Complete Care At Inglemoor, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to provide the Resident and the Resident's Representative a written notification of the reason for transfer to the hospital, and also send a copy to a representative of the Office of the State Long-Term Care Ombudsman (LTCO) for 1 of 1 resident (Resident #159) reviewed for hospitalization. This deficient practice was evidenced by the following: On 3/7/25 at 10:47 AM, the surveyor observed Resident #159 lying on bed with head of bed elevated approximately 45 degrees, eyes closed, with tube feeding (TF) formula of Glucerna 1.2 running via a pump at 50 ml/hr (milliliters/hour), with 159 ml fed, and remaining in the container was 500 ml. The surveyor reviewed Resident #159's medical records and revealed: A review of the admission Record (an admission summary) reflected that Resident #159 was admitted to the facility with medical diagnoses which included but not limited to; type 2 diabetes…

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 accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 1 of 18 residents, (Resident #6), reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: On 3/7/25 at 10:52 AM, the surveyor observed Resident #6 was seated in a wheelchair inside their room with Certified Nursing Aide #1 (CNA#1). S#1 also observed CNA#2 with hoyer lift machine and Staffing Coordinator came out of the resident's room. The surveyor reviewed Resident #6's medical records and revealed: A review of the admission Record (an admission summary) reflected that Resident #6 was admitted to the facility with medical diagnoses which included but not limited to; other Alzheimer's Disease, dysarthria (is a speech sound disorder resulting from neurological injury of the motor component of the motor-speech system) following unspecified cerebrovascular disease (stroke), unspecified osteoarthritis, unspecified site,…

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

Based on the interview, record review, and review of pertinent documents, it was determined that the facility failed to ensure residents who were discharged to the community had a discharge summary that was completed by the physician in accordance to the regulation and facility's policy and procedure. This deficient practice was identified for 1 of 1 resident, (Resident #58), reviewed for discharge. This deficient practice was evidenced by the following: Surveyor #1 (S#1) reviewed the medical records of Resident #58, and revealed: A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to, sepsis (serious condition in which the body responds improperly to an infection), unspecified organism and low back pain unspecified. A review of the most recent Discharge Return Not Anticipated (DRNA) Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, of Resident #58, revealed in Section A Identification Information that the discharge (d/c) status was coded…

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 that residents receive treatment and care in accordance with professional standards of practice, by failing to ensure; a.) that the physician order was clarified, b.) care plan (CP) intervention was revised, and c.) the fall investigation included the statement of the staff to complete the investigation, and in order to determine root cause analysis. This deficient practice was identified for 1 of 2 residents, (Resident #6), reviewed for accidents and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a) obtain weights for a resident according to the physician's orders and facility policy for 1 of 2 residents (Resident #13) reviewed for nutrition; and b) monitor and document the fluid intake for a resident with a physician's order for fluid restrictions for 1 of 2 residents (Resident #28) reviewed for nutrition. This deficient practice was evidenced by the following: 1. On 3/7/25 at 10:50 AM, the surveyor observed Resident #13 sitting in a wheelchair in their room, being provided care by staff. On 3/12/25 at 9:06 AM, the surveyor reviewed the paper chart and the Electronic Medical Record (EMR) of Resident #13. The admission Record (a summary of important information about the resident) documented Resident #13 had diagnoses that included but were not limited to, respiratory failure, chronic obstructive pulmonary disease (a lung condition that blocks airflow and makes it…

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

Based on observation, interview, and record review, it was determined that the facility failed to ensure appropriate storage of a nebulizer treatment equipment in accordance with facility protocol and infection control. This deficient practice was identified in 1 of 1 resident (Resident #55), reviewed for respiratory care. The deficient practice was evidenced by the following: On 3/7/25 at 1:40 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 about the changing of nebulizer (neb) tubing and mask equipment. LPN #1 was not sure of the facility's policy regarding changing of oxygen (O2) tubing and neb tubing equipment. LPN #1 accompanied the surveyor to the Resident #55's room to observe the resident's neb machine equipment. Resident #55 was sitting on their bed, alert and verbally responsive. The neb mask was resting on the resident's nightstand uncovered attached to a tubing which was connected to the neb machine. LPN #1 stated the date on the neb mask was 2/18/25. On 3/7/25 at 1:44 PM, the surveyor interviewed Minimum Data Set (MDS) Coordinator #1 about the changing…

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

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medications and medical supplies safely and per standards of practice. This deficient practice was identified in 1 of 2 medication storage areas observed on the 2nd floor of the facility. 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 licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 3/10/25 at 11:19 AM, the surveyor observed on the 2nd floor unit, in the presence of the assigned Licensed Practical Nurse (LPN) the following: 1. The surveyor observed adjacent…

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, review of medical record, and review of other pertinent facility documents, it was determined that the facility failed to offer residents a pneumococcal and influenza vaccines or document the refusal and reason for ineligibility for the vaccines for 1 of 5 residents reviewed for unnecessary medications (Resident #55). The deficient practice was evidenced by the following: Reference: According to the Centers for Disease Control (CDC) and Prevention, recommends pneumococcal vaccination (PCV) for many adults based on age, having certain risk conditions, and pneumococcal vaccines already received . CDC recommends PCV15, PCV20, or PCV21 for adults who never received a PCV and are Ages 65 years or older Ages 19 through 64 years with certain risk conditions. Chronic conditions and other factors that increase someone's risk for pneumococcal disease include Chronic heart, kidney, liver, or lung disease (Chronic lung disease includes chronic obstructive pulmonary disorder (COPD), emphysema, 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.

Based on interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer a resident a COVID-19 Immunization. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #55). The deficient practice was evidenced by the following: The surveyor reviewed the Resident's #55's medical record which revealed the following information: A review of the admission Record (an admission summary) revealed that Resident #55 had been admitted to the facility with diagnoses which included but not limited to type 2 diabetes mellitus with hyperglycemia (is characterized by elevated glucose levels in the blood, typically above 180 to 200 mg/dL [milligrams per deciliter]) and moderate protein-calorie malnutrition. A review of the most recent comprehensive Minimum Data Set (cMDS), an assessment tool, with an assessment reference date (ARD) of 2/18/25, had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition. Further review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ00180296 Based on interviews, record review, and review of pertinent facility documents on 12/03/2024, it was determined that the facility failed to ensure that a resident (Resident #1) was free from involuntary confinement when on 09/18/2024 a nurse on duty in night shift attached a hospital gown on the Resident's doorknob and looped it to the handrail in the hallway outside of Resident's room after the Resident in her/his wheelchair was brought back to her/his room from another resident's room. The deficient practice was observed in one of three residents and was evidenced as follows: A review of the facility's Reportable Event Record/Report (RER), a document submitted by the facility to the New Jersey Department of Health (NJDOH), dated 9/18/2024, completed by the facility Director of Nursing (DON), indicated that on 9/18/2024 it was reported to the administrator by another resident that the [Resident #'s name] door was closed in a way to prevent the resident from leaving her room. He [the other…

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 the facility provided documentation, it was determined that the facility failed to: a) establish, assess, and maintain record measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems, this deficient practice had the potential to affect all 54 residents; b) properly doffed (remove) and discard the PPE (personal protective equipment) for one of three staff observed; c) perform handwashing appropriately for one (Certified Nursing Aide) of six staff observed for hand hygiene; d) disinfect and sanitize the equipment used for checking blood pressure for one of two nurses during medication administration), and e) adhere to accepted standards of infection control practices for the proper storage of respiratory tubing, and nasal cannula after use for one of two residents, Resident #47 reviewed for oxygen use in accordance with the facility policy and the Centers for Disease Control and Prevention (CDC) guidelines. This deficient practice was evidenced by the following: According 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, and review of medical records, it was determined that the facility failed to develop a person-centered comprehensive care plan to address: a) the use of antipsychotic medication for one of five residents (Resident #27) from August 2022 through January 23, 2023 reviewed for unnecessary medications, for a total of five months and b) activities of daily living (ADL) of one of seventeen residents (Resident#44), reviewed for comprehensive care plan. This deficient practice was evidenced by the following: 1. On 01/22/23 at 11:20 AM, Surveyor#1 observed Resident #27 laying on the bed with their eyes closed. Surveyor#1 reviewed Resident #27's medical records. The admission Record (AR or face sheet; an admission summary) showed that the resident was admitted to the facility with diagnoses that included type two diabetes mellitus with diabetic polyneuropathy (a complication of diabetes mellitus characterized by progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers), essential hypertension…

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 provided documents, it was determined that the facility failed to follow up on the Consultant Pharmacist's (CP) recommendations of a medication irregularity for one of five residents (Resident #27) reviewed for unnecessary medications for a total of five months from August 2022 through January 2023. This deficient practice was evidenced by the following: On 01/22/23 at 11:20 AM, the surveyor observed Resident #27 laying on the bed with their eyes closed. The surveyor reviewed Resident #27's medical records. The admission Record (or face sheet; an admission summary) showed that the resident was admitted to the facility with diagnoses that included type two diabetes mellitus with diabetic polyneuropathy (a complication of diabetes mellitus characterized by progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers), essential hypertension (elevated blood pressure), dementia in other diseases classified elsewhere without behavioral disturbance and psychotic…

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 the facility provided documents, it was determined that the facility failed to consistently monitor, document, and evaluate the ongoing benefit use of Seroquel, an antipsychotic medication (used to treat bipolar disorder- depressive and manic episodes and schizophrenia-mental disorder interpret reality abnormally). This deficient practice was identified for one of three residents (Resident #27) reviewed for antipsychotic use for a total of five months from August 2022 through January 2023. This deficient practice was evidenced by the following: On 01/22/23 at 11:20 AM, the surveyor observed Resident #27 laying on the bed with their eyes closed. The surveyor reviewed Resident #27's medical records. The admission Record (or face sheet; an admission summary) showed that the resident was admitted to the facility with diagnoses that included type two diabetes mellitus with diabetic polyneuropathy (a complication of diabetes mellitus characterized by progressive death of nerve fibers, which leads to loss of nerves, 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 the observation, interview, record review, and other pertinent facility documentation it was determined that the facility failed to: a) conduct testing in a manner that is consistent with current standards of practice for conducting COVID-19 tests and b) perform COVID-19 testing for three of six residents (Resident #6, #17, and #32) reviewed for PUI (person under investigation) and one of three staff members reviewed for COVID-19 testing in accordance with the facility policy and Centers for Disease Control and Prevention guidelines (CDC) for infection control and to mitigate the spread of COVID-19 (A highly contagious respiratory disease caused by the SARS-CoV-2 virus). This deficient practice was evidenced by the following: According to the U.S. CDC Guidance for SARS-CoV-2 Rapid Testing Performed in Point-of-Care Settings, Specimen Collection & Handling of Rapid Tests in Point-of-Care Settings, updated 4/04/22, included that Each point-of-care test has been authorized for use with certain specimen…

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 the facility provided documents, it was determined that the facility failed to ensure that a nurse aide had the skills and techniques necessary prior to providing care to residents. This deficient practice occurred for one (1) of four (4) newly hired employees and was evidenced by the following: On [DATE] at 9:59 AM, the surveyor interviewed Registered Nurse#1 (RN#1) and a Licensed Practical Nurse (LPN) who stated that they were the two nurses assigned to the second floor for that day. RN#1 and LPN stated that they had a resident census of 30 residents and that there were four Certified Nurses Aides (CNA) working on the second floor. At that time, RN#1 provided the surveyor with a CNA assignment sheet for the second floor. In addition, RN#1 and LPN were able to point out, from a distance, each of the employees corresponding to the four CNA names listed on the assignment sheet that were working on the second floor. On [DATE] at 12:00 PM, the surveyor interviewed the…

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

Based on observation, interview, and review of facility provided documents, it was determined that the facility failed to routinely and accurately post the nurse staffing information on four of six days during the survey period in a place within the facility readily accessible to the residents and the visitors. This deficient practice was evidenced by the following: On 01/22/23 at 9:14 AM, upon entry into the facility, the surveyor observed that the Nursing Home Resident Care Staffing Report (NHRCSR) that was posted in the reception area of the lobby showed a staffing report dated 01/20/23 with the census (total number of residents) of 57 for Day Shift, shift hours of 7 AM - 3 PM. On 01/22/23 at 10:28 AM, during the Entrance Conference of the surveyor with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Infection Preventionist Nurse (IPN), the LNHA stated that the facility census was 55 with one bed hold. On 01/22/23 at 01:04 PM, during the team meeting of the surveyors, there were discrepancies on what was provided on Entrance Conference and facility…

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 other pertinent facility documentation, it was determined that the facility failed to ensure a medication used for moderate to severe pain (Oxycodone) was available and administered as ordered for a resident with a history of chronic pain (Resident #458). This deficient practice was identified during the Medication Storage Task for one of one resident reviewed for pain management. The evidence was as follows: On 01/ 26/23 at 10:42 AM, while performing the Medication Storage Task the surveyor interviewed the Director of Nursing (DON). The surveyor asked if the facility had any unresolved narcotic discrepancies with their automated medication dispensing machine and the DON responded no, but they did have an incident last month with a nurse. The DON stated a nurse who had worked night shift had received the pharmacy delivery, one of the medications delivered was for Resident #458, Oxycodone 30 milligram (mg) tablets. The pharmacy had dispensed the tablets using two blister pack cards, one containing thirty tablets and one containing twenty-six…

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 facility provided documentation, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation performed on 01/24/23, the surveyor observed two (2) nurses administered medications to five (5) residents. There were 27 opportunities, and two (2) errors were observed, which calculated to a medication administration error rate of 7.41 %. This deficient practice was identified for two (2) of five (5) residents, (Resident #31 and #42), that were administered medications by one (1) of two (2) nurses. The deficient practice was evidenced by the following: 1. On 01/24/22 at 8:34 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN) in the room of Resident #31. The surveyor observed the LPN obtained vital signs using an electronic blood pressure machine. The surveyor also observed the LPN discussed with the resident the…

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

Based on observation, interview, and review of facility provided documentation, it was determined that the facility failed to store foods and maintain kitchen sanitation in a manner intended to prevent the spread of food borne illness as evidenced by the following: On 01/22/23 at 12:31 PM, the surveyor toured the kitchen with the Food Service Manager (FSM), in the presence of the Region Food Service Director (RFSD) and the Account Manager (AM) and observed the following: 1. In the freezer the surveyor found; one opened box of hamburgers without an open and use by date. The interior bag holding 12 hamburgers was opened and unlabeled. The FSM stated that the exterior of the box should be labeled with the open and used by date. He also stated, the interior bag once opened should be label and dated. 2. In the freezer the surveyor found; one opened box of tilapia fish fillets. The exterior of the box was labeled with 01/18/2023. The morning (AM) cook or the FSM could not explain if 01/18/2023 was a used by or open date. The interior bag holding nine tilapia fish fillets was open 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.

Based on observation, interview, and review of the facility provided documentation, it was determined that the facility failed to properly dispose and maintain waste in garbage dumpster areas. This deficient practice was identified for three of three garbage dumpsters in garbage disposal area. This deficient practice was evidenced by the following: On 01/22/2023 at 9:15 AM, the surveyor observed trash and food waste behind and surrounding three dumpsters in the parking lot. The dumpster lids and surrounding gate were not closed. On 01/23/2023 at 11:15 AM, the surveyor observed trash and food waste behind and surrounding three dumpsters in the parking lot. The dumpster lids and the surrounding gates were not closed. On 01/23/23 at 11:40 AM the Regional Maintenance Director (RMD), explained that it is every departments responsibility to maintain the dumpster area. The RMD stated that the Housekeeping was supposed to keep the grounds picked up, the lids closed, and the gates shut. He further stated that it can cause an issue if not done because of pests and vagrants. During 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.

Based on interview and review of facility documents, it was determined that the facility failed to a.) employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, b). employ a full-time dietitian, or c.) employ a qualified director of food and nutrition services. This deficient practice was evidence by the following: On 4/29/21 at 9:38 AM, the surveyor interviewed the Dining Services Director (DSD) in the presence of another surveyor. The DSD stated that he was Serve Safe Certified. On 5/04/21 at 10:29 AM, the surveyor interviewed the Registered Dietitian (RD) in the presence of another surveyor. She stated that she worked two -eight-hour days a week, usually Tuesdays and Thursdays. On 5/04/21 at 11:00 AM, the surveyor reviewed the DSD's Serve Safe Certification which revealed an expiration date of 11/11/20. On 5/04/21 at 11:30 AM, the Regional Nurse provided the surveyor a Professional Certification dated 1/5/21 for a Certified Food Manager for the DSD. Review of the certification agency on the document 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.

Based on observation, interview, record review, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store potentially hazardous and dry foods in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was observed during two kitchen tours and was evidenced by the following: On 4/29/21 at 9:38 AM, the surveyor conducted an initial tour with the Dining Services Director (DSD) in the presence of another surveyor and observed the following: There was a small black plastic garbage bin without a lid, uncovered and overflowing with trash at the handwashing sink. The handwashing sink was observed flush alongside and at the height of the stainless-steel table attached to the sanitizer sink. The paper towel dispenser was mounted directly over the same table. The top reach in milk refrigerator's internal thermometer was unreadable, however the external thermometer read 38 degrees Fahrenheit (F). Neither surveyor nor the DSD could decipher the temperature. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to have Consultant Pharmacist Services for the Month of April 2021. This deficient practice was identified for 12 of 12 residents (Residents #2, #3, #4, #6, #10, #16, #17, #30, # 35, # 38, # 41, and # 192) reviewed for drug regimen. This deficient practice was evidenced by the following: 1. On 5/4/21 at 11:25 AM, the surveyor reviewed the admission Record for Resident #2 which indicated that the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to: Heart Failure, Cerebrovascular Disease and Hypertension. Review of the Consultant Pharmacist Evaluation Report revealed that the last monthly drug regimen review was dated 3/26/21. 2. On 5/4/21 at 11:30 AM, the surveyor reviewed the admission Record for Resident #3 which indicated that the resident was admitted to the facility on [DATE] with diagnoses which included, but not limited to: Schizophrenia, Parkinson's Disease 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.

Based on observation, interview, and record review, it was determined that the facility failed to provide: a.) a meal in accordance with their weekly cycle menu for 13 residents observed during the lunch meal on 5/3/21; b.) the correct portion of milk for 21 residents observed during the breakfast meal on 5/4/21 and 5/5/21 in accordance with their weekly cycle menu; and c.) individual resident preferences as indicated on a meal ticket identified for 1 of 13 residents reviewed. This deficient practice was evidenced by the following: On 5/03/21 at 10:26 AM, the surveyor conducted a resident council meeting with three residents in the presence of another surveyor. One resident was the resident council president. Two of the three residents expressed concerns regarding food and the menus. They stated that what they receive does not always match the menu and/or the meal tickets. On 5/3/21, the team conducted lunch meal rounds on the first and second floors, and observed the following: The posted lunch menu was for Open-faced Hot Turkey Sandwich, Fresh Mashed Potatoes, Seasoned [NAME]…

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 the personal protective equipment (PPE) was readily available and accessible to the staff on the persons under investigation (PUI) unit; b.) ensure proper use of PPE for 1 of 4 staff; c.) perform handwashing appropriately for 2 of 13 staff in accordance with the Centers for Disease Control and Prevention (CDC) guidelines for infection control to mitigate the spread of COVID-19; and d.) follow appropriate infection control practices for the administration of eye drops, identified for 1 of 2 nurses during the medication observation pass. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated February 23, 2021, included; 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2: Personal Protective Equipment-HCP who enter…

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 monitor and track the use of antibiotics for 2 of 2 units from January through March 2021 according to the Antibiotic Stewardship Program. This deficient practice was evidenced by the following: According to the U.S. CDC Core Elements of Antibiotic Stewardship for Nursing Home, page last reviewed June 11, 2020, included, Tracking and Reporting Antibiotic Use and Outcomes Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Process measures: Tracking how and why antibiotics are prescribed Perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation, and antibiotic selection were in accordance with facility…

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.) clarify a physician's order for 1 of 12 residents (Resident #3) and b.) follow a physician's order with regards to a Glucerna supplement for 1 of 12 residents, (Resident #44) according to the standards of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 2 of 4 medication carts and 1 of 2 medication refrigerators inspected. This deficient practice was evidenced by the following: On [DATE] at 11:00 AM, the surveyor inspected the 2nd floor low-side medication cart in the presence of a Registered Nurse (RN#1). The surveyor observed an opened bottle of Pro-Heal solution with an opened date of [DATE]. An opened bottle of Pro-heal solution has a 60-day expiration date. The surveyor interviewed RN #1 who stated that the opened bottle of Pro-Heal solution was expired and should have been removed from the medication cart. On [DATE] at 11:15 AM, the surveyor inspected the 2nd floor medication refrigerator cart in the presence of RN #1. The surveyor observed a bottle of Combigan eye drops that was stored in the medication refrigerator, a medication that should be stored at room temperature. The surveyor interviewed RN#1 who…

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.