Aristacare At Cherry Hill

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to revise an individual comprehensive care plan (ICCP) for a resident with an order for a tracheostomy (a surgically created hole, also called a stoma, in your windpipe, also known as your trachea). This deficient practice was identified for 1 of 2 residents reviewed for respiratory care (Resident #14), and was evidenced by the following:On 8/21/25 at 11:13 AM, during the initial tour of the facility, the surveyor observed Resident #14 seated in their wheelchair in their room watching television. The surveyor did not observe a tracheostomy for Resident #14. On 8/22/25 at 12:45 PM, the surveyor observed Resident #14 seated in their wheelchair in their room. Resident #14 stated that when they were admitted to the facility he/she had a tracheostomy in place, but it was removed a couple years ago. On 8/22/25 at 10:42 AM, the surveyor reviewed the medical record for Resident #14. A review of the admission Record face sheet (admission summary) reflected that the resident…

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 facility documents, it was determined that the facility failed to ensure that residents with decreased range of motion and mobility received prescribed treatments to prevent contractures for 1 of 3 residents (Resident #6) reviewed for limited range of motion. This deficient practice was evidenced by the following:On 8/22/25 at 1:34 PM, the surveyor observed Resident #6 lying in bed awake. When interviewed, the resident stated that he/she had a history of a stroke and could not move their left arm. The resident stated that he/she had a splint in one of the drawers, but the staff had not put it on for a long time. The resident's left upper extremity was covered with a thin blanket. On 8/22/25 at 1:47 PM, the surveyor interviewed the Certified Nursing Assistant (CNA) #3 who stated that she had just finished providing personal care to Resident #6. CNA #3 further stated that the resident did not have any contractures and their skin was intact.On 8/22/25 at 1:18 PM, the surveyor reviewed the medical record for Resident #6. 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 observation, interview, and review of pertinent facility documents, it was determined that the facility failed to place a resident's urinary catheter drainage bag inside of a privacy bag to maintain resident dignity. This deficient practice was identified for 1 of 1 resident reviewed for urinary catheters (Resident #90), and was evidenced by the following:On 8/21/25 at 10:56 AM, during the initial tour of the facility, the surveyor observed Resident #90 lying in their bed awake. The resident stated that they had an issue with their suprapubic catheter (a type of indwelling catheter that drains urine from the bladder into a collection bag). The surveyor observed the indwelling catheter drainage bag secured to the bed frame, not placed in a privacy bag, exposing the contents (urine) in the bag. The surveyor was able to observe the urine in the resident's catheter drainage bag from the hallway. On 8/21/25 at 11:40 AM, the surveyor observed Resident #90 lying in their bed awake. The resident stated that the facility used to put their catheter drainage bag in a privacy screen,…

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 documents, it was determined that the facility failed to ensure that oxygen was administered in accordance with a physician's order. The deficient practice was identified for 2 of 2 residents (Resident #1 and #122) reviewed for Respiratory Care and was evidenced by:1.) On 8/21/25 at 11:13 AM, during the initial tour the surveyor observed Resident #122 awake and alert lying in bed wearing oxygen via nasal cannula (prongs that are placed in the nostrils) at three (3) liters (L). On 8/22/25 at 9:11 AM, the surveyor observed Resident #122 lying in bed with their eyes closed wearing oxygen via nasal cannula at 3L. On 8/25/25 at 9:00 AM, the surveyor reviewed the medical record for Resident #122. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, acute and chronic respiratory failure with hypoxia (lack of sufficient oxygen reaching the body's tissues or an environment with low oxygen levels) and dependence on supplemental oxygen. A review…

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 #: NJ185404 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 6/27/2025, it was determined that the facility failed to update the care plan (CP) with interventions for a resident (Resident #1) involved in a staff to resident abuse allegation. This deficient practice was identified in 1 of 7 residents reviewed for care plans and was evidenced by the following: According to the admission Record (AR), Resident #1 was admitted to the facility in April 2025 with diagnoses which included but were not limited to: Diabetes, Major Depressive Disorder, and Hypertension. According to the admission Minimum Data Set (MDS), an assessment tool dated 4/12/2025, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. According to the facility's Investigation, Summary and Conclusion dated 4/11/2025, revealed the social worker was doing rounds and the resident reported that his/her Certified Nursing Assistant (CNA) was rough with him/her. Resident #1 stated…

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#: NJ00183319, NJ00184308 Based on interview, medical record review, and review of pertinent facility documentation on 2/11/25, 2/12/25, and 2/14/25, it was determined that the facility failed to: a.) implement a care plan intervention for a physical therapy (PT) consult and b.) provide a resident with a Physical Therapy/Occupational Therapy (PT/OT) assessment after a fall as recommended by the Interdisciplinary Team (IDT). This deficient practice was identified for 1 of 6 residents (Resident #2) reviewed and was evidenced by the following: Resident #2 was no longer at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record revealed that Resident #2 was admitted to the facility with diagnoses that included but were not limited to: Huntington's Disease (an inherited disorder that causes nerve cells in parts of the brain to gradually break down and die), severe protein-calorie malnutrition, and adult failure to thrive. Review of the admission Minimum Data Set (MDS) an assessment tool used to facilitate the management 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.

COMPLAINT#: NJ00183319, NJ00184308 Based on interview, medical record review, and review of pertinent facility documentation on 2/11/25, 2/12/25, and 2/14/25, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted an initial comprehensive visit. This deficient practice was identified for 1 of 6 residents (Resident #2) reviewed and was evidenced by the following: Resident #2 was no longer at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record (AR) revealed that Resident #2 was admitted to the facility with diagnoses that included but were not limited to: Huntington's Disease (an inherited disorder that causes nerve cells in parts of the brain to gradually break down and die), severe protein-calorie malnutrition, and adult failure to thrive. The AR further revealed the name of the resident's Attending Physician, who was also the facility's Medical Director. Review of the admission Minimum Data Set (MDS) an assessment tool used to facilitate 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.

COMPLAINT#: NJ00181569 Based on observation, interview and review of medical records and other pertinent facility documents it was determined that the facility failed to maintain an accurately documented and complete medical records in accordance with acceptable standards and practice. This deficient practice was identified for 1 of 6 residents (Resident #4) reviewed and was evidenced by the following: Resident #4 was no longer at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record revealed that Resident #4 was admitted to the facility with diagnoses that included but were not limited to: seizures, severe protein-calorie malnutrition, and COPD. Review of the admission Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 12/18/24 indicated that Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that the resident's cognition was intact. Review of Resident #4's Order Summary Report indicated an order as follows: -Clonazepam [Klonopin] Oral Tablet 2…

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 report to the New Jersey Department of Health within two hours for a.) an allegation of exploitation and misappropriation of resident property and b.) an allegation of verbal abuse. This deficient practice was identified for 2 of 4 incidents of abuse reviewed (Resident #47), and was evidenced by the following: 1. On 2/28/24 at 12:14 PM, the surveyor interviewed Resident #47 who stated he/she had an issue with a Certified Nursing Aide (CNA #1) who no longer worked at the facility. The resident stated he/she developed a bond with CNA #1, and the aide asked the resident to borrow money which he/she provided. The resident continued CNA #1 always paid them back the borrowed money, and there were multiple financial transactions, but CNA #1 stopped paying the resident back the money she borrowed. The resident stated he/she transferred the money using money applications (app) on their phone, and CNA…

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

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate a.) an allegation of exploitation and misappropriation of resident property and b.) an allegation of verbal abuse. This deficient practice was identified for 2 of 4 incidents of abuse reviewed (Resident #47), and was evidenced by the following: 1. On 2/28/24 at 12:14 PM, the surveyor interviewed Resident #47 who stated he/she had an issue with a Certified Nursing Aide (CNA #1) who no longer worked at the facility. The resident stated he/she developed a bond with CNA #1, and the aide asked the resident to borrow money which he/she provided. The resident continued CNA #1 always paid them back the borrowed money, and there were multiple financial transactions, but CNA #1 stopped paying the resident back the money she borrowed. The resident stated he/she transferred the money using money applications (app) on their phone, and CNA #1 owed him/her around $330 that was never paid back. The resident stated the facility's Director of Quality…

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 #162587; 163869 Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to a.) administer medications within scheduled parameters on various shifts for two residents (Resident #38 & Resident #42); b.) complete the dialysis communication book for a resident on dialysis (Resident #37); and c.) follow a for physician's order to monitor a resident for urinary retention in accordance with professional standards of practice. This deficient practice was identified for 4 of 27 residents reviewed for professional standards of practice (Resident #37, #38, #42, & #45). 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…

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, review of Nurse Staffing Report sheets, and other pertinent facility documents, it was determined that the facility failed to ensure a Registered Nurse worked seven days a week for at least eight consecutive hours a day for 5 of 16 weekends reviewed. This deficient practice was evidenced by the following: During entrance conference on 2/27/24 at 10:13 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) how the facility's staff was, and the LNHA stated that staffing was good; that the facility primarily utilized agency staff for certified nursing aides (CNA); the facility did have callouts. At this time, the surveyor requested the Nurse Staffing Report to be completed for the following weeks: 1/1/23 through 1/7/23; 2/12/23 through 2/18/23; 2/19/23 through 2/25/23; 3/12/23 through 3/18/23; 5/21/23 through 5/27/23; 5/28/23 through 6/3/23. The surveyor reviewed the Nurse Staffing Reports which revealed there was no Registered Nurse (RN) to work eight consecutive hours on the following dates: 1. No RN on 1/7/23; the last…

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 a.) properly label and date medication in accordance with manufacturer recommendations and b.) maintain a medication refrigerator temperature log to ensure safe medication storage. This deficient practice was observed in 1 of 2 medication storage rooms (Second-Floor) and 1 of 3 medication carts (low cart- Second-Floor) inspected, and was evidenced by the following: 1. On 3/4/24 at 10:47 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the Second-Floor nursing unit's low cart and observed the following multi-dose medications had been opened and undated: Incruse Ellipta 62.5 microgram (mcg) inhaler (medication used for symptoms of chronic obstructive pulmonary disease, COPD) dated opened 1/14. Instructions on the package were discard the inhaler six weeks after opening the moisture-protective foil tray . Advair HFA 230 mcg/21 mcg inhaler (medication used for asthma or COPD, opened and undated. Instructions on the package were…

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 a.) ensure residents who received the standard serving of the main entree for a regular texture lunch meal was adequate in protein based on the nutritional needs of the residents; b.) ensure the menu was followed; c.) ensure the facility's Registered Dietitian reviewed the menus for nutritional adequacy; and d.) ensure that residents received food and beverage in accordance with their preferences (Resident #6, #21, and #99) This deficient practice was identified for 1 of 2 regular texture meals observed and 3 of 6 residents reviewed for food (Resident #6, #21, & #99), and was evidenced by the following: 1. During entrance conference on 2/27/24 at 10:13 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) the facility's menus for the survey period which included that week and the following week. A review of the menu provided titled S/S Week 3 which was identified by the LNHA for the week of 2/25/24 through…

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 serve residents a nourishing snack when there was more than a fourteen-hour span of time between the dinner and breakfast mealtimes. This deficient practice was identified for five of five residents sampled for bedtime snacks (Resident #18, #19, #51, #65, and #73), and was evidenced by the following: On 2/29/23 at 10:33 AM, the surveyor conducted a Resident Council meeting which included five residents (Resident #18, #19, #51, #65, and #73). All five residents informed the surveyor during the meeting that bedtime (HS) snacks were not offered every night. They further stated that they had to ask for a snack and if there were any snacks left in the bins kept under the nurses station, they were given chips, pretzels, or cookies. All residents stated it would be nice if the facility automatically provided each resident with an HS snack. The residents confirmed dinner was served between 4:30-5:00 PM on the First-Floor nursing unit and breakfast between 8:00-8:45 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, and review of pertinent facility documents, it was determined that the facility failed to a.) store, label, and date potentially hazardous foods to prevent food-borne illness; b.) discard potentially hazardous foods past their date of expiration; and c.) maintain storage areas in a sanitary manner. This deficient practice was evidenced by the following: On 2.27/24 at 10:42 AM, the surveyor toured the kitchen with the Director of Dietary (DD) and observed the following: 1. In the walk-in refrigerator, one five-pound container of sour cream dated opened 2/1/24. The container had a manufacturer printed expiration date of 5/24/24, but the DD was unsure how many days the sour cream could be used for once opened. 2. In the walk-in refrigerator, one five-pound container of cottage cheese dated opened 2/13/24, with an expiration date of 2/24/24. 3. In the walk-in refrigerator, one gallon of mayonnaise opened. The container had no opened date or when to use by; the DD stated mayonnaise was good for one month after opened. 4. In the walk-in freezer, the vinyl…

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# 162587 Based on interview and review of pertinent facility documents, it was determined the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 75 out of 105 day shifts reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 02/01/2021: One Certified Nurse Aide (CNA) to every eight residents for the day shift. One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and One direct care staff…

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 # NJ161584 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that infection control practices were followed by a.) ensuring appropriate personal protective equipment was worn for residents on enhanced barrier precautions; b.) maintaining and storing medical supplies and tubing in a sanitary manner to prevent infection; c.) ensure medical equipment and privacy curtains were maintained in a sanitary manner to prevent infection; d.) ensure proper and hygiene was performed prior to dining; and e.) infection control practices were followed during medication observation. This deficient practice was identified on 2 of 3 nursing units (First and Second-Floor) and was evidenced by the following: 1. On 2/27/24 at 10:55 AM, the surveyor observed outside Resident #58's room, a sign that indicated the resident was on Enhanced Barrier Precautions which instructed before entering and exiting the room, you must perform hand hygiene; wear (don) a gown for high contact resident care activities which included…

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 implement an adequate antibiotic stewardship program. This deficient practice was identified during a review of the last three months of antibiotic use and conducted surveillance from November 2023 through February 2024, and was evidenced by the following: This deficient practice was evidenced by the following: On 3/5/24 at 8:54 AM, the surveyor requested the facility's surveillance for the facility's Antibiotic Stewardship Program. At that time, the Infection Preventionist (IP) met with the surveyor, but the IP could not provide surveillance documentation for antibiotics used. The IP stated that the nurses filled out blue forms on the units for antibiotic use, and she reviewed them during the morning meeting. She stated that she had a spreadsheet that she documented and prepared a monthly report for the Director of Nursing (DON). At that time, the surveyor requested the forms and the spreadsheet from the IP, but the IP could not provide the forms. On 3/6/24 at 1:06 PM, the Chief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain a resident bathroom sink (Resident room [ROOM NUMBER]) in a sanitary working condition and b.) maintain resident rooms and common area in a safe, sanitary, and comfortable environment for 1 of 3 nursing units (Second-Floor). The evidence was as follows: 1. During a water temperature tour on 2/29/24 at 10:50 AM, the surveyor observed in the presence of the Maintenance Director (MD) in Resident room [ROOM NUMBER]'s bathroom, the sink did not operate properly, that the water dripped out. The MD stated at the time of the observation, that he was unaware that Resident room [ROOM NUMBER]'s bathroom sink was not working. The MD stated all maintenance work that needed to be done was entered into the electronic work order system [name redacted]. At this time the surveyor requested the electronic work order system [name redacted] report for the year. On 2/29/24 at 12:09 PM, 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 observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure residents were served their meals in a dignified manner during meal services. This deficient practice was identified on 1 of 3 nursing units (Second-Floor), and was evidenced by the following: On 2/27/24 from 12:18 PM to 12:49 AM, the surveyor made the following meal observations in the Second- Floor dining room: On 2/27/24 at 12:19 PM, the food truck arrived to the Second-Floor nursing unit. There were sixteen residents observed seated in the dining room at five different tables. The Certified Nursing Aide (CNA #1) placed a tray in front of Resident #30 and walked away. Resident #30's tablemate proceeded to take Resident #30's tray and removed the dome from the tray. The surveyor observed that CNA #2 from the opposite side of the dining room addressed the resident in a raised voice stating, Leave it alone [Resident's name] [he/she] is feeder. On 2/27/24 at 12:29 PM, the surveyor observed the staff did not serve residents by tables. The surveyor observed…

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 #NJ160540 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) provide a wheelchair for resident use when out of bed(Resident #43); b.) maintain the call bell within reach of the resident (Resident #58); and c.) accommodate a resident whose preference was to smoke without getting wet during inclement weather (Resident #31). This deficient practice was identified for 3 of 28 residents reviewed for accommodation of needs (Resident #31, #43, and #58), and was evidenced by the following: 1. On 2/28/24 at 9:15 AM, the surveyor observed Resident #43 in bed and there was no wheelchair observed in the room. On 2/29/24 at 12:04 PM, the surveyor observed the resident in bed with head of bed elevated, eyes closed. The resident did not respond to surveyor inquiry. There was no observed wheelchair noted in the room. On 2/29/24 at 12:09 PM, the surveyor interviewed the resident's primary Certified Nurse Aide (CNA #1), who stated the resident needed complete care and she wanted to get the resident out of bed, but…

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 resident was free of exploitation and misappropriation of resident property. The deficient practice was identified for 1 of 6 residents reviewed for abuse (Resident #47), and was evidenced by the following: On 2/28/24 at 12:14 PM, the surveyor interviewed Resident #47 who stated he/she had an issue with a Certified Nursing Aide (CNA #1) who no longer worked at the facility. The resident stated he/she developed a bond with CNA #1, and the aide would ask the resident to borrow money which he/she provided. The resident continued CNA #1 always paid them back the borrowed money, and there were multiple financial transactions, but CNA #1 stopped paying the resident back the money she borrowed. The resident stated he/she transferred the money using money applications (app) on their phone, and CNA #1 owed him/her around $330 that was never paid back. The resident stated the facility's Director of Quality Experience (DQE) and current Licensed Nursing Home…

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 a.) develop an abuse policy that was in accordance with regulatory guidelines and b.) implement their abuse policy for an allegation of misappropriation of resident property. This deficient practice was identified for 1 of 6 residents reviewed for abuse (Resident #47), and was evidenced by the following: During entrance conference on 2/27/24 at 10:13 AM, the surveyor requested and provided the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) with the Centers for Medicare & Medicaid Services (CMS) Entrance Conference Worksheet which indicated in section 32. Abuse Prohibition Policy and Procedures to be provided to the surveyor for the next day. On 2/28/24 at 9:00 AM, the surveyor reviewed the facility's undated Abuse Policy and Procedure which did not include how the facility would protect residents from abuse through screening, training, preventing, identification, and protecting. The policy included investigation and reporting. 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, and review of pertinent facility documents, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) assessment for 1 of 5 residents reviewed for unnecessary medications (Resident #80), and was evidenced by the following: On 2/29/24 at 11:50 AM, the surveyor observed Resident #80 in a wheelchair in the hallway self-propelling using their feet. The surveyor reviewed the medical record for Resident #80. A review of the admission Record face sheet (an admission summary) reflected that Resident #80 was admitted to the facility with diagnoses that included schizophrenia, bipolar disorder, cerebral infarction (stroke- parts of the brain become damaged or die). A review of the Psychiatric Progress Noted dated 2/12/24 included under diagnosis and plan that the resident had a current diagnosis of schizoaffective disorder- depressed type, insomnia, and Post Traumatic Stress Disorder (PTSD). A review of the resident's most recent comprehensive MDS, an…

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 develop and implement a comprehensive person-centered care plan that identified services to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. This deficient practice was identified for 3 of 28 residents reviewed for comprehensive care plans (Resident #45, #80, and #102), and was evidenced by the following: 1. On 2/28/24 at 10:18 AM, the surveyor observed Resident #45 sleeping in bed on his/her right side. The surveyor reviewed the medical record for Resident #45. A review of the admission Record face sheet (an admission summary), Resident #45 was admitted to the facility with diagnoses including, but not limited to, osteomyelitis (infection of the bone) of left femur, pressure ulcer (Stage 4) left hip, and heart failure. A review of the admission Minimum Data Set (MDS), an assessment tool reflected that the resident was not able to complete…

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 a.) revise a comprehensive care plan and for pressure wounds and b.) revise a care plan to include a resident gave staff money. This deficient practice was identified for 2 of 27 residents reviewed for care plans revisions (Resident #47 & Resident #79) and was evidenced by the following: 1. On 2/28/24 at 11:50 AM, the surveyor observed the resident seated in a high-back wheelchair with foot pedals. The surveyor reviewed the medical record for Resident #79. A review of the admission Record face sheet (an admission summary) reflected that the resident had a diagnosis that included but was not limited to anemia, fracture of the right femur, and hypertension. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 2/6/24, reflected the resident had a cognitive mental status of memory problems with severe impairment. Further review revealed the resident had a stage III…

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 a.) assist a resident out of bed daily with the use of a hoyer lift as ordered by the physician. This deficient practice was identified for 1 of 28 residents reviewed for quality of care (Resident #102), and was evidenced by the following: On 2/29/24 at 12:00 PM, the surveyor observed Resident #102 in bed. The resident stated that he/she was waiting for their lunch meal and that he/she needed assistance getting out of bed and wished that the staff would get him/her out of bed. Resident #102 stated that he/she had not been out of bed for over a week. On 3/1/24 at 12:45 PM, the surveyor observed Resident #102 in bed eating their lunch. Resident #102 stated that he/she still had not been assisted out of bed. The surveyor reviewed the medical record for Resident #102. A review of 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 peripheral vascular…

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 that a resident with limited range of motion of the right hand received appropriate services to prevent further decrease in range of motion. This deficient practice was identified for 1 of 3 residents reviewed for positioning/mobility (Resident #6), and was evidenced by the following: On 2/27/24 at 12:44 PM, the surveyor interviewed Resident #6 who stated that they had a contracture to the right hand. When asked if he/she was supposed to wear a brace, the resident opened their dresser drawer to show the surveyor a brace. Resident #6 stated that they do not wear it because it hurts. The resident stated that he/she had told the nursing staff, but nothing had been done. On 2/29/24 at 11:21 AM, the surveyor observed Resident #6 dressed and seated in their wheelchair. The resident did not have the brace applied. On 3/4/24 at 10:53 AM, the surveyor observed Resident #6 dressed and seated in their wheelchair. The resident did not have the brace applied. 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 review of pertinent facility documents, it was determined that the facility failed to ensure that a resident was assessed and the comprehensive care plan was updated post fall with safety interventions for a resident with a history of falls. This deficient practice was identified for 1 of 7 residents reviewed for falls (Resident #79), and was evidenced by the following: On 2/28/24 at 11:50 AM, the surveyor observed the resident seated in a high-back wheelchair with foot pedals in the dining area. The surveyor reviewed the medical records for Resident # 79. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses that included anemia, fracture of the right femur, and hypertension. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 2/6/24, reflected a cognitive mental status of memory problems with severe impairment. Further review of Section I Active Diagnoses reflected a fall diagnosis. A review of the Progress Note included a Health…

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 the facility failed to accurately document the administration of a controlled medication for 1 sampled resident (Resident #171) identified upon inspection of 1 of 3 medication carts (low-cart Second-Floor), and was evidenced by the following: On 3/4/24 at 10:47 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the Second-Floor nursing unit low-side medication cart. A review of the narcotics located in the secured and locked narcotic box and reconciled to the controlled drug administration record, a declining inventory sheet, revealed Resident #171's tramadol 50 milligram (mg) tablet, a medication used to relieve pain, did not match. The blister packs contained 36 tablets and the declining inventory sheet indicated there should be 37 tablets remaining. The LPN stated she had administered the medication earlier and she had forgotten to sign the declining inventory sheet for the dose she had administered. The LPN further stated the declining inventory 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, and review of pertinent facility documentation, it was determined that the facility failed to ensure safe and appetizing temperatures of food for 2 of 2 regular texture meals observed during 1 of 1 meal observations (lunch) on 1 of 3 nursing units (Second-Floor). This deficient practice was evidenced by the following: On 2/29/24 at 10:33 AM, the surveyor conducted a Resident Council meeting which included five residents (Resident #18, #19, #51, #65, and #73). Four of the five residents informed the surveyor during the meeting that the meals served at the facility were cold; room temperature if lucky. On 3/1/24 at 11:22 AM, the surveyor informed the Director of Dietary (DD) they wanted to observe the lunch meal for the day including food temperatures. The surveyor asked the DD to calibrate the facility's digital thin probe thermometer in their presence; which the DD completed using an ice bath, and the thermometer reached 33 degrees Fahrenheit (F). The surveyor completed the same process, and their thermometer reached 32 F. On 3/1/24 at 11:40 AM, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #:NJ00164488 Based on observation, interview, record review, and review of other facility documentation on 11/28/23 and 11/30/23, it was determined that the facility failed to provide care for a resident with a suprapubic catheter (a tube used to drain urine from the bladder through a cut in the abdomen) in accordance with physician's orders. The deficient practice was identified for Resident #1, 1 of 3 residents reviewed for bladder and bowel care and was evidenced by the following: On 11/28/23 at 10:32 AM the surveyor observed Resident #1 lying in bed with a drainage bag hanging off their bed with a small amount of yellow liquid inside the bag. When interviewed, Resident #1 stated that it depended on which staff members were working if their drainage bag was emptied or their suprapubic catheter was flushed. According to the admission Record, Resident #1 was admitted on [DATE], with medical diagnoses that included but were not limited to multiple sclerosis (a potentially disabling disease of the brain…

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 #: NJ00163880, NJ00164147 Based on observation, interview, record review, and review of other facility documentation on 11/28/23 and 11/30/23, it was determined that the facility failed to follow up with a medical provider when a routinely scheduled medication was unavailable. The deficient practice was identified for Resident #2, 1 of 3 residents reviewed for medication administration, and was evidenced by the following: On 11/28/23 at 11:02 AM, the surveyor observed Resident #2 in their bed. The resident did not respond to the surveyor's questions. According to the admission Record, Resident #2 was admitted on [DATE], with medical diagnoses that included but were not limited to seizures, cerebral infarction (disrupted blood flow to the brain), and traumatic subdural hemorrhage (bleeding in the area between the brain and the skull) with loss of consciousness. The annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/02/23, revealed that the resident 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.

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 11/19/21 at 10:29 AM, the surveyor, in the presence of the Food Service Director (FSD), observed the following during the kitchen tour: 1. A stack of five aluminum pans was stored on a multi-tiered cart. The surveyor observed the five aluminum pans were wetnesting and noted a slimy unknown substance on the edge of the bottom aluminum pan. The surveyor wiped the edge of the bottom aluminum with a napkin and noted debris and a slimy unknown substance on the napkin. 2. A soiled dishware was stored on the top shelf of a multi-tiered cart alongside clean and sanitized dishware. 3. A stack of seven one-third pans was stored on a multi-tiered cart. The seven one-third pans were wetnesting. 4. In the juice box area, a juice nozzle was not attached to a juice box and touched the floor. When…

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 facility documentation, it was determined that the facility failed to administer medication in accordance with the physician's orders. This deficient practice was identified in 1 of 5 residents reviewed for unnecessary medications (Resident #95) and was evidenced by the following: According to the resident's admission Record, Resident #95 had a diagnosis including, but not limited to, essential (primary) hypertension (high blood pressure in which additional and underlying causes contributing to the high blood pressure are not present). According to the Physician's Orders, Resident #95 had an order for Hydralazine tablet 50 milligrams (mg) - give 50 mg by mouth three times a day for hypertension - hold if SBP is less than 130 mm HG, where SBP (systolic blood pressure) is the first (top) number and is a measure of the exertion of blood against the artery walls, when the heart beats. Further review of the orders revealed that the referenced medication order and hold parameter began on 08/12/21 and remained current into November 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 and interview, it was determined that the facility failed to a.) provide residents' meals with food items as requested, b.) speak to the residents about alternate food items when the items first requested were not available and c.) provide food at a preferable and appetizing temperature. This deficient practice was identified for Residents #8, #21, #26, #37, #71, #247, #297, and #298 observed by the surveyors during a breakfast and lunch meal on 2 of 2 nursing units (1st Floor and 2nd Floor Units), and 5 of 5 residents who attended the Resident Council and was evidenced by the following: On 11/16/21 at 9:33 AM, during the initial tour of the 1st Floor Unit, Surveyor #1 observed Resident #247 sitting at beside with a disposable breakfast tray on the overbed table. When interviewed, the resident stated the breakfast meal consisted of a boiled egg, muffin, oatmeal, and that it was not hot. Surveyor #1 reviewed Resident #247's breakfast meal ticket which indicated the following under Hot items: oatmeal, egg and cheese, breakfast ham, and an English muffin. Resident…

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 documents, it was determined that the facility failed to maintain the call bell within reach for 1 of 4 residents (Resident #52) reviewed for accidents. This deficient practice was evidenced by the following: On 11/16/2021 at 9:40 AM, the surveyor observed Resident #52 lying in bed asleep and the call bell was on the floor, to the left side of the resident's bed. On 11/17/2021 at 1:04 PM, the surveyor observed Resident #52 lying in bed awake and the call bell was on the floor, at the foot of the bed. The resident stated he/she uses the call bell to call for help, but that the call bell is usually on the floor. On 11/18/2021 at 10:43 AM, the surveyor observed Resident #52 lying in bed awake and the call bell was on the floor, at the foot of the bed. The resident stated that he/she yells out for help when the call bell is not within reach or relies on his/her roommate to get assistance. According to the admission Record, Resident #52 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.

Based on interview, record review, and review of other facility documentation, it was determined that facility staff failed to complete neurological assessments after a resident fall, in accordance with professional standards. This deficient practice was identified for 1 of 4 residents (Resident #95) reviewed for accidents 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 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 Act for the State of New Jersey states: The practice of nursing…

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 documents, it was determined that the facility failed to ensure a floor mat was in place for 1 of 3 residents (Resident #52) reviewed for falls. This deficient practice was evidenced by: On 11/17/2021 at 1:04 PM, the surveyor observed Resident #52 lying in bed. The resident's left side of the bed was against the wall and a floor mat was folded next to the resident's right side of the bed, exposing the bottom right half of the bed to the floor. On 11/18/2021 at 10:43 AM, the surveyor observed Resident #52 lying in bed. The resident's left side of the bed was against the wall and a floor mat was folded at the foot of the resident's bed, exposing the entire right side of the bed to the floor. According to the admission Record, Resident #52 was admitted with diagnoses that included, but were not limited to, cerebral infarction (stroke) and hemiplegia (partial paralysis) and hemiparesis (partial weakness) affecting the left non-dominant side.…

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

Based on observation, interview, and review of other facility documents, it was determined that the facility failed to provide a sanitary environment for residents, staff and the public by failing to keep the garbage container area free of garbage and debris, and failed to have a cover over the openings of 1 of 2 garbage containers/dumpsters. This deficient practice was evidenced by the following: On 11/16/21 at 10:51 AM, the surveyor toured the kitchen with the Food Service Director (FSD), and requested to see the outside garbage receptacle area. The surveyor observed a garbage container (GC) that was uncovered and exposed to the elements. The GC had a closed lid on the left-side, but the right-side lid was open exposing multiple trash bags inside. The surveyor further observed that both the left-side and right-side doors of the GC was also open exposing multiple trash bags inside. The surveyor observed that the outside garbage receptacle area was littered with debris, used gloves, clear bags, and juice cartons. When interviewed at that time, the FSD stated that everyone 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.