Hammonton Center for Rehabilitation and Healthcare

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure: a.) respiratory equipment was stored in an appropriate way to prevent the spread of infection, and b) a physician's order (PO) was obtained for necessary treatment for 2 of 3 residents (Resident #110 and #184) reviewed for respiratory care.This deficient practice was evidenced by the following:On 1/5/2026 at 10:26 AM, the surveyor observed Resident #184 in the bed with a C-PAP (Continuous Positive Airway Pressure) machine (a common treatment for sleep apnea that uses pressurized air delivered through a mask to keep your airway open during sleep, improving breathing, and overall health by preventing pauses in breathing which consisted of a motor, a hose, and a mask (nasal or full-face) that delivers a steady stream of air) on the nightstand next to them. The C-PAP mask was uncovered and touched the surface of the nightstand.At that time, Resident #184 stated that they last used their C-PAP one day last week, and they typically used it a couple of…

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

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 5 of 5 forms reviewed. This deficient practice was evidenced by the following: On 1/9/25 at 2:09 PM, the surveyor reviewed the facility provided DEA 222 forms which revealed on five of the five provided forms Part 5, had not been completed upon receipt of the medications from the provider pharmacy as instructed on the reverse of the ordering form. The forms were as follows: Order form #240870463 dated 3/11/25 #240870454 dated 5/27/25 #250798148 dated 7/31/25 #250798149 dated 9/5/25 #250798150 dated 10/15/25 - Part 5 was not completed with the number of items received and the date they were received On 1/12/2026 10:00 AM, the surveyor interviewed the Director of Nursing (DON) who stated the process for completing the DEA 222 form entailed that the DON filled in…

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 review of pertinent facility documents, it was determined that the facility failed to: follow appropriate infection control practices by having necessary personal protection equipment (PPE) readily available for a resident who required enhanced barrier precautions (EBP). This deficient practice was identified for 1 of 10 residents (Resident #55) reviewed for infection control and was evidenced by the following: This deficient practice was evidenced by the following: 1. On 1/9/26 at 11:18 AM, the surveyor knocked on Resident #55's closed door, at that time the surveyor observed a sign posted outside of Resident #55's door that revealed Enhanced Barrier Precautions, once inside the room, the surveyor observed the resident seated in a wheelchair, hair disheveled and the resident smelled of smoke. When the surveyor asked the resident if the staff wore a gown and gloves while caring for them, Resident #55 stated, I don't know. The surveyor did not observe any PPE (personal protective equipment-Clothing or equipment worn to protect one from injury or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of facility documents, it was determined that the facility failed to a.) document the administration of the influenza vaccine after signed consent was obtained for one (Resident #41) of five sampled residents; b) ensure the provision of the influenza and pneumococcal vaccines were properly offered to a resident with impaired cognition for one (Resident #6) of five residents reviewed for influenza and pneumococcal immunizations. This deficient practice was evidenced by the following:On 1/6/2025 at 12:42 PM, the surveyor observed Resident #6 walking in the hallway and yelling. A review of the admission Record, an admission summary, revealed Resident #6 had diagnoses which included, but were not limited to: Schizophrenia, Major Depressive Disorder, and Anxiety Disorder. A review of Resident #6's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/8/2025, revealed the resident had a Brief Interview for Mental Status…

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 interviews and review of other pertinent facility documents on 11/01/24, 11/04/24, and 11/06/24, it was determined that the facility failed to ensure that the Administrator ensured that two staff that were currently working as Assistant Administrators were licensed as Nursing Home Administrators (NHA) per the facility's Job Description for Assistant Nursing Home Administrator. On 11/01/24, at 10:20 AM, the surveyor completed the entrance conference with Assistant Administrator (AA) #1, who stated that he had worked at the facility for 2.5 months. On 11/01/24, at 2:20 PM, Surveyor #1 requested a copy of Nursing Home license from AA #1 and AA #2. AA #1 stated that he was licensed in New York and not in New Jersey. AA #2 stated that he did not have a Nursing Home Administrator License. Both AA #1 and AA #2 stated that their job titles at the facility were Assistant Nursing Home Administrator. On 11/01/24, at 2:43 PM, AA #1 verified that he is a licensed Administrator in New York, and not in New Jersey. A copy of the license was provided for review. Surveyor #2 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.

COMPLAINT #: NJ00179283 Based on observation, interviews, medical record review, and review of other pertinent facility documents on 11/01/24, 11/04/24, and 11/06/24, it was determined that the facility failed to develop a comprehensive person-centered care plan (CP) for a resident that included action taken by staff to educate the resident regarding alternatives and consequences. The facility also failed to follow its Care Plans - Comprehensive policy. The deficient practice was identified for 1 of 9 residents (Resident #9) reviewed for CP and was evidenced by the following: On 11/06/24 Surveyor #2 observed Resident #9 seated in a wheelchair dressed in a sweatshirt and pants. The resident was self-propelling the wheelchair out of the elevator onto the first floor. The resident stated recalling a recent incident that involved him/her and another resident. Surveyor #2 reviewed Resident #9's admission Record which revealed that the resident was admitted to the facility with diagnoses that included but were not limited to: cerebral aneurysm (a bulge or ballooning in a blood vessel in…

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 faciloirty documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: A review of the facility policy titled Food Storage, Last Date Revised 7/19/2023, revealed the following under the heading POLICY: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. The following was revealed under the PROCEDURE section: 10. Food will be stored a minimum of 6 inches above the floor, 18 inches from the ceiling and 2 inches from the wall on clean racks or other clean surfaces, and is protected from splashes, overhead pipes, or other contamination (ceiling sprinklers, sewer/waste disposal pipes, vents, etc.). 12. Leftover food will be stored in covered containers…

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 other facility documentation, it was determined that the facility failed to issue the required beneficiary notices for 2 of 3 residents reviewed for Beneficiary Protection Notification (Resident # 140 and Resident # 162. This deficient practice was evidenced by the following: A review of a facility policy on 07/29/2024 at 8:32 AM, titled Notice-Advanced Beneficiary Notice (ABN) with a creation date of 7/2019, revealed under the Policy section; The Advanced Beneficiary Notice of non-coverage (ABN) is issued by the facility to original Medicare (fee for service-FFS) beneficiaries in situations where Medicare payment is expected to be denied. Medicare requires SNF's (Skilled Nursing Facilities) to issue SNFABN to Original Medicare, also called FFS beneficiaries prior to providing care that Medicare usually covers but may not pay for in this instance because the care is: not medically reasonable and necessary or considered custodial. On 07/23/2024 at 01:45 PM, the surveyor requested 3 random residents, 1 resident who went home and 2 residents 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.

Complaint #: NJ00173786 Based on interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to notify in writing, the representative of the New Jersey Long-Term Care Ombudsman's office (LTCO) of resident emergency transfers to the hospital/discharges, when practicable, as mandated by Federal law. This deficient practice was identified for 2 of 37 sampled residents (Resident #54 and Resident # ADD NUMBER) and was evidenced by the following: On 07/25/2024 at 04:00 PM, a review of a facility policy titled NJ Ombudsman Mandatory Reporting with last revised date of 2/2023 under procedure section Transfer/Discharge, Copies of all facility-initiated (non-resident-driven) discharge notices shall be provided to the LTCO. 1. On 07/22/2024 at 01:29 PM, the surveyor reviewed the Electronic Medical Record (EMR) for Resident # 54 which revealed the following: Resident # 54 was admitted to the facility with diagnoses including but not limited to: Urinary Tract Infection, Urinary Calculus (kidney stones), and Hydronephrosis (excess…

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

Based on observation, interview, review of the medical record, and review of pertinent facility documents, it was determined that the facility failed to consistently implement and revise a care planned intervention (use of heel booties (prevent pressure ulcers from forming) for 1 of 2 residents (Resident #78) reviewed for position/mobility. This deficient practice was evidenced by the following: The surveyor reviewed the facility policy titled Care Plans - Comprehensive, Last Date Revised: 10/2019. The following was revealed at POLICY: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The following was revealed under PROCEDURE: 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. c. Describe services that would otherwise be provided for the above but are not provided due 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 observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to follow hold parameters for administration of insulin (a diabetic medication) in accordance with the resident's physician's orders and in accordance with professional standards of practice. This deficient practice was identified for 1 of 36 residents reviewed for professional standards of practice (Resident #39). A review of the facility's Medication Administration policy dated revised 12/2023, included medications must be administered in accordance with orders, including any required time frame . 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…

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

Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to follow physician orders specifically to change the piston syringe (a device intended for medical purposes that consists of a calibrated hollow barrel and a movable plunger) every 24 hours for 1 of 2 residents reviewed for Tube Feeding, (Resident #37.). This deficient practice was evidenced by the following: A review of facility policy on 07/24/2024 at 12:08 PM, titled Enteral Feedings with last revised date of 4/2023, did not include documentation of the care and changing of the piston syringe kit. On 07/31/2024 at 10:26 AM, the DON provided the surveyor the same policy titled Enteral Feedings. The following was highlighted under the Procedure section: 4. Ensure that equipment and devices are working properly by performing any calibrations or checks as instructed by manufacturer. 12. Administration and feeding sets. a. Feeding may be reused for next scheduled feed as long as it is free from contamination, however; b. Replace tubing and feeding…

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, review of the medical record, and review of other pertinent facility records, 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 #22 and Resident #63). This deficient practice was identified by the following: The surveyor reviewed the facility policy titled Nebulizer Medication/COVID 19, Last Revised Date: 1/2023. The following was revealed under the heading POLICY: Nebulization is used to deliver medications along the respiratory tract and is indicated for various respiratory problems and diseases. The therapy must be prescribed by a properly licensed physician or physician extender. The purpose of the procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Nebulizer treatments will be given by licensed nursing staff or respiratory therapists as directed, using proper technique…

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

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 3 of 3 forms provided. The evidence was as follows: A review of the facility's provided Medication- Narcotic Management policy with a revised date of 4/2023 did not include information related to the completion of the DEA 222 forms. On 7/30/2024 at 10:15 AM, the surveyor reviewed the facility provided DEA 222 forms which revealed on three of the three provided forms Part 5, had not been completed upon receipt of the medications from the provider pharmacy as instructed on the reverse of the ordering form. The forms were as follows: Order form number: 221690894; 221690895; and 221690896. On 7/30/2024 at 1:39 PM, the surveyor and Director of Nursing (DON) reviewed the provided DEA 222 forms. The DON acknowledged she should have completed the Part 5 as instructed 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.

NJ COMPLAINT #: 169607 Based on interview and review of pertinent facility documents, it was determined that the facility failed to complete a significant change in status assessment using the Resident Assessment Instrument (RAI) process for a resident who elected hospice services. This deficient practice was identified for 1 of 6 residents reviewed for accidents (Resident #565), and was evidenced by the following: A review of facility's Electronic Submission of MDS policy dated revised August 2023, included that all MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data .a Significant Change in Status (SCSA) Comprehensive has a MDS Completion Date is the 14th calendar day after determination of significant change in status . A review of the facility's Centers Health Care…

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 #: NJ00172065 and NJ00169138 Based on interview and review of pertinent facility documents, it was determined that the facility failed to revise comprehensive care plans in a timely manner following an allegation of abuse. This deficient practice was identified for 2 of 36 residents (Resident #515 and #265) reviewed for care plans. A review of the facility's Care Plan policy, last revised 10/2019, included .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. A review of the facility's undated Job Description Licensed Practical Nurse document included .Participate in the development of a plan of care for each resident. A review of the facility's undated Job Description Registered Nurse document included .Reviews and regularly evaluates resident care plans to meet nursing goals. A review of the facility's undated Job Description Unit Manager document included .Responsible for the evaluation and monitoring of all levels of resident care through on-site observations and audits, including…

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.

NJ Complaint #:163266 Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure a resident who smoked cigarettes was assessed for safety; educated on facility rules and safety for smoking; and care planned for smoking to ensure resident safety. The deficient practice was identified for 1 of 7 residents reviewed for accidents (Resident #266), and was evidenced by the following: A review of the facility's Smoking Program dated revised October 2022, included a Smoking Assessment will be completed by the nurse for all new admissions who are identified as patients who smoke. If a resident previously identified as a nonsmoker expresses the desire to begin smoking, the Smoking Assessment will be completed at that time .An individualized plan of care will be developed for the resident to ensure his/her smoking safety based on the outcome of the Smoking Assessment . On 7/25/24 at 8:45 AM, the surveyor requested from the Assistant Administrator (AA) to provide a copy of Resident #266's Facility Report Event (FRE) that was reported 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.

Complaint: NJ00160690, NJ00163037, NJ00166486 Based on observation, staff interview, and facility policy review, the facility failed to ensure clean plates and pans were air dried prior to storage and not stacked wet. This failure had the potential to increase the risk of foodborne illness and had the potential to affect 155 of 157 residents in the facility who received dietary services at the time of the survey. Two residents received tube feedings. Findings include: Review of the facility's policy ''Dish Washing and Storage Policy,'' dated 06/17/19, revealed, ''Policy: Dishes, pots and pans will be washed and dried using the procedures, chemicals and equipment that result in clean, sanitized dishes, pans flatware and utensils. Procedure: Dish Machine Washing: .Dishes, pots, pans, utensils, and flatware must be air dried before being stored. Do not dry with towels . 7. Employees are trained in proper dishwashing and drying procedures . Observation and interview on 02/20/24 at 11:40 AM, the plates stacked in two different plate warmers, next to the steam table to be used for lunch…

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 #: NJ000165571, NJ00160246, NJ00163849 Based on record review, interview and policy review, the facility failed to ensure the timely administration of a medication for one (Resident (R) R11) out of 15 residents reviewed in the sample. Specifically, R11's sliding scale insulin was administered late four times between 02/01/24 and 02/20/24. Findings include: Review of the facility's policy titled Medication Administration dated 12/2019 indicated, .3. Medications must be administered in accordance with the orders, including any required timeframe . Review of R11's Electronic Medical Record (EMR) titled admission Record located under the Profile tab revealed R11 was admitted to the facility on [DATE] with diagnosis including Type 2 diabetes. Review of R11's admission Minimum Data Set (MDS), found in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 01/24/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident's cognition was intact.…

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 # NJ00165000, NJ00163037 Based on policy review, record review, observations, and interviews, the facility failed to ensure effective infection control practices were maintained for one Resident (R ) R11 out of four residents observed during medication administration. Specifically, Licensed Practical Nurse (LPN 4) was observed administering a blood sugar check and sliding scale insulin and failed to ensure the glucometer was appropriately sanitized before and after use, failed to ensure a clean barrier was utilized when placing the glucometer down on a surface in the resident's room while administering the blood sugar check, and failed to ensure appropriate hand hygiene by wearing false 1.5-inch-long nails during the administration of R11's medication. Findings include: Review of the facility's policy titled, Cleaning/Disinfecting Resident Care Items and Equipment dated 05/18/23 indicated, .2. Shared resident care items/equipment shall be cleaned/disinfected between each resident and use 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ00157442, NJ00153388 Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner. This deficient practice was identified for 4 of 9 residents (Resident #45, #160, #155 and #72) observed for incontinence care on 2 of 3 units (First Floor 1 C and Second Floor 2 B) observed for incontinence care. This deficient practice was evidenced by the following: Refer to F725 1. During the initial tour of the facility on 05/17/23 at 9:42 AM, the surveyors noted a strong smell of urine that permeated the air on the first floor of the facility in the hallway beyond the main entrance to the facility that led to the first floor nursing units. On 05/24/23 at 9:02 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #3 who stated that she was assigned to 13 residents. CNA #3 stated that she had to pass breakfast trays before she performed 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 Based on observation, interview and record review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner in order to prevent food borne illness. This deficient practice was evidenced by the following: On 05/17/2023 at 9:33 AM, the surveyor accompanied by the Food service Director (FSD) observed the following in the kitchen: The surveyor observed a number of unlabeled items throughout the kitchen which included three bags of sugar on the table, on a shelf there were rolls and bagels, in the meat freezer there was a bag of chicken wings and one veggie burger in a box. In the ice cream freezer there were three boxes of Dixie ice cream cups. In the dry storage there was one can of Mashed potatoes and one box of Raisin Bran cereal. Over the sink on a shelf were five bags of cake mix. In the walk in refrigerator there was one block of margarine. On the counter there was a container of [NAME] thickener that was unlabled. The FSD 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY NJ #00151692, NJ #00153388, NJ#00157947, NJ#00158216, NJ00157442, NJ00158731, NJ00158017 Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to: a.) provide nursing and related services to assure the residents safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care in accordance with the facility assessment and b.) provide sufficient staffing numbers to meet minimum staffing requirements. This deficient practice was observed on 2 of 3 nursing units and for 4 of 9 residents' reviewed, (Resident #45, #72, #155 and #160) ) for care related to staffing. This deficient practice was evidenced by the following: Refer to F677 1. During the initial tour of the facility on 05/17/23 at 9:42 AM, the surveyors noted a strong smell of urine that permeated the air on the first floor of the facility in the hallway beyond the main…

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, review of medical records and other facility documentation, it was determined that the facility failed to provide privacy and promote dignity during resident assessment. This deficient practice was identified for 1 of 1 resident (Resident #120) reviewed for dignity. This deficient practice was evidenced by the following: On 05/22/23 at 10:51 AM, the surveyor entered the second floor nurse's station and observed the Nurse Practitioner as he listened to Resident #120's lung sounds with a stethoscope as the resident stood outside of the day room in the presence of other residents and staff. When interviewed at that time, the Nurse Practitioner stated that he usually assessed the resident in his/her room but the resident had a tendency to walk out of the room as he/she was a wanderer. According to the admission Record Resident #120 was admitted to the facility with diagnosis which included but were not limited to: Dementia without behavioral disturbance, chronic obstructive pulmonary disease (COPD, condition of constriction of the airways and difficulty…

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 provide reasonable space to allow the resident to move about the room without impairment. This deficient practice was identified for 1 of 3 residents (Resident #91) reviewed for position and mobility. This deficient practice was identified by the following: On 05/24/23 at 11:19 AM, the surveyor observed Resident #91 who self-propelled in the wheelchair with notable right sided weakness. The resident reportedly was unable to access his/her night stand or get out of bed on the left side as Resident #160's bed was placed horizontally against the wall and was pushed snugly up against Resident #91's night stand. CNA #3 was present and stated that she realized that Resident #160's bed was too far over and blocked the Resident #91 access to his/her night stand but she had not reported it to maintenance. CNA #3 stated that Resident #160's bed and night stand should have pushed over so that Resident #91 had more room to get in and out of bed. 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 observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to provide a safe, clean and homelike environment. This deficient practice was identified for 1 of 8 nursing units (Unit 2 B) in 2 of 3 residents (Resident #45 and #160) observed for incontinence care This deficient practice was evidenced by the following: 1. On 05/22/23 at 11:36 AM, the surveyor entered Resident #160's room and noted that there were two large holes in the wall behind the entry door of the room with exposed mesh. The area surrounding both holes had a thick, white coating around them which differed from the color the room was painted. The surveyor asked the resident how long the holes were there? The resident responded, The holes have been there forever. On 05/24/23 at 9:44 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #3 who stated that the two holes behind Resident #160's door had been there for months. CNA #3 stated that she had not reported the holes herself, but maintenance already knew about it. CNA #3 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Annual Minimum Data Set (MDS), an assessment tool for 3 of 4 residents (Resident #169, Resident #87, and Resident #45) reviewed for smoking. This deficient practice was evidenced by the following: 1. On 05/17/2023 at 11:01 AM, during the initial tour of the facility Resident #169 was observed ambulating in the hallway towards the room. The resident told the surveyor they were just on a smoke break. Review of the admission Record indicated that Resident #169 was admitted to the facility on 03/2023. Medical diagnoses included, but not limited to surgical aftercare following surgery on the digestive system, abscess (collection of pus) of the abdominal wall, anxiety disorder and bipolar disease (psychiatric illness that has both depressive and manic episodes). Review of the admission MDS, dated [DATE] showed the resident had a Brief Interview of Mental…

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 implement a physician's order for an orthosis (a device to correct alignment). The deficient practice was identified for 1 of 3 residents (Resident #67) reviewed for positioning and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The nurse practice act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical…

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 NJ#00158216, NJ#00157947, NJ#00158017, and NJ#00158731 Based on interview, and record review it was determined that the facility failed 1.) to clarify a physician's order for wound care consistent with professional standards of practice to promote wound healing for Resident #284 and 2.) to follow an active physician's order for the daily wound care treatment for Resident #103. This deficient practice was identified for 2 of 3 residents reviewed for pressure ulcers (Resident #284 and Resident #103), and was evidenced by the following: 1. Resident #284 was admitted to the facility and had diagnoses which included, but was not limited to fracture of the second cervical vertebra and chronic kidney disease. A review of the order Summary Report with active orders as of 9/5/22 reflects a physician order (PO) dated 9/5/22 for Santyl Ointment (a cream used for wound care) 250unit/MG (collagenase) apply to per additional directions topically everyday shift for wound care. There is no location specified. A review of 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, interview, review of medical records and other facility documentation, it was determined that the facility failed to ensure that a resident with decreased range of motion (ROM) and mobility received prescribed treatments to prevent contractures (Deformity of joints) and maintain current level of function for 1 of 3 residents reviewed for decreased ROM (Resident #91). This deficient practice was evidenced by the following: During the initial tour of the facility on 05/17/23 at 11:20 AM, Resident #91 was observed self-propelling in the wheelchair with notable right sided weakness. The resident motioned the surveyor into his/her room and showed the surveyor a right hand splint that was on the window sill and was reportedly not offered to the resident for assistance with application. According to the admission Record, Resident #91 was admitted to the facility with diagnosis which included, but were not limited to: sequelae of cerebral infarction (stroke), hemiplegia (paralysis on one side of body) and Hemiparesis (weakness or inability to move one side of 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, interviews, review of the medical record and other facility documentation, it was determined that that the facility failed to: a) properly assess and implement the facility's fall management policy for a resident after a reported, unwitnessed fall b) ensure fall prevention interventions were followed by ensuring that a resident's bed was in the locked position This deficient practice was identified for 2 of 5 residents (Resident #99, Resident #284) reviewed for falls. This deficient practice was evidenced by the following: 1. During the initial tour of the facility on 05/17/23 at 10:52 AM, the surveyor observed Resident #99 who was seated at the foot of an unsampled resident's bed visiting with friends. The Resident reported a fall from bed a couple of nights ago and lifted their shirt and revealed a large circular purple bruise on the right side of the upper abdomen. The resident stated he/she also had a bruise and a cut on the right knee which was covered beneath the resident's clothing.…

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 provide a resident with nutritional interventions that were recommended for a resident with significant weight loss. This deficient practice was identified for 1 of 2 residents (Resident #102) reviewed for nutrition. This deficient practice was evidenced by the following: On 05/24/23 at 9:06 AM, the surveyor observed Resident #102 lying in bed with the head of the bed elevated eating breakfast. The Certified Nursing Assistant (CNA) #1 who assisted the resident stated that the resident always ate all of his/her food and asked for seconds. Review of the admission Record revealed that Resident #102 was readmitted to the facility in February of 2022 with diagnoses which included but were not limited to: vascular dementia, cerebral infarction (stroke), aphasia (language disorder that affects a persons ability to communicate), dysphagia (difficulty swallowing), alcoholic…

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, facility documentation review and clinical record review, it was determined that the facility failed to provide oxygen (O2) therapy consistent with physician's order. This deficient practice was identified for 1 of 2 residents reviewed for oxygen therapy, Resident #70 and was evidenced by the following: On 05/24/2023 at 11:00 AM, the surveyor observed Resident #70 sitting on the bed receiving oxygen per nasal cannula (NC) (device used to deliver supplemental oxygen therapy via nasil passages) by way of a concentrator (concentrates the oxygen from a gas supply by removing nitrogen to supply oxygen). The O2 concentrator was set to deliver O2 at a flow rate of 3 liters via NC and there was separate tubing on the dresser across the room that was partially inside the top drawer. The Certified Nursing Assistant (CNA) was assisting Resident #70 with getting dressed and removed the tubing and laid it down on the residents' bed. The O2 tubing was observed on the bed and was dated for 5/24/2023 with a piece of plastic tape. During an interview with 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 record review, it was determined that the facility failed to A. establish a system of records for all controlled drugs in sufficient detail to enable an accurate reconciliation for the dispensing of controlled medications and B. ensure a controlled drug was dispensed in accordance with professional standards of practice. This deficient practice was observed for 2 of 4 medication carts inspected and during the medication pass and was evidenced by the following: A.On 5/24/23 at 10:43 AM, in the presence of the Licensed Practical Nurse (LPN), the surveyor inspected the medication cart on First Floor C Unit for storage and labeling of medications. During reconciliation of controlled medications, the surveyor observed the following: 1. 1 bottle of Methadone (a narcotic medication used to treat pain) in the narcotic box but the Controlled Drug Sheet (CDS) documented 2 bottles were left. 2. 41 Clonazepam (a narcotic medication used for anxiety) 0.5mg pills in the blister pack but the CDS documented there were 42 left. The LPN stated that she should have…

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