Deptford Center for Rehabilitation and Healthcare

Based on observation, interview, and pertinent record review, it was determined that the facility failed to ensure the accountability of the narcotic Shift Count logs were completed in accordance with facility policy and accurately account for and document the administration of controlled medications. This deficient practice was identified on 4 of 4 medication carts observed on 4 of 4 nursing units and was evidenced by the following: Repeat deficiency from recertification survey of 09/20/2022 On 2/28/2024 at 11:00 AM, the surveyor, in the presence of a second state surveyor and a federal surveyor, interviewed Licensed Practical Nurse (LPN #4), who stated nurses coming on duty along with the nurse going off duty are to count the narcotics in the medication cart together and sign the Shift Count log together to confirm the count is accurate and narcotics are accounted for. She confirmed there should be no missing documentation or blank sections for each shift change. At this point the surveyor, along with LPN #4, reviewed the medication cart and narcotic logs as well as the shift…

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

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) properly store and secure medications and properly label opened multidose medications and b.) properly secure wound treatment carts when not attended. This deficient practice was observed in a.) 2 of 2 medication storage rooms and 4 of 4 medication carts on 4 of 4 nursing units reviewed for medication storage and labeling and in b.) 1 of 1 treatment carts observed during wound observation. This was evidenced by the following: Repeat deficiency from recertification survey of 09/20/2022 a.) On 02/28/2024 at 9:39 AM, the surveyor, in the presence of a second state surveyor and a federal surveyor, interviewed Registered Nurse/Unit Manager (RN/UM #1), who stated all nurses are responsible to maintain the medication storage room's organization and cleanliness. She added that there should be no open medication containers in the storage room and any multidose medications that are stored in the medication room or refrigerator should be labeled and dated with the date…

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

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: Repeat deficiency from recertification survey of 09/20/2022 On 02/27/2024 from 9:32 AM to 10:21 AM, the surveyors, accompanied the Director of Food Services (DOFS), observed the following in the kitchen: The surveyors observed a dietary aide (DA) in the kitchen. The DA had lengthy braids to mid shoulder and was observed wearing a baseball style hat. The braids extended past the shoulders and were exposed. The DA did not have a hair net in place and the hair was exposed. In the dry storage room, a can of corn on the 4 wheeled mobile can rack had a significant dent and a can of artichokes on a shelf had a significant dent on the seam. On interview the DOFS agreed that the cans should have been placed in the designated dented can area, In the dessert and juice refrigerator the surveyors…

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 #NJ169732 Complaint #NJ170765 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a) provide a homelike dining experience on 1 of 2 units, (2nd floor), and b) maintain the facility and equipment in clean and sanitary environment. This deficient practice was identified for 2 of 2 units, (1st and 2nd floor) and was evidenced by the following: Repeat deficiency from recertification survey of 09/20/2022 a.) During the initial tour of the 2nd floor on 02/27/2024 12:22 PM, Surveyor #1observed the nurse pass the first tray and no placemats observed on the trays. There were no tablecloths on the tables. All food and drinks were left on the tray for all residents and not placed directly on the tables. On 02/28/2024 at 12:05 PM, the 1st meal truck arrived at the dining room/patient lounge on the 2nd floor. Resident meals were observed being served on trays and not placed directly on the tables. During an interview with the surveyor 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and review of other facility documentation, it was determined that the facility allowed Non-Certified Nursing Aides (NAs) to continue working as an NA after the specified 120 days from date of hire. This deficient practice was identified for 7 NAs, (NA1, NA2, NA3, NA4, NA5, NA6, NA7) during the NA review. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health memo dated [DATE], sent to Nursing Homes included the following: Facilities are advised as follows: II. Nurse Aides Nurse Aides (not TNAs) who are enrolled in a NATCEP program must finish training and pass the nurse-aide written or oral exam and the State approved clinical skills competency exam within the usual 120 days, pursuant to N.J.A.C. 8:39-43.10. After completing the first 16 hours of training, the nurse aide may work in a nursing home while completing the training and testing. After the surveyor review of NA files provided by the facility, on [DATE] at 12:50 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.

Repeat deficiency from recertification survey of 09/20/2022 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide all the items that were on the corporate menu. This deficient practice occurred during one breakfast meal that was observed on the first floor and was evidenced by the following: Repeat deficiency from recertification survey of 09/22/2022 1. On 02/28/2024 at 09:24 AM, Resident #146 had not received their breakfast tray at that time. Resident #146 stated that they usually receive breakfast between 9-9:15 AM. The meal cart arrived on the unit at (9:30 AM and Resident #146 received his/her tray at 9:34 AM.) Resident #146 received scrambled eggs, bagel (whole) with cream cheese, an 8-ounce (oz) skim milk, 6 oz coffee, cold cereal portion control, a small muffin, and 4 oz orange juice. The facility menu provided to the survey team from the Director of Food Services (DOFS) revealed the following meal was to be served at breakfast on 2/28/2024: 4 fl oz (fluid ounce) Cranberry Juice, 6 fl oz Oatmeal,…

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 # NJ00171057 Repeat deficiency from recertification survey of 09/20/2022 Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to consistently serve foods at a safe and appetizing temperature. This deficient practice was evidenced by the following: On 02/27/2024 at 12:14 PM, during the initial tour of the facility Resident #146 stated that the food has improved but we need more variety, and the portions are small. Resident stated that meal trays arrive between 12:15 and 12:45, you never know. Sometimes food is cold, not what menu says is received. On 2/28/2024 at 10:30 AM, during the resident council meeting 8 of 8 residents attending the resident council meeting complained of cold food to the surveyor. On 02/28/2024 at 09:13 AM, the surveyor observed residents plates on a pellet covered with the bottom of another pellet. On 02/28/2024 at 09:24 AM, Resident #146 had not received his/her breakfast tray. Resident stated that they usually receive breakfast between 9-9:15 AM. Resident stated that…

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

Based on observation, interviews, record review, and review of other facility documentation, it was determined that the facility failed to: 1.) donn (put on) the appropriate personal protective equipment (PPE) prior to entering an isolation room to prevent the transmission of infection 2.) maintain proper infection control practices while performing wound care and 3.) maintain proper infection control practices during the dining observation. This deficient practice was identified for: 1.) 1 of 3 residents (Resident #645) on transmission-based precautions, 2.) 1 of 2 residents observed for wound care (Resident #126), and 3.) 1 of 3 dining rooms observed for meals (first floor dining room). This deficient practice was evidenced by the following: 1. On 02/28/2024 at 12:33 PM, Surveyor #1 observed a Contact Precautions sign at Resident #645's doorway. Instructions on the sign included, but were not limited to: Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also: put on gloves before room entry. Discard gloves before room…

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

Based on observation, interview, and review of the medical record, it was determined that the facility failed to ensure a resident was dressed appropriately while in common areas of the unit and did not expose him/herself to other residents as well as failed to transport a resident from one area of the facility to another in a dignified manner. This deficient practice was identified for 1 of 48 sampled residents reviewed for dignity, (Resident # 89) and was evidenced by the following: During the initial tour of the 2nd floor on 02/27/2024 at 10:35 AM, the surveyor observed Resident #89 in Activity room/patient lounge on the 2nd floor in a reclining Geri chair. Resident #89 was dressed in a hospital gown, pulled up and his/her brief exposed to room. 10 other residents were in the room along with activity staff. An unidentified Certified Nursing Assistant (CNA) walked in the room looked at resident and left the room without covering him/her with the blanket. On 02/27/2024 at 12:20 PM, Resident #89 was pushed forward in the Geri chair out of lounge and put in hallway. Gown was 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.

Based on observations and interviews it was determined that the facility failed to maintain the most recent State of New Jersey inspection results in a place readily accessible to the residents, families, and the public. This deficient practice was evidenced by the following: On 02/27/2024 at 09:00 AM, during initial entrance to the facility the surveyor observed the State Results Binder on a small table next to the reception desk. There was a set of double doors between the lobby and a hallway which led to the nursing units. The doors were locked and required a four-digit code to open the doors to enter the nursing units or to exit back to the entrance lobby, where the binder was located. On 02/28/2024 at 10:30 AM, the surveyor held a Resident Council meeting with 10 residents. During the meeting the surveyor asked the residents if they were aware of the survey results and the location. Ten of the ten residents told the surveyor they were not aware of the results being accessible to them or a location where they can view the results. On 03/04/2024 at 2:10 PM, the surveyor met with…

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 protect the confidentiality of a resident's health related information. This deficient practice was identified at 1 of 2 nursing stations and was evidenced by the following: On 03/01/2024 at 12:26 PM, at the 2nd floor nursing station, the surveyor observed a medication cart unattended with the Medication Administration Record (MAR) opened to full view, exposing a resident's personal identification which include the following information: The resident's name, photo, date of birth , medical diagnoses, allergies, diet, and medications. The MAR was displayed on a fixed laptop attached to the top of the medication cart located at the nursing station across from hallway C. The medication cart was locked. On 03/01/24 at 12:29 PM, the Licensed Practical Nurse (LPN #5) returned to her cart. At that time, the surveyor interviewed LPN #5 who stated, I didn't realize I didn't lock the screen. I should have hidden the screen, I didn't realize. When asked what she should have done, she replied, I should always lock…

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

Based on interview and record review, it was determined that the facility failed to provide information and educate residents on the grievance process. This was deficient practice was identified for 10 of 10 residents interviewed (Resident #9, 26, 46, 75, 82, 86, 125, 166, 172, and 446)) on the grievance process during a Resident Council meeting conducted on 02/28/2024 at 10:30 AM and was evidenced by the following: On 02/28/2024 at 10:30 AM, during the resident council meeting with ten alert and oriented residents, the surveyor asked the residents if they were aware of what a grievance was and how to file a grievance with the facility if necessary. Ten of the ten residents present during the meeting told the surveyor they did not know the definition of a grievance or how to file a grievance or formal complaint in writing. When the surveyor reviewed the resident council meeting minutes for November 2023, December 2023, and January 2024, prior to having the resident council meeting, the minutes did not include education on the grievance process being provided to the residents. 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, and record review it was determined the facility failed ensure a Preadmission Screening and Resident Review (PASARR) one was completed accurately for a newly admitted resident. This deficient practice was identified in 1 of 3 residents reviewed for PASARR (Resident #150) and was evidenced by the following: On 02/27/2024 at 10:09 AM, during the initial tour of the facility, the resident was sitting in the bed with eyes opened. A review of the admission Record indicated Resident #150 had medical diagnoses which included but were not limited to :dementia, psychotic disorder (a mental illness), aphasia (inability to express self verbally). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 08/04/23, revealed the resident had a Brief Interview of Mental Status of 00 meaning the resident was unable to complete the interview due to severe cognitive impairment. On 02/28/2024 at 09:45 AM, the facility provided the surveyor with a PASARR one that was completed by the transferring acute care facility prior to entering the current…

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 to meet a resident's medical needs and failed to implement focus and interventions that are specific to the resident's catheter care and respiratory diagnosis. The deficient practice was identified for 1 of 2 Residents (Resident # 48) for catheter care and of 2 Residents (Resident #170) for respiratory diagnosis, investigated for care plans. The deficient practice was evidenced by the following: 1. On 02/27/2024 at 10:43 AM during the initial tour of the facility the surveyor observed Resident # 48 sitting in the dining room. Resident # 48 was observed to have a indwelling catheter (a medical device that helps drain urine from your bladder) in a blue privacy bag. On 02/29/2024 at 10:40 AM, the surveyor observed Resident # 48 lying in bed. The indwelling catheter was observed in a blue privacy bag attached to the bed frame.…

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 the facility failed to update a care plan for a resident following a hospitalization and change in condition. This deficient practice was identified in 1 of 48 residents reviewed for care plans (Resident #80) and was evidenced by the following: On 02/27/2024 at 09:22 AM, during the initial tour of the facility Resident #80 was observed in bed with eyes open. The surveyor did not observe a feeding pump or feeding tube supplies in the resident's room. Resident #80 told the surveyor that he/she used to have a feeding tube when they were admitted to the facility, but no longer had a feeding tube and tolerated a regular diet. Review of the admission Record revealed Resident #80 had medical diagnoses which included but were not limited to Parkinson's disease (disorder of the central nervous system), failure to thrive, and diabetes (abnormal blood sugar levels). Review of the quarterly Minimum Data Set (MDS), an assessment tool dated 01/21/24 revealed…

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 documents, it was determined that the facility failed to ensure care and services are provided according to accepted standards of clinical practice, specifically by not providing a resident a medication that was available in the automated medication dispenser and failing to follow a physician's order for oxygen administration. The deficient practice was identified for 2 of 2 residents (Resident # 124 & # 170) investigated for Services Provided to Meet Professional Standards. The deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual 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…

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, review of medical records and other facility documentation, 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 4 residents (Resident #112) reviewed for limited range of motion. This deficient practice was evidenced by the following: During the initial tour of the facility on 02/27/2024 at 10:36 AM, the surveyor observed Resident #112 lying in bed awake. The resident's left hand was contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity or rigidity of joints) and a right hand deformity was noted. When interviewed the resident stated that he/she had a brace somewhere that staff put on once in a while. The resident further stated that he/she wanted to have it on more frequently. The resident's family member was present and agreed with the resident's statement and expressed a desire for 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 other facility documentation, it was determined the facility failed to maintain a urinary catheter and provide services in a manner consistent with standards of practice for 1 of 2 residents reviewed for urinary catheter care (Resident #80). This deficient practice was evidenced by the following: On 02/27/2024 at 09:22 AM, during the initial tour of the facility, Resident #80 was observed in bed with eyes open. The surveyor observed a urinary drainage bag hanging on the left side of the bed facing towards the doorway of the residents' room. The drainage bag was not in a privacy bag, meaning the bag did not have a cover to conceal the contents. Review of the admission Record revealed Resident #80 had medical diagnoses which included but were not limited to Parkinson's disease (disorder of the central nervous system), and obstructive uropathy (disorder of the urinary tract due to obstructed urinary flow). Review of the quarterly Minimum Data Set (MDS), an assessment tool dated 01/21/24 revealed the resident had a Brief…

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

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to follow their own policy for storage of respiratory equipment. This deficient practice was identified for 1 of 2 (Resident #154) residents reviewed for respiratory concerns and was evidenced by the following: During a tour of the facility on 02/27/2024 at 09:58 AM, Resident #154 was observed in bed. On 02/29/2024 at 03:19 PM, the surveyor observed the nebulizer machine (a nebulizer machine delivers aerosol medication to the person via a mouthpiece and chamber/cup that holds the medication, via tubing that is attached to the machine. It is used to treat respiratory conditions such as COPD, bronchitis, and asthma.) on an overbed table. The surveyor observed the tubing and mouthpiece of the nebulizer machine exposed to air and uncovered. At that time, the surveyor observed moisture in the chamber of the mouthpiece that was attached to the tubing. On 03/01/2024 at 08:09 AM, the surveyor observed the tubing and mouthpiece of the nebulizer machine exposed…

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, review of medical records and other facility documentation, it was determined that the facility failed to ensure that the resident's prescribed dietary supplement and preferences were accurately identified and implemented for 1 of 3 residents (Resident #25) reviewed for dining services. This deficient practice was evidenced by the following: On 02/27/24 from 11:59 AM to 12:49 PM, the surveyor observed dining services in the first floor main dining room. At 12:19 PM, The surveyor observed a Dietary Aide (DA) as she called out for a condiment cart after the resident's meals had already been served and the residents had begun to eat their meals. The surveyor observed Resident #25's meal ticket and noted that the resident had not received creamer for his/her coffee, salt, pepper and a health shake (dietary supplement). When interviewed at that time, the resident stated that he/she needed assistance to get creamer for their coffee and salt and pepper. The resident was accompanied by another unsampled resident. On 02/27/24 at 12:34 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ00165456 Based on interview, medical record review, and review of other pertinent facility documentation on 10/20/23, 10/24/23, and 10/26/23, it was determined that the facility failed to develop a baseline care plan for a newly admitted resident who experienced pain. This deficient practice was identified for Resident #2, 1 of 2 residents reviewed for baseline care plans and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #2: According to the admission Record, Resident #2 was admitted to the facility on [DATE] with medical diagnoses that included but were not limited to cerebral infarction (disrupted blood flow to the brain), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move one side of the body) following cerebral infarction, cognitive communication deficit, opioid abuse, cocaine abuse, and muscle wasting and atrophy (decrease in size). Review of the Discharge Return Anticipated Minimum Data Set (MDS),…

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 #: NJ00168282, NJ00168313 Based on observation, interview, review of medical records, and review of other pertinent facility documentation on [DATE], [DATE], and [DATE], it was determined that the facility failed to update a comprehensive care plan for a resident who had a life-threatening event. The deficient practice was identified for Resident #3, 1 of 4 residents reviewed for comprehensive care plans and was evidenced by the following: During an interview with the surveyor on [DATE] at 12:23 PM, Resident #3 stated that they overdosed on fentanyl (a synthetic opioid) twice at the facility within the last few months. The resident stated that facility staff used Narcan (opioid overdose treatment) on him/her and that they were sent out to the hospital after each overdose. According to the admission Record, Resident #3 was readmitted to the facility on [DATE] with medical diagnoses that included but were not limited to poisoning by other drugs, medicaments (substance used as medicine) and biological…

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 #: NJ00165456 Based on interview, medical record review, and review of other pertinent facility documentation on 10/20/23, 10/24/23, and 10/26/23, it was determined that the facility failed to provide treatment for a resident with a pressure ulcer. The deficient practice was identified for Resident #2, 1 of 2 residents reviewed for pressure ulcers and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #2: Review of the admission Record revealed that Resident #2 was admitted to the facility on [DATE] with medical diagnoses which included but were not limited to cerebral infarction (disrupted blood flow to the brain), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move one side of the body) following cerebral infarction, cognitive communication deficit, and muscle wasting and atrophy (decrease in size). Review of the Discharge Return Anticipated 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.

Based on observation and interview it was determined that the facility had insufficient staffing in the kitchen to carry out the duties of the food service operations competently. This deficient practice was evidenced by the following: Cross-reference: F 760, F803, F804, F809 and F812 On 08/30/22 at approximately 10:00 AM, during the initial brief tour of the kitchen, the surveyor questioned the Director of Food Services (DOFS) why the kitchen staff were still assembling breakfast trays at 10:00 AM. The DOFS explained, We are normally done breakfast tray line by 9 AM. I had to call in (2) staff and borrow a cook from a sister facility. Staffing has been an issue for the month I've been here. It is slowing and affecting our production. On 08/30/22 at 11:24 AM, the surveyor observed CNA #3 assisting resident #92 with the breakfast meal at 11:24 AM. The surveyor asked CNA #3 if that was breakfast or lunch. CNA #3 stated, It's breakfast. They didn't send a puree tray and we had to wait for another. We get the trays based on how many people show up to work in the kitchen. On 09/01/22 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.

Based on observation, interview, and record review, it was determined that the facility failed to a) ensure that staff were following the menu over multiple meal observations which affected all residents of the facility and b) failed to obtain approval of menu substitutions in accordance with facility policy. This deficient practice was evidenced by the following: 1. On 08/30/22 at 11:24 AM, Surveyor #1 observed a Certified Nursing Assistant (CNA #3) assisting resident #92 with the breakfast meal. The surveyor asked CNA #3 if that was the breakfast or lunch meal. CNA #3 stated, It's breakfast. They didn't send a puree tray and we had to wait for another. According to the admission Record, Resident #92 was admitted to the facility with diagnosis including but not limited to: Parkinson's disease, neurocognitive disorder with Lewy bodies, need for assistance with personal care, dysphagia (difficulty swallowing), and mild protein-calorie malnutrition. According to the interdisciplinary care plan for Resident #92, Resident #92 was care planned for a nutrition problem: Related to Lewy…

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, and record review and review of other facility documentation, it was determined that the facility failed to serve meals at regular times in a manner that meets the residents needs for 2 of 2 residents (Resident #92 and Resident #74) observed during mealtime. This deficient practice was evidenced by the following: Cross reference F760, F802 1. On 08/30/22 at 11:24 AM, while on the initial tour of the facility on the 2nd floor, the surveyor observed a Certified Nursing Assistant (CNA #3) assisting Resident #92 with eating his/her meal at 11:24 AM. The surveyor asked CNA #3 if that was the breakfast or lunch meal. CNA #3 responded, It's breakfast. They didn't send a puree tray and we had to wait for another. We get the trays based on how many people show up to work in the kitchen. According to Resident #92's admission Record, Resident #92 was admitted to the facility with the following diagnoses: Parkinson's disease, aphasia (an inability to comprehend or formulate language), mild protein-calorie malnutrition, and need for assistance with personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 08/30/22 from 09:18 AM to 10:08 AM the surveyor, accompanied by the Director of Food Service (DOFS), observed the following in the kitchen: 1. On a middle shelf of a multi-tiered rack in the dry storage room a Styrofoam cup without a lid contained an unidentified liquid. The cup had not been labeled or dated. The DOFS stated, That doesn't belong there. 2. On a middle shelf (2) gallon containers of Fresh Kosher Chips had a received date of 6/24/21. The inside of the plastic gallon jug appeared to have a green/black mold and there was unidentified white debris surrounding the upper neck below the lid of the jug internally and unidentified debris externally. The DOFS stated, I would agree they appear to have mold. I'm…

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 other facility documentation, it was determined that the facility failed to consistently revise and/or update resident care plans for 2 of 38 residents (Resident #6 and Resident #62) reviewed for comprehensive care plans. This deficient practice was evidenced by the following: 1. According to the admission Record, Resident #6 was admitted with diagnoses that included, but were not limited to, senile degeneration of brain, hemiplegia (paralysis of one side of the body) and muscle weakness. Review of the Significant Change in Status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 08/14/2022, revealed staff identified Resident #6 as severely cognitively impaired, with no behaviors, required total assist of one staff for bed mobility and dressing and was at risk of developing pressure ulcers/injuries. Review of an Inservice Form for Resident #6's palm protector (a type of splinting that provides a barrier…

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 consistently complete neurological evaluations (neuro checks) after unwitnessed falls for 1 of 6 residents (Resident #189) reviewed for accidents. This deficient practice was evidenced by the following: On 08/31/22 at 11:46 AM, the surveyor observed Resident #189 resting comfortably in bed with the head of bed (HOB) slightly elevated. The surveyor observed floor mats positioned on both sides of the resident's bed. According to the admission Record, Resident #39 was admitted with diagnoses which included, but were not limited to, acute respiratory failure with hypoxia (low levels of oxygen in your body tissue) and dementia. Review of Resident #189's Significant Change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/24/22, included the resident had a Brief Interview for Mental Status of 05, which indicated that the resident's cognition was severely cognitively impaired. Further review of the MDS revealed 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 other facility documentation, it was determined that the facility failed to follow a physician's order for the application of a palm protector (a type of splinting that provides a barrier between the fingers and the palm to prevent injury to the palm from finger contracture) for 2 of 3 residents (Resident #6 and Resident #62) reviewed for positioning and mobility. The deficient practice was evidenced by the following: 1. During tour of the 2B unit on 08/30/22 at 11:14 AM, the surveyor observed Resident #6 in bed with the head of bed (HOB) elevated. The surveyor observed that Resident #6 had limitation to the left hand and did not have on a palm protector. When interviewed, Resident #6 was unable to provide any information about his/her care. The Hospice Certified Nurse Assistant (Hospice CNA) was present in the room and stated the resident required total assistance with activities of daily living. According to the admission Record, Resident #6 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to: a.) follow professional standards of nursing practice by administering expired insulin medication and b.) ensure that insulin medication was administered to residents within an appropriate time frame according to physician's order and manufacturer specifications. This deficient practice was identified for 4 of 35 sampled residents, (Residents #12, #93, #182 and #168) reviewed for the administration of insulin (a medication used for Diabetes) during medication administration and was evidenced by the following: 1. On 09/07/22 at 11:40 AM, the surveyor, in the presence of the Licensed Practical Nurse (LPN #2), observed within the 2C Wing medication cart, one opened box of Insulin Lispro (Humalog) 100 unit/milliliter (ml) inside a plastic bag for Resident #12. The box was labeled with an opened date of 08/02/22. At that time LPN #2 stated that Resident #12 only received insulin…

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 pertinent facility documentation, it was determined the facility failed to maintain an orderly and sanitary environment by leaving garbage bags, a spill, gowns, linens, and unpackaged incontinence briefs in the hallway of B unit. The deficient practice was identified for 1 of 4 wings (B Wing) on the first floor and was evidenced by the following: On 8/31/22 at 10:26 AM, in the B Wing, the surveyor observed two trash bags filled with garbage unattended on the floor. The surveyor also observed linen with unpackaged incontinence briefs left on top of a plastic supply bin in the hallway. Further, the surveyor observed another opened bag of incontinence briefs on a chair in the hallway. On 09/01/22 at 9:54 AM, the surveyor observed a red trash bin used for personal protective equipment (PPE) (equipment such as, but not limited to gowns, gloves, and eye protection worn to create a barrier from pathogens) overflowing with pieces of used gowns. The surveyor also observed an opened package of incontinence briefs on a chair and towels left…

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 other facility documentation, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) a.) an allegation of physical and verbal abuse for 1 of 1 resident (Resident #134) reviewed for abuse and b.) an unwitnessed event resulting in major injury for 1 of 3 residents (Resident #41) reviewed for falls. This deficient practice was evidenced by the following: 1. On 09/01/22, the surveyor requested the personnel files for five employees hired within the last four months. Review of Certified Nursing Assistant (CNA) #8's personnel file revealed an Employee Warning Record (EWR), dated 08/02/22, that included a conduct violation with a violation date of 07/31/22 at 11:00 AM in Resident #134's room. Further review of the EWR revealed [Resident #134] stated that [CNA #8] was mean and degrading. CNA called resident nasty and refused to place resident on toilet, and pulled resident's arm and [Resident #134] was scared that CNA was going…

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 thoroughly investigate an allegation of physical and verbal abuse for 1 of 1 resident (Resident #134) reviewed for abuse. This deficient practice was evidenced by the following: On 09/01/22, the surveyor requested the personnel files for five employees hired within the last four months. Review of Certified Nursing Assistant (CNA) #8's personnel file revealed an Employee Warning Record (EWR), dated 08/02/22, that included a conduct violation with a violation date of 07/31/22 at 11:00 AM in Resident #134's room. Further review of the EWR revealed [Resident #134] stated that [CNA #8] was mean and degrading. CNA called resident nasty and refused to place resident on toilet, and pulled resident's arm and [Resident #134] was scared that CNA was going to break [his/her] arm. Resident was in tears and had to be calmed down by staff. The EWR was signed by the Director of Nursing (DON). On 09/06/22 at 10:03 AM, the surveyor observed Resident #134 lying in bed. 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.

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 complete a significant change in status (SCSA) Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care. This deficient practice was identified for 1 of 1 resident (Resident #208) reviewed for expired resident and was evidenced by the following: Within 14 days after the facility determines or should have determined that there has been a significant change in the resident's physical or mental condition, a SCSA/MDS must be completed. (For purpose of this section, a significant change is a decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.) Review of the admission Record reflected that Resident #208 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to a.) follow a physician's order for bilateral side rail pads for one resident, 1 of 6 residents (Resident #6) reviewed for accidents. The deficient practice was evidenced by the following: During tour of the 2B unit on 08/30/22 at 11:14 AM, the surveyor observed Resident #6 in bed with the head of bed (HOB) and bilateral half side rails elevated. The surveyor observed that Resident #6 was leaning to the right side and there was no padding to either side rail. When interviewed, Resident #6 was unable to provide any information about his/her care. According to the admission Record, Resident #6 was admitted with diagnoses that included, but were not limited to, senile degeneration of brain, hemiplegia (paralysis of one side of the body) and muscle weakness. Review of the Significant Change in Status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 08/14/2022, revealed 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.

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to ensure that a resident with an indwelling urinary catheter (tube inserted into the bladder to facilitate the flow of urine) had physician orders for the care of the catheter. The deficient practice was identified for 1 of 2 residents (Resident #136) reviewed for catheters. This deficient practice was evidenced by the following: On 08/30/22 at 10:27 AM, during the initial tour of the 1st floor, the surveyor observed Resident #136 in bed. At that time, the surveyor observed a urinary catheter drainage bag attached to the bed frame. The catheter drainage bag was also observed on 08/31/22 and 09/01/22. A review of Resident #136's electronic medical record (EMAR) under Diagnosis revealed a diagnosis of but not limited to, Neuromuscular Dysfunction of the Bladder (lack of bladder control due to brain, spinal cord or nerve problems). A review of Resident #136's most recent Minimal Data Set, an assessment tool, dated 07/28/22, revealed Resident #136 had 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, record review and review of other facility documentation, it was determined that the facility failed to implement infection control measures for the handling and storage of respiratory equipment for 2 of 4 residents reviewed for respiratory care, (Resident # 10 and Resident # 180). This deficient practice was evidenced by the following: 1. On 09/06/22 at 12:29 PM, Surveyor #1 observed the mouthpiece, chamber, and tubing of Resident #10's nebulizer propped in an upright position by the machine. The mouthpiece, chamber, and tubing was not contained in a bag and was exposed to the surrounding environment. A nebulizer machine delivers aerosol medication to the person via a mouthpiece and chamber/cup that holds the medication, via tubing that is attached to the machine. It is used to treat respiratory conditions such as COPD, bronchitis, asthma etc. On 09/08/22 at 8:04 AM, Surveyor #1 observed the mouthpiece, chamber and tubing of Resident #10's nebulizer draped over the nebulizer…

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

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to obtain a physician order to monitor the dialysis access site and failed to ensure the dialysis transfer forms of ongoing records of communication between the facility and dialysis center were consistently completed for 1 of 1 resident reviewed for dialysis care, (Resident #119). This deficient practice was evidenced by the following: During an interview with the surveyor on 09/06/22 at 9:21 AM, Resident #119 said he/she goes to dialysis on Monday-Wednesday-Friday (MWF). Resident #199 went on to say that he/she gets dialysis through a catheter in right chest as the shunt is not ready for use. According to the admission record Resident #119 was admitted to the facility with diagnoses, including but not limited to, infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, End Stage Renal Disease, and dependence on renal dialysis. A review of the most recent Minimum Data Set (MDS), an assessment tool used to…

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

Based on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to supervise the administration of medication for 1 of 10 residents (Resident #19) reviewed for medications. This deficient practice was evidenced by the following: On 09/06/22 at 9:50 AM, the surveyor observed Resident #19 lying in bed. There was a medicine cup with pills in it on the resident's over-the-bed table. When asked about the medicine cup, the resident stated the nurse left the medication at the bedside because the resident was waiting for his/her breakfast tray before taking the medications. During an interview with the surveyor on 09/06/22 at 9:51 AM, Licensed Practical Nurse (LPN) #3 stated she completed the morning medication pass for her assignment. She further stated that the medication administration process included making sure the resident swallowed their medications before leaving the resident's room because sometimes they can choke, or drop the medication, and that medication should not be left with the resident. When asked about…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to ensure expired and discontinued medications were removed from active inventory and medications were appropriately labeled and dated when opened in 1 of 4 medication carts reviewed. This deficient practice was evidenced by the following: On [DATE] at 11:40 AM, the surveyor, in the presence of the Licensed Practical Nurse (LPN #2), observed the following within the 2C Wing medication cart: -One opened box of Insulin Lispro (Humalog) 100 unit/milliliter (ml) located inside a plastic bag for Resident #12. The box was labeled with an opened date of [DATE]. At that time LPN #2 stated that Resident #12 only received insulin when needed because he/she was on a sliding scale (received insulin depending on the blood sugar level) and that insulin had an expiration date of 30 days once opened. -Incruse Ellipta Aerosol Powder Inhalation Powder 62.5 micrograms (mcg) (used to treat asthma or Chronic Obstructive Pulmonary…

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

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to consistently serve foods at a safe and appetizing temperature. This deficient practice was evidenced by the following: Cross Reference F 802 On 08/30/22 at approximately 10:05 AM, the surveyor conducted the initial tour of the kitchen. The surveyor questioned the Director of Food Services (DOFS) why the kitchen staff were still assembling breakfast trays at 10:00 AM. The DOFS explained, We are normally done breakfast tray line by 9 AM. I had to call in (2) staff who were scheduled off today and borrow a cook from our sister facility. Staffing has been an issue for the month I've been here. It is slowing and affecting our production. On 09/01/22 at 10:22 AM, the surveyor conducted an interview with the DOFS to determine why the breakfast trays were late to arrive on the 2-C unit, as per the meal delivery schedule provided to the surveyor on entrance. The surveyor questioned the DOFS if trays had arrived late because the kitchen was short of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and other pertinent facility documents, it was determined that the facility failed to ensure personal protective equipment (PPE) (equipment such as, but not limited to gowns, gloves, and eye protection worn to protect the wearer from the spread of infection or illness) was used appropriately and failed to ensure handwashing was performed before and after exiting and entering resident rooms that were on isolation and between changing gloves. The deficient practice was observed on 1 of 4 units on the first floor. The deficient practice was evidenced by the following: On 08/30/22 at 10:17 AM during the initial tour, the surveyor observed a resident room with a transmission-based precaution sign (notification sign that specific precautions must be followed prior to entering or leaving the room) that revealed, ISOLATION DROPLET/CONTACT PRECAUTIONS Everyone Must: including visitors, doctors, and staff Clean hands when entering and leaving the room, Wear mask, Wear eye protections, Gown…

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.