Lawrence Rehabilitation Hospital

Based on interview, record review and review of pertinent documentation it was determined that the facility failed to ensure that appropriate care and services were provided for a resident with a physician order for a bladder scan upon removal of a indwelling urinary catheter. The deficient practice occurred for 1 of 1 resident reviewed for unplanned hospitalization and urinary tract infection (Resident #69). The evidence was as follows: On 1/28/26 at 12:00 PM, the surveyor reviewed Resident #69's electronic medical record which revealed the following: The admission Record revealed the resident had diagnoses which included, but were not limited to: dementia, retention of urine and benign prostatic hyperplasia (enlargement of the prostate gland). A Progress Note (PN) documented by the Unit Manager (UM) dated 12/23/25 at 7:04 AM which revealed: Went to visit Resident #69 for wound rounds and noted that vomited green colored liquid and was lethargic . and skin extremely hot .patients temperature was 104 Farenheight -F (normal 97 to 99 F) and blood pressure was low .62/48 and 64/58…

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 ensure the necessary respiratory care and services for a resident with a tracheostomy (trach; a device inserted into a surgically created opening in the neck into the windpipe to help with breathing) in accordance with standard of practice. This deficient practice was identified for one (1) of one (1) resident reviewed for respiratory/tracheostomy care (Resident #77) and was evidenced by the following:On 1/27/26 at 11:42 AM, during the initial tour, Resident #77 was observed asleep, in bed, the head of the bed was elevated and was receiving oxygen (O2) via tracheostomy tube. The surveyor reviewed the medical record for Resident #77. According to the admission Record, face sheet, an admission summary, reflected that Resident #77 was admitted to the facility with diagnoses which included but were not limited to: cognitive communication deficit (impairment in communication) and tracheostomy (trach; a device inserted into a surgically…

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

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to thoroughly review dialysis communication sheets post dialysis and informed the physician of new recommendations based on laboratory chemistry obtained at dialysis treatment, and ensure the care plan addressed the care of the dialysis access site. This deficient practice was identified for 1 of 1 residents (Resident #4) reviewed for dialysis and was evidenced by the following: a. On 1/27/26 at 11:30 AM during the initial tour of the facility, the surveyor observed Resident #4 in bed. The resident informed the surveyor they just returned from dialysis treatment.On 1/27/26 at 12:10 PM, the surveyor inquired regarding the dialysis communication book and obtained the communication book from the nurse assigned to the unit.A review of the admission Record, an admission summary, revealed the resident had diagnoses that included, but were not limited to end-stage renal (kidney) disease, dependence on renal dialysis, hemiplegia and hemiparesis, and diabetes…

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

Based on interview, record review, and review of facility documents, it was determined that the facility failed to evaluate the performance of all Certified Nursing Aides (CNAs) on an annual basis. This deficient practice was identified for 3 of 5 CNAs whose personnel records were reviewed and was evidenced by the following:On 1/29/26 at 1:33 PM, the surveyor reviewed the Annual Staff Performance Appraisals for five randomly selected CNAs.CNA#1, with a date of hire of 5/24/23, had their most recent Annual Staff Performance Appraisal signed as completed on 3/20/24.CNA#2, with a hire date of 9/8/20, had their most recent Annual Staff Performance Appraisal signed as completed on 4/8/24.CNA#3, with a hire date of 3/27/23, had their most recent Annual Staff Performance Appraisal signed as completed on 8/24/24.On 1/30/26 at 11:41 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) regarding concerns with the annual performance appraisals. The LNHA stated that the 2025 evaluations would not be completed until 2026. She further 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 record review, it was determined that the facility failed to ensure a.) Lokelma (sodium zirconium cyclosilicate, a potassium binder for those with high potassium) a medication was administered in accordance with manufacturer's specifications for one (1) of four (4) nurses observed b.) Questran (cholestyramine used to lower cholesterol), a medication was labeled with cautionary instructions for proper administration, for one (1) of four (4) residents observed during the medication pass, c.) quality control testing (calibration) was conducted for the blood glucose (bg) monitors, both used for residents as per manufacturer's specifications, for two (2) of two (2) medication carts inspected, d.) consistent disposition (destruction), reconciliation, and accountability of the controlled dangerous substance (narcotic; medications, with high potential for abuse, were tracked with detail) for one (1) of one (1) medication carts inspected, and e.) consistent maintenance of the system…

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

Based on observation, interview, and record review, it was determined that the facility failed to ensure the Consultant Pharmacist identified irregularities during the drug regimen review of a newly admitted resident. The deficient practice was identified for one (1) of four (4) residents observed during the medication pass (Resident #55). Refer to 755. Reference:According to the manufacturer's specifications for Lokelma section 2.3 Reconstitution and Administration: In general, Lokelma should be administered at least 2 hours before and 2 hours after Lokelma. According to the manufacturer's specifications for Questran under Drug Interaction; since Questran may bind other drugs given concurrently, it is recommended that patients take other drugs at least one hour before or four (4) to 6 hours after Questran (or at as great an interval as possible) to avoid impeding their absorption. On 1/29/26 at 9:19 AM, during the medication pass observation, the surveyor observed Licensed Practical Nurse (LPN #1) prepare 14 medications for Resident #55 that included Lokelma and Questran. A review…

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

Based on observation, interview, and record review, it was determined that the facility failed to perform appropriate hand hygiene for 2 of 2 staff observed and disinfect shared medical equipment prior to and after use, in accordance with facility infection control policy. This deficient practice was evidenced by the following:On 1/27/26 at 11:30 AM, the surveyor observed a signage posted at the entrance door of Resident #4's room. The signage indicated Enhanced Barrier Precaution. There was a Personal Protective Equipment box hung outside the door that included gowns and gloves. The surveyor then observed the LPN approached the room with the medication cart and a blood pressure machine. The LPN placed the medication cart next to the entrance door. The LPN, donned (put on) gloves and a gown and entered the room without first performing hand hygiene. The LPN then used the gloved hands to remove the resident's blanket, located the dialysis access site on the resident chest, palpated the dressing, returned the blanket on top of the resident, then used the blood pressure machine 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 interview and review of facility documentation, it was determined that the facility failed to ensure that a) Certified Nursing Aides (CNAs) received 12 hours of mandatory annual in-service training for 2 of 5 CNAs reviewed and b) CNA education included abuse training for 3 of 5 CNA education files reviewed. The deficient practice was evidenced by the following:On 1/29/2026 at 1:33 PM, the surveyor reviewed the in-service education hours for five randomly selected CNAs, which were provided by the facility.The [Name Redacted] Transcripts provided showed the following: CNA#1, with a hire date of 5/24/23, had 3.4 hours of education from 5/24/24 - 5/24/25, which did not include training on abuse. The last abuse training documented was 7/3/24. CNA#2, with a hire date of 9/8/20, had 4.98 hours of education from 9/8/24 - 9/8/25. CNA#4, with a hire date of 5/8/24, had a most recent abuse training dated 5/8/24. CNA#5, with a hire date of 5/6/24, had a most recent abuse training dated 8/1/24. On 1/30/26 at 11:28 AM, the facility provided an education calendar listing all education…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, it was determined that the facility failed to ensure the admission Agreement did not required residents to waive their right to receive 30-day written notice of discharge. This deficient practice was identified for 1 of 1 residents reviewed for appropriate discharge (Resident # 71) and was evidenced by the following: On 1/27/26 at 1:05 PM, the surveyor reviewed the facility entrance binder (a binder that contained the required recertification survey documentation per the Centers for Medicare and Medicaid-CMS- entrance conference requirements) that was provided by the LNHA. A 44 Page Welcome Packet was identified as the facility admission Agreement. The Notice of Resident's Rights Regarding Transfer or discharge: You may be transferred or discharged for one of the following reasons: 1. The move is necessary for your own welfare, and your needs cannot be met withing the facility. 2. Your health has improved sufficiently so that you no longer need the services provided by 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 interview, record review and review of pertinent documents it was determined that the facility failed to ensure an appropriate discharge process was in place for residents who had a change in payor source. This deficient practice occurred for 1 of 1 resident reviewed for appropriate discharge (Resident #71) and was evidenced by the following: On 01/27/26 at 11:04 AM, during the facility entrance conference held with the Licensed Nursing Home Administrator (LNHA), and an Executive [NAME] President (EVP) the surveyor asked what the resident population of the facility was. The LNHA stated the residents were all short term, and there were no long-term care residents at the facility. When asked if the facility held resident council meetings, the LNHA stated there was no resident council meeting held at the facility. When the surveyor again asked about long-term care residents at the facility, the LNHA confirmed that there was no long-term care residents at the facility, only short term. The LNHA then 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, review of medical records, other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 3 of 19 residents reviewed (Resident #71, Resident # 72, and Resident #74). This deficient practice was evidenced by the following:On 1/28/2026 at 9:25 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #71 which revealed an admission record (face sheet) with diagnoses that included but not limited to hemiplegia and hemiparesis (weakness) following CVA (stroke) affecting the right dominant side and dysphagia (difficulty swallowing).The individual comprehensive care plan (ICCP) included a focus area initiated 10/27/25 of discharge potential with interventions which included referrals to other community agencies as deemed appropriate. A social service late entry note dated 12/4/25 indicated Resident #71 had been…

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 develop or initiate a comprehensive, person-centered care plan to address a.) the care of a Foley catheter. This deficient practice was identified for 1 of 27 residents (Resident #80) reviewed for a comprehensive Care Plan (CP) and was evidenced by the following:On 1/27/2 at 11:45 AM, the surveyor observed Resident #80 in the room sitting in a wheelchair by the bed. Resident #80 was awake and alert and able to answer the surveyor's inquiry. The resident informed the surveyor that they were in Physical therapy this morning and they were admitted to the facility for rehabilitation. The surveyor observed that Resident #80 wore a urinary catheter leg bag. The surveyor reviewed the Electronic Health Record (EHR) of Resident #80. The admission Record documented that Resident # 80 was admitted with diagnoses that included but were not limited to diabetes mellitus, hypertension and atherosclerotic heart disease of native…

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

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to post the nursing staffing report daily. This deficient practice was evidenced by the following: On 1/27/26, on entrance and initial tour, the survey team did not observe the nursing staffing report to be posted in the facility.On 1/28/26 at 12:56 PM, the surveyor did not observe the nursing staffing posted in the lobby, on the second floor, or on the fifth floor.On 1/28/2026 at 1:06 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) about the posted staffing. She stated it is posted on floors two and five by the time clock. LNHA walked with surveyor to the second-floor time clock, staffing was not observed to be posted there. The LNHA stated she observed it posted there yesterday. admitted that it should be posted there.On 1/29/2026 at 9:56 AM, the surveyor interviewed the staffing coordinator who stated the supervisors are responsible for posting the staffing. She further stated they had a new supervisor, who was educated yesterday when…

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

Based on interview and review of other pertinent facility documentation, it was determined that the facility who had been in an active COVID-19 (potentially, deadly virus) outbreak since 08/21/24, failed to conduct complete and thorough contact tracing (method used to identify COVID-19 exposure and prevent transmission) upon the identification of a single new case of COVID-19 in a resident or staff member in accordance with the facility policy, Centers for Disease Control (CDC), Local Health Department, State Health Department and all current guidance related to infection control. This deficient practice was identified for 1 of 1 resident, (Resident #21) reviewed for COVID-19. This deficient practice was evidenced by the following: On 09/03/24 at 7:26 AM, the surveyor entered the facility and was informed by the Registered Nurse Night Supervisor (RNNS) that the facility was in an active outbreak and the last positive resident (Resident #21) was expected to complete isolation precautions that day. There was signage posted on the front door of the facility and at the receptionist desk…

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 handle potentially hazardous food to prevent food borne illness. This deficient practice was evidenced by the following: On 09/03/24 at 8:46 AM, during the initial tour of the kitchen, the surveyor observed the following in the walk-in meat freezer in the presence of two (2) Food Service Directors (FSD #1 and FSD #2). 1. An opened slab of roast beef on the top shelf was not labeled or dated. 2. An opened bag containing six (6) salisbury patties was not labeled or dated. At that time, during an interview with the surveyor, FSD #1 stated, everything that is in the freezer should have dates. Once it is opened, it should be dated. FSD #2 discarded the roast beef and salisbury patties. On 09/05/24 at 1:15 PM, during an interview with the surveyor, the Licensed Nursing Home Administrator stated, when food packages are opened, it should be labeled and dated with the use by date. A review of the facility policy titled Food Receiving and Storage (revised November 2022)…

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

Based on interview and review of pertinent facility documentation, it was determined that the facility failed to ensure that their Quality Assurance and Performance Improvement Program's (QAPI) sources of quantitative data was being analyzed to evaluate program effectiveness and implement new processes. This deficient practice was identified during the standard survey and was evidenced by the following: Refer to S1410 On 09/03/24 at 08:32 AM, during the entrance conference the surveyor requested the facility's QAPI book. On 09/06/24 at 08:45 AM, the Licensed Nursing Home Administrator (LNHA) provided the QAPI book. A review of the QAPI book revealed that the facility started a QAPI in January of 2024 on the two-step tuberculosis (TB) skin test (a procedure that helps determine if a person has a recent TB infection or a boosted reaction to an old infection) for employee health and that the Infection Preventionist (IP) and Human Resources (HR) were responsible to audit the active employee files which was ongoing. Further review of the QAPI book revealed that in April 2024 the two-step…

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 pertinent facility documentation, it was determined that the facility failed to ensure full implementation of the antibiotic stewardship program, including ongoing monitoring and use of a nationally recognized surveillance criteria prior to consulting the prescriber. This deficient practice was identified for 1 of 1 resident reviewed for antibiotic stewardship, (Resident #27). This deficient practice was evidenced by the following: On 09/04/24 at 9:38 AM, the surveyor interviewed the Infection Preventionist (IP) regarding the facility Antibiotic Stewardship Program (efforts to ensure that antibiotics are used only when necessary and appropriate). The IP stated that she had worked at the facility for nearly one year and had worked as an IP since 2019. When the surveyor asked the IP to describe how the Antibiotic Stewardship Program worked she stated, With a prayer. The IP stated that she monitored residents on antibiotics. When the surveyor requested to view the Antibiotic Stewardship documentation, the IP stated that she would need to run a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and review of other pertinent facility documentation, it was determined that the facility failed to ensure that the administration of a resident's enteral tube feeding (allows liquid food to enter the stomach or intestine through a tube) was consistently documented to indicate if it were administered or held on the Medication Administration Record. This deficient practice was identified for 1 of 1 resident, (Resident #27) reviewed for tube feedings. This deficient practice was evidenced by the following: During the initial tour of the facility on 09/03/24 at 8:38 AM, the surveyor observed Resident #27 lying awake in bed. The resident stated that their tube was clogged four to five weeks ago. A review of Resident #27's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included but was not limited to: other pneumonia (lung infection), and dysphagia, pharyngeal phase (problems in the throat during swallowing). A review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to a) ensure that meals were consistently delivered on time as per resident's preferences for seven (7) of 21 residents (Resident #5, #18, #147, #199, #202, #203 and #204) which represented two (2) of two (2) units reviewed for mealtime preferences and b) make reasonable accommodation of needs and preferences for 1 of 21 residents reviewed, (Resident #244). This deficient practice was evidenced as follows: 1.On 5/23/23 at 10:10 AM, a resident council meeting was conducted with five residents. Five out of five residents stated that the meals were not delivered on time and were consistently late. On 5/23/23 at 12:00 PM, the surveyor observed Resident #147 seated in a wheelchair in his/her room and was agreeable to be interviewed. During the interview at 12:15 PM, the Certified Nurse's Aide (CNA) #1 brought the resident his/her lunch tray. The resident stated that he/she had been…

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 NJ00161372 Based on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards a.) accurately transcribe a physician order, for 1 of 2 residents observed during medication pass (Resident #150), b.) ensure that residents' medications were available for medication administration for 2 of 2 residents observed during medication pass (Resident #149 and Resident #150) and c). ensure that all routine medications on the physician order's sheet (POS), and medication administration record (MAR) had a corresponding medical indication for 10 of 21 residents reviewed (Residents #150, #149, #5, #18, #35, #147,#145, #146, #248 and #249). 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…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of hot and cold food and drink served to the residents. This deficient practice was identified for four (4) of five (5) residents interviewed during the Resident Council meeting and confirmed during the lunchtime meal service on 6/2/21 for 2 of 2 nursing units tested for food temperatures by four surveyors and was evidenced by the following: On 5/23/23 at 10:10 AM, the surveyor met with five (5) residents for council meeting. Four out of five residents stated that they were displeased with food temperatures and that hot food items were not served hot. 06/02/23 11:36 AM, the Registered Dietitian (RD) surveyor calibrated two state issued digital thermometers via the ice bath method to 32 degrees Fahrenheit (F) in the presence of the survey team. On 6/02/23 at 11:53 AM, the surveyors observed the Certified Nurse's Aide (CNA) #1 delivering lunch meals…

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, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently identified and implemented for eight (8) of eight (8) residents (Resident #5, #18, #145, #147,#199, #202, #203 and #204) which represented two (2) of two (2) units reviewed for dietary preferences. This deficient practice was evidenced as follows: On 5/23/23 at 10:10 AM, a resident council meeting was conducted with five residents. Five of five residents stated that they did not receive food that they ordered from the menu and that items were missing from their meal trays. In addition, five of five residents stated that someone brings them menus to fill out, but the menus are often not picked up. Resident # 202 stated that the following occurred: I asked for rice crispy cereal and a banana and for some reason they gave me pancakes and other things I don't want, and he/she also stated that they received cereal…

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 NJ00161372 Based on observations, interviews, and review of facility provided documentation, the facility failed to a.) ensure call bells were answered timely for 4 of 21 residents reviewed (Residents #151, #204, #244 and #246) and b.) maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 32 of 48-day shifts and 2 of 48 evening shifts reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 2/01/21: One Certified Nurse Aide (CNA) to every eight residents for the day shift. One direct care staff member to every 10 residents for the evening shift,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of facility documents, it was determined that the facility failed to maintain a clean/homelike and sanitary environment for the residents. This deficient practice was identified on 1 of 2 nursing units and was evidenced by the following: During the initial tour of the 2nd floor unit on 05/22/23 from 10:06 AM to 01:35 PM, the following was observed by the surveyors: 1. In room [ROOM NUMBER] (double occupancy room): -the wall behind A bed (bed closest to the door) had multiple areas of white substance with multiple open holes and scrape marks -the wall on the opposite side of the room had multiple areas of white substance with multiple open scrapes 2. In room [ROOM NUMBER] (listed as a private room): -the wall behind A bed had multiple areas of white substance with multiple open holes and scrape marks -the same wall as A bed (beyond the bed headboard) but in an open area above the electrical outlet there were multiple areas of white substance with multiple open holes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined that the facility failed to a.) maintain the necessary care and services for residents who were receiving oxygen (O2) treatment according to standards of practice and b.) ensure a physician's order was obtained for a resident receiving O2. This deficient practice was identified for two (2) of two (2) residents (R # 146 and R # 145) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 5/24/23 at 12:00 PM, the surveyor observed Resident #146 awake and seated in a wheelchair across from the nurse's station. Oxygen was in use via a nasal cannula (consisting of two hollow prongs projecting from a hollow face piece) at two liters per minute (LPM). The oxygen was attached to a portable oxygen tank attached to the back of the wheelchair. The O2 tubing was undated. On 5/25/23 at 12:18 PM, the surveyor observed the resident awake and seated in a wheelchair inside his/her room with oxygen in use at two LPM via nasal…

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 secure medications in 1 (one) of 2 (two) emergency crash carts inspected. This deficient practice was evidenced by the following: On 5/31/23 at 11:30 AM, the surveyor inspected the 2nd-floor emergency crash cart that contained the facility's Emergency-Kit (E-Kit) in the presence of a Licensed Practical Nurse/Unit Manager (LPN/UM#1). The surveyor observed the crash cart which was covered and secured by Velcro straps. The surveyor observed LPN/UM #1 remove the covering and then move a handle on the top portion of the crash cart from the locked to unlocked position. The surveyor then observed LPN/UM#1 open each drawer of the crash cart and the surveyor observed the third drawer contained syringes and the 4th drawer contained a E-Kit box that contained 14 medications. The surveyor inspected the E-Kit box that contained the following medications: 1. Albuterol 0.083% nebulizer solution (5 nebulizers) 2. Aspirin 81 mg chewable tablets (4 tablets) 3. BD POSIFLUSH INJ 0.9% (two) 4.…

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, record review and other pertinent facility documentation, it was determined that the facility failed to maintain proper infection control practices by ensuring a.) appropriate personal protective equipment (PPE) was worn in a room where a resident was on contact precautions (contact precautions are intended to prevent transmission of infectious agents and microorganisms, which are spread by direct or indirect contact with the patient), this was identified on one (1) of two (2) units, b.) housekeeping staff wear gloves appropriately on 1 of 2 units, c.) disposable PPE was appropriately contained in rooms where residents were identified as COVID - 19 positive, this was identified for two (2) of three (3) rooms on the fifth floor unit, and d.) one (1) of (1) resident (Resident #196) identified as exposed to COVID-19 positive nurse staff member was tested in accordance to Centers for Disease Control and Prevention (CDC) guidelines. This deficient practice was evidenced as follows:…

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.