Complete Care at Bayshore LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent documents it was determined that the facility failed to provide adequate supervision and implement specific and meaningful interventions to prevent a resident identified at high falls risks and assessed as being cognitively impaired from experiencing unnecessary falls. This deficient practice was identified for 1 of 2 residents reviewed for accidents (Resident #30), and was evidenced by the following. The evidence was as follows: A review of the facility policy titled; Fall Prevention Program, Date Implemented 1/2/25 revealed: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 3. The nurse will indicate in the resident's record the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's risk. 4. Provided interventions that address unique risk factors…

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 provide appropriate care and services for residents who required oxygen therapy by failing to administer oxygen according to the physician order. This deficient practice occurred for 2 of 5 residents, including a resident (Resident # 53) with a history of aspiration pneumonia (inhaling food into lungs) and acute hypoxic respiratory failure and Resident #74 reviewed for respiratory therapy 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,…

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 DeficiencyBased on observation, interview, and record review, it was determined that the facility failed (a) to follow Physician Orders (PO) with regards to medications with parameters for 2 of 29 residents (Resident #14 and Resident #63) reviewed for medication management (b) to properly secure a medication in one (1) of four (4) nursing units, and C). accurate reconciliation and administration of narcotic medication with potential for drug diversion .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…

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 properly label, dispose of and store medications in 2 of 6 medication carts and 1 of 3 medication rooms.The deficient practices was evidenced by the following: On 5/7/26 at 8:55 AM, the surveyor inspected B-Wing medication cart #2 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed 2 unidentifiable tablets that were loose inside the medication cart. The surveyor also observed a Fluticasone propionate nasal spray with a used by date of 2/6/26.At that time, the surveyor interviewed LPN#1 who stated that the medication carts are cleaned daily and that any loose pills should have been discarded immediately in a pill buster (medication disposal system). LPN#1 also stated that any medication that is past it's used by date should be removed from the medication cart.On 5/7/26 at 9:50 AM, the surveyor inspected the subacute unit medication room in the presence of LPN #2. The surveyor observed a tablet that was in a medication package in a bin of normal saline IV bags, 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.

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to have a process in place to ensure that consistent communication between the facility and the hospice provider occurred for the coordination of resident care. This deficient practice was identified for one 1 of 2 residents reviewed for hospice care (Resident #13) and the deficient practice was evidenced by the following:On 05/04/2026 12:10 PM the surveyor observed Resident #13 lying in bed watching television. Resident #13 stated that they were in no pain and comfortable. A review of Resident #13's Electronic Medical Record (EMR) revealed diagnosis of but not limited to; Idiopathic Normal pressure hydrocephalus (fluid backup in the brain with no known cause leading to neurological problems), and palliative care (care to provide symptom relief and maintain quality of life).A review of Resident's EMR revealed an order for hospice care, with an order date of 04/01/2026.A review of the significant change Minimum Data Set (SCMDS), an assessment tool used…

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 document review, it was determined that the facility failed to have a system in place to ensure prior to hire, all employees were pre-screened to ensure that they had not been found guilty in a court of law of abuse, neglect, or misappropriation, or had findings entered into the state nurse aide registry or against a professional license, and b) a process was in place to maintain documentation to confirm an appropriate pre-screening had occurred for all contracted facility employees which including dietary. The deficient practice was identified for 4 of 73 employee files reviewed that were provided by the facility and was evidenced by the following:On 5/3/26, during entrance conference, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) a list of all employees that were hired since last survey, including name, date of hire, title, and including contracted employees and their files including medical information. On 5/4/26 at 10:38 AM, the LNHA provided the list of employees, status, position, department, and date hired and their human…

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 care and services in accordance with professional standards by adjusting medication times of administration to accommodate for dialysis treatment (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) scheduled times. This deficient practice was identified for 1 of 1 residents (Resident #14) reviewed for dialysis 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 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.…

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 resident call bell was operationional. This deficient practice was identified for 1 of 2 residents reviewed for accidents (Resident #30) and was evidenced by the following: On 05/05/26 at 8:30 AM, the surveyor observed Resident #30 in bed and the Certified Nurse Aide (CNA) was at the bedside setting up the meal. On 05/05/26 at 8:45 AM, a subsequent interview with the CNA revealed that Resident #30 would get out of bed every other day, Monday, Wednesday and Friday, with a mechanical lift and 2-persons to assist. When asked the CNA if the resident could press the call bell, the CNA then placed the call bell in the resident's hand and instructed the resident to press the call bell. The resident then tried to press the call bell, and it was not functioning. The CNA then confirmed that Resident #30's call bell was not functioning after she pressed the bell and it did not work. A further review of Resident #30's…

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, staff interviews, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded to reflect the resident's clinical status regarding bladder function for one of five sampled residents (Resident (R) 1) reviewed for resident assessment. This failure had the potential to affect care planning, infection risk management, and the provision of necessary services.Findings include:Review of R1's admission Record located in the electronic medical record (EMR) under the Profile tab revealed R1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic obstructive pulmonary disease, and chronic kidney disease, stage 3A.Review of R1'sMDS with an Assessment Reference Date (ARD) of 01/06/26, located in the EMR under the MDS tab, revealed R1 was coded as having an indwelling urinary catheter.Review of physician orders, treatment records, and nursing documentation found in the EMR revealed no evidence that…

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

Based on interview and review of facility documents, it was determined that the facility failed to ensure that the facility-wide assessment identified the required services and procedures necessary for ventilator-dependent residents. This deficient practice was identified by the following:On 12/26/25, the surveyor requested a copy of the Facility Assessment (FA).On 12/30/25, the surveyor reviewed the FA dated completed 9/30/25.The FA under Part 1: Our Resident Profile indicated that the facility is licensed to provide care for 232 residents but did not specify that the facility has a license for 220 long-term care beds and 12 ventilator care beds.The FA under, Diseases/conditions, physical and cognitive disabilities, of the FA the facility identified under Category, respiratory system and under Common Diagnoses, Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, Asthma, Chronic Lung Disease, Respiratory Failure. Ventilator-dependent residents were not included.The FA under Decisions regarding caring for residents with conditions not listed above: 1.4 Complete Care at Bayshore…

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 maintain kitchen equipment in a clean and sanitary manner. This deficient practice has the potential to affect all residents, and the evidence was as follows: On 10/22/24 at 9:53 AM, the surveyor in the presence of the Food Service Director (FSD) and Regional Food Service Director (RFSD) toured the kitchen and observed the following: 1. The ice machine had stains, brown and tan debris on the outside and flap of the machine. The FSD stated, it should be cleaned daily. The FSD and RFSD both acknowledge that it looked dirty and was not cleaned. 2. There were two, thirty-two gallon waste receptacles that were not covered which exposed the two food preparation stations to the refuse. The stations were not actively being used. The RFSD acknowledged that the waste receptacles did not have lids and staff were not currently using them. The unlidded thirty-two-gallon waste receptacles at counter height had the potential for cross contamination of food. 3. The eight-burner…

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 Complaint # NJ169941 Based on interview, review of the closed medical record, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident was sufficiently prepared for a discharge from the facility by providing a prescription for an active antibiotic treatment. This deficient practice was identified for 1 of 2 residents reviewed for discharge (Resident #239), and was evidenced by the following: On 10/28/24 at 10:23 AM, the surveyor reviewed the closed medical record for Resident #239 which revealed the resident was admitted to the facility in 2023 and discharged from the facility in 2023. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses including but not limited to; displaced trimalleolar fracture of left lower leg (severe injury that affects the ankle joint), infection and inflammatory reaction due to internal right hip prosthesis (infection around the right hip replacement…

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 develop an individualized comprehensive care plan for a resident with chronic pain. This deficient practice was identified for 1 of 1 resident reviewed for pain management (Resident #10), and was evidenced by the following: On 10/22/24 at 12:17 PM, during initial tour of the facility, the surveyor observed Resident #10 in bed with eyes closed. On 10/24/24 at 10:01 AM, the surveyor reviewed the medical record for Resident #10. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with medical diagnoses which included but were not limited to; diabetes (high blood sugar), depressive disorder, and chronic pain syndrome. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 9/15/24, revealed the resident had a Brief Interview of Mental Status score of 15 out of 15, meaning the resident was cognitively intact. A review of Section J Health Conditions revealed 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 # NJ169671 Based on interviews and review of pertinent facility documents, it was determined that the facility failed to revise an individual comprehensive care plan for a resident with a history of falls while at the facility. This deficient practice was identified for 1 of 1 resident reviewed for falls (Resident #189), and was evidenced by the following: On 10/24/24 at 11:32 AM, the surveyor reviewed the closed medical record for Resident #189. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with medical diagnoses that included but were not limited to; heart failure, difficulty in walking, surgical aftercare, and muscle weakness. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 10/16/23, revealed the resident had a Brief Interview of Mental Status score of 10 out of 15, meaning the resident had moderate cognitive impairment. A review of the the incidents and accidents for Resident #189 revealed the resident had a fall on 12/4/23. The resident was found by a Certified…

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 ensure recommendations by the wound care consultant were implemented to prevent the worsening of a pressure ulcer. This practice was identified in 1 of 2 residents reviewed for pressure ulcers (Resident #13), and was evidenced by the following: On 10/22/24 at 11:12 AM, during the initial tour of the facility, the surveyor observed Resident #13 in bed. The resident told the surveyor that they had a sore that opened. At that time, the surveyor did not observe a low air mattress (a mattress designed to prevent and treat pressure wounds) pump on the bed. The surveyor asked the resident if they were on a low air mattress or a specialty mattress and the resident replied, No, I don't know what they are doing. On 10/24/24 at 12:10 PM, the resident was observed in bed with eyes closed. The surveyor did not observe a low air loss mattress on the resident's bed. On 10/25/24 at 9:35 AM, the surveyor reviewed the medical record for Resident #13. A review of the admission…

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

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) ensure the accountability of the narcotic shift count logs were completed; and b.) accurately account for and document the administration of controlled medications. This deficient practice was identified on 2 of 2 medication carts reviewed for medication storage, and was evidenced by the following: During medication storage review on 10/24/24 at 10:39 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN #1), reviewed the Vent unit medication cart A's September and October 2024 Change of Shift - Controlled Substances Count Sheet (a shift-to-shift controlled substance and narcotics (narc) count sheet signed by the incoming and outgoing nurses each shift) which revealed the following: The nursing signatures were blank for the incoming nurse for the following shifts: For the 7:00 AM (7 AM) shift on: 9/14, 9/29, 10/4, 10/5, 10/6, 10/20, and 10/24. For the 7:00 PM (7 PM) shift on: 9/6, 10/1, 10/15, and 10/22. For the 11:00 PM (11 PM) shift 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 pertinent facility documents, it was determined that the facility failed to properly store medications. This deficient practice was observed in 1 of 4 medication carts reviewed for medication storage and labeling, and was evidenced by the following: On 10/24/24 at 10:39 AM, the surveyor observed the Vent nursing unit's medication cart A. The medication cart was kept at the nurse's station and was left unattended by the Licensed Practical Nurse (LPN #1) while she administered medication to an unsampled resident. On the cart's unlockable pull-out tray/drawer, was observed packets of individually wrapped medications stored and visible with the tray/drawer in the retracted position. Upon return of LPN #1, the surveyor reviewed the cart and observed the following unsecured medications in the tray/drawer: One Eliquis 5 milligram (mg) tablet (tab) (medication used to prevent blood clots). Two midodrine HCl 5 mg tabs (medication used to treat low blood pressure). Two midodrine HCl 2.5 mg tab. One memantine HCl 10 mg tab (medication used to…

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

Complaint #: NJ00166783, NJ00171418, NJ00172419 Based on interview and record review on 03/28/24, 04/01/24, and 04/04/24, it was determined that the facility failed to follow acceptable standards of clinical practice related to a.) consistently documenting the administration of a medication in the electronic Medication Administration Record (MAR) and b.) consistently document that a treatment was completed in the electronic Treatment Administration Record (TAR) This deficient practice was identified for two residents reviewed (Resident #2 and Resident #3) and was evidenced by the following: 1.) Resident #2 was not at the facility; a closed record review was completed. A review of the admission Record face sheet (an admission summary) reflected that Resident #2 was admitted to the facility with diagnoses which included but were not limited to, pyelonephritis (a bacterial infection causing inflammation of the kidneys), type 2 diabetes, severe protein-malnutrition, and hypertension. A review of the 01/21/24 Quarterly Minimum Data Set (MDS), an assessment tool reflected that the…

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

C #: NJ00171641 Based on observation, interview, and review of medical records and other pertinent facility documentation on 2/14/24, it was determined that the facility failed to follow professional standards of clinical practice for a). the administration of medications and b.) following a physician's orders, and c). adhering to the facility's policy for using the Medication Administration Record for 1 of 3 residents (Resident #2) reviewed for medication administration. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual 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…

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 00159893 Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to a.) accurately document the administration of medications in the electronic medical administration record (eMAR), b.) clarify duplicate physician's orders for an over-the-counter medication, aspirin 81 mg, and c). failed to obtain a medication for pain. This deficient practice occurred for 3 of 24 residents, (Resident #58, #112, and #220) reviewed for medication review. 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…

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

Based on observations, interviews, record review, and a review of pertinent facility documentation, it was determined that the facility failed to a). follow appropriate infection control practices for proper hand hygiene, b). ensure staff wore the appropriate personal protective equipment (PPE) for three residents who were on transmission-based precautions (TBP) (Resident #19, #56 and #378) c).ensure communication that all COVID-19 positive residents were communicated from shift to shift accurately (Resident #99) and failed to d). ensure that multiuse medical equipment was properly disinfected on 2 of 4 nursing units (A-unit and the 2nd floor subacute unit). The deficient practice was evidenced by the following: 1. On 10/4/23 at 10:20 AM, during the entrance conference, the facility administration staff told the surveyor that all staff were required to wear full PPE prior to entering a COVID-19 (infectious disease cause by SARS-CoV-2 virus ) room. Full PPE included wearing a N95 mask (respirator mask), goggles, gown and gloves. On 10/4/23 at 12:45 PM, during the initial tour 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, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to update and revise a Care Plan in a timely manner to include a fall intervention for 1 of 3 residents, (Resident #91), reviewed for falls. This deficient practice was evidenced by the following: On 10/4/23 at 1:04 PM, the surveyor observed Resident #91 sitting upright in a recliner across from the nursing station. The resident's eyes were closed, and he/she did not respond to the surveyor. The surveyor reviewed the medical record for Resident #91. 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 dementia, difficulty walking, repeated falls, and fracture the of left pubis (either of a pair of bones forming the two sides of the pelvis). Review of a significant change Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 9/13/23, revealed that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ000162720 Based on interview and review of medical records, it was determined that the facility failed to to follow professional standards of clinical practice with respect to a.) clarifing a Physician's Order (PO) for Betadine solution 10% on admission, b.) accurately transcribe a PO for Betadine Solution 10% onto the Feburary 2023 electronic treatment administration (eTAR) and c.) document a wound treatment order as administered on 1/30/23 and 1/31/23. This deficient practice was identified for 1 of 8 residents (Resident # 372) reviewed for closed records. This deficient practice was evidenced by the following: Reference: New Jersey Statues, 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…

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, record review, and review of other facility documentation, it was determined that the facility failed to a.) ensure that a resident received the appropriate care to maintain a Peripherally Inserted Central Catheter (PICC) (a thin soft tube that is inserted into a vein in the arm for long-term intravenous (IV) antibiotics) consistent with professional standards of practice and b.) update the care plan for a resident with a PICC. This deficient practice was identified for 1 of 1 resident (Resident #30) reviewed for IV therapy. This deficient practice was evidenced by the following: The surveyor reviewed the Electronic Medical Record (EMR) for Resident #30. Review of the admission Record (an admission summary) revealed that the resident was admitted to the facility in September of 2023 with diagnoses which included but was not limited to; acute osteomyelitis (a serious infection of the bone) left ankle and foot, sepsis (the body's extreme response to an infection), and Type 2 Diabetes. Review of the admission Minimum Data Set (MDS), an assessment tool used to…

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

Based on observations, interviews, and record review, it was determined that the facility failed to a.) ensure a physician's order was obtained for a resident receiving oxygen and b.) the care plan was updated to include the resident was receiving oxygen. This deficient practice was identified for 1 of 1 resident (Resident #111) reviewed for oxygen therapy. This deficient practice was evidenced by the following: On 10/04/23 at 12:43 PM, the surveyor observed Resident #111 awake and in bed, wearing oxygen via nasal canula. The oxygen concentrator was set at two liters per minute (LPM). The resident stated that they needed oxygen before their admission to the facility. The surveyor reviewed the medical record of Resident #111. Review of the admission Record (an admission summary) revealed that the resident was admitted to the facility in August of 2023 with diagnoses which included but was not limited to; Pneumonia and Chronic Obstructive Pulmonary Disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems) with Acute Exacerbation (COPD, a group 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, record review, and review of other pertinent facility documentation, it was determined that the facility failed to accurately monitor a resident's hemodialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) treatment access site. This deficient practice was identified for 1 of 1 resident (Resident #93) reviewed for dialysis. This deficient practice was evidenced by the following: On 10/12/23 at 10:10 AM, the surveyor observed Resident #93 in bed. The resident was alert, oriented, and responded appropriately to the surveyor. The resident stated that he/she went to hemodialysis (HD) on Monday, Wednesday and Friday in the afternoon. The resident stated that the HD access site was in the right upper chest (the resident pointed to the area). Review of Resident #93's admission Record (an admission summary) reflected diagnoses which included but was not limited to; acute kidney failure and hypertension. Review of the Quarterly Minimum Data Set (MDS), an assessment tool to facilitate the management 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, record review, and review of other pertinent facility documents it was determined that the facility failed to provide adequate indications and documentation supporting the rationale for COVID-19 related medications for a resident who tested negative for COVID-19. This deficient practice was identified for 1 of 24 residents (Resident #99) reviewed during medical record review and was evidenced by the following: On 10/5/23 at 10:00 AM, the surveyor observed Resident #99, self-propelling in their wheelchair toward the bathroom. The resident was alert and oriented but did not want to be interviewed. The surveyor observed the resident's room which had no stop sign or isolation signage on the door or wall, and no personal protection equipment (PPE) bin located outside of the resident's room. The surveyor reviewed the medical record for Resident # 99. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to hypertension (elevated blood pressure), cerebral…

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 a). secure medications in 1 of 4 nursing units inspected, b). secure medications in 1 of 4 emergency kits (E-kits) inspected, and c). properly label, store and dispose of medications in 3 of 10 medication carts and 1 of 4 medication rooms inspected. This deficient practice was evidenced by the following: 1. On 10/05/23 at 2:10 PM, the surveyor observed two bags containing medications on the A unit nursing station, no residents were in the vicinity. The two bags included the following medications: Eliquis (blood thinner), Tessalon (medication for coughing), Vitamin D (vitamin), Norvasc (blood pressure), Diltiazem (blood pressure), Tradjenta (diabetes), Carafate (stomach medication), Xarelto (blood thinner), Nadolol (blood pressure) and Sevelamer (phosphate binder). At that same time, the surveyor interviewed a Licensed Practical Nurse (LPN #1 ) who stated that the medications inside the two bags were discontinued medications that were going to be returned to the…

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