Manahawkin Health And Rehabilitation Center

Complaint # 2564823 Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 07/18/2025, it was determined that the facility failed to administer medications according to the acceptable standards of nursing practice. This deficient practice was identified for 1 of 3 residents reviewed (Resident #3).This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. 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 prescribe by a licensed or otherwise legally authorized physician or dentist. Diagnosing in the context of nursing practice means that identification of and discrimination between physical 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 record review, review of hospital records, interview, and review of facility policy, the facility failed to ensure ordered treatments were completed for fungal dermatitis (skin infection) and arterial ulcers for one of three residents (Resident (R) 2) reviewed for skin integrity out of a total sample of nine residents. This had the potential for fungal dermatitis and arterial ulcers to worsen and a potential for infection.Review of the facility's policy titled, Skin Integrity-Incontinence Associated Dermatitis (IAD) with a date implemented 02/14/23, revealed Residents who are incontinent will receive appropriate treatment and services for the prevention and management of IAD.e. For residents with fungal skin infection, apply antifungal products as ordered by the physician.Review of R2's admission Record located in the electronic medical record (EMR) under the admission Record tab revealed R2 was admitted to the facility on 05/25 with diagnoses including peripheral vascular disease (PVD) and gangrene. The resident was discharged from the facility in 07/25.Review of R2'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.

Based on record review, review of hospital records, interview, and review of facility policy, the facility failed to ensure ordered treatments were completed for pressure ulcers for one of three residents (Resident (R) 2) reviewed for pressure ulcers out of a total sample of nine residents. This had the potential for the pressure ulcers to worsen and a potential for infection. Review of the facility's policy titled, Pressure Injury Prevention and Management with a date implemented 02/14/23, revealed This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection, and the development of additional pressure ulcers/ injuries.2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment.Review of R2's admission Record located in the electronic medical record (EMR) under the admission Record tab revealed R2 was admitted to the facility on 05/25 with diagnoses…

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, review of Nursing Staffing Report sheets and facility provided documents, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 2 of 14 days reviewed 11/17/2024 through 11/30/2024. Based on interview and review of Nurse Staffing Report sheets, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 2 of 14 days reviewed. This deficient practice was evidenced by the following: A review of the Nurse Staffing Reports completed by the facility for the week of 11/17/2024 through11/23/2024, revealed the facility had no RN coverage for all shifts on 11/18/2024 and 11/23/2024. During an interview with the surveyor on 12/06/2024 at 2:06 PM, the Director of Nursing (DON) expressed that staffing needs are met to some extent but not fully. When an RN is unavailable to work the required 8 consecutive hours, the DON steps in as a supervisor, rather than fulfilling the DON role. At that time, the Licensed…

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

Repeat deficiency from recertification survey of 09/23/2023 Based on observations, interviews, and review review of other facility documentation, it was determined that the facility failed to follow the planned, written menu and ensure residents were notified in advance of menu changes for 3 of 3 meals observed. This deficient practice was evidenced by the following: 1. On 12/03/2024 at 12:12 PM, the surveyor observed the lunch meal on the 2nd floor dining/activity room. The surveyor observed Resident #48 and seven (7) additional residents at the lunch meal. All eight (8) residents were observed to have received diced peaches in a clear plastic portion control cup for dessert at the lunch meal. According to the 12/3/2024 Week 4 cycle menu provided to the surveyor on entry to the facility, residents were to receive yellow cake for the dessert at the lunch meal on 12/03/2024. There was no yellow cake observed. When interviewed the Food Service Director (FSD) told the surveyor that they (kitchen staff) didn't make any. In addition, the lunch menu also included that a dinner roll was to…

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

Based on observation, interview, and review of there facility 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: On 12/02/2024 at 9:23 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. On the top shelf of a multi-tiered rack in the dry storage area, a previously opened pack of coffee filters were removed from their original packaging and left uncovered. The usable surface was exposed to contamination. 2. On a middle shelf of the walk-in freezer contained frozen pizza box previously opened. The lids to the box were open and the plastic bag inside that contained the pizza was opened and the pizza was exposed to the air and contamination. 3. The surveyor observed the kitchen staff operating the high temperature dish machine after the breakfast meal. The staff were actively washing dishes during this observation. The surveyor asked the FSD what the facility process was for…

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 other facility documentation, it was determined that the facility failed to maintain a clean, safe, and sanitary environment. This deficient practice was identified for 2 of 2 units (1st floor and 2nd floor) and was evidenced by the following: On 12/03/2024 at 11:22 AM, Surveyor #1 observed the wheels on 2 East and 2 [NAME] medication carts. There was hair and strings wrapped around the wheels. On 12/03/2024 at 11:26 AM, Surveyor #1 observed hair and debris wrapped around the wheels of the Hoyer lift on 2nd floor. On 12/03/2024 at 11:33 AM, Surveyor #1 observed 1/2 PB&J sandwich under the bed of room [ROOM NUMBER]. On 12/03/2024 at 11:42 AM, Surveyor #1 observed the 1 west treatment cart with hair wrapped around the wheels. On 12/03/2024 at12:16 PM, Surveyor #1 observed the wheels on 1 [NAME] with large amount dark hair wrapped around the wheels. On 12/06/24 at 11:18 AM Surveyor #2 observed the interior of Resident #260's room. Resident #260 had there bed against…

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 other facility documentation, it was determined that the facility failed to ensure that an accurate Minimum Data Set (MDS), an assessment tool, was completed. This deficient practice was identified for 6 of 28 residents reviewed (Residents #35, Resident #107, Resident #99, Resident #67. Resident #102, and Resident #1). and was evidenced by the following: 1.During the initial tour of the facility on Resident #35 was observed lying in bed using a cell phone with his/her left hand. Resident #35's right hand was observed to be contracted. A review of the Electronic Medical Record (EMR) on 12/02/2024 at 2:14 PM revealed the following: According to the admission Record, Resident #35 was admitted to the facility with diagnoses including but not limited to: Cerebral Infarction due to Thrombosis (stroke due to a blood clot). A review of the most recent comprehensive MDS dated [DATE], revealed that Resident #35 had impaired mobility on one side of both…

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 Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to develop a person-centered comprehensive care plan to address the use of A. an anticoagulant (blood thinner) medication, B. oxygen therapy, C. a splint used to prevent further contracture, and D. a wander alarm used to prevent elopement. This deficient practice was identified for 4 of 28 sampled residents, (Resident #8, Resident #18, Resident #35, and Resident #99) and was evidenced by the following: A.) On 12/2/2024 at 11:01 AM, during the initial tour, Resident #8 was identified as being on an anticoagulant. A review of Resident #8's EMR on 12/02/2024 at 02:11 PM, revealed the following: A review of Resident #8's admission Record revealed that he/she had diagnoses that included but were not limited to: Acute Embolism (a blockage of a pulmonary artery) and Thrombosis of Deep Veins of the Upper Extremity (a blood clot forms in a vein deep inside a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure that treatment for range of motion limitations were provided for 3 of 3 residents (Resident #102, Resident #1, and Resident #35) reviewed for limited range of motion. This deficient practice was evidenced by the following: 1. On 12/03/2024 at 10:21 AM, Surveyor #1 observed Resident #102 lying in bed with a black splint on his/her left lower arm and wrist area. He/she stated that the orthopedic doctor provided the black arm splint and a black cam boot due to a broken left arm and ankle, but he/she no longer wears the cam boot. He/she puts the splint on his/her left lower arm and wrist at night and removes it when he/she chooses. On 12/03/2024 at 9:00 AM, Surveyor #1 reviewed the EMR for Resident #102 as follows: According to the admission Record Resident #102 was admitted to the facility with diagnoses including but not limited to: fracture of shaft of left…

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, record review and review of other facility documentation, it was determined that the facility failed to obtain a physician's order for supplemental oxygen and not replacing and properly storing a nasal cannula (tube used to deliver oxygen to a person) in accordance with facility policy. This deficient practice occurred for 3 of 3 residents (Resident #54, Resident #261, and Resident #18) reviewed for respiratory care. The deficient practice was evidenced by the following: 1. On 12/3/2024 at 1:38 PM, Surveyor #1 observed Resident #54 in their room sitting on their bed and was being administered oxygen via nasal cannula. The resident informed the surveyor they had COPD (chronic obstructive pulmonary disease) and would use the oxygen concentrator when in their room but when they wanted to go outside their room, they used the portable canister. The surveyor reviewed the medical record for Resident #54 and the following was revealed: A review of the admission Record reflected 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, review of the Electronic Medical Record (EMR) and review of other documentation, it was determined that the facility failed to ensure a resident was transported from one area of the unit to another in a dignified manner for 1 of 28 sampled residents, (Resident #84). This deficient practice was evidenced by the following: On 12/04/2024 at 11:37 AM, the surveyor observed the Licensed Practical Nurse/Unit Manager (LPN/UM #1) to pull a resident (Resident #84) backward in his/her wheelchair (w/c) from the nurse's station to the dining/recreation room. Resident #84's feet on which he/she was wearing slippers, were dragging on floor. There were no foot rests observed on the w/c for the resident to put his/her feet on. The surveyor reviewed the EMR on 12/04/2024 11:54 AM, as follows: According to the admission Record Resident #84 was admitted to the facility with diagnoses including but not limited to: Alzheimer's disease. A review of the most recent Minimum Data Set (MDS) an assessment tool used to facilitate care dated 11/2/2024, revealed a Brief Interview…

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 SNF (Skilled Nursing Facility) Beneficiary Protection Notification (SNF BPN), (Resident #9 and #22). This deficient practice was evidenced by the following: On 12/04/2024 at 09:35 AM, the surveyor presented the facility certified social worker (CSW) with three (3) SNF BPN, one (1) resident discharged to home and two (2) residents that remained in the facility with Medicare A time remaining. The CSW explained to the surveyor that she just started issuing the SNF BPN forms in October after her predecessor left the facility. The CSW further told the surveyor on 12/04/2024 at 10:28 AM, I was unable to find the other form for the residents that went home (NOMNC CMS 10123). In my previous experience it just used to be a verbal conversation. The surveyor explained to the CSW that residents discharged to the facility with Medicare A time remaining required two (2) forms, Notice of Medicare Non-Coverage/NOMNC…

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 Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to develop and implement a baseline care plan (BCP) within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident. This deficient practice was identified for 1 of 28 sampled residents (Resident #102) and was evidenced by the following: On 12/03/2024 at 10:21 AM, Surveyor #1 observed Resident #102 lying in bed with a black splint (medical device used to immobilize, support, or protect a body part) on his/her left lower arm and wrist area. He/she said that the orthopedic doctor (medical professional who specializes in the musculoskeletal system) provided the black arm splint and a black Controlled Ankle Motion boot (CAM) boot (medical boot used to immobilize and protect the foot, ankle, and lower leg following an injury or surgery) due to a broken left arm and ankle, but he/she no longer wears the CAM boot. He/she puts the splint on his/her…

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

Based on the interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to document a discharge summary which included a recapitulation of the resident's stay and a final summary of the resident's status for 1 of 1 resident reviewed for hospitalization, (Resident #109). This deficient practice was evidenced by the following: On 12/4/2024 at 1:49 PM, the surveyor reviewed the closed medical record for Resident #109 which revealed the following: Resident #109's admission Record indicated the resident had been admitted to the facility with medical diagnoses that included myocardial infarction (heart attack), anxiety and adult failure to thrive (a syndrome in older adults characterized by a significant decline in physical and mental health). A review of the resident's Discharge assessment- return not anticipated Minimum Data Set (DRNAMDS), an assessment tool used to facilitate the management of care, reflected the resident had a planned discharge to short-term general hospital. A review of the resident's Progress Notes…

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 record review it was determined that the facility failed to address recommendations made by the Consultant Pharmacist (CP) in a consistent and timely manner. This deficient practice was identified for 2 of 5 residents reviewed for medication management (Resident #22 and Resident #90) and was evidenced by the following: The deficient practice was evidenced by the following: 1. On 12/2/24 at 10:28 AM, during initial tour the Surveyor #1 observed Resident #22 in their room seated in a chair dressed and well-groomed. When asked if the staff took good care of them the resident responded by shaking their head yes then proceeded to get up from the chair and walk out of the room and down the hallway. Surveyor #1 reviewed Resident #22's medical record on 12/03/2024 at 09:51 AM as follows: A review of the admission Record reflected that the resident was admitted to the facility with diagnoses that included dementia, multiple fractures of the bones in the fingers, wrist and arms, and depression. 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 interviews, record reviews, and policy reviews on 10/31/2024, the facility failed to notify the Physician of laboratory results for 1 of 3 Resident (Resident #3.) reviewed for laboratory services. Specifically, the facility failed to notify the Physician of Resident#3 of the abnormal urinalysis results. The Surveyor reviewed the Electronic Medical Record (EMR) was as follows: According to the admission Face Sheet Resident #3 was admitted to the facility with diagnoses which included but not limited to: Acute Kidney Failure and Acute Ethmoidal Sinusitis. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 08/23/2024 showed a Brief Interview for Mental Status score of 15. This indicated that resident #3's cognition was intact. On 10/31/2024 at 10:20 AM, the Surveyor interviewed Unit Manager LPN (UM) who informed the Surveyor that urine specimen for Resident #3 was collected on 10/17/2024, The results were received by the facility on 10/18/2024. Resident #3 was started on antibiotic on 10/24/2024. UM stated the lab report…

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 #: NJ173948 Based on interviews, medical record review, and review of other pertinent facility documentation on 06/26/2024 and 06/27/2024, it was determined that the facility failed to follow standards of clinical practice for documenting the administration of medications in the electronic Medication Administration Record (EMAR). This deficient practice was identified for 1 of 3 residents reviewed for medication administration (Resident #3) 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 licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey…

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 other facility 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: On 9/11/2023 from 9:15 to 9:58 AM, the surveyors, accompanied by the facility Food Service Director (FSD), observed the following in the kitchen: 1. Upon entry to the kitchen the surveyors observed a staff member at the ice machine inside of the kitchen door. The staff was actively filling a cooler on top of a wheeled cart with ice obtained from the ice machine. The staff member identified him/herself as a Recreation Assistant (RA). The female RA had lengthy hair and no hair net. The RA's hair was exposed while in the kitchen. The FSD agreed that all staff should don a hair net while in the kitchen. 2. On an upper shelf in the dry storage room a previously opened bag of uncooked pasta noodles had no dates. On interview the FSD stated that once…

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 documents, it was determined that the facility failed to ensure that their Quality Assurance and Performance Improvement (QAPI) Program was being implemented, and failed to provide sources of qualitative data that showed the facility had analyzed or identified quality deficiencies and evaluated program effectiveness. This deficient practice was evidenced by the following: On 09/15/2023 at 10:17 AM, the Administrator and the Director of Nursing (DON) advised the surveyor that they were unable to provide any sign-in sheets or documentation of a comprehensive QAPI program. During an interview with the surveyor on 09/15/2023, at 11:55 AM, the Administrator stated that the facility prior to his arrival in September 2023, was not conducting QAPI committee meetings. He added that the previous administration did not maintain any documentation that a QAPI program was implemented or maintained as required by the regulation. On 09/15/2023 at 01:13 PM during an interview with the DON, she stated that there has not been a QAPI program in place…

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

Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure that all Certified Nursing Assistants (CNAs) received 12 hours of mandatory in-service training and Dementia training as required. This was identified for 5 of 5 CNA files reviewed for in-service training under Sufficient and Competent Nurse Staffing task. The deficient practice was evidenced by the following: A review of five randomly selected CNA education files did not reveal the mandatory 12 hours in-service training and Dementia training. A review of Mandatory In-service sheets for year 2022 revealed that CNA #1 was hired on 11/11/2021 and completed 5.5 hours of the training. CNA #2 was hired on 06/16/2022 and completed 5.5 hours of the training. CNA #3 was hired on 07/26/2021 and completed 5.0 hours of the training. CNA #4 was hired on 05/18/2021 and completed 6.0 hours of the training. CNA #5 was hired on 08/12/2021 and completed 5.5 hours of the training. On 09/19/2023 at 12:10 PM, during an interview with the surveyor, the Staff Development…

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

Based on observation and interview, it was determined that the facility failed to ensure a homelike atmosphere for 1 of 2 dining rooms, 2nd floor. This deficient practice was evidenced by the following.: On 9/11/2023 at 12:18 PM, the surveyor observed the lunch meal on the 2nd floor dining room. 14 total residents were in the dining room. 14 of 14 residents were served their meal on the tray and the food remained on the tray throughout the meal. On 9/13/2023 at 11:50 AM, the surveyor observed the lunch meal on the 2nd floor. 16 of 16 residents were served their meal on the tray and the food remained on the tray throughout the meal. On 9/15/2023 at 12:24 PM, the surveyor observed lunch meal on the 2nd floor dining room. All residents were served their meal on the tray and the food remained on the tray throughout the meal. During an interview with the surveyor on 9/18/2023 at 1:01 PM, Licensed Practical Nurse #1 said everything should come off the tray in Dining Room. I don't think post covid people know to do that. During an interview with the surveyor on 09/18/2023 at 2:01 PM, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to identify the use of a merry walker (a folding wheeled walker with a seat designed for use by individuals with balance or walking disabilities) as a physical restraint for 2 of 5 residents (Resident #77 and Resident #79) reviewed for falls. This deficient practice was evidenced by the following: 1. On 09/11/2023 at 10:23 AM, during the initial tour of the facility, the surveyor observed Resident #77 in the 2nd floor dining room positioned in a merry walker. Resident #77 was non-interview able and pleasantly confused. Resident #77 was observed to be able to ambulate independently in the merry walker. The gate bar was observed to be in the closed position. The surveyor was unable to determine if Resident #77 was able to get out of the merry walker independently on this observation. On 09/13/2023 at 10:02 AM, the surveyor observed Resident #77 seated in the merry walker the 2nd…

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 facility documents, it was determined that the facility failed to 1.) follow fall prevention interventions as written on the resident's plan of care and ordered by the physician and 2.) ensure a resident who sustained multiple falls and cause determined to be Seizure activity, was followed by a specialist. This deficient practice was identified for 2 of 5 residents (Resident #79, and Resident #167) reviewed for falls and accidents and was evidenced by the following: 1. On 09/11/2023 at 10:18 AM, Surveyor #1 observed Resident #79 lying in bed. Resident #79 was unable to be interviewed at the time but was awake and alert. Resident #79 had a splint on their lower left arm and was wrapped with an ace bandage. Resident #79 was unable to tell the surveyors what happened to his/her left arm when asked. The bed was observed in a low position and the call bell was accessible. According to the admission Record Resident #79 was admitted to the facility with…

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 reviews, it was determined that the facility 1.) failed to follow the planned, written menu and ensure residents were notified in advance of menu changes for 2 of 2 meals observed and 2.) failed to post the menu in area that was accessible to residents. This deficient practice was evidenced by the following: 1. On 09/13/2023 at 12:03 PM the surveyor observed the lunch meal in the 2nd floor dining/recreation room. The surveyor observed Resident #77. Resident #77 received an 8oz skim milk, coffee, lemonade 4oz, mechanical pork tenderloin with gravy, mashed potato with onions, wax beans, and applesauce. On 09/13/23 at 12:13 PM the surveyor reviewed the facility menu for the lunch meal on Wednesday 9/13/2023. The Food Service Director (FSD) stated to the surveyor on the initial tour of the kitchen that the facility was currently on week 2 of the cycle menu. The menu indicated that on week 2 on Wednesday 9/13/2023 the lunch meal was to consist of the following: Cheeseburger with bacon, macaroni & cheese, baby carrots, Bun, Brownie, beverage…

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

Based on observation and interview, it was determined that the facility failed to ensure that the residents' dining experience was provided in a manner to promote the dignity and respect of the residents, who were not served their meal at the same time while seated at the same table as well as serving all residents who are seated in the dining room at the same time. This deficient practice was observed for 1 of 2 dining rooms, 2nd floor and was evidenced by the following: On 9/11/2023 at 12:18 PM, the surveyor observed the lunch meal in the 2nd floor dining room. On the 2nd floor a meal cart indicated was DR (dining room) cart. However, in the dining room was 14 total residents and 1 resident was actively eating and the other 13 were not yet served. On 9/11/2023 at 12:23 PM, a 2nd meal cart arrived in the DR and 5 residents received their lunch meal but 9 residents still with no tray and cart was removed to the unit to finish passing. On 9/11/2023 12:30 PM, a 3rd meal cart arrived to the DR. Prior to that, 2 residents had received their trays. The remaining 7 resident received their…

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

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to inform the beneficiaries of potential financial liability and related standard claim appeal rights for 1 of 3 residents (Resident #368) reviewed for the Beneficiary Notification task. The deficient practice was evidenced by the following: On 09/15/2023 at 11:14 AM the surveyor randomly selected three residents that the facility identified on the Entrance Conference Worksheet, Beneficiary Notice - Residents discharged Within the Last Six Months for the Beneficiary Notification task. A review of the facility-completed, Skilled Nursing Facility Beneficiary Protection Notification Review forms revealed that Resident #368 did not have the Notice of Medicare Non-Coverage (NOMNC). The Skilled Nursing Facility Beneficiary Protection Notification Review form for Resident #368 revealed a hand-written note that read, Cannot be found [NOMNC]. On 09/15/2023 at 12:59 PM, during an interview with the surveyor, the Director of Nursing stated, We don't have it…

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

Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to complete criminal background checks on employees prior to employment as well as to complete reference checks on employees before their start date. The deficient practice was identified for 6 of 10 employees reviewed for criminal background checks and 10 of 10 employees reference checks reviewed under Sufficient and Competent Nurse Staffing task. The deficient practice was evidenced by the following: A review of employee personnel files revealed that six of ten employees did not have a criminal background check completed prior to the start of the employment. A review of the same ten requested employee files revealed that all ten did not have reference checks done prior to start of the employment. On 09/18/2023 at 12:14 PM, during an interview with the surveyor, the Human Resources Director (HRD) replied, Every employee who wants to work here needs to have one done when the surveyor asked who was required to have a criminal background check completed. During 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 other facility documentation, it was determined that the facility failed to implement a care plan for nail care as identified in the facility policy for 1 of 1 residents (Resident #101) investigated for Activities of Daily Living. On 09/11/2023 at 09:42 AM, during the initial tour, the surveyor observed Resident #101 in a wheelchair in his/her room. At that time, the surveyor observed Resident #101's fingernails on his/her left hand. The fingernails were long and discolored. Resident #101 said to the surveyor that he/she needs them cut. On 09/12/2023 at 11:09 AM, during an interview with the surveyor, Resident #101 said that a doctor came to cut his/her toenails. Resident #101 told the surveyor again that he/she wants their fingernails cut. Resident #101's fingernails continued to appear long, discolored, and dirty. A review of Resident #101's Diagnoses located in the Electronic Medical Record (EMR) revealed diagnoses of but not limited to, Type II Diabetes Mellitus (a chronic condition that affects the way the body…

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 provide necessary services to maintain good personal hygiene for a resident specifically by not providing fingernail care. The deficient practice was observed for 1 of 1 residents (Resident #101) investigated for Activities of Daily Living and was evidenced by the following: On 09/11/2023 at 09:42 AM, during the initial tour, the surveyor observed Resident #101 in a wheelchair in his/her room. At that time, the surveyor observed Resident #101's fingernails on his/her left hand. The fingernails were long and discolored. Resident #101 said to the surveyor that he/she needs them cut. On 09/12/2023 at 11:09 AM, during an interview with the surveyor, Resident #101 said that a doctor came to cut his/her toenails. Resident #101 told the surveyor again that he/she wants their fingernails cut. Resident #101's fingernails continued to appear long, discolored, and dirty. A review of Resident #101's Diagnoses located in the Electronic Medical Record (EMR)…

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, and review of other facility documentation, it was determined that the facility failed to consistently provide services to treat and prevent a decline in Range of Motion (ROM) for a resident with a contractures of the right hand. This deficient practice was identified for 1 of 2 residents reviewed for limited ROM (Resident #2) and was evidenced by the following: On 09/12/2023 at 08:54 AM, Resident #2 was observed in bed and being assisted with the breakfast meal by staff. Resident #2's hands were covered with bedding on this observation and the surveyor was unable to observed for right hand contracture. On 09/13/23 09:55 AM, Resident #2 was observed lying in bed and the soft comfy splint was observed to be on top of the bedside nightstand. On 09/13/20233 at 11:54 AM, the surveyors visited the room of Resident #2. Resident was not present on this observation, however, the surveyors did observe Resident #2's soft and comfy splint on the bedside nightstand. Resident #2 was then observed in the 2nd floor dining room at 11:59 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.

Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to complete a performance review of a Certified Nurse Aide (CNA) at least every 12 months. The deficient practice was identified for 1 of 5 Certified Nurse Aides reviewed under Sufficient and Competent Nurse Staffing task. The deficient practice was evidenced by the following: A review of the facility-provided CNA annual performance evaluations revealed that 1 of the 5 CNAs did not have an annual performance evaluation. On 09/15/2023 at 12:01 PM, during an interview with the surveyor, the Human Resources Director confirmed one performance evaluation was not completed for one of the five CNAs. On 09/19/2023 at 01:08 PM, during an interview with the surveyor, the Director of Nursing (DON) replied, It should be done yearly when asked what the process for reviewing the performance evaluation for nurse aides was. The DON confirmed that the annual performance evaluation was not completed for one of the CNAs by replying, Yes when the surveyor stated that the CNA should…

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 other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 7/19/2021 from 7:45 to 8:23 AM, the surveyor, accompanied by the cook, observed the following in the kitchen: 1. A stand up fan at the entrance of the dry storage room and facing the food production area was in operation. The fan was observed to be covered with brown dust and debris on the fan guard. When interviewed the cook stated, We had it on every day because it's been so hot in here. [NAME] or the dishwasher could clean it. 2. On a lower shelf in the walk-in refrigerator a 1/6 pan was covered with plastic wrap and labeled sauce. The label was dated 7/13-7/16. On interview the cook stated, That's expired, I'm getting rid of it. The cook removed the 1/6 pan of sauce in the presence of the surveyor. 3. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of other facility documentation. it was determined that the facility failed to maintain the call light within reach of the resident according to the facility policy. This deficient practice was observed for 2 of 20 sampled residents, (Resident #56 and #69) and was evidenced by the following: 1. On 7/19/2021 at 9:04 AM, during the initial tour of the facility, the surveyor observed Resident #56 in their room. On interview Resident #56 was unable to show the surveyor where his/her call light was located. The surveyor observed Resident #56's call light on the floor in front of their roommates bedside table. The call light was not within reach of Resident #56. A review of the 5/27/2021, quarterly Minimum Data Set (MDS), an assessment tool, which revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 6/15, indicating resident # 56 had severe cognitive impairment and a diagnosis of Non-Alzheimer's dementia. On 7/20/2021 at 8:26 AM, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a clean and sanitary environment on 2 of 2 units. The deficient practice was evidenced by the following: 1. On 7/19/21 at 7:53 AM, during the initial tour on the first floor of the facility, the surveyor observed cracked drywall and ripped wallpaper in room [ROOM NUMBER]. The surveyor also observed what appeared to be a broken door stop among crumbled drywall behind the room door. Resident #63 was present in the room during the observation. He/she stated, the room is filthy. On 7/20/21 at 8:46 AM, the surveyor entered room [ROOM NUMBER]. Resident #63 was present. The cracked drywall and ripped wallpaper from the previous day were observed again. The broken doorstop, and crumbled drywall from the previous day were also observed. During the visit, the surveyor observed the window screen which appeared to have buildup of dirt and dust. On the windowsill, behind the blinds were cobwebs…

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 other facility documentation, it was determined that the facility failed to follow a physician ordered consult for Pain Management for 1 of 1 resident reviewed for pain management, (Resident #87). This deficient practice was evidenced by the following: On 7/20/21 at 12:15 PM, they surveyor observed resident #87 lying in bed watching television. The resident stated that he/she has suffered from chronic pain for 20 plus years. Resident #87 stated as long as he/she gets his/her pain medication on time, he/she can maintain a comfort level to function. Resident #87 added that he has not had a pain management consultation. A review of the medical record indicated that Resident #87 had a diagnosis of Multiple Trauma, Spinal Cord Injury, Neuropathy (nerve pain) and Chronic Pain Syndrome. A Quarterly Pain assessment dated [DATE], indicated that the resident reported pain level as 8/10 with frequent chronic pain in the arms and legs. A review of the most…

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 other facility documentation, it was determined that the facility failed to detect and remove expired medication from 1 of 2 facility medication rooms reviewed during the Medication Storage task. This deficient practice was evidenced by the following: On [DATE] at 10:49 AM, in the presence of the Licensed Practical Nurse (LPN), the surveyor observed 37 tablets of Oxycontin CR ( a controlled narcotic pain medication) 30 mg tablets in the first-floor medication room lockbox that had an expiration date of [DATE]. The LPN confirmed that the tablets were dated and expired on [DATE]. During an interview on [DATE] at 11:16 AM, the Registered Nurse (RN #1) stated that one tablet of the expired Oxycontin CR was given to Resident #16 on [DATE] at 9:00 AM. During an interview on [DATE] at 11:57 AM, the Director of Nursing confirmed the facility received the expired Oxycontin from the pharmacy on [DATE]. She further stated, Don't get me wrong. We are wrong but I am going to call…

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.