyor observed Resident #134 seated in a wheelchair in the Therapy room (also known as the dining area) with other five residents for early lunch. The surveyor reviewed the hybrid (combination of paper and electronic) medical record for Resident #134. Resident #134's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to hypotension unspecified (low blood pressure), traumatic subdural hemorrhage (caused…

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 documents, it was determined that the facility failed to ensure a.) a non-certified Nurse Aide (NA) did not continue to work as an NA after the specified 120 days for one (1) of two (2) NAs reviewed during the Sufficient and Competent Nurse Staffing task (NA #1); and b.) there was a delineated policy and/or program in place for the hiring of non-certified NAs. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health memo dated April 21, 2023 sent to Nursing Homes included the following: On February 27, 2023, the Centers for Medicare and Medicaid Services (CMS) announced that all nurse aide emergency training waivers will terminate at the end of the Federal Public Health Emergency (PHE). The PHE is expected to end on May 11, 2023. At that time, all Temporary Nurse Aides (TNAs) hired prior to the end of the PHE and who have enrolled in a NATCEP program and completed the first 16 hours of training prior to May 11, 2023, must complete the NATCEP and pass the nurse aide…

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 pertinent facility documents, it was determined that the facility failed to ensure that the 24-hour staffing report was posted and in a prominent place within the facility readily accessible to the residents and the visitors. This deficient practice was evidenced by the following: On 6/24/24 at 9:00 AM and 6/25/24 at 8:55 AM, the surveyor entered the facility and observed that there was no Nursing Home Resident Care Staffing Report (NHRCSR) posted in the entrance area. On 6/25/24 at 9:37 AM, the surveyor interviewed the Receptionist regarding the posting of the NHRCSR. The Receptionist stated that the NHRCSR was usually posted on the wall behind her. The surveyor observed three sheet protectors that did not have any documents in them hanging on the wall. The Receptionist stated that the Staffing Coordinator (SC) would post them and that the last time she saw them posted was last week. On 6/25/24 at 9:44 AM, the surveyor interviewed the SC regarding the posting 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication for one (1) of 28 residents reviewed. (Resident #67). The deficient practice was evidenced by the following: On 6/24/24 at 11:17 AM, the surveyor observed Resident #67 lying in bed. The resident agreed to speak with the surveyor. During the brief interview, the surveyor asked the resident if they can toilet themselves. The resident stated, no, the nurses aides come to assist them and change if needed. The surveyor reviewed Resident #67's electronic medical record (EMR) which revealed the following. Resident #67's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to type 2 diabetes (a disease where the body does not regulate blood sugar properly, anemia (a problem of not having enough healthy red blood cells or hemoglobin…

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 administration observation on 6/26/24, the surveyor observed four (4) nurses administer medications to six (6) residents. There were 25 opportunities for error, and three (3) errors were observed which calculated to a medication administration error rate of 12%. This deficient practice was identified for two (2) of six (6) residents, (Resident #34 and Resident #132), that were administered medications by two (2) of four (4) nurses that were observed. The deficient practice was evidenced by the following: 1. On 6/26/24 at 8:31 AM, during the medication (med) administration observation, the surveyor observed the Licensed Practical Nurse #1 (LPN #1) preparing to administer medications (meds) to Resident #34. The surveyor observed the resident's Electronic Medication Administration Record (eMAR) which reflected an order for Colace oral capsule (a medication used to soften the stool), give one…

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 pertinent documents, it was determined that the facility failed to ensure that medications were stored and labeled appropriately. This deficient practice was identified in one (1) of five (5) medication carts inspected and two (2) of two (2) medication storage rooms inspected on three (3) of four (4) units. This deficient practice was evidenced by the following: On [DATE] at 10:35 AM, the surveyor inspected the Pink Unit Medication (med) Room. The surveyor accessed the med refrigerator located in the med room. The surveyor observed an unlabeled amber plastic vial in the refrigerator. Upon inspection of the amber vial, the surveyor observed an unlabeled vial of Retacrit (a med used to increase red blood cell production) located inside. The surveyor opened an under counter drawer in the med room and observed a Novolin R Flex Pen (a self-contained device used to administer insulin, a med used to treat high blood sugar) with a pharmacy label and dispensed date 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY COMPLAINT: NJ#172727 Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain complete, available, and readily accessible medical records. This deficient practice was identified for three (3) of the 31 residents reviewed (Residents #86, #134, and #196). This deficient practice was evidenced by the following: 1. On 6/24/24 at 9:15 AM, during an interview with the surveyor, regarding the process for reportable, the Licensed Nursing Home Administrator stated that when an incident occurred, he was supposed to be notified with the Director of Nursing (DON) immediately. We also notify the physician, family, state agency and the ombudsman's office for a reportable. The LNHA also stated that determining the cognitive level such as the BIMS (Brief Interview for Mental Status) score, when a resident was not able to explain, that needs to be investigated and depending on what was learned will depend on if it should be a reportable or…

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.

REPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices to prevent and control the spread of infection: a) improper storage of a urinary drainage bag for one (1) of two (2) residents (Resident #103), reviewed for urinary catheter care, b) performing hand hygiene during a wound treatment observation by one (1) of one (1) nurse (Licensed Practical Nurse), and c) doffing (taking off) of Personal Protective Equipment (PPE) when exiting an Enhanced Barrier Precaution (EBP) room during a wound treatment by one (1) of one (1) nurse. This deficient practice was evidence by the following: 1. On 6/24/24 at 10:49 AM, the surveyor observed Resident #103 with their face only visible from behind the privacy curtain drawn. Resident #103 greeted the surveyor and for the surveyor to approach their bedside. Resident #103 was observed lying in bed, alert and verbally responsive. The surveyor observed the resident's incontinent brief was open, their pants were below their…

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 ensure have an Infection Preventionist (IP) dedicated solely to the infection prevention and control program (IPCP) who worked at least part-time and had completed specialized training in infection control and prevention for one (1) of two (2) staff. According to the NJ Executive Directive 21-012 (revised 12/22/22) included The facility's designated individual(s) with training in infection prevention and control shall assess the facility's IPCP by establishing or revising the infection control plan, annual infection prevention and control program risk assessment, and conducting internal quality improvement audits. According to the CMS QSO-22-19-NH Memo dated 6/29/22 and Fact Sheet, Updated Guidance for Nursing Home Resident Health and Safety dated 6/29/22, effective date on October 24, 2022 Overview of New and Updated Guidance, Summary of Significant Changes, included that in Infection Control, requires the facilities to have a part-time IP. While the requirement is to…

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 interviews, record review, and review of other pertinent provided facility documents, it was determined that the facility failed to ensure that a.) each resident was offered influenza and pneumococcal immunizations, b.) education was provided regarding the benefits and potential side effects of the immunizations, c.) resident or representative has the opportunity to refuse immunizations unless the immunization was medically contraindicated or the resident had been immunized. This deficient practice was identified for one (1) of five (5) residents, Resident #134, reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 6/24/24 at 11:39 AM, the surveyor observed Resident #134 seated in a wheelchair in the Therapy room (also known as the dining area) with other five residents for early lunch. The surveyor reviewed the hybrid (combination of paper and electronic) medical record for Resident #134. Resident #134's admission Record (an admission summary) reflected 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.

Based on interview, and review of pertinent documents it was determined that the facility failed to have written procedures in place to ensure: a.) all residents were protected from abuse when an allegation of staff to resident abuse occurred, b.) a process was in place for identifying other potential victims of abuse, and c.) a process to ensure all potential witnesses/persons aware of the allegation were interviewed. This deficient practice was evidenced for 4 of 4 resident units, and for 1 of 2 residents reviewed for abuse, and occurred when an allegation of abuse by a Certified Nurse Aide (CNA #1) against a resident (Resident #182) was received on 01/17/23 and CNA #1 proceeded to work a resident care shift the following day, 01/18/23, and had access to Resident #182 and other residents who resided at the facility, and was prior to an abuse investigation being completed. The deficient practice was evidenced by the following: Refer to 600J On 01/19/23 at 8:27 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a request to speak with a family member. 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 observation, interview, review of medical records and review of other pertinent documentation, it was determined that the facility failed to treat all residents in a dignified manner by failing to provide: a.) oral and incontinence care to a resident assessed to be dependent on staff for activities of daily living (ADL's), and prior to serving the resident meal, b.) a timely clothing change to a resident whose clothing was visibly soiled, and c.) a resident with respect and dignity. This deficient practice was identified 2 of 26 residents reviewed (Resident #45 and #179), on 2 of 4 units, and was evidenced by the following: 1. On 01/04/23 at 9:30 AM, the surveyor observed Resident #45 in bed. The Certified Nursing Assistant (CNA) was at the bedside assisting the resident with care. On 01/04/23 at 10:37 AM, the surveyor conducted an interview with the CNA who revealed that Resident #45 required extensive assistance with care, could feed his/herself after set up, and was incontinent of bowel and bladder. On 01/06/23 at 7:45 AM, the surveyor completed a care tour with one 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to provide appropriate incontinence care, and personal hygiene care for 6 of 26 residents (Resident #19, #45, #66, #75, #92 and #179) sampled on 2 of 4 resident units, and failed to offer oral hydration and mouth care to a dependent resident (Resident #179). The deficient practice was evidenced by the following: 1. On 01/03/23 at 10:05 AM, the surveyor observed Resident #19 in bed, the head of the bed was elevated, and the resident was able to answer questions. The residents lips appeared very dry and crusty. The resident's right hand was contracted. On 01/04/22 at 8:30 AM, the surveyor observed Resident #19 in bed in the dorsal recumbent position (a reclining position with both knees flexed, hips rotated outward, and both soles kept flat on the bed), the resident informed the surveyor that she/he had not been changed. On 01/04/22 at 10:30 AM, the surveyor returned to the room 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.

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 ensure appropriate care and related services were provided, and failed to follow their change in condition policy to identify and assess a resident who had a change in condition, and there was a delay in treatment, and the resident subsequently required hospitalization on 01/09/23. This deficient practice occurred for 1 of 26 residents reviewed for care, (Resident #92), and who was transferred to the hospital emergency department via 911, and was diagnosed with hypernatremia and sepsis and was evidenced by the following: During the initial tour of the facility on 01/03/23 at 10:15 AM, the surveyor observed Resident #92 in bed facing the wall. On 01/04/23 at 10:36 AM, the surveyor observed Resident #92 in bed, and was facing the wall. The breakfast tray was on the bedside table and was untouched. On 01/05/23 at 8:37 AM, the surveyor entered the room and observed Resident #92 in bed and was facing the wall, 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 interview, record review, and review of other pertinent documentation, it was determined that the facility failed to enter signed progress notes (PN) in the hybrid medical record (electronic or paper) at each visit. This deficient practice was identified on 4 of 4 units and was evidenced by the following. On 01/11/23 through 01/13/23, the surveyor began to review the hybrid medical records of sampled residents. The surveyor reviewed the following: The Behavioral Health Unit (BHU): Resident #6: hybrid record revealed late entries: Effective Date (the date the resident was seen by the practitioner): 12/23/2022; Department: Physicians; Position: Physician; Created By: a physician's name was entered; Created Date: 01/3/2023. This represented an 11-day delay in the Progress Note (PN) being entered into the hybrid record. Effective Date: 12/15/2022; Department: Physicians; Position: Physician; Created By: a physician's name was entered; Created Date: 01/9/2023. This represented a 25-day delay in the PN being entered into the hybrid record. Effective Date: 01/06/2023; Department:…

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 provide sufficient and competent staff to provide: a.) nursing and related services to meet the residents's needs as determined by resident assessments and individual plans of care and b.) sufficient staffing numbers to meet minimum staffing requirements. This deficient practice was identified on 2 of 4 nursing units and for 6 of 23 sampled residents, Resident #19, #45, #66, # 72, #92 and #179, reviewed for care related services. The deficient practice was evidenced by the following. Refer to F677 and F 689 1.) On 01/03/23 at 10:05 AM, on 01/04/23 at 8:15 AM, and on 01/04/23 at 10:30 AM, the surveyor observed Resident #19 in bed in dorsal recumbent position. The resident indicated that he/she had not been turned and had not been provided with incontinence care. Resident #19's mouth was dry and a crusty white substance was noted around the mouth. On 01/05/23 at 11:30 AM, the surveyor observed during a care tour, that the resident had not been changed and 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 observations, interview, record reviews, and review of pertinent documents, it was determined that the facility failed to: a.) implement infection control practices and adhere to the facility's policy in regards to hand hygiene during medication administration, b.) store a Foley urinary catheter drainage bag in a manner to prevent infection for 1 of 1 residents reviewed for urinary catheters (Resident #19), c.) ensure a visitor was educated and instructed to wear a mask while in the facility, d.) wear Personal Protective Equipment (PPE) while in the room of a residents on transmission-based droplet precautions for 2 of 4, and use hand hygiene prior to donning (putting on) PPE on 1 of 4 units, and e.) follow their Covid-19 Outbreak Response Plan and Policy for Infection Control, and follow the latest guidance from the Centers for Disease Control and Prevention (CDC) for the surveillance of Healthcare Personnel (HCP) to prevent the spread of infection. This deficient practice was observed during…

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 document review, it was determined that the facility failed to have a process in place to identify a bed that was broken for 1 of 26 residents reviewed who had a visibly broken bed (Resident #180). The deficient practice was evidenced by the following: On 01/03/23 at 12:09 PM, the surveyor interviewed Resident #180 while the resident was sitting in bed. The resident stated the only issue was that he/she could feel the screws from the bed frame and it was hard to sleep. Resident #180 stated he/she had to sleep a certain way, and kept telling them (the facility staff) and nothing is done. Resident #180 was sitting in the bed and the surveyor was unable to observe the mattress at that time. On 01/04/23 at 11:53 AM, the surveyor observed that Resident #180 was not in the room and observed that the mattress was not covered by a blanket and was visibly sunken in, in a circular pattern about a foot long. The surveyor brought the Unit Manager (UM) into Resident #180's room and asked him to look at the mattress. The UM looked at the mattress, felt 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 interview and document review, it was determined that the facility failed to ensure an allegation of abuse was reported timely to the Department of Health. This deficient practice occurred for 1 of 2 residents reviewed for abuse (Resident #182) and was evidenced by the following: Refer to 600J and 600F On 01/19/23 at 8:46 AM, the surveyor contacted the family member (FM) of Resident #182 and conducted a telephone interview. The FM stated Resident #182 had an issue with CNA #1 who had walked into Resident #182's room and was nasty to Resident #182 on 01/17/23. The FM stated CNA #1 told the resident that she was not going to have to change (provide incontinence care) the resident again, since Resident #182 was not her only resident. CNA #1 told Resident #182 that she was on her break at the time, and CNA #1 refused to change Resident #182. CNA #1 then proceeded to throw down the food lid with force on Resident#182's over bed table. The FM stated that he/she had made the Director of Social Services (DSS) aware of what happened on the same day, 01/17/23. On 01/19/23 at 8:46 AM,…

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 pertinent documentation, it was determined that the facility failed to document the administration, or refusal of medications on the Medication Administration Record (MAR). This deficient practice was identified for 1 of 26 residents (Resident #6) reviewed and 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 regimes 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 states: The practice of nursing as 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.

Based on interview, and review of pertinent documents, it was determined that the facility failed to a) identify through their Quality Assurance Performance Improvement (QAPI) program, that their abuse prevention program did not incorporate a component to protect all residents from potential abuse. The deficient practice was evidenced by the following. Refer to F 600 J and F 607 F On 01/03/23 at 10:26 AM, the facility provided the survey team with a copy of their, Abuse Prevention Program, revised 10/21/22. On 01/19/23 at 8:27 AM, the survey team reviewed an allegation of abuse reported by a resident's family member. The abuse allegation referred to a Certified Nursing Assistant (CNA) being abusive towards a resident on the 7:00 AM to 3:00 PM shift on 01/17/23. On 01/19/23 at 8:46 AM, a surveyor interviewed the resident who confirmed on 01/17/23, a CNA was nasty, threw down a meal tray, and refused to provide incontinent care. The resident stated that the incident had been reported to the Director of Social Services (DSS) on 01/17/23 (no time provided). On 01/19/23 at 9:23 AM, 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.