Abingdon Care & Rehabilitation Center

Based on interview and review of facility documentation, it was determined that the facility failed to employ a full time Social Worker (SW) from 12/7/24 to 4/16/25. This deficient practice was evidenced by the following: On 4/15/25 at10:17 AM, the surveyor met with seven residents for a resident council meeting. During that meetin, 6 out of the 7 alert and oriented residents voiced concerns that the facility did not have a full-time social worker. The residents explained for the last 2 or 3 months there was a social worker that worked only Saturdays/Sundays for about 5 hours. On 4/15/25 at 1:05 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated there was a new social worker starting this week. He confirmed the current social worker (SW#2) usually comes in a few hours on Saturday's and Sundays. He verified the last SW's (SW#1) last day was 12/6/24. A review of the facility provided time clock punches for SW #2 revealed SW #2 worked as follows: -12/7/24 to 12/29/24 a total of: 31.5 hours -1/8/25 to 1/25/25 a total of: 22.58 hours -2/1/25 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 pertinent facility documents, it was determined that the facility failed to post the nurse staffing report daily. This deficient practice was evidenced by the following: On 4/14/25 at 9:31 AM, the surveyor did not observe the nursing staffing report posted at the front reception desk, the time clock, the elevator, or at either nursing unit. The receptionist was present at the front desk. On 4/15/25 at 9:31 AM, the surveyor did not observe the nursing staffing report posted at the front reception desk, the time clock, the elevator, or on the Noble nursing unit. The receptionist was present at the front desk. On 04/16/25 at 9:44 AM, the surveyor observed the nursing staffing report posted at the front desk dated 4/15/25 for the 7-3 shift. On 4/16/25 at 11:16 AM, the surveyor observed the nursing staffing report posted at the front desk dated 4/16/25 for the 7-3 shift. On 04/17/25 at 9:24 AM, the surveyor observed the nursing staffing report posted at the front desk dated 4/17/25 for the 7-3 shift. On 4/22/25 at 9:32 AM, the surveyor…

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

Based on interview and review of pertinent facility documentation, the facility failed to ensure the required committee members, the Infection Preventionist (IP), was present for two out of four Quality Assurance and Performance Improvement (QAPI) meetings reviewed and was evidenced by the following: 04/23/25 11:33 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated QAPI meetings were held at least quarterly and as needed, he added we also meet monthly. He stated the required members were the administrator (LNHA), the director of nursing (DON), the medical director and other staff were required to attend the meetings at least quarterly. The LNHA stated also will be including a certified nursing assistant in the meetings. At that time, the LNHA reviewed the facility provided QAPI sign in sheets, he removed the sign in sheets for the quarterly QAPI meetings. A review of the Quarterly QAPI Meeting Attendance sign in sheets revealed meeting were conducted on 4/17/2024, 7/17/2024, 10/16/24 and 1/15/2025. The surveyor asked the LNHA to identify the IP…

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

Repeat Deficiency Based on observation, record review, interview, and review of pertinent facility documents, it was determined that the facility failed to prevent the potential for cross contamination by not placing a resident with open wounds on Enhanced Barrier Precautions (EBP- a gown and gloves be worn when performing high contact care), for one of two residents (Resident #45) reviewed for pressure ulcers. The deficient practice was evidenced by the following: On 4/16/25 at 9:33 AM, during a wound treatment observation, the surveyor observed the Certified Nurse Aide (CNA) holding Resident #45 on their right side with their sacral and right heel wound exposed. The CNA was wearing gloves. The surveyor then observed the Licensed Practical Nurse (LPN) cleanse the sacral wound and apply the treatment and dressing. The LPN was wearing gloves. After performing hand hygiene, the LPN donned (put on) gloves and the LPN cleansed the right heel wound and applied the treatment. The surveyor had not observed EBP signage at the resident's doorway or in the room. The surveyor reviewed 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 observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain an effective pest control program so that the kitchen was free of pests. The deficient practiced was evidenced by the following: On 4/14/25 at 10:05 AM, the surveyor conducted a kitchen tour with the Food Service Director (FSD). During this tour, he stated that he used a [name redacted] electronic communication system as well as verbal communication with the Director of Environmental Services (DES) when there was a maintenance concern in the kitchen. The surveyor observed an open drain on the floor next to a grease trap. The surveyor observed many flies in this area, coming from the drain, in the air and on the wall. The FSD acknowledged this and stated they were drain flies, and that the grease trap needed to be cleaned. In addition, the FSD stated the exterminator treated the area and that it did not help since there was an open drain. On 4/22/25 at 1:01 PM, the surveyor conducted a second kitchen tour with an additional surveyor and the FSD. The…

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

Based on interview and review of facility documentation, it was determined that the facility failed to ensure the surety bond contained sufficient funds to protect the residents' trust funds. This deficient practice had the potential to affect all residents who resided in the facility that had Personal Needs Account (PNA) funds and was evidenced by the following: On 10/19/23 a 12:45 PM, the Licensed Nursing Home Administrator (LNHA), provided the surveyor with a three-page document labeled Checking Account Statement, Statement Type: Bank, Trust Account [number redacted]. The document was dated 07/25/23 through 10/18/23. The document revealed a beginning balance $144,211.45, on 07/25/23, and a balance of $129,340.81 on 10/18/23. Additionally, the surveyor was provided with a 2-page Checking Account Statement dated 07/20/23 through 10/18/23 which was labeled as Petty Cash Account [number redacted]. On 10/19/23 1:10 PM, the LNHA provided a copy of the Surety Bond. The document revealed a Renewal Verification/Continuation Certificate for an anniversary premium Period dated 4/1/23 -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to consistently provide appropriate Activities of Daily Living (ADLs) care, for residents dependent on staff assistance for care, by failing to provide: a) nail care, b) assistance with dressing, c) personal hygiene care, and d) provide incontinence care, including prior to delivering a meal tray. This deficient practice was identified for 5 of 21 residents reviewed for ADLs (Resident #7, #13, #14, #41, and #73) on 2 of 2 resident care units (Noble and [NAME]). This deficient practice was evidenced by the following: a. On 10/18/23 at 9:40 AM, Surveyor #1 toured the [NAME] unit and observed Resident #7 lying in his/her bed. The surveyor observed Resident #7's fingernails to be long and jagged with a brown substance under the fingernails. Resident #7's right hand ring finger had a long fingernail that was curled over and inward and in direct contact with the resident's fingertip. 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 review of facility documentation, it was determined that the facility failed to: a.) ensure that staff were competent and appropriate care was provided for the hemodialysis (the filtration of waste when the kidneys are no longer able to do so) access sites, and staff were trained to differentiate between an AV (Arteriovenous) Fistula (an abnormal connection between an artery and a vein), and a Permacath (tunneled hemodialysis catheter) a flexible tube used for dialysis treatment, and b.) ensure that staff were trained to properly assess, and document care of the hemodialysis access sites which includes the auscultation/palpation of the AV fistula for Bruit (an abnormal sound generated by turbulent arterial blood flow) and Thrill (a palpable sensation of blood flow) to assure adequate blood flow and to monitor the hemodialysis access site for bleeding, signs of infection and pain. This deficient practice was identified for 1of 4 residents (Resident #90) reviewed for hemodialysis treatment and was evidenced by the following: On 10/19/23 at 10:55 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ 00162113 Based on observation, interview and review of pertinent documents it was determined that the facility failed to ensure sufficient staff were available to (a) provide assistance dressing, provide personal hygiene and incontinence care for residents who were dependent on staff for Activities of Daily Living (ADLs), b) provide nail care for a resident who was dependent on staff for ADLs, and c) respond to call lights in a timely manner. This deficient practice was identified for 5 of 21 residents (Resident #13, #14, #41, #73 and #7 ) on 2 of 2 nursing units. This deficient practice was evidenced by the following: Refer to 684G and 677F. Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/21, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing…

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: a) a Medication Regimen Review (MRR) of each resident was performed at least once a month by a licensed pharmacist, and b) provide documentation that the recommendations were acted upon in a timely matter. This deficient practice was observed for 2 of 2 nursing units with a census of 101, for August 2023 and September 2023, and was evidenced by the following: During an interview with the surveyor on 10/25/23 at 9:22 AM, the Registered Nurse Unit Manager (RN UM) stated that MRR were completed monthly, but the facility had changed pharmacy consultants and not sure how the reporting was being done at present. The process with the prior consultant pharmacy was that the Consultant Pharmacist (CP) would email all recommendations to the Director of Nursing (DON) then the DON would email them to the Unit Manager. On 10/25/23 at 10:07 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the presence of a consultant pharmacist. The LNHA stated that she…

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 ensure that garbage was regularly removed from the facility in a manner to prevent the potential spread of infection and vermin infestation. The deficient practice was evidenced by the following: On 10/18/23 at 8:53 AM, during the initial approach from the parking area/rear of the building, the surveyor observed a large pile of garbage bags that covered approximately one- half of the loading dock. The garbage bags were piled up against the back wall of the loading dock and adjacent to a chain link fence cage that appeared to have oxygen cylinders inside with a sign affixed Danger, No Smoking, No Open Flames to the outside of the cage and above a pile of the garbage bags. The garbage bags that were piled up against the back wall obstructed a sign Notice all cardboard needs to be . making it unreadable in it's entirety. There was a large compacter type dumpster below the loading dock, and an uncovered cardboard type dumpster next to it. There was also debris strewn about next to the compacter dumpster 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 facility documents, it was determined that the facility failed to follow facility policy to limit the spread of potential infection by ensuring: a.) hand hygiene at the lunch meal service, b.) hand hygiene and clean procedure during the care of a feeding tube dressing, c.) the demonstration of a hemodialysis access assessment, and d.) the Clean Dressing Change Policy was followed for 1 of 1 resident (Resident #14) observed during a wound care treatment observation. This deficient practice was identified for 3 residents (Resident #358, #90, and #14) on 2 of 2 nursing units and was evidenced by the following: a.) On 10/19/23 at 11:48 AM, Surveyor #1 observed the [NAME] unit staff passed out the lunch meal trays. A Certified Nursing Assistant (CNA) #1 was observed not performing hand hygiene prior to, or after delivery of meal trays as follows: 11:50 AM, into room [ROOM NUMBER]. 11:51 AM, into room [ROOM NUMBER] and another tray into room [ROOM NUMBER].…

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 and interview, it was determined that the facility failed to maintain resident common areas, resident rooms and equipment in a clean, sanitary and safe functional manner as evidenced by the following: During the initial tour of the Noble unit on 10/18/23 at 10:14 AM, the surveyor observed in room [ROOM NUMBER] the air conditioner unit with blue tape and card board around the bottom of the unit. On 10/18/23 at 10:30 AM, the surveyor toured the [NAME] unit day room and observed an unsampled resident (UR #1) ambulating independently and was looking out of a window that was above an air conditioning unit, and another unsampled resident (UR #2) was sitting at a table watching the television. Upon entering the day room, the surveyor observed a row of wooden cabinets that appeared visibly soiled on the exterior, and the cabinet door appeared to be loose on its hinges. At 10:32 AM, the Activity Director entered the day room, and the surveyor showed her the debris on the wooden cabinets and upon…

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

Based on interview, record review and review of pertinent documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) two incidents for one resident (08/20/23 & 09/23/23) for injuries that resulted in fractures. The deficient practice was identified for 1 of 2 (Resident #52) residents reviewed for reportable events and was evidenced by the following: On 10/23/23 at 12:24 PM, the facility provided incident reports for Resident #52. The documents revealed Resident #52 had a fracture of the distal phalanx (bone) of the third finger to the left hand (middle finger of the left hand) which occurred on 08/20/23. Resident #52 also had an incident dated 09/23/23, which resulted in a right nasal bone fracture, minimally displaced nasal septum fracture, and nondisplaced left nasal bone fracture (3 bones in the nose). On 10/25/23 at 12:41 PM, Surveyor #1 interviewed the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The DON spoke to the incident/accident process, stating that an investigation should start…

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

Based on interview, record review and review of pertinent documents it was determined that the facility failed to complete and document a thorough investigation and follow the facility Abuse Policy for a.) two incidents that resulted in two different fractures for one resident who resided on a secure unit with a diagnosis of Dementia, and b.) failed to conduct an investigation for a resident who was observed self-injecting with an unknown substance. This deficient practice occurred for 2 residents (Resident #52 and Resident #356) reviewed for accidents and incidents and was evidenced by the following: a.) On 10/18/23 at 9:47 AM, Surveyor #1 observed Resident #52 seated in a chair next to the bed. The Resident was alert but unable to answer questions asked due to the resident being confused. At that time, the RN (Registered Nurse) was present and explained the resident can get confused at times and needed re-direction often. The RN also stated the resident had a diagnosis of Dementia. On 09/20/23 at 9:50 AM, Surveyor #2 reviewed the Electronic Medical Record (EMR) and reviewed a…

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

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 a.) a resident who was dependent on supplemental oxygen via a tracheostomy was provided with respiratory services to maintain their oxygenation status according to the physician's order and the facility's policy, b) that a resident received oxygen as ordered by the physician, and c) oxygen related treatments were provided in a manner to prevent the spread of infection. This deficient practice was identified for 2 of 2 residents reviewed for respiratory services, Resident #14 and #92 and was evidenced by the following: 1.) On 10/18/23 at 09:10 AM, the surveyor observed Resident #14 in bed. The resident was non verbal. The resident had a tracheostomy (a surgical opening in the anterior neck providing an alternate airway for breathing), and was connected to an oxygen concentrator. The concentrator was set to deliver oxygen at 4 liters per minute via the trachea collar. The surveyor observed the label on 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 failed to ensure that the meals were served at a palatable temperature for 2 of 2 Residents reviewed for food (Resident #23 & Resident #87). The deficient practice was evidenced by the following: On 10/18/23 11:29 AM, the surveyor observed Resident #87 awake and alert sitting in bed. The surveyor asked about the food at the facility and Resident #87 stated the food is horrible and it is cold. On 10/18/23 at 11:40 AM, the surveyor observed Resident #23 awake and alert sitting in wheelchair inside the resident's room. When asked about the meals, Resident #23 stated the food *, the food is always cold. On 10/20/23 at 8:27 AM, the surveyor observed the meal cart brought to the second floor by the dietary staff. On 10/20/23 at 8:32 AM, the second to last tray was delivered and the requested the last tray which belonged to Resident #23 and proceeded to check the temperatures of the food items in the presence of the Registered Nurse. The meal tray was labeled Regular diet and contained scrambled eggs which were 122…

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 and document review it was determined that the facility failed to ensure that a process was in place for explaining the arbitration agreement to a resident prior to having the resident sign the agreement. This deficient practice occurred for 1 of 2 residents reviewed for arbitration agreements (Resident #16) and was evidenced by the following: On [DATE] at 12:19 PM, the Licensed Nursing Home Administrator (LNHA) informed the surveyor that the facility utilized arbitration agreements which were part of the admission agreement and would provide a list of residents who have signed the agreement. The LNHA stated the admission Diretor was responsible for having the residents sign the agreements. On [DATE] at 11:30 AM, the surveyor received the list of facility arbitration agreements which include resident #16. A reviewed of Resident #16's electronic medical record (EMR) revealed Resident #16 entered into the Arbitatrion Agreement (AA) by signing the Arbitration Agreement on [DATE]. The AA 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, and document review, it was determined that the facility failed to provide education and assess staff competencies for staff who provided care for residents who received dialysis [a type of treatment used to clean the blood when kidneys do not function properly] as identified as residents with skilled needs per the Facility Assessment. The deficient practice was evidenced by the following: On 10/19/23 at 10:55 AM, the surveyor observed Resident #90 lying in bed awake, watching television with snacks on his/her bedside table. Resident #90 stated that he/she had been going to hemodialysis for a while. The resident stated that he/she used to have a catheter in his/her chest, while pointing to his/her right side of chest and neck area, but now had a fistula in his/her right arm, pointing to his/her right upper arm. The surveyor did not observe any catheter or permacath in resident's right chest wall. The surveyor observed 2 bulging sites on the resident's right upper arm. There were no dressings on the 2 sites and some bruising was noted. Resident #90…

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

Complaint # NJ 162113 Based on interview, and record review it was determined that the facility failed to ensure that resident temperatures were documented per physician order for 1 of 1 closed record (Resident #356) reviewed for physician orders. The deficient practice was evidenced by the following: On 10/20/23 at 10:31 AM, a review of the closed medical record for Resident # 356 revealed a Physician Order dated 02/18/23 for Blood pressure (BP) monitoring every shift, HR [heart rate], RR [respiratory rate], Temp [Temperature], SPO2 [Pulse Oximetry], Pain every shift for BP monitoring. The Electronic Medical Record (EMR) documentation of Temp was reviewed from 02/18/23 through 03/04/23 when resident was transferred to the hospital and indicated the following: Date: Time: Temp: 3/4/2023 09:04 [7AM-3PM shift] 97.4 °F 3/3/2023 23:27 [3PM-11PM shift] 97.3 °F 3/3/2023 13:20 [3PM-11PM shift] 97.4 °F 3/3/2023 00:25 [11 PM-7AM shift] 97.7 °F 3/2/2023 14:45 [7AM-3PM shift] 97.5 °F 3/2/2023 00:15 [11 PM-7AM shift] 97.5 °F 3/1/2023 19:37[3PM-11PM shift] 97.6 °F 3/1/2023 00:59[11 PM-7AM 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 facility documents it was determined that the facility failed to properly label and date medications in 2 of 4 medication carts inspected. The deficient practice was evidenced by the following: 1. On 10/19/23 at 11:00 AM, the surveyor inspected the low side of the Noble Unit medication cart on the 2nd floor with the Licensed Practical Nurse (LPN#1) who was assigned to the cart. Inside of the medication cart the surveyor observed following: -1 bottle of Nitroglycerin tablet (medication used to treat angina) with an expiration date of 07/23 -1 multi dose vial of insulin opened but not dated, a pack of Oxycodone 5/325 milligrams( mg) (medication to treat pain) with an expiration date of 09/23 -5 multi dose vials of Insulin that had an open date and no expiration date -1 multi doses vial of Aspart Insulin opened 09/07/23 last used 10/19/23. 2. The surveyor inspected the medication storage room on the Noble Unit with LPN #1. Inside the locked medication refrigerator was the following: -1 multi doses vial of PPD (Purified Protein Derivative)…

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 maintain the resident nurse call system to operate as designed with visual and audible signals at the nursing station for 1 of 21 residents ( Resident #15) on 1 of 2 units (Noble). This deficient practice was evidenced by the following: On [DATE] at 10:59 AM, the surveyor observed when Resident#15's call bell was illuminated, there was no audible or visual signal emitting from the resident call system console located at the Noble Unit nurse's station. At 11:06 AM, the surveyor observed the call light outside Resident #15's room was not illuminated (turned off). On [DATE] at 11:40 AM, the surveyor observed that the nurse call light outside Resident #15's room was illuminated. The surveyor observed the Registered Nurse Unit Manager (RN UM) sitting at the nurse's station next to the resident call system console. At that time, the surveyor interviewed the RN UM who stated that when a resident activated the call light…

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 document assessments of the resident's condition by monitoring for complications after dialysis treatments were received at a certified dialysis center for 1 of 2 residents (Resident #61) reviewed for dialysis documentation. This deficient practice was evidenced by the following: On 8/24/21 at 11:20 AM, the surveyor observed Resident #61 seated in a wheelchair with oxygen infusing at 3 liters/minute via nasal cannula. The resident stated they went out of the facility for dialysis treatments on Monday, Wednesday, and Friday. Resident #61 informed the surveyor that the hemodialysis access site (Arteriovenous shunt/fistula) was not assessed by the facility nurse before leaving or after returning to the facility after dialysis. A review of the current physician's order (PO) reflected an order for hemodialysis three days a week on Monday, Wednesday and Friday; Monitor Fistula in the Right Arm for patency, prevent injury…

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 maintain proper infection control practices identified during 1 of 1 wound treatment observation for Resident # 79. This deficient practice was evidenced by the following: On 8/25/21 at 11:08 AM, during the initial tour, Resident #79 was observed in bed, with eyes closed. A review of Resident #79's Face Sheet (an admission summary) reflected that the resident was admitted to the facility on [DATE] with diagnoses that included but not limited to, Parkinson's Disease, Type II Diabetes Mellitus, Hypertension and Schizo-Affective Disorder. A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate care management dated 7/15/21, indicated a Brief Interview for Mental Status scored at 15, which indicated that the resident was cognitively intact. The surveyor reviewed the August 2021 Physician Order Summary, which reflected a Physicians' order (PO) to cleanse sacral wound with Normal Saline (NS),…

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.