Laurel Brook Rehabilitation And Healthcare Center

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff implemented facility policies and procedures to ensure a.) residents were provided with care and services to achieve their highest practical wellbeing, and b.) maintain the resident environment, equipment and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified for and 5 out of 5 nursing units, and was evidenced by the following: Refer to F584, F645, F657, F689, F758, and F812 A review of the Administrator's job description provided by the facility revealed the following: The Administrator's primary purpose is to direct the day-to-day functions of the center in accordance with current federal, state, and local standards, guideline, and regulations that govern nursing centers to assure that the highest degree of quality care can be provided to the residents at all times. Duties and Responsibilities included but not limited to: plan, develop, organize, implement,…

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

Based on interviews, record review, and review of pertinent facility documentation it was determined that the facility failed to accurately complete a Preadmission Screening and Resident Review (PASARR) to ensure the resident was referred to the appropriate state-designated authority for level II PASARR evaluation and determination. This deficient practice was identified for one (1) of 1 resident (Resident #97) reviewed for level II PASARR and was evidenced by the following: On 10/15/24 at 10:08 AM, the surveyor reviewed the electronic medical record for Resident #97. A review of the admission Record face sheet (an admission summary) reflected that the resident had diagnosis that included, intellectual disability, schizophrenia and generalized anxiety. A review of the PASARR level I Screening Tool dated 2/7/24 and signed by the facility's social worker (SW), indicated the following: Section II - Mental Illness Screen showed the resident had diagnosis or evidence of a major mental illness and the screen was negative. Section II- Intellectual Disability/Developmental…

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 revise a resident's individualized comprehensive care plan (ICCP) related to smoking for 3 of 6 residents (Resident #73, #102 and #198) reviewed for accidents. This deficient practice was evidenced by the following: 1.) On 10/9/24 at 1:52 PM, the surveyor observed Resident #102, awake and alert, sitting in a chair at a table in the outside smoking patio. The surveyor observed a red pack of cigarettes with a black lighter on top of the pack of cigarettes on the patio table. The resident confirmed the cigarettes and lighter were his/hers and that he/she did not use a smoking apron anymore. Resident #102 further stated that he/she can come out to smoke anytime between 8:00 AM and 8:00 PM, and there was no supervision by the staff. Resident #102 stated that they kept their cigarettes in the drawer in their room. A review of the admission Record face sheet (an admission summary) reflected that Resident #102 was admitted to the facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2.) On 10/08/24 at 9:31 AM, the surveyor observed Resident #167 in his/her room. A review of the admission Record (admission summary) reflected the resident had diagnoses which included, but were not limited to, anxiety disorder, depression, and bipolar disorder (mental illness that causes unusual shifts in mood). A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 9/4/24, revealed the resident had a Brief Interview for Mental Status score of 15 which indicated that the resident's cognition was intact. A review of Resident #167's Physician's orders located in the Electronic Medical Record (EMR) revealed an order for Lorazepam (medication used for anxiety) 0.5 milligram tablet to by given by mouth every 6 hours as needed for anxiety disorder, with a start date of 08/29/24. The active order did not include a duration for use or stop date. A review of the Pharmacy Consultant Report, dated 8/30/24, revealed the following documentation: Resident has a PRN (as needed) order for Lorazepam as…

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

Based on observation, interviews, record review, and review of other pertinent documentation, it was determined that the facility failed to provide necessary dental care services in a timely manner for 1 of 1 resident (Resident #143) reviewed for dental care services. This deficient practice was evidenced by the following: On 10/8/24 at 11:06 AM, during the initial tour of the facility the surveyor observed Resident #143 lying in bed awake with a visitor present at the bedside. The resident stated that he/she was ordered a mechanical soft diet (designed for people who have trouble chewing/swallowing). The resident further stated, I lost my bottom denture a year ago and thought that the facility was going to replace them, but it never happened. A review of Resident 143's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: Dysphagia (difficulty swallowing) following cerebral infarction (stroke), muscle wasting and atrophy (waste away), and type 2 (two) diabetes (the body has trouble…

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

Based on interviews, record review and review of other pertinent documentation, it was determined that the facility failed to report timely an allegation of staff to resident abuse to the facility administrator and the New Jersey Department of Health (NJDOH). This deficient practice was identified for 1 of 3 residents (Resident #173) reviewed for an allegation of abuse. This deficient practice was evidenced by the following: During the initial tour of the facility on 10/08/24 at 1:36 PM, Resident #173 was observed seated on the side of their bed. When interviewed, the resident was tearful at times as they described how they were spoken to by the Nurse Practitioner (NP). The resident stated that the NP told them that they would die if they did not take their potassium. The resident stated that he/she did not want care forced upon them. The resident stated that they preferred to take a more natural approach like eating bananas instead of taking medication such as potassium. The resident stated that they had declined the medication and that was what the NP was mad about. The resident…

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 record review, it was determined that the facility failed to complete a Tracking Record (Discharge) Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, for 2 of 38 residents (Resident #108 and Resident #406) reviewed for resident assessments. The deficient practice was evidenced by the following: 1. On 10/11/24 at 1:00 PM, the surveyor completed record review of Resident #108 specific to MDS assessment. Resident #108 was discharged to home on 9/10/24. The Discharge Return Not Anticipated/End of PPS Part A Stay MDS was completed on 10/11/24. The discharge MDS was 17 days overdue. 2. On 10/11/24 at 3:00 PM, the surveyor completed record review of Resident #406 specific to MDS assessment. Resident #406 was discharged to the hospital on 7/9/24. The Discharge Return Anticipated MDS was completed on 8/2/24. The discharge MDS was 10 days overdue. Resident #406 was discharged to the hospital on 7/15/24. The Discharge Return Anticipated MDS was completed on 8/2/24. The discharge MDS was four days overdue. Resident #406…

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 the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives, timelines, and interventions to meet resident's psychological needs specifically by failing to implement a care plan for a resident diagnosed with anxiety on admission. The deficient practice was identified for 1 of 6 residents (Resident #167) reviewed for unnecessary medication. This deficient practice was evidenced by the following: On 10/8/2024 at 9:31 AM, during the initial tour, the surveyor observed Resident #167 in their room. A review of Resident 167's admission Record face sheet (an admission summary) revealed that they had a diagnosis that included but not limited to; major depressive disorder, bipolar disorder, and generalized anxiety disorder. A review of the comprehensive Minimum Data Set (MDS), an assessment tool, dated 9/5/2024, under Section I- revealed an active diagnosis of anxiety. A review of the physician orders (PO) revealed the…

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

Complaint #: NJ176224 Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) a resident was assessed by a Registered Nurse (RN) after sustaining a fall and b.) a resident was evaluated by a physical therapist as per a physician's order. This deficient practice was evidenced for 1 of 6 residents (Resident #305) reviewed for accidents and evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing…

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 #: NJ177592 Based on interview, record review, and a review of other pertinent documentation, it was determined that the facility failed to ensure that the appropriate care was provided with no delay in treatment for a.) a resident who had a change in condition, with left lower extremity swelling and bruising, suspected DeepVein Thrombosis (DVT, blood clot) received a STAT (immediate) venous doppler (diagnostic test to rule out DVT) in a timely manner before being transferred to the hospital with emergency services, and b.) a resident who had a change in condition and experienced nausea, weight loss, and indigestion was rescheduled for an outpatient CT scan (x-ray image) in a timely manner in accordance with professional standards of nursing practice. This deficient practice was identified for 1 of 1 resident (Resident #255) reviewed for a change in condition and 1 of 5 residents (Resident #7) reviewed for nutrition. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act…

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

Based on observation, interviews, record review, and review of other pertinent documentation, it was determined that the facility failed to perform and document a skin assessment, obtain a treatment order, and implement timely interventions to prevent the development of a pressure ulcer upon the identification of an alteration in skin integrity for a resident previously identified to be at risk for the development of pressure ulcers. This deficient practice was identified for 1 of 2 residents (Resident #101) reviewed for pressure ulcers. This deficient practice was evidenced by the following: On 10/8/24 at 10:18 AM, during the initial tour of the facility the surveyor observed Resident #101 lying awake in bed with an air mattress motor noted at the foot of the bed. The resident stated that they had a wound on their bottom and did not receive care or pain medicine for the wound in a timely manner when requested during the 11 PM to 7 AM shift. The resident stated that the last incidence occurred three (3) weeks ago when they waited 3 hours. A review of Resident #101's admission Record…

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 a.) ensure an indwelling urinary catheter drainage bag and tubing did not touch the floor and b.) ensure the urinary catheter drainage bag was changed as ordered by the physician for 2 of 2 residents (Resident #174 and #188) reviewed for urinary catheter. This deficient practice was evidenced by the following: 1.) On 10/8/24 at 11:27 AM, the surveyor observed Resident #188 sitting in a wheelchair with a urinary catheter drainage bag (a collection device attached to a tube placed in the body to empty urine) secured to the wheelchair. The drainage bag was touching the floor. On 10/9/24 at 09:03 AM, the surveyor observed Resident #188 sitting in a wheelchair with a urinary catheter drainage bag secured to the wheelchair. The tubing that connected the drainage bag to the catheter was touching the floor. On 10/10/24 at 10:24 AM, the surveyor observed Resident #188 sitting in a wheelchair with a urinary catheter drainage bag secured to the wheelchair.…

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

Based on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) provide fortified foods as prescribed by the physician, b.) obtain weekly weights as recommended by the Registered Dietician, and c.) obtain re-weights according to the facility's policy for 2 of 5 residents (Resident #91 and #7) reviewed for nutrition. This deficient practice was evidenced by the following: 1.) On 10/11/24 at 12:12 PM, the surveyor observed Resident #91 receive his/her lunch tray which included a sealed pudding pack without a label. According to the resident's meal ticket, the resident was supposed to receive fortified pudding (pudding that contains extra nutrients). The surveyor took a picture of the lunch tray. At 12:35 PM, the Korean Program Assistant Director translated for the resident who stated he/she would sometimes eat the pudding and did not have a preference for flavor. On 10/15/24 at 12:37 PM, the surveyor observed Resident #91's lunch tray which included a serving of pudding packaged by the facility. According…

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

Based on observations, interviews, record review, and review of other pertinent documentation, it was determined that the facility failed to store respiratory equipment in a safe and sanitary manner when not in use to reduce the incidence of infection for 1 of 3 residents (Resident #123) reviewed for respiratory care. This deficient practice was evidenced by the following: On 10/8/24 at 1:11 PM, during the initial tour of the facility, the surveyor entered Resident #123's room with permission and observed a nebulizer machine (an electrically powered machine that turns liquid medication into a mist so that it can be inhaled directly into the lungs through a mask or mouthpiece) that was stored on top of a crowded table with the resident's personal belongings. The mask was not stored in a bag and condensation (moisture) was noted in the clear, plastic chamber. A vast area of an unknown brown substance was noted on two of the four sides of the nebulizer machine. The nebulizer unit was stored directly above a wall unit air conditioning unit which had a thick coating of dust on the vent…

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 review of pertinent facility documents, it was determined that the facility failed to complete a performance review of all Certified Nurse Aides (CNA) at least every twelve months and provide regular in-service education based on the outcome of employee job performance reviews. The deficient practice was identified for 2 of 6 CNAs (CNA # 12 and #8) reviewed for the completion of annual performance evaluations and was evidenced by the following: 1.) On 10/11/24 at 11:09 AM, the surveyor reviewed the personnel files of five Certified Nursing Assistants and noted that the Annual Staff Performance Appraisal of CNA #12 dated 12/20/23, was not signed by the employee, Supervisor or Department Head in the spaced provided. The caption above the signature block indicated, This performance appraisal has been reviewed and acknowledged by the Employee, Supervisor and Department Head, and a copy shall be placed in the employee's Human Resource File. During an interview with the surveyor on 10/11/24 at…

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

Based on observations, interviews, record review and review of other pertinent documentation, it was determined that the facility failed to ensure that the current resident census was accurately reflected and recorded on the Nursing Home Resident Care Staffing Report prior to posting the notice in prominent areas for residents and the general public to view. This deficient practice was identified on three of six survey dates was evidenced by the following: On 10/8/24 at 9:11 AM, the Licensed Nursing Home Administrator (LNHA) stated that the facility census was 207. A review of the facility daily staffing sheet indicated that the resident census was 208. A review of the Nursing Home Resident Care Staffing Report dated 10/8/24-Day Shift, reflected that the Current Resident Census was 203. On 10/09/24 at 10:57 AM, the surveyor reviewed the Nursing Home Resident Care Staffing Report dated 10/9/24 which reflected that the current census was 203. A review of the facility daily staffing sheet indicated that the resident census was 208. On 10/11/24 at 1:08 PM, the surveyor reviewed the…

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

Complaint #: NJ177069 Based on observation, interview, and pertinent record review, it was determined that the facility failed to a.) ensure the accountability of the Narcotic Shift Count logs were completed in accordance with facility policy, b.) ensure that narcotics were properly secured under two secured locks per facility policy, and c.) obtain and administer a medication per physicians order. This deficient practice was observed in 1 of 5 medication carts reviewed for medication storage and 1 of 5 residents (Resident # 355) reviewed for medication adminsitration, and was evidenced by the following: 1.) On 10/10/24 10:45 AM, the surveyor, in the presence of Registered Nurse #1 (RN #1), reviewed the North 1 Unit's medication B Cart shift to shift narcotic count logs which indicated the following missing documentation: Nurse's signature going off duty for 9/26/24 7 AM - 3 PM shift Nurse's signature coming on duty 10/9/24 11 PM - 7 AM shift Nurse's signature coming on duty 10/10/24 7 AM - 3 PM shift The Is count correct: Yes / No column was blank for all shifts from 9/26/24…

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

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to ensure that all medications were administered without an error rate of 5% or less. During the medication pass observation on 10/9/24 at 8:21 AM, the surveyor observed four nurses administer medications to four residents. There were 32 opportunities and 2 errors which calculated to a medication administration error rate of 6.25%. This deficient practice was identified for 1 of 4 residents (Resident #92) and was evidenced by the following: On 10/9/24 at 8:21 AM, the surveyor observed Licensed Practical Nurse (LPN) #2 obtain a bottle labeled probiotic from the supply of house stock medications (medication that can be obtained over the counter without a prescription). The LPN placed the probiotic capsule in a medication cup and immediately after, documented on the Medication Administration Record (MAR) that the medication was administered. The LPN gathered all the resident's medications, including the probiotic. The surveyor asked the LPN if she had all 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 review of pertinent facility documentation, it was determined that the facility failed to properly dispose of expired medical equipment and maintain clean and sanitary medication storage areas. This deficient practice was observed in 2 of 3 medication storage rooms and 1 of 5 medication carts reviewed for medication storage and labeling and was evidenced by the following: On 10/10/24 at 9:31 AM, the surveyor, in the presence of the Registered Nurse Unit Manager (RN/UM) observed the East Medication Storage Room, which contained one (1) box of Shiley inner cannulas (a plastic medical tube which is inserted into a resident's tracheostomy (an opening in the neck into the windpipe to help a person breathe) containing 10 expired cannulas with an expiration date of 3/25/24. On 10/10/24 at 10:07 AM, the surveyor, in the presence of Licensed Practical Nurse Unit Manager #1 (LPN/UM #1) observed the North One nursing unit's medication storage room in which the following expired items were identified: One (1) tracheostomy care tray expired 9/10/23 Two (2)…

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 documentation, it was determined that the facility failed to A.) perform hand hygiene before preparing and administering medications. B.) failed to maintain a non-touch technique when returning excess medication to the original bottle. and C. failed to disinfect the blood pressure equipment after each use. This breach in infection control practice occurred during 2 of 4 medication administration observation. This deficient practice was evidenced by the following: 1.) On 10/09/2024 at 08:21 AM during the Medication Administration task, the surveyor observed Licensed Practical Nurse (LPN) #1 prepare and administer Resident #92's medication. He/She did not perform hand hygiene prior to preparing the resident's medication and after administration. 2.) During the same medication observation, Resident #92 had an order for Tylenol extra strength tablet, give two tablet by mouth every 12 hours. LPN #1 erroneously poured 3 tablets into the bottle cap instead of 2 tablets. As LPN #1 returned the excess tablet to the original…

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 #: NJ165714 Based on observations, interviews, a review of the medical record, and other pertinent facility documents on 10/3/23, it was determined that the facility failed to provide documented evidence of care provided to a resident (Resident #2). The facility also failed to follow the Certified Nursing Assistant's job description and its policies titled, Activities of Daily Living (ADL), Supporting for 1of 4 residents (Resident #2) reviewed. This deficient practice was evidenced by the following: Review of the Electronic Medical Record (EMR) was as follows: According to the AR Resident #2 was admitted to the facility on 7/2//23 with diagnoses which included but were not limited to Obstructive Sleep Apnea, Difficulty Walking, Major Depressive Disorder, Hypertension, and Muscle Wasting. According to the Minimum Data Set (MDS), an assessment tool dated 7/6/23, Resident # 2 had a BIMS score of 15/15, which indicated the Resident #2 was cognitively intact. The MDS also showed Resident #2 had unstageable sacral pressure ulcer, needed total assistance and two-person physical…

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 report to the New Jersey Department of Health (NJDOH) an allegation of resident-to-resident verbal abuse between Resident #72 and #146 that occurred on 5/19/23. This deficient practice was identified for 1 of 2 reportable investigations reviewed, and was evidenced by the following: On 5/22/23 at 12:28 PM, the surveyor observed Resident #72 sitting in their room. Resident #72 informed the surveyor that on Friday (5/19/23), he/she was involved in a verbal screaming match and cursing with their roommate (Resident #146). Resident #72 reported that Resident #146 was speaking with their Nurse Practitioner (NP), and the NP asked Resident #146 a question, which the resident did not respond so he/she (Resident #72) answered the NP's question. Resident #72 continued that Resident #146 became upset that he/she was speaking on their behalf to their NP, and a screaming match with the use of profanity…

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 investigate a.) an incident of resident-to-resident verbal abuse for Resident #72 and #146 on 5/19/23, and b.) an incident with a resident sent to the emergency department with a diagnosis of fecal impaction to rule out neglect on 3/3/23. This deficient practice was identified for 2 of 3 residents reviewed for abuse and neglect (Resident #72 and #189), and was evidenced by the following: 1. On 5/22/23 at 12:28 PM, the surveyor observed Resident #72 sitting in their room. Resident #72 informed the surveyor that on Friday (5/19/23), he/she was involved in a verbal screaming match and cursing with their roommate (Resident #146). Resident #72 reported that Resident #146 was speaking with their Nurse Practitioner (NP), and the NP asked Resident #146 a question, which the resident did not respond so he/she (Resident #72) answered the NP's question. Resident #72 continued that Resident #146 became…

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

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) administer medications according to physician's orders; b.) clarify a physician's order; and c.) contact the pharmacy and physician for a medication (vitamin E) that was unavailable in accordance with professional standards of practice. This deficient practice was identified for 1 of 3 residents observed for medication administration (Resident #282), and was evidenced as follows: 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. 1. On 5/18/23 at 8:10 AM, the surveyor observed 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 review of pertinent facility documents, it was determined that the facility failed to ensure all medications were administered without an error of 5% or more. During the medication observation on 5/18/23, the surveyor observed three (3) nurses administer medications to three (3) residents. There were 30 opportunities, and two (2) errors were observed which calculated a medication administration error rate of 6.6%. This deficient practice was identified for one (1) of three (3) residents (Resident #282) that were administered medications by one (1) of three (3) nurses. The deficient practice was evidenced as follows: On 5/18/23 at 8:10 AM, the surveyor observed the Licensed Practical Nurse (LPN) preparing to administer twenty-two (22) oral medications to Resident #282 which included three (3) tablets of ascorbic acid (vitamin C) 1000 milligram (mg) tablets and one (1) tablet of multiple vitamins with iron. On 5/18/23 at that same time, the surveyor observed the LPN enter Resident #282's room to administer the medications. The surveyor asked 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 pertinent facility documents, it was determined the facility failed to a.) maintain medication storage rooms free of expired nutritional formula (Jevity 1.5 calorie) for 1 of 3 medication storage rooms inspected (North 1), and b.) ensure the required Federal narcotic acquisition forms (DEA 222 form) were completed with sufficient detail to enable accurate reconciliation for 2 of 8 forms reviewed. The deficient practice was evidenced by the following: 1. On [DATE] at 12:13 PM, in the presence of the Unit Manager/Licensed Practical Nurse (UM/LPN), the surveyor inspected the inventory and medications in North 1 Medication Room. The surveyor observed twenty-three (23) eight-ounce (8 oz) cartons of Jevity 1.5 calorie with the expiration date of [DATE]. At this time, the UM/LPN confirmed that the formula was expired and should not be in active supply. The UM/LPN confirmed there were no residents who currently received Jevity 1.5 calorie formula. When asked who had 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.