New Vista Nursing & Rehabilitation Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure Practitioner Orders for Life-Sustaining Treatment (POLST) was documented to clarify resident/resident representative the choice between cardiopulmonary resuscitation (CPR) and do not resuscitate (DNR), were thoroughly completed to include a date and physician signature for three of three residents (Residents (R) 9, R1, and R10) of 19 sample residents. This failure had the potential to affect the accuracy of POLST forms used when transferred from the facility to communicate resident/resident representative choice. Findings include: 1. Review of R9's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date in [DATE] with a readmission date in [DATE] and medical diagnoses to including dementia and other cerebrovascular disease. Review of R9's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of [DATE] revealed a Brief…

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 facility policy reviews, the facility failed to resolve grievances for two of three residents (Resident (R) 3 and R5) reviewed for grievances of 19 sample residents. Specifically, the facility failed to resolve grievances related to misappropriation of funds and transportation concerns related to medical appointments. This failure had the potential to violate resident rights for all residents residing in the facility. Findings include: 1. Review of R3's admission Record located in the electronic medical record (EMR) under the Resident tab revealed the resident was admitted to the facility in July 2021 with diagnoses including type two diabetes, bipolar disorder, hypertension, and bladder cancer. Review of R3's Resident Concern Form provided by the facility and dated 06/16/24, revealed R3 states that the unit clerk continuously messes up his/her doctor appointment. She gets dates mixed up, she'll forget transporter or transportation. The action section at the bottom of the form was blank. During an interview on 03/25/25 at 1:06 PM, R3 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and facility policy review, the facility failed to ensure that a medical appointment was identified and implemented following a surgical procedure according to professional standards of practice for one of three residents (Resident (R) 8) reviewed for medical appointments of 19 sample residents. This failure had the potential to negatively impact on the residents' health status. Findings include: Review of R8's admission Record located in the electronic medical record (EMR) under the Resident tab indicated he/she was admitted to the facility in August 2022 with a primary diagnosis of acute cerebrovascular insufficiency. Review of R8's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 02/06/25 included a Brief Interview for Mental Status (BIMS) score of six out of 15 indicating R8 was severely cognitively impaired. Review of R8's Care Plan located in the EMR under the Care Plan tab and revised 04/11/24 included…

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

Based on interview, record review, and review of facility policy, the facility failed to maintain a complete and accurate medical record for one of 19 sampled residents (Resident (R) 3). Specifically, the nursing staff failed to document the completion of physician orders on the resident's medication administration records. This failure had the potential to affect accuracy of records. Findings include: Review of R3's admission Record located in the electronic medical record (EMR) under the Resident tab indicated he/she was admitted to the facility in July 2021with a primary diagnosis of diabetes mellitus. Comorbidities included bipolar disorder, benign prostatic hypertrophy, hyperlipidemia, malignant neoplasm of the bladder, and major depressive disorder (MDD). Review of R3's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 01/13/25 included a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R3 was cognitively intact. Medications included antipsychotics, antidepressants, antihypnotics, 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.

REPEAT DEFICIENCY Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices as well as store and discard potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 01/29/234 at 9:24 AM, the surveyor in the presence of the Food Service Director (FSD) and a Federal Surveyor (FS) observed the following during the kitchen tour: 1. On a tray cart, the surveyor observed multiple 6 ounce (oz) disposable individual cups that the FSD stated the contained rice crispy cereal. No labels with made or use by dates noted. FSD stated the cereal cups were put together yesterday but could not state why they were not labeled. 2. The juice machine was observed with a clear tubing from orange juice with brown colored spots on the tubing. FSD unable to state what the brown spots were but would call the service company to change the tubing. 3. Dietary aide (DA #1) was observed preparing salads with lettuce, cucumbers, and…

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

Based on interviews, and review of pertinent facility provided documents, it was determined that the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. This failure had the potential to affect all 273 residents who currently live in the facility. Refer to F607E, F728E, F730E, F804D, F883E, and S0560 The deficient practice was evidenced by the following: On 01/29/24 at 10:22 AM, during the entrance conference held with the facility's Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor in the presence of another surveyor requested information regarding the QAA (Quality assessment and assurance) committee, last three quarters sign in sheets for QAPI meetings, and QAPI plan. On 02/05/24 at 01:09 PM, the surveyor reviewed the facility provided QAA (a committee composition and frequency of meetings in nursing facilities requires facilities to develop and implement appropriate plans of action to correct identified…

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 and review of pertinent facility documentation, the facility failed to have the Infection Preventionist present for three (3) of three (3) quarterly Quality Assurance Performance Improvement (QAPI) meetings. This failure had the potential to affect all 273 residents who currently live in the facility. The deficient practice was evidenced by the following: On 02/05/24 at 8:45 AM, the surveyor in the presence of the Social Services Director interviewed the Licensed Nursing Home Administrator (LNHA) regarding the submitted QAPI Attendance for the last three quarters: 5/11/23, 9/07/23, and 11/30/23. The surveyor asked the LNHA to confirm who attended the last three quarters of QAPI because the 5/11/23 QAPI Attendance did not include the title and department for some attendees. During an interview, the LNHA confirmed that on 5/11/23, 9/07/23, and 11/30/23 there was no Infection Preventionist (IP) who attended the quarterly QAPI meetings. The LNHA acknowledged that IP was part of the key members of the QAPI team that should be present in the QAPI meetings. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide the residents with a safe, comfortable, clean, and homelike environment. This deficient practice was identified in one (1) of three (3) residents' rooms, (Resident #132) and one (1) of two (2) dining areas on the 4th floor observed during environmental rounds. This deficient practice was evidenced by the following: 1. On 01/30/24 at 8:25 AM, the surveyor observed Resident #132 on the bed with an air mattress, indwelling catheter in use, and head of the bed elevated approximately 45 degrees while on tube feeding (TF, a way to provide nutrition when a resident cannot eat or drink safely by mouth) pump, at 75 ml/hr (milliliters per hour). The surveyor observed that the TF pole with scattered dried brownish color and resembled the color of the milk that was hung on the pole, and the surrounding floor area with the same dried brownish color. On that same date and time, the surveyor…

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

Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to ensure licensed staff credentials were verified upon hire. This deficient practice was identified for five (5) of seven (7) newly hired licensed staff reviewed, Staff #2, #4, #5, #7, and #10 evidenced by the following: On 02/05/24 at 10:03 AM, the surveyor reviewed ten randomly selected new facility employee files. The review for license verification for seven of the new licensed employees revealed the following: 1. Review of Staff Member #2 (SM2), an Occupational Therapist, hired on 5/02/22, had a New Jersey Division Consumer Affairs (NJDCA) license verification printout (used to verify the status of a license for license verification) dated 11/03/22. The verification was completed after the staff member was hired. There was no documented evidence that SM2's license was verified prior to the date of hire (doh). 2. Review of Staff Member #4 (SM4), a Registered Nurse, hired on 12/05/23, did not have a NJDCA license verification printout. There was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of medical records and facility documents, it was determined that the facility failed to develop and implement a comprehensive plan of care to meet residents' preferences and goals and address the resident's medical, physical, mental, and psychosocial needs. This deficient practice was identified for four (4) of 38 residents (Residents #19, #36, #132, and #267) reviewed for a care plan. This deficient practice was evidenced by the following: 1. On [DATE] at 12:54 PM, the surveyor observed Resident #19 in their room with tube feeding (TF, a way to provide nutrition when a resident cannot eat or drink safely by mouth). The surveyor reviewed the hybrid (a combination of paper-based and electronic health records that primarily involves tracking and storing a resident's health records in several formats and places) medical records of Resident #19 as follows: Resident's admission Record (AR, admission summary) reflected that the resident 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.

REPEAT DEFICIENCY Based on observation, interview, and review of other pertinent provided facility documents, it was determined that the facility failed to ensure that oxygen care and services were provided according to the standard of clinical practice and physician's order for three (3) of five (5) residents, (Residents #19, #145, and #235 reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 02/01/24 at 8:48 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN#1) who informed the surveyor that Resident #19 was cognitively impaired and required total care with activities of daily living (ADL). He further stated that the resident was recently hospitalized and came back three weeks ago for pneumonia (an infection that affects one or both lungs). On that same date and time, LPN#1 stated that it was the responsibility of the Unit Manager (UM) to initiate and update the care plan of the resident including the care plan for oxygen (O2) use. He further stated that there was no UM for one and a half (1 1/2) years and he did not know who does…

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 facility documentation, it was determined that the facility failed to ensure that the facility Certified Nursing Aides (CNA) received annual performance reviews for five (5) of five (5) CNA files reviewed. This deficient practice was evidenced by the following: On 1/29/24 at 10:22 AM, in the presence of a federal surveyor, the survey Team Coordinator met with the Licensed Nursing Home Administrator (LNHA) for an entrance conference and requested a list of the facility's CNAs with their date of hire and license numbers listed. On 2/1/24 at 11:02 AM, the LNHA provided the survey Team Coordinator an updated list of CNAs. The surveyor randomly chose five CNAs from the updated facility list and requested the education provided, annual performance reviews and competencies done for the five CNAs. On 2/5/24 at 11:16 AM, the surveyor still had not received the annual performance reviews for the selected 5 CNAs and once again requested them from the LNHA. The facility did not provide the requested performance reviews. There was no documented…

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 REPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to: a) conduct COVID-19 testing and to conduct appropriate surveillance for COVID-19 (a deadly, highly transmissible infectious disease) during an outbreak, for three (3) of three (3) residents (Residents #62, #121 and #155) and three (3) of (3) staff members reviewed for unit-based testing, b) follow appropriate storage of PPE (personal protective equipment) for one (1) of one (1) nurse (Licensed Practical Nurse #1 [LPN#1]), and c) follow appropriate hand hygiene practices for two (2) of three (3) staff (LPN#2 and Certified Nursing Aide #3), in accordance with the facility's policies and Centers for Disease Control and Prevention (CDC) guidelines for infection control. The deficient practice was evidenced by the following: According to the CDC guidance titled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to ensure: a) that the resident's medical record included documentation that indicated the consent for administration or refusal of the Influenza Annual Vaccination for four (4) of six (6) residents (Resident #7, #132, #149, and #214) reviewed for influenza immunizations, and b) the Pneumococcal vaccine was administered to the residents, (Residents #100 and #127) identified during the medication storage and labeling observation for one (1) of three (3) medication rooms. This deficient practice was evidenced by the following: Reference: A review of the Centers for Disease and Control Prevention (CDC) guidelines for Pneumococcal vaccination included: For adults who only received the Pneumococcal polysaccharide vaccine (Pneumovax/PPSV 23) regardless of risk and condition, should received one (1) dose of Pneumococcal conjugate vaccine (PCV 15 or PCV20) at least one year after the most recent PPSV23. 1. On 02/1/24 at 9:55…

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

Based on observation, interview, and record review, it was determined that the facility failed to serve all residents seated at a table their lunch trays in a timely manner for one (1) of five (5) tables observed, involving a total of four residents (Residents #90, #91, #133, and #148) reviewed for Resident Rights. This deficient practice was evidenced by the following: On 1/31/24 at 12:11 PM, the surveyor observed the 4 East dining area having three Certified Nursing Aides (CNA), one (1) nurse, and 18 residents during lunch. There were five tables located in the 4 East dining area with residents seated for lunch. The 1st lunch truck was already in the process of being distributed at the time of the observation. On 1/31/24 at 12:12 PM, the surveyor observed table one, located near the wall with a total of 4 residents seated at the table. At table one there were two residents seated that had their lunch served at the time of the observation and two residents were already eating. At this time, the surveyor observed Table two with four residents seated. Resident # 90 seated at Table…

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

Based on observation, interview, and record review, it was determined that the facility failed to ensure that the resident or resident's representative were offered the opportunity to formulate an Advance Directive (AD), a written statement of a person's wishes regarding medical treatment, often including a living will be made to ensure those wishes are carried out should the person be unable to communicate to them. This deficient practice was noted to 1 of 39 residents reviewed for AD, Resident #77. This deficient practice was evidenced by the following: On 2/5/24 at 10:15 AM, the surveyor observed Resident #77 lying in bed with eyes closed. The surveyor reviewed Resident #77's hybrid medical records. The admission Record reflected that Resident #77 was admitted to the facility with medical diagnoses which included but were not limited to Dementia, Hypertension, Type II Diabetes Mellitus, and Anxiety Disorder. A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 1/15/24 reflected that the resident had a Brief Interview 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.

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an injury of unknown origin in accordance with federal and state requirements for reporting such injury to the state agency. The deficient practice was identified for one (1) of five (5) residents reviewed for falls (Resident #185) and was evidenced by the following: Reference: According to Centers for Medicare and Medicaid Services (CMS) definition: Injuries of unknown source - An injury should be classified as an injury of unknown source when all of the following criteria are met: The source of the injury was not observed by any person; and The source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. On 01/29/24 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 observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to complete a thorough investigation of a fall incident for one (1) of five (5) residents, (Resident #149) reviewed for falls. This deficient practice was evidenced by the following: On 01/30/24 at 12:56 PM, the surveyor asked the Director of Nursing (DON) for investigations and incidents/accident records of Resident #149, and the DON stated that she would get back to the surveyor. On that same date at 02:02 PM, the surveyor observed the resident laying on the bed, awake, nonverbal, and the tube feeding (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely) was off. The surveyor reviewed the hybrid (a combination of paper-based and electronic health records that primarily involves tracking and storing a resident's health records in several formats and places) medical records of Resident #149 as follows: The admission Record (an admission summary) reflected that the resident was admitted to the…

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

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 accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for three (3) of 38 residents, Residents #77, #145, and #242, reviewed for accuracy of MDS assessment coding. This deficient practice was evidenced by the following: 1. On 02/05/24 at 10:15 AM, the surveyor observed Resident #77 lying in bed with eyes closed. The surveyor reviewed Resident #77's hybrid medical (combination of paper and electronic) records. The admission Record (AR, admission summary) reflected that Resident #77 was admitted to the facility with medical diagnoses which included but were not limited to dementia, hypertension (elevated blood pressure), type II diabetes mellitus, and anxiety disorder. The surveyor reviewed the most recent MDS assessment dated [DATE] under Section O0250. Influenza Vaccine (IV) which reflected that Resident #242 received the IV on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of other pertinent documentation, it was determined that the facility failed to ensure: a) medication was administered in accordance with manufacturer's cautionary specifications and professional standards of clinical practice for one (1) of three (3) nurses administered medications to one (1) of three (3) residents (Resident #69, observed during medication administration and b) care and services were followed for resident who was at risk for wandering for one (1) of two (2) residents, (Resident #55) reviewed for elopement according to physician's order, assessment and standards of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: 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…

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 provided documents, it was determined that the facility failed to provide wound care in accordance with the facility's policy and professional standards of clinical practice for one (1) of one (1) resident reviewed and observed for wound care observation, Resident #56. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers (HCP) for Hand Hygiene and COVID-19, page last reviewed 01/08/2021 included that the HCP should perform hand hygiene before and after direct contact with the residents, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. In addition, wear gloves, according to Standard Precautions, when it can be anticipated that contact with blood or other potentially infectious materials, mucous membranes,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined that the facility failed to ensure that the urinary output of resident's with indwelling catheters (IC) were monitored to ensure patency to further prevent any infections. This deficient practice was noted to two (2) of two (2) resident's reviewed with IC, Resident #242 and Resident #266. This deficient practice was evidenced by the following: 1. On 01/31/24 at 10:10 AM, the surveyor observed Resident #242 in the room lying in bed. The surveyor reviewed Resident #242's hybrid (combination of paper and electronic) medical records. The resident was admitted to the facility with diagnosis that included but not limited to cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), type II diabetes mellitus, hypertension (elevated blood pressure), and hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood). A review of the quarterly…

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 a) a non-certified Nurse Aide (NA) did not continue to work as an NA after the specified 120 days for one (1) of three (3) NAs reviewed during the Sufficient and Competent Nurse Staffing task (NA #1) and b) there was a delineated policy and/or program in place for the hiring, staffing, and assignments of non-certified NAs. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health memo dated April 21, 2023 sent to Nursing Homes included the following: On February 27, 2023, the Centers for Medicare and Medicaid Services (CMS) announced that all nurse aide emergency training waivers will terminate at the end of the Federal Public Health Emergency (PHE). The PHE is expected to end on May 11, 2023. At that time, all Temporary Nurse Aides (TNAs) hired prior to the end of the PHE and who have enrolled in a NATCEP (Long Term Care Facilities Training and Competency Evaluation Program) program and completed the first…

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 that the 24-hour staffing report was posted in a prominent place within the facility and readily accessible to the residents and the visitors. This deficient practice was evidenced by the following: On 1/29/24 at 9:18 AM, the survey team entered the facility and observed that there was no Nursing Home Resident Care Staffing Report (NHRCSR) posted at the entrance area or elevator area. On 1/30/24 at 9:25 AM, after the surveyor did not observe a NHRCSR posted, the surveyor interviewed the Security staff in the front lobby regarding the posting of the NHRCSR. The Security staff stated that the Administration staff usually place the posting on the bulletin board that was behind the wall near the elevators. The Security staff confirmed that there was no NHRCSR posted on the bulletin board. On 1/30/24 at 9:31 AM, the surveyor interviewed the Staffing Coordinator (SC) regarding the posting of the NHRCSR. The SC stated that she usually posted the NHRCSR in 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 provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a) labeling of medication with an expiration date, b) expired medication was removed from active inventory, c) beyond use date was in accordance with standard of practice, and d) discontinued medications were removed from active inventory. The deficient practice was identified for two (2) of six (6) medication carts, and (one) 1 of three (3) medication rooms and was evidenced by the following: Reference: USP Compounding Standards and Beyond-Use-Dates (BUDs; the date or time after which a compounded sterile preparation may not be stored or transported and is calculated from the date and time of compounding). According to the revised <795> -Non-preserved aqueous had a BUD of 14 days. 1) On 01/31/23 at 9:58 AM, in the presence of the Registered Nurse #1 (RN#1), the surveyor began the inspection of Cart A on the west wing of the fifth floor. The surveyor observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ 167957 REPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of hot foods served to the residents. This deficient practice was identified for one (1) of one (1) resident complaint, Resident #107, and confirmed during the lunchtime meal service on 01/31/24 for one (1) of three (3) nursing units tested for food temperatures and was evidenced by the following: A review of a complaint in-take form indicated the food is not received on time. 1. On 01/29/24 at 10:41 AM, during the initial tour, the surveyor observed Resident #107 sitting on his/her bed. The resident was pleasant and stated, the food is bad here. At 12:05 PM, the surveyor interviewed Certified Nursing Assistant #1 (CNA #1) who stated there were four of them assigned to the west side of the fourth floor, at that time. The surveyor visually saw four CNA's adjacent to the dining area. At 12:12 PM, the surveyor…

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, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage compactor and dumpster free of garbage and debris. On 1/29/24 at 9:56 AM, the surveyor, in the presence of the Food Service Director (FSD) and a Federal Surveyor toured the kitchen and the designated garbage area observing the following: There was garbage debris that included food, cups, bottles, gloves, paper products, and brown paper bags, surrounding the garbage compactor and dumpster. The FSD stated that the area should have been cleaned by the maintenance and dietary departments. On 2/5/24 at 1:23 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) of the debris findings. The LNHA clarified that the garbage disposal area is shared with another facility on the same property but admitted that the facility maintenance department is responsible for keeping the area clean and free of debris. On 2/6/24 at 12:54 PM,…

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

Complaint NJ#162723, 162811 Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain complete and readily accessible medical records. This deficient practice was identified for two (2) of 38 residents reviewed (Residents #470 and #269). This deficient practice was evidenced by the following: 1. On 02/05/24 at 11:20 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) about where Certified Nurse Assistants (CNAs) documented resident care. The LPN showed the surveyor an ADL [Activities of Daily Living] binder at the nurses station. The ADL binder consisted of monthly forms which the CNAs would document CNA and ADL care for residents. The LPN stated the CNAs used to document electronically but now it was paper based. The LPN could not recall exactly when the change occurred and stated sometime last year. On 02/05/24 at 12:25 PM, the surveyor reviewed the closed hybrid (paper and electronic) medical records of Resident #470. The admission Record (AR, admission summary) reflected that…

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

Based on observation, interview, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits at least once every sixty days and wrote progress notes to address nutritional issues for a resident with weight loss for one (1) of 10 residents, Resident #77 reviewed for nutrition, and was evidenced by the following: On 02/05/24 at 10:15 AM, the surveyor observed Resident #77 lying in bed with eyes closed. The surveyor reviewed Resident #77's hybrid (both paper and electronic) medical records. The admission Record (an admission summary) reflected that Resident #77 was admitted to the facility with medical diagnoses which included but not limited to dementia; hypertension (elevated blood pressure), type II diabetes mellitus; and anxiety disorder. The quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 01/15/24 reflected that the resident had a Brief Interview for Mental Status score 03 of 15 indicating that the resident had severely…

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 facility documentation it was determined that the facility failed to: a.) properly handle and store potentially hazardous foods in a manner to prevent the potential development of food borne illness, b.) maintain equipment and kitchen areas in a clean and sanitary manner to prevent microbial growth and cross contamination, and c.) maintain adequate infection control practices during the meal service in the kitchen. This deficient practice was observed and evidenced by the following: On 09/10/21 from 9:04 AM - 11:07 AM the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the following: 1. The FSD had visible facial hair that was not restrained. The FSD acknowledged he was not wearing a beard restraint and stated that he should have covered his facial hair. The FSD stated it was important to wear hairnets to prevent contamination of the food. 2. The foot pedal trash can that was located at handwashing sink #3 did not contian…

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 ensure that residents who were admitted into a newly created behavioral unit received a pre-admission screening and resident review (PASRR) assessment, prior to admission, to determine the appropriateness of long term care (LTC) placement. This deficient practice occurred for 25 of 33 unsampled residents reviewed for PASRR and was evidenced by the following: On 09/10/21 at 10:05 AM, the surveyor conducted the facility entrance conference with the Director of Nursing (DON) and Administrator (LHNA). The LHNA stated there were 33 residents who were transferred from the temporary boarding home which was located on the the 6th floor, and now resided on the 5th floor East unit (5E) . The LHNA stated the residents were transferred in June, 2021 and the facility was working with another [State agency] (Agency #1) regarding the residents. The DON stated the 5E was considered a behavioral unit without aggression and it was a locked unit. On 09/14/21 at 12:10 PM, the surveyor interviewed the social worker (SW)…

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 #000148010 Complaint #000147748 Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to provide sufficient nursing staff to: a.) provide nursing and related services to ensure the residents safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments, individual plans of care and in accordance with the facility assessment, and b.) meet minimum staffing requirements. This deficient practice was identified on 3 of 3 nursing units, during interviews conducted with 2 of 10 residents (Resident #27 & Resident #57) who attended a resident council meeting, for 2 of 40 residents reviewed, (Resident #215 & Resident #240) for care concerns related to staffing and during a meal observation. The deficient practice was evidenced by the following: Refer to F688 & F692, & NJAC 8:39-5.1(a) The deficient practice was evidenced by the following: 1. On 09/10/21 at 10:02 AM, during tour, the surveyor observed Resident #240 sitting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to ensure the necessary services to maintain a resident's highest functional level were provided by failing to: a.) implement interventions designed by the Occupational Therapy Assistant (OTA) to promote mobility, positioning, and strength training exercises and b.) ensure the proper equipment was obtained and utilized for 1 of 1 residents (Resident #240) reviewed for rehabilitation and restorative care. The deficient practice was evidenced by the following: On 09/10/21 at 10:02 AM, during tour, the surveyor observed Resident #240 sitting upright in a bariatric bed (a bed for people who are overweight or obese). The resident agreed to be interviewed at this time and stated he/she had been in the facility for six weeks and had met with a rehabilitation therapist only twice since admission. The resident stated that he/she had not been out of bed and was not provided 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 observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure: a.) resident re-weights were obtained per facility policy, and b.) a significant unplanned weight loss of 15.9% (18.8 pounds over a 16 day period) was identified and addressed. This deficient practice was identified for 1 of 5 residents reviewed (Resident #215) for weight loss and was evidenced by the following: On 09/15/21 at 9:57 AM, the surveyor observed that Resident #215 was seated on the side of the bed and appeared very thin. At that time, the surveyor interviewed Resident #215 and the resident stated that he/she weighed 130 pounds prior to hospitalization and now he/she weighed 100 pounds. During the interview, the resident's physician entered the room. At that time the surveyor interviewed the physician who stated that he was aware that Resident #215 had lost weight from the admission from the fifth-floor nursing unit and the weight when the resident was transferred to the third-floor nursing unit. The physician did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) post a cautionary and safety sign to indicate the use of oxygen (O2), and b.) accurately sign the Treatment Administration Record (TAR) for the administration of oxygen per a physician order. This deficient practice was identified for 2 of 3 residents reviewed, (Resident #144 & Resident #157) for respiratory care and was evidenced by the following: 1. The admission Record (AR) indicated that Resident #157 was admitted to the facility with diagnoses that included, but were not limited to, congestive heart failure (the heart fails to pump blood well - CHF) and stage 5 chronic kidney disease (the kidneys are close to failure - CKD). The five-day Medicare Minimum Data Set (MDS) an assessment tool dated 08/4/21, indicated that Resident #157 was cognitively intact and required limited assistance with activities of daily living (ADL's). On 09/10/21 at 9:38 AM, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to serve hot and cold foods at an acceptable temperature for the residents. This deficient practice was identified for 10 of 10 residents who attended a Resident Council group meeting, and on 1 of 3 nursing units during the lunch meal service. The deficient practice was evidenced by the following: 1. On 09/14/21 at 10:36 AM, the surveyors conducted a group meeting with ten residents who regularly attended the facility resident council meetings. Ten out of ten residents indicated the food was always cold. 2. On 09/16/21 two surveyors conducted a test tray with the Assistant Food Service Director (AFSD) and Food Service Director (FSD) which resulted in the following: At 11:53 the Surveyor #1 exited the kitchen with the test tray and the AFSD. At 11:57 AM Surveyor #2 observed a blank food service temperature log for the lunch meal, with the FSD. At that time, the FSD audibly sighed and had no…

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 facility documentation, it was determined that the facility failed to follow infection control protocol to prevent the spread of infection during a wound care treatment observation. The deficient practice was identified for 1 of 1 sampled residents (Resident #215) and was evidenced by the following: On 09/15/21 at 9:57 AM, the surveyor observed Resident #215 seated on the bed. Resident #215 had a pressure relieving device attached to the bed. The surveyor interviewed, Resident #215 at that time and the resident stated he/she had a wound on his/her buttocks that was cared for by the staff. The surveyor reviewed Resident #215's medical record which revealed the following information: Resident #215 was admitted to the facility with diagnoses which included chronic kidney disease, neuromuscular dysfunction of the bladder and an unstageable pressure sore (full thickness tissue loss and is covered by necrotic tissue or eschar) to the sacrum. The admission Minimum Data Set (MDS), a resident assessment tool, dated 07/26/21, revealed that…

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