Dwellside Care And Rehab

Based on interview, record review, and review of facility documents, it was determined that the facility failed to report an allegation of staff-to-resident verbal abuse to the New Jersey Department of Health (NJDOH) within two hours of the allegation being made for 1 of 2 residents (Resident #4) reviewed for abuse. This deficient practice was evidenced by the following: On 5/14/25 at 9:01 AM, the surveyor observed Resident #4 seated in the wheelchair at the nurse's station. The resident stated that he/she wanted to leave the facility. The resident further stated that a nurse called him/her a bitch yesterday. When the surveyor asked the resident who said that, the resident pointed to a nurse who walked past the nursing station in blue scrubs. The resident was unable to state the nurse's name or to give any further details. The resident then pointed to the accused nurse a second time and stated, That's her. The surveyor reviewed the medical record for Resident #4. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of pertinent facility documents it was determined that the facility failed to code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care for all residents, accurately. This deficient practice was identified for 1 of 28 residents reviewed for MDS (Resident #69), and was evidenced by the following: On 5/13/25 at 9:52 AM, during entrance conference with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor requested a list of residents who smoke. On 5/13/25 at 10:33 AM, during the initial tour, Licensed Practical Nurse/Unit Manager (LPN/UM) #3 identified Resident #69 as a smoker. On 5/13/25 at 10:51 AM, during the initial tour, the surveyor observed Resident #69 sitting in a wheelchair in their room resting with their eyes closed. On 5/13/25 at 2:05 PM, the surveyor reviewed the medical record for Resident #69. A review of the admission Record, an admission summary, revealed 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 interview, record review, and review of pertinent documents, it was determined that the facility failed to develop and implement a baseline care plan within 48 hours of admission to include a resident's code status for 1 of 1 resident (Resident #142) reviewed for death. This deficient practice was evidenced by the following: On 5/13/25 at 12:49 PM, the surveyor reviewed the medical record for Resident #142. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, dementia, chronic kidney disease, and adult failure to thrive. A review of the Baseline Care Plan, dated 2/28/25, revealed the Code Status was left blank. A review of the Universal Transfer Form, dated 2/28/25, include a Code Status of Do Not Resuscitate (DNR). A review of the Social Service Assessment, dated 3/3/25, included a Code Status of DNR. On 5/16/25 at 9:03 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #3 who stated the facility had 48 hours to complete the baseline care plan. When asked if the code…

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 facility documents, it was determined that the facility failed to develop an individual comprehensive care plan to include a resident's fall risk for 1 of 4 residents (Resident # 12) reviewed for accidents. This deficient practice was evidenced by the following: On 5/14/25 at 12:46 PM, the surveyor observed Resident #12 being fed by staff in the day room. The surveyor reviewed the medical record for Resident #12. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, dementia, muscle weakness, and difficulty in walking. A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/1/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident had one fall with injury since the prior assessment. A review of the individual comprehensive care plan (ICCP),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility documents, it was determined that the facility failed to obtain a physician's order for a resident's code status (medical instructions regarding resuscitation and other lifesaving measures in the event of a medical emergency) for 1 of 1 resident reviewed (Resident #142) for death. This deficient practice was evidenced by the following: On [DATE] at 12:49 PM, the surveyor reviewed the medical record for Resident #142. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but was not limited to, dementia, chronic kidney disease, and adult failure to thrive. A review of the Order Summary Report (OSR) as of [DATE], did not include a physician's order (PO) for the resident's code status. A review of the Baseline Care Plan, dated [DATE], revealed the Code Status section was left blank. A review of the Universal Transfer Form (UTF), dated [DATE], included a Code Status of Do Not Resuscitate (DNR). 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, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to obtain, record, and monitor weights on admission, readmission, and weekly in accordance with professional standards of practice. This deficient practice was identified for 2 of 3 residents (Resident #20 and Resident #48) reviewed for nutrition and was evidenced by the following: 1.) On 5/13/25 at 10:01 AM, the surveyor observed Resident #20 awake and alert sitting in a wheelchair in the lounge. On 5/14/25 at 9:18 AM, the surveyor observed Resident #20 during breakfast, but the resident refused to eat. The resident had a split plate, built-up angled utensils, nectar thickened liquids, and a fortified frozen supplemental dessert on his/her tray. On 5/14/25 at 1:15 PM, the surveyor observed Resident #20 during lunch. Resident #20 was seated in a wheelchair with a clothing protector eating lunch with built-up utensils and drinking thickened liquids out of a cup. The surveyor reviewed the medical record for Resident #20. A review of the admission…

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

3.) On 5/13/25 at 10:27 AM, during the initial tour of the B Unit, the surveyor observed Resident #79 awake, alert, and lying in bed. Resident #79 stated that his/her medications were always late, usually about an hour and a half late. Resident #79 further stated I did not get my morning medications yet. On 5/13/25 at 1:06 PM, the surveyor reviewed the medical record for Resident #79. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: metabolic encephalopathy (a change in how your brain works due to an underlying condition), depression, Type 2 Diabetes, Non -Hodgkin's Lymphoma (a type of blood cancer), anxiety, and chronic pain. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/21/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident took the following high-risk medications:…

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 #: NJ184692 Based on observation, interview, record review, and other facility documents, it was determined that the facility failed to ensure that resident's preferences were accurately identified and implemented for 2 of 5 residents (Resident #111 and Resident #128) reviewed for food and dining services. This deficient practice was evidenced by the following: 1.) On 5/14/25 at 9:12 AM, the surveyor observed Resident #128 lying in bed with their meal tray in front of them. The resident's meal ticket indicated that the resident was on a liberalized diabetic diet with no pork, beef, or fish, and included that the resident received regular skim milk six (6) ounces (oz). The surveyor observed the meal tray and noted that the resident had received whole milk instead of skim milk. On 5/15/25 at 12:44 PM, the surveyor observed Resident #128 seated in the wheelchair in the dining room with their meal tray in front of them. The resident stated that he/she received everything that was requested except for skim milk. The resident stated that he/she received whole milk again, and not…

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

Based on observation, interview, and review of facility documents, it was determined that the facility failed to properly dispose of waste in and around the trash compactor in order to maintain a safe, and sanitary environment. This deficient practice was evidenced by the following: On 5/13/25 at 10:46 AM, in the presence of the Food Service Director (FSD) the surveyor observed that there were three cigar tips and an empty pack of cigars outside of the trash compactor on the loading dock. The FSD stated that staff cleaned the area around the trash compactor three times daily. When the surveyor asked if staff were permitted to smoke on the loading dock, the FSD stated that smoking was not permitted. The FSD stated the cigar packaging and cigar tips may have blown from trash onto the ground. The surveyor also observed that there was a surgical mask, two pair of disposable gloves, and a coffee cup on the ground. The FSD stated that those items were usually placed in the trash can after use. The surveyor also observed that there were two No Smoking signs in the immediate vicinity. 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, record review, and review other facility documentation, it was determined that the facility failed to ensure residents' records were kept confidential for 1 of 4 residents (Resident #13) observed during the medication administration pass. This deficient practice was evidenced by the following: On 5/15/25 at 8:12 AM, the surveyor observed Licensed Practical Nurse (LPN) #4 prepare medications for Resident #13. When the LPN left the medication cart to administer the resident's medications, she did not put up a privacy screen to cover the resident's information displayed on the laptop. On 5/15/25 at 8:49 AM, the surveyor interviewed LPN #4 who stated that she should have put the privacy screen up on her laptop when leaving the medication cart to protect the resident's private information. On 5/16/25 at 9:41 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated the nurse should put the privacy screen up on the laptop when leaving the medication cart to ensure all resident information was not accessible. On 5/16/25 at…

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

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 adhere to proper infection control practices during the provision of a wound treatment. This deficient practice was identified for 1 of 2 residents (Resident #47) reviewed for Pressure Ulcer/Injury and was evidenced by the following: Refer to F584 On 5/14/25 at 9:44 AM, the surveyor observed Resident #47 lying in bed awake. The resident stated that he/she had a Stage 3 (three) pressure ulcer (a deep wound with full-thickness skin loss with no exposed bone, tendon, or muscle) that developed in the hospital on 4/6/25. The resident stated that Licensed Practical Nurse (LPN) #1 changed the dressing the day prior. The resident agreed to allow the surveyor to observe his/her next scheduled wound treatment. The surveyor reviewed the medical record for Resident #47. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure the environment was clean, sanitary, and homelike for four out of 11 sampled residents (Resident (R)4, R17, R18, R27) who resided on the second floor ([NAME] unit). Specifically, the only shower room on the second floor ([NAME] unit) and common area floors on the second floor were unclean. Additionally, food carts with partially eaten meals from the previous day were observed in the hallway on the first floor. Findings include: Review of the facility's Homelike Environment policy dated August 2024 revealed, Residents are provided with a safe clean, comfortable and homelike environment . The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: Clean, sanitary, and orderly environment . 1. Residents residing on the second-floor reported concerns about cleanliness and the condition of the shower…

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

Based on observations, interviews, record review, review of Resident Council Meeting Minutes, and policy review, the facility failed to provide palatable food to eight out of 32 sampled residents (Residents (R)4, R17, R18, R26, R1, R28, R6, and R30). Additionally, there were complaints from Resident Council Meetings without responses. The food was not at an appetizing temperature when residents received their meals, the food was bland, food was not prepared appropriately, and condiments were not available or served. This created the potential for weight loss and resident dissatisfaction. Findings include: Review of the facility's undated Food Preparation Guidelines policy revealed, It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status . Food palatability refers to the taste and/or flavor of the food. Proper (safe and appetizing) temperature means both appetizing to the resident and minimizing the risk for scalding and burns .Food shall be prepared by methods that conserve nutritive value, flavor 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 record review, interview, and facility policy review, the facility failed to ensure abuse investigations were thoroughly investigated for three out of five investigations reviewed affecting four out of 32 sampled residents (R20, R21, R22, and R24) Specifically, the facility failed to interview the alleged victims, perpetrators, witnesses, and failed to determine whether abuse occurred, the extent, the cause, and failed to ensure complete and thorough documentation was maintained. This created the potential for abuse to occur unchecked. Findings include: Review of the facility's, Abuse, Neglect, and Exploitation policy dated 10/21/24 revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse . Written procedures for investigations include: . 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator,…

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, staff interview, and review of facility policy, the facility failed to ensure that one of two medication carts on A Hall was secure when staff were not present. This had the potential to affect all residents on that hall who could have accessed the cart. Findings include: Review of the facilities policy titled, Security of Medication Cart, revised August 2024 revealed, medication carts must be secured during medication pass to prevent unauthorized entry. During an observation on 02/26/25 at 6:07 AM revealed a medication cart sitting in the front of the nurse's station outside the hallway down from resident rooms [ROOM NUMBERS] was not locked and the computer screen was also open and upright revealing 14 resident names. There was one certified nurse's aide walking down the hallway. During an interview on 02/26/25 at 6:11 AM Licensed Practical Nurse (LPN) 6 walked up from another hallway and stated she knew the cart was unlocked. She said there were no families visiting or residents up 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.

COMPLAINT #: NJ00167155 Based on interviews, medical record review, and review of other pertinent facility documents on 1/26/24 and 1/30/24, it was determined that the facility failed to initiate a comprehensive person center care plan for a resident with a vaginal infection. The facility also failed to follow its undated policy titled Nursing Documentation. This deficient practice was identified for 1 of 2 residents (Resident #4) reviewed for comprehesive Care Plan (CP) and was evidenced by the following: Review of the Medical Record was as follows: According to the Face Sheet, Resident #4 was admitted to the facility with diagnoses that included but were not limited to: Multiple Sclerosis (a condition that happens when the immune system attacks the brain and spinal cord), neuromuscular dysfunction of bladder (lacking bladder control), and Vaginitis, vulvitis, and vulvovaginitis (vaginal infections). The surveyor reviewed the progress notes (PN) for Resident #4 which revealed: -A Physician PN, dated 08/22/23, at 3:22 P.M., Resident #4 was receiving treatment for: Anogenital…

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 #: NJ00170403 Based on interviews, medical record review, and review of other pertinent facility documents on 1/26/24 and 1/30/24, it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the resident according to facility policy and protocol for 2 of 2 residents (Resident #4 and Resident #5) reviewed for documentation. This deficient practice was evidenced by the following: 1.) According to the admission Record (AR), Resident #4 was admitted to the facility with diagnoses that included but were not limited to: Multiple Sclerosis (a condition that happens when the immune system attacks the brain and spinal cord), muscle weakness, and epileptic seizures. The Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/04/23, indicated that Resident #4 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated…

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

COMPLAINT #: NJ00166293 Based on observation, interview, record review, and other facility documentation on 1/26/24 and 1/30/24, it was determined that the facility failed to submit a specimen to the laboratory in a timely manner. This deficient practice was identified for 1 of 1 resident (Resident #4)reviewed for laboratory services and was evidenced by the following: The surveyor reviewed the medical record for Resident #4. According to the admission Record, Resident #4 was admitted to the facility with diagnoses that included but were not limited to Multiple Sclerosis (is a condition that happens when the immune system attacks the brain and spinal cord), muscle weakness, and epileptic seizures. The Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/04/23, indicated that Resident #4 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident's cognition was intact. The surveyor reviewed Resident #4's Order Summary Report (OSR) for the active orders as of 08/01/23, which 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.

Complaint #: NJ00165770 Based on observation, interview, record review, and review of other pertinent facility documentation on 01/26/24 and 01/30/24, it was determined that the facility failed to provide shower care to a resident that was dependent on staff for activities of daily living (ADLs). This deficient practice was identified for 1 of 2 residents (Resident #4) reviewed for showers, and was evidenced by the following: The surveyor reviewed the medical record for Resident #4. According to the admission Record, Resident #4 was admitted to the facility with diagnoses that included but were not limited to Multiple Sclerosis (is a condition that happens when the immune system attacks the brain and spinal cord), muscle weakness, and epileptic seizures. The Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 12/04/23 revealed that Resident #4 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident's cognition was intact. The MDS also indicated that the resident required substantial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of pertinent facility documentation it was determined the facility failed to follow resident rights for the distribution of funds from a resident's personal needs allowance (PNA). This deficient practice was identified for five (5) of five (5) residents (Resident #30, #47, #56, #72 and #87) who attended a Resident Council (RC) group meeting and was evidenced by the following: On 04/14/23 at 11:04 AM, the surveyor conducted RC with five (5) residents (Resident #30, #47, #56, #72 and #87), who were alert and oriented and regularly attended the RC group meeting. During the RC meeting, five (5) out of five (5) residents had complaints regarding their PNA. They stated that they should not be told several times during the day that there was not enough money for withdrawal. They all stated that the facility should make sure that there was an ample amount of funds at the facility. Resident #87 stated that they were limited to $40.00 a day. Resident #47 stated that 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, record review and review of pertinent facility documentation it was determined the facility failed to: a.) ensure staff consistently document the urine output from the indwelling urinary catheter drainage bag for, (Resident #41), b.) ensure staff consistently follow a Physician Order (PO) to apply heel booties and offload heels for, (Resident #100), and c.) notify a resident's representative of an injury that occurred at the facility for, (Resident #24). This deficient practice was identified for three (3) of 38 residents reviewed for professional standards of practice related to nursing care. 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…

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 the facility failed to ensure discharge summaries were documented which included a recapitulation (recap) of the resident's stay and a final summary of the resident's status for five (5) of five (5) residents (Resident #29, #123, #325, #326, and #327) reviewed for discharge. This deficient practice was evidence by the following: 1.) On 04/06/23 at 10:02 AM, during the initial tour, the surveyor observed Resident #29 sitting in his/her wheelchair watching television in their room. Resident #29 stated that he/she might be discharged on Saturday 04/08/23, due to insurance issues but was not completely sure. The surveyor reviewed the electronic medical record (EMR) for Resident #29. A review of the resident's admission Record (AR) reflected that the resident was initially admitted to the facility in September of 2022 and readmitted February of 2023, with diagnoses which included: Hypertension (high blood pressure), type two (2) diabetes mellitus (high blood sugar), end stage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a.) ensure a resident who had multiple clinical diagnoses received their medications to treat their clinical diagnoses in accordance with physician prescribed orders consistently over a two month time frame, b.) ensure a resident received their medications in accordance with manufacturer specifications and c.) follow their medication administration policy and procedure. This deficient practice was identified for one (1) of 38 residents, (Resident #35), reviewed for quality of care and was evidenced by the following: Refer to F697H On 04/06/23 at 12:35 PM, Surveyor #1 observed Surveyor #2 talking to Resident #35 at the end of the hallway on the [NAME] unit. Surveyor #1 overheard the resident tell Surveyor #2 that he/she had not received any of his/her medications that day. At that time, Surveyor #1 observed Surveyor #2 walk toward the Licensed Practical Nurse/Acting Unit…

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, medical record review and review of other pertinent facility documentation it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents documented physician visit progress notes at the time of each visit. This deficient practice was identified for seven (7) of sixteen (16) residents reviewed (Resident #6, #13, #29, #31, #57, #72, #225) and one (1) of two (2) physicians reviewed for physician visits and was evidenced by the following: On 04/18/23 at 12:23 PM, the surveyor reviewed physician visits in the electronic medical records for the following residents which revealed the following information: 1.) The admission Record (AR) indicated that Resident #6 was admitted to the facility with the diagnoses which include but was not limited to diabetes mellitus (high blood sugar) and schizoaffective disorder (psychiatric illness). The surveyor reviewed the Physician Visit Progress Note (PVPN) which revealed four (4) visits were documented late. The PVPN reflected the following: -On 12/22/22, there was a PVPN…

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: a.) properly store potentially hazardous foods in a manner intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was evidenced by the following: On 04/06/23 from 09:34 AM until 10:42 AM, the surveyor toured the kitchen in the presence of the Food Services Director (FSD) and observed the following: 1.) The blue base of the can opener mounted on the counter was observed with brown debris. The FSD acknowledged that it was dirty and stated it should not have been like that. The FSD stated that the can opener got cleaned nightly and that it was missed last night. The FSD then removed the can opener and base from the counter and handed it to the dishwasher to clean. 2.) In the walk-in freezer, on the fourth shelf of a metal rack, there was an opened cardboard box that was marked best before or use by 10/24/22 that contained four (4), 10 pound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a.) ensure that an urinary catheter drainage bag was stored in a manner to prevent the spread of infection for a resident, (Resident #63) one (1) of two (2) residents reviewed for urinary catheter care, b.) provide appropriate infection control practices to prevent the spread of infection during one of one wound treatment observation for, (Resident #6) one of two residents reviewed for pressure ulcers, and c.) provide appropriate hand hygiene while passing out food to three unsampled residents during the lunch meal pass observation, observed on one of three (3) resident dining rooms, the [NAME] unit. This deficient practice was evidenced by the following: 1.) On 04/14/23 at 11:29 AM, the surveyor observed Resident #63 lying in bed in his/her room. The surveyor observed that the resident's indwelling urinary catheter bag was attached to the bed frame and the tubing to 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, record review and review of pertinent facility documentation, it was determined that the facility failed to: a.) store respiratory equipment in a manner to prevent infection, b.) create a Care Plan for the use of respiratory equipment for the resident and c.) provide physician orders for the care of the respiratory equipment. This deficient practice was identified for one (1) of one (1) resident, (Resident #57) reviewed for respiratory care and was evidenced by the following: On 04/06/23 at 11:12 AM, the surveyor observed Resident #57 in bed in his/her room. At that time, the surveyor observed that the resident had a Continuous Positive Airway Pressure (CPAP) machine (a treatment option for sleep apnea which provides air pressure just high enough to prevent collapse of the airway) and a CPAP mask on the nightstand next to the resident's bed. The surveyor saw that the CPAP mask was left open to air, uncovered and was in direct contact with the CPAP machine. The surveyor observed that the resident had a nebulizer mask, resting on the nebulizer machine…

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: a.) ensure that medication records were in order and b.) an account of all controlled medications were maintained and reconciled for one (1) resident's, (Resident #43's) controlled medications which was identified during the inspection of medication carts. This deficient practice was observed in 1 of three (3) medication carts inspected and was evidenced by the following: The admission Record indicated that Resident #43 was admitted to the facility with diagnoses which included but was not limited to epilepsy (seizures disorder). The quarterly Minimum Data Set (MDS), an assessment used to facilitate the management of a resident's care) dated 02/18/2023, indicated that the resident had short- and long-term memory deficits and was nonverbal. The MDS further indicated that the resident was unable to be interviewed. The surveyor reviewed the resident's electronic medical record (EMR) for the last six months which revealed the resident did not have…

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 documentation it was determined that the facility failed to serve hot and cold foods at an acceptable temperature for the residents. This deficient practice was identified for five (5) of five (5) residents who attended a Resident Council (RC) group meeting, and on one (1) of three (3) nursing units, the [NAME] unit, during the lunch meal service on 04/19/23. The deficient practice was evidenced by the following: 1.) On 04/14/23 at 11:04 AM, the surveyor conducted RC with five (5) residents (Resident #30, #47, #56, #72 and #87), who were alert, oriented and regularly attended the RC group meeting. During the RC meeting, 5 out of 5 residents had complaints regarding the temperature of the food. Residents #72 and #87 resided on B wing located on the first floor of the facilty and Residents #30, #47 and #56 resided on the second floor [NAME] unit. They all agreed that the food was cold and told the surveyor that the food was currently only warm…

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 properly handle and store hazardous foods in a manner that is intended to prevent the spread of food borne illnesses. This deficient practice was observed in the facility kitchen and was evidenced by the following: On 03/02/21 at 09:20 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the following: 1. The surveyor went to the handwashing station to wash her hands and observed there was not a trash can for the discarded paper towels. The surveyor asked the FSD where to discard the paper towels and he pointed to a trash bin approximately 10 feet across the kitchen. 2. In the main cooking area the surveyor noted large food particles, paper particles and crumbs on the floor under two ovens and under the gas range. During the observation nothing was cooking on the stove and no cook was in the area. 3. A white plastic two-shelf cart with a stainless-steel container on the top shelf. The white cart had dried liquids…

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 remove and discard expired medication and medical supplies from medication storage rooms. This deficient practice was observed for 2 of 3 medication storage areas and was evidenced by the following: On [DATE] 10:57 AM, in the presence of staff Licensed Practical Nurse (LPN) the surveyor inspected the medication room on A wing and identified the following expired items: 1. 15 - BD Vacutainers with expiration dates of [DATE] 2. 2 - sterile white top specimen containers with expiration dates of [DATE] 3. 6 - sterile orange top specimen containers with expiration dates of [DATE] 4. 2 - Bactiswab collection and transport system with expiration dates of [DATE] 5. 5 - Vacutainer blood transfer device expiration date [DATE] 6. 79 - 0.9% sodium Chloride flush 5 cc expiration [DATE] On [DATE] at 11:05 AM, in the presence of the Registered Nurse Unit Manager (RN/UM), the surveyor reviewed the expired items in the A Wing…

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.