Village Point

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy, the facility failed to implement residents' care plans related to a mechanical lift transfer (hoyer) for one of 24 sampled residents (Resident (R) 112). This failure placed the resident at risk of harm due to inappropriate transfers.Findings include:Review of the facility's policy titled, Resident Care Plan, dated 10/2024 revealed, .Specific, individualized steps or approaches that staff will take to assist the resident to achieve goals will be listed. Interventions should be short and concise, easy for all staff to follow and serve as a care guide.Review of R112's Face Sheet located on the Home Page of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses that included a history of multiple sclerosis (MS-a neurological disorder) and vascular dementia with behavioral disturbances.Review of R112's annual Minimum Data Set (MDS) located in the MDS tab of the EMR with an…

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 the facility policy, the facility failed to ensure activities of daily living (ADLs) were provided for two of three residents (Residents (R) 2 and R76) reviewed for ADLs out of 24 sampled residents. The facility failed to ensure showers were received per the shower schedule. This failure placed the residents at risk for a diminished quality of life.Findings include: Review of the facility policy titled, Showering the Resident, revised 01/21/25 revealed, A shower will be given to residents as requested or as per the care plan. 1. Review of R2's Face Sheet located on the Home Page of the electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE]. Review of R2's admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) 06/09/25 revealed R2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 was cognitively intact. The MDS also revealed R2 required…

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 facility policy, the facility failed to provide care and services for two residents (Residents (R) 112 and R44) out of 24 sampled residents. The facility failed to ensure R112 had adequate monitoring and timely medical care after the facility identified discoloration and swelling to R112's right leg which was later identified as a closed right tibial fracture. In addition, the facility failed to ensure R44 received medications as ordered by the provider. These failures placed residents at risk for unmet care needs and a diminished quality of life.Findings include:Review of the facility's policy titled, Change of a Resident's Condition, dated 08/01/01 revealed, .To ensure that when a resident has a change of condition, appropriate assessments are performed, documented and that timely notification of the resident's physician and family occurs.All accidents involving the resident which results in injury and has the potential for requiring physician…

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 the facility policy, the facility failed to ensure the medical record was complete and accurate for one resident (Resident (R) 5) out of 24 sampled residents. This failure placed the residents at risk for unmet care needs.Findings include:Review of the facility's policy titled, Charting and Documentation, dated 01/10/25 revealed, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.Review of R5's Face Sheet located on the Home Page of the electronic medical record (EMR) revealed that R5 was admitted to the facility on [DATE] with diagnoses that included right hip fracture with hip replacement.Review of R5's admission Minimum Data Set (MDS) located in the MDS…

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 document review it was determined that the facility failed ensure: a) the kitchen environment and equipment was maintained in a clean and sanitary manner, b) the dish machine was functioning in a manner to ensure proper wash and rinse temperatures were maintained, c) refrigerated resident food storage areas (3 of 4 observed) were maintained in a clean manner and food was appropriately labeled and dated, and d) staff performed appropriate hand hygiene, to limit potential bacteria growth and potential food borne illness. The deficient practice was evidenced by the following: On 11/13/23 at 9:24 AM through 10:07 AM, the surveyor conducted a tour of the kitchen with several staff including the Regional Director of the Food Management Company, Executive Chef, Registered Dietitian (RD) and observed: 1. At 9:26 AM, the dish machine was observed in use and resident meal items, including insulated lids and trays were being washed. The surveyor observed the temperature screen to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, it was determined that the facility Quality Assurance Performance Improvement (QAPI) Committee failed to a.) improve quality of life and improve quality of care for residents by not having a system in place to identify residents who sustained significant unplanned weight loss, and b.) ensure the kitchen and associated areas were maintained in a sanitary manner. This deficient practice occurred for 1 of 2 residents (Resident #23) and during observations conducted on 11/13/23 and 11/15/23 and was evidenced by the following: Refer to 692G and 812F On 11/17/23 at 9:25 AM, the surveyor intrviewed the Licensed Nursing Home Administrator (LNHA) regarding the currently active QAPI plans. The LNHA stated the facility was working on reducing falls and psychotropic medications as part of the QAPI program. The surveyor inquired to the LNHA if the identified concerns identified during the survey regarding the significant unplanned weight loss for Resident #23 and the sanitation…

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. ) adhere to accepted standards of infection control practices for the proper storage of respiratory tubing and mask after use for 3 of 3 residents reviewed for respiratory services (Resident #39, #75 and #149). b.) follow the facility infection control policy to limit the potential spread of infection by failing to perform hand hygiene prior to serving and assisting with resident meal tray preparation and during medication pass administration, and c.) ensure individuals providing services under a contractual arrangement were educated on infection control practices. This deficient practice was observed on 2 of the 4 units (Willow and Evergreen) and was evidenced by the following: 1. During the initial tour of the facility on 11/13/23 at 9:13 AM, the surveyor observed Resident #149 in bed. The surveyor observed a continuous positive air pressure machine (C-PAP ) on the bedside table. The C-PAP Mask including 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 conduct a thorough investigation for an injury of unknown origin for Resident #87. This Deficient practice was identified for 1 of 5 residents reviewed for accidents and was evidenced by the following: On 11/13/23 at 9:30 AM, the surveyor observed Resident #87 sitting at the table in the common area of the [NAME] unit. The resident was observed with a bandage covering to the right eyebrow and blackish purple discoloration in the surrounding area. On 11/13/23 at 11:18 AM, the surveyor reviewed the Electronic Medical Record (EMR) and reviewed a Physician note dated 10/09/23. The note revealed that Resident #87 fell and sustained a laceration to the right side of forehead and a skin tear to the right forearm. On 11/14/23 at 11:46 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN) about Resident #87's injuries. The LPN #1 stated that the resident went home with the family on Sunday 11/12/23…

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

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure the physician: a.) addressed a significant weight loss of 8.6 pounds (lb.) (5.3%) x 30 days, a significant 24.4 lb. (13.6%) weight loss x 90 days, and a significant 33.4 lb. (17.7%) weight loss x 180 days, b.) monitored weekly and monthly resident weights, and c.) implemented nutritional interventions in a timely manner for 1 of 4 residents (Resident #23) reviewed for nutrition. The deficient practice was evidenced by the following: Refer F692G On 11/13/23 at 10:29 AM, during the initial tour of the facility, the surveyor observed Resident #23 awake and alert sitting in a wheelchair in the dining room with the activities department. On 11/13/23 at 12:55 PM, the surveyor observed Resident #23, awake and alert, sitting in the dining room eating lunch. On 11/14/23 at 09:14 AM, the surveyor observed Resident #23 lying in bed with his/her eyes closed. At 9:21 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that the…

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

Based on observation, interview and document review it was determined that the facility failed to serve meals at an appetizing temperature for 1 of 1 resident reviewed for food (Resident #148) and on 1 of 4 resident units (Willow). The deficient practice was evidenced by the following: On 11/13/23 at 10:18 AM, during the initial tour, Resident #148 expressed concerns about the quality of the meals served and the temperature of the meals served. The breakfast meal sat on the bedside table, untouched, during the interview. On 11/15/23 at 8:04 AM, the surveyor observed residents in the [NAME] unit dining room sitting at tables waiting for the breakfast meal. On 11/15/23 at 8:09 AM, a meal cart was brought to the unit and the first tray was served. On 11/15/23 at 8:52 AM, the 2nd to last tray was removed from the cart and the surveyor removed the last tray to review for the test tray. The meal was Regular consistency meal. At 8:56 the Food Service Director (FSD) and the surveyor proceeded to test the food temperatures. The FSD stated that the hot food should be 140 degrees Farenheight…

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 document review, the facility failed to have the Medical Director (MD) and the Director of Nursing (DON) present for one of four Quality Assurance and Performance Improvement (QAPI) meeting as evidenced by the following: On 11/17/23 at 9:15 AM, the surveyor reviewed the QAPI policy and procedure and requested the sign-in sheets or the last four quarterly QAPI meetings. On 11/20/23 at 9:00 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with four quarterly sign-in sheets for the each quarter of 2023, which revealed: The First Quarter 2023: January 17, 2023, Quarterly QAPI Team Meeting Signature Log. The sign-in sheet was missing the attendance of the Medical Director (MD) and the Director of Nursing (DON). At that time, the LNHA stated that on January 17, 2023 the MD was on vacation and the DON was not present. The facility provided QAPI plan policy included but was not limited to: The Quality Improvement (QI) Committee consists of the Director of Nursing, the Medical Director, the Administrator, Activity Director, Social Work,…

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, and review of facility documentation it was determined that the facility failed to a.) properly label, date and store potentially hazardous foods and dry foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On 11/29/21 at 07:53 AM the surveyor toured the kitchen in the presence of the Dietary Aide (DA) and observed the following: 1. The foot pedal trash can at handwashing sink #2 was not lined with a trash bag and both trash and food debris were observed in the can. 2. In the main refrigerator was one rolling metal food prep cart with a tray of individually wrapped plates of pie with no labels and no dates. The DA identified them as apple pie and acknowledged they should have a label and date. 3. In the same refrigerator, on the third shelf of a five tiered metal shelf, there…

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 medical records, it was determined that the facility failed to follow a physician order for a Peripherally Inserted Central Catheter (PICC) (used to access to a large central vein for medication) line dressing change consistent with professional standards of clinical practice. This deficient practice was identified for 1 of 23 resident reviewed, Resident #139 and was evidenced by the following: Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, Title 45, Chapter11, Nursing Board, The Nurse Practice…

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.