Sinai Post-Acute Nursing & Rehab Center

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 consistently maintain appropriate infection control practices to limit the spread of infection. The deficient practice was observed with 1 staff person and 2 residents, (#2 and #39) and observed in 1 resident room, (room [ROOM NUMBER]), and evidenced by the following. 1. The surveyor observed the lunch meal in the 3rd floor day room on 6/10/25 at 12:31 PM. An Activity Aide (AA) was observed as she passed out hand sanitizing wipes to 6 individual residents. The AA collected the 6 used wipes in her hand and disposed of them. Without performing hand hygiene, the AA wiped the hands of 3 additional residents. She did not perform hand hygiene in between residents. The AA proceeded to the pantry hand-wash sink, applied soap to her hands, lathered for 10 seconds and rinsed the soap from her hands. The surveyor spoke with the AA explaining the surveyor's observations to the AA. The AA stated she should have performed hand…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined that the facility failed to a.) maintain a Tube Feeding (TF) pump and pole in, safe, sanitary and optimal condition for Resident # 349 and b.) maintain a geriatric chair in safe, sanitary and optimal condition for Resident #2. This deficient practice was observed for 2 of 35 residents reviewed and was evidenced by the following: On 6/9/25 at 11:15 AM, the surveyor observed Resident #349 in bed on a specialty mattress. The Resident did not respond to the surveyor's greeting. The surveyor observed a TF Pump (used to deliver nutrition to patients who cannot obtain such by swallowing) at resident #349's bedside. The TF pump was soiled with a brown and white substance and the pole was soiled with a brown and white substance and was heavily rusted. On that same date, at that same time, during an interview with the surveyor, the Licensed Practical Nurse/ Unit Manager (LPN/UM) stated that Resident #349 received tube feedings which started 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ186463 Based on observation, review of the medical record and other pertinent facility documents on [DATE], it was determined that the facility failed to develop a comprehensive care plan for emotional services/support for a resident who witnessed the death of another resident. This deficient practice was identified for 1 of 6 residents reviewed for care plans (Resident#2), and was evidenced by the following: On [DATE] at 12:15 PM, the surveyor interviewed Resident #2, who stated Resident #1 and an unidentified resident came to their room and all three residents were smoking crack and cocaine. According to Resident #2, they observed Resident #1 in the chair falling to the side and Resident #2 notified the Licensed Practical Nurse (LPN #1), who told the resident and the unidentified resident to leave the room. Resident #2 observed LPN #1 perform cardiopulmonary resuscitation (CPR; emergency life-saving procedure performed when someone's breathing or heart beat has stopped) on Resident #1. On [DATE]…

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 #: NJ186463 Based on interviews, review of the medical records review and other pertinent facility documentation on [DATE] and [DATE], it was determined that the facility failed to ensure a.) adequate supervision for a Resident (Resident #1) with a known history of drug and drug paraphernalia (equipment needed for or connected with a particular activity) in the facility who had an unexpected death in the facility and was administered Narcan (drug used to reverse an opioid overdose) by nursing staff and b.) conduct and document a thorough investigation for incidents where Narcan was administered to prevent further accidents related to drug use. This deficient practice was identified for 1 of 2 residents reviewed for accidents and hazards (Resident #1), and was evidenced by the following: On [DATE] at 12:15 PM, the surveyor interviewed Resident #2, who stated on [DATE], Resident #1 and another unidentified resident came to Resident #1's room, and all three of the residents were smoking crack and cocaine.…

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 #: NJ186463 Based on observation, interview, and record review, it was determined that the facility failed to ensure that a Licensed Practical Nurse (LPN) had the specific competencies and skill sets necessary to care for a resident's pain management needs. This deficient practice was identified for 1 of 6 residents reviewed for resident needs (Resident #5), and was evidenced by the following: According to Resident #5's admission Record face sheet (an admission summary), the resident was admitted to the facility with diagnoses that included but were not limited to; displaced intertrochanteric fracture of the right femur (broken hip bone at the neck of the thigh bone causing the bone to shift or separate) and unspecified fracture of sacrum (lower back). According to the Minimum Data Set (MDS), an assessment tool dated 05/14/2025, Resident #5 had severe cognitive impairment. The MDS also indicated that Resident #5 required assistance from staff for completion of their activities of daily living (ADLs). A review of Resident #5's Order Summary Report (OSR) with an admission…

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 #: NJ186463 Based on interviews, review of medical records, and review of other pertinent facility documentation on [DATE] and 5/2725, it was determined that the facility failed to provide a resident with behavioral healthcare services after the resident (Resident # 2) witnessed the death of another resident in their room after allegedly using illicit drugs. This deficient practice was identified for 1 of 5 residents reviewed for resident care (Resident #2), and was evidenced by the following: A review of the progress notes revealed that on [DATE] at approximately 6:00 PM, adult emergency services was called to the 6th floor nursing unit to Resident #2's room, where Resident #1 was found unresponsive. The Licensed Practical Nurse (LPN #1) entered Resident #2's room, and found Resident #1 unresponsive. Narcan (drug used to reverse opioid overdose) was administered twice by LPN #1, cardiopulmonary resuscitation (CPR; emergency life-saving procedure performed when someone's breathing or heartbeat has…

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.

C #: NJ 175921 Based on record review, as well as review of pertinent facility documents on 7/31/24 and 8/1/24, it was determined that the facility failed to review and revise the care plan timely for 1 of 5 sampled residents (Residents #2) reviewed for care plans. This deficiency is evidenced by the following: 1. The admission Record for Resident #2, showed that the Resident was initially admitted to the facility with diagnoses that included but were not limited to: Displaced Oblique Fracture of Shaft of Right Fibula, Muscle Wasting and Atrophy, Opioid Dependence, and Cocaine Abuse. The Minimum Date Set (MDS), an assessment tool dated 7/3/24, showed that the resident was cognitively intact with a BIMS of 15 and required a partial/moderate assistance from staff with Activities of Daily Living (ADL). Review of Resident #2's incident report (RI #1) and corresponding documentation from the progress notes (PN), revealed that on 7/1/24 at 2:20 p.m. resident was found on floor grunting, not responding to simple commands, Narcan was administered once, resident responded after 3 minutes.…

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 C#: NJ 175921 Based on interviews and record review, as well as review of pertinent facility documents on 7/31/24 and 8/1/24 it was determined that the facility failed to follow the Physician's order and to implement the facility policy titled Medication Administration Policy for 2 residents (Resident #3 and Resident #4), reviewed for medication administration. This deficient practice was evidenced by the following: 1. According to the admission RECORD (AR), Resident #3 was admitted with diagnosis that included but were not limited to Surgical Aftercare Following Surgery On The Skin and Subcutaneous Tissue. According to the Resident's Minimum Data Set (MDS), an assessment tool dated 5/7/24, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident's cognition was intact. The care plan (CP), initiated on 5/1/24 and revised on 5/20/24, indicated that Resident #3 had an actual skin breakdown, potential for deterioration and further skin breakdown. Interventions 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ 175415 Based on observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to provide a meaningful group and individualized activity programs that reflected the resident's preferences. This deficient practice was identified for 11 of 11 Justice Involved Residents (JIRs) (Resident #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11), reviewed for activities, and was evidenced by the following: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016, S & C 16-21-ALL, documented Skilled Nursing Facilities must permit residents to have autonomy and choice to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. 1. According to the admission Record, Resident # 1 was admitted to the facility on [DATE], 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, interview, and record review, it was determined that the facility failed to maintain resident's equipment and living areas in a clean and home like manner. This deficient practice was identified for 1 of 2 residents (Resident #171) reviewed for environment. This deficient practice was evidenced by the following: On 12/14/23 at 10:14 AM, the surveyor observed Resident #171 sitting up at the side of their bed. The resident's bed was positioned against the wall. Behind the resident the surveyor observed a precise square cut hole in the wall. The surveyor observed wall insulation peering out and a wire running from the hole down the wall, behind the resident's bed. The surveyor could not see the floor behind the resident's bed. Resident #171 stated there was something in the hole previously and whatever was there fell out. The resident stated it may have been like that for about four months. Resident #171 could not identify which staff members were aware about the hole in the wall. A review of Resident #171's electronic medical record revealed the following:…

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 2 of 38 residents, Resident #346 and #548 reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 12/18/23 at 12:38 PM, the surveyor reviewed the closed hybrid medical records for Resident #346, who was documented on the 10/24/23 Discharge MDS section A as Discharge assessment-return not anticipated, Unplanned discharge to Short-Term General Hospital . Review of the admission Record (a one-page summary of important information about the patient) reflected Resident #346 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Opioid Dependence, Anxiety Disorder, Anemia, Cocaine Dependence and Depression. Review of the 10/23/23 20:50 INTERDISCIPLINARY CARE Planning (IDCP) CONFERENCE NOTES Late…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined that the facility failed to develop a comprehensive, person-centered care plan (CP) for 3 of 35 residents reviewed for comprehensive care plans (Resident #171, #313, and #2). This deficient practice was evidenced by the following: 1. On 12/12/23 at 11:35 AM, the surveyor observed Resident #171 sitting up at the side of the bed in their room. The resident was alert, verbally responsive, and conversant. The surveyor observed the resident's bedside was cluttered with personal belongings, that included but were not limited to clothes, and food items. The windowsill was cluttered with clothing. The top of the resident's dresser was covered with items, including clothing and had a drawer partially open which was also filled with items. The resident's bedside table was filled with items, which included various containers and bottles. The resident stated they had other belongings that were in storage within the facility. Resident #171 verbalized 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 record review, it was determined that the facility failed to revise a resident's comprehensive care plan (CCP) for 1 of 35 residents reviewed, Resident #103. This deficient practice was identified by the following: On 12/12/23 at 11:40 AM, the surveyor observed Resident #103 in their room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor reviewed Resident #103's hybrid medical records. The admission Record (AR) reflected that Resident #103 was admitted to the facility with medical diagnoses which included but was not limited to Dependence on Renal Dialysis Chronic Kidney Disease (CKD) Stage 5 and Atrophy of Kidney (Terminal). According to Resident #103's Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate the management of care, dated 10/20/23, the Brief Interview for Mental Status (BIMS) was conducted and revealed that Resident #103's BIMS score was 15 out of 15 indicating the resident had an intact cognition. The surveyor reviewed the residents CCP dated 11/2/23, which reflected a…

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

Based on observation, interview and record review, it was determined that that facility failed to ensure that a follow up visit for an eye consultation was arranged for a resident with an eye impairment. This deficient practice was identified for 1 of 1 resident reviewed for vision, Resident #2 and was evidenced by the following: On 12/12/23 at 11:59 AM, the surveyor observed Resident #2 seated in a recliner wheelchair inside the day/dining room. The surveyor further observed that Resident #2 had their right eye shut proving some impaired vision to the right eye. The surveyor reviewed Resident #2's hybrid medical records. The admission record (AR) reflected that Resident #2 was admitted to the facility with medical diagnoses which included but were not limited to Type II Diabetes Mellitus; Atrial Fibrillation; Bullous Keratopathy OD (right eye) and Cataracts OU (both eyes). A review of the Annual Minimum Data Set (A/MDS), an assessment tool used to facilitate the management of care, dated 9/10/23 reflected that the resident had a Brief Interview for Mental Status score of 9 out of…

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

Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident's medication times were adjusted to accommodate their dialysis (a clinical purification of blood as a substitute for the normal function of the kidneys) schedule for 1 of 1 resident, Resident #11 reviewed for dialysis. This deficient practice was evidenced by the following: On 12/12/23 at 11:58 AM, the surveyor observed that Resident #11 was not in their room. The resident was at dialysis which was scheduled every Tuesday, Thursday, and Saturday. A review of Resident #11's electronic medical record (EMR) revealed the following: According to the admission Record (an admission summary), Resident #11 was admitted with diagnoses that included but were not limited to, End Stage Renal Disease, and Dependence on Renal [kidney] Dialysis. A Quarterly Minimum Data Set (MDS) assessment, a tool used to facilitate management of care, dated 11/3/23, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #11 scored 8 out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents: a) wrote physician progress notes (PPN) at least every 30 days, b) wrote physician progress notes (PPN) at least every 60 days with alternating Nurse Practitioner (NP) visits, and c) accurately date physician progress notes (PPN). This deficient practice was observed for 9 of 35 residents, Resident #176, 141, 154, 11, 174, 255, 103, 22, and 104 reviewed. This deficient practice was evidenced by the following: 1. On 12/12/23 at 12:08 PM, the surveyor observed Resident #176 lying in their bed, awake, alert and verbally responsive. The resident verbalized no concerns. The surveyor reviewed Resident #176's hybrid (paper and electronic) medical records. According to the admission Record (an admission summary) (AR), Resident #176 was admitted to the facility with diagnoses that included but were not limited to Chronic Obstructive Pulmonary Disease, Type 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 facility policies, the facility failed to ensure that foodservice equipment was stored properly when not in use. This deficient practice was observed and evidenced by the following: On 12/12/23 at 9:23 AM, during the initial tour of the kitchen in the presence of the Food Service Director (FSD), the surveyor observed the following: On Chef prep table #3, the deli slicer was not in use and the slicing blade was not in locked position. When the FSD attempted to lock the slicing blade, the blade was not able to completely close, leaving the blade exposed. The FSD stated that the slicing blade needed to be in a locked position and in a nonexposed position when not in use for the safety of the dietary staff. On 12/19/23 at 9:57 AM, the surveyor team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to review areas of concerns in the kitchen, that included the slicer. The surveyor also requested policies on kitchen equipment and safety. On 12/19/23 at 10:15 AM, the FSD provided the surveyor with a facility…

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 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 12/12/23 at 09:23 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour: 1. In the food preparation area, two dietary aides with hair not fully restrained under their hairnet. 2. On the three shelf storage unit, one 32 ounce bottle of Gravy Master Grilling, Seasoning and Browning Sauce missing the top closing cap which provides an airtight seal on the bottle preventing contamination and freshness. The surveyor observed the bottle with plastic wrap around the top opening. 3. In walk in freezer #2, multiple boxes of ice cream were stocked to top of ceiling, not utilizing 18 inches below ceiling storage regulation. 4. In walk-in refrigerator #1, multiple boxes of creamer were observed stocked to…

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

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices for performing hand hygiene to decrease the possibility of spreading infection. This deficient practice was observed during wound treatment observation with 1 of 1 nursing staff on 1 of 5 units and was evidenced by the following: On 12/19/23 at 10:17 AM, the surveyor observed Licensed Practical Nurse #1 (LPN#1) perform wound treatment for Resident #154. On 12/19/23 at 10:29 AM, LPN #1 was observed preparing to wash her hands at the sink in Resident #154's room after preparing the supplies for the wound treatment at the bedside table. LPN #1 turned on the faucet, wet her hands with water from the sink, applied soap, lathered her hands for 15 seconds outside the running water prior to rinsing, dried her hands with a paper towel from the dispenser on the wall and used another paper towel to turn off the faucet. On 12/19/23 at 10:32 AM, LPN #1 removed and discarded her gloves after removing the resident's old wound…

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 assure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders. This deficient practice was observed for 6 of 38 residents (Resident #68, #139, #100, #134, #159, #321) reviewed. The deficient practice continued for several months and was evidenced by the following: On 8/10/21 at 10:00 AM, the surveyor asked the Director of Nursing (DON) if the physician's are signing the monthly orders electronically or hard copy in the the chart. The DON stated the physician's are signing the orders on the paper copy in the chart. 1. The surveyor reviewed the Physician Order's (PO) for resident #68 which revealed that the physician did not sign and date the monthly PO for the months of June 2021 and July 2021. On 8/12/21 at 12:50 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who was assigned to Resident #68. LPN #1 stated the orders should have been signed by the physician. On 8/17/21 at 1:30 PM, the surveyor discussed 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 consistently provide pressure ulcer care in a manner to reduce the spread of infection for 2 residents, Resident #155 and #4, of 2 observed during pressure ulcer treatments. The deficient practice was evidenced as follows: 1. The surveyor observed Resident #155 on 8/10/21 at 10:54 AM reclined in a gerichair. The resident was awake, alert and orientated. At that time the Registered Nurse Unit Manager (RNUM) stated the resident had a sacral pressure ulcer. A review of the resident's medical record revealed the following: The admission Record included diagnoses of paraplegia, fracture of the thoracic spine, and hemiplegia. The 6/6/21 admission Minimum Data Set an assessment tool, indicated the resident had no cognitive deficits, required extensive assistance with activities of daily living, had range of motion impairment on one side of the upper and lower extremities, and was admitted with multiple pressure ulcers. 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 record review, it was determined that the facility failed to follow through with the resident's Restorative Nursing Program (RNP) for 1 of 2 residents (Resident #306), according to the facility's policy and procedure and standards of clinical practice. This deficient practice was evidenced by the following: On 8/1/21 at 9:58 AM, the surveyor observed Resident #306 lying on the bed, with a left-hand splint in use, hemiwalker (a small, one-handed walker that is intended to be used by persons whose one-half of their body is weakened) at the bedside. On 8/12/21 at 10:02 AM, the surveyor observed the resident lying on the bed, with hemiwalker at the bedside. The resident was not wearing the hand splint. The resident informed the surveyor that sometimes the aide comes and applies the left-hand splint and at times, the resident was the one who put it on. The resident stated that he/she walks with the use of a hemiwalker from bed to the bathroom with staff assistance. The resident further stated that I don't think I declined, functionally regarding…

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 documents it was determined that the facility failed to conduct post dialysis assessments for Resident #106, 1 of 3 residents reviewed for dialysis care and services. The deficient practice was evidenced by the following: On 8/10/21 at 11:13 AM, the surveyor observed Resident #106 in the day room in an activity. The resident was sitting in a regular chair with a walker in front of the resident. The resident was participating in the name that tune game. On 8/17/21 at 10:48 AM, the surveyor reviewed the Facility and Dialysis Communication Sheet. There didn't appear to be a section for the facility nurse to document a post dialysis assessment when the resident returned from dialysis. The surveyor asked the Licensed Practical Nurse (LPN) who was assigned to Resident # 106 about the Facility and Dialysis Communication Sheet. The LPN explained that the top half of the sheet was filled in by the facility nurse prior to the resident leaving for dialysis and the bottom half of the sheet was filled in by the dialysis nurse at 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 record review, it was determined that the facility failed to follow up on the Consultant Pharmacist's (CP) recommendations and report of a medication irregularity for 1 of 38 residents (Resident #59) reviewed for a total of 15 months from June 2020 through August 2021. This deficient practice was evidenced by the following: On 8/11/21 at 10:09 AM, the surveyor observed Resident #59 lying in bed with eyes closed. The surveyor reviewed Resident #59's medical records that revealed the following: According to the admission Record, Resident #59 was admitted to the facility with diagnoses that included Dementia, Hypertension (elevated blood pressure), and Peripheral vascular disease. The 5/7/21 Comprehensive Minimum Data Set, an assessment tool used to facilitate care management, indicated a Brief Interview for Mental Status (BIMS) score of 1, which reflected that the resident's cognition was severely impaired. The August 2021 Order Summary Report showed an active order dated 5/5/20 for Morphine Sulfate (prescription medication used for moderate to…

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

Based on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 2 of 15 medication carts and 1 of 5 medication refrigerators inspected. This deficient practice was evidenced by the following: On 8/11/21 at 9:45 AM, the surveyor inspected the Three North medication cart in the presence of a Registered Nurse (RN) The surveyor observed an opened bottle of Pro-Stat solution and an opened Admelog Insulin vial that were not dated. At that time, the surveyor interviewed the RN who stated that both an opened bottle of Pro-Stat solution and an opened vial of Admelog Insulin should have been dated. On 8/11/21 at 10:00 AM, the surveyor inspected the fifth floor medication room refrigerator in the presence of a Licensed Practical Nurse (LPN #1). The surveyor observed an opened vial of Admelog Insulin vial that was not dated. At that time, the surveyor interviewed LPN #1 who stated that an Admelog insulin vial should have been dated. On 8/11/21 at 10:40 AM, the surveyor inspected the Six North medication cart…

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 store potentially hazardous foods (PHF) in a manner to prevent food borne illness. This deficient practice was evidenced by the following: On 8/10/2021 at 10:55 AM, in the presence of the Dietary Director (DD), the surveyor observed the following: The surveyor inspected the walk-in produce refrigerator, which contained PHF as well as produce. The internal thermometer read 44 degrees Fahrenheit (F). The DD stated that the refrigerator doors are constantly opened by the food service workers and the temperature should adjust if the doors are closed for at least 15 minutes. The surveyor and the DD waited 15 minutes and re-checked the refrigerators' temperature. The internal walk-in produce refrigerator's temperature still read 44 degrees F. At this time, the DD used his calibrated thermometer to check the internal temperature of a PHF which read 48 degrees. The DD stated that he would need to discard the PHF foods which included three (3 pound containers) of pre-cooked hard boiled eggs 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 observation, interview, and record review, it was determined that the facility failed to a.) maintain Hospice Nurse Communication record for 1 of 2 residents reviewed (Resident#59), and b.) maintain a plan of care that respected the resident's right to choose advanced directives for 1 of 2 residents reviewed (Resident #258). This deficient practice was evidenced by the following: 1. On 8/11/21 at 10:09 AM, the surveyor observed Resident #59 seated in a regular chair in their room. At 10:20 AM, Licensed Practical Nurse#1 (LPN#1) informed the surveyor that Resident #59 was on hospice care. LPN#1 stated that the hospice aide comes every Monday through Friday for an hour and the hospice nurse (HN) at least once a week. The surveyor reviewed Resident #59's medical record that revealed the following: According to the admission Record, Resident #59 was admitted to the facility with diagnoses that included Dementia, Hypertension (elevated blood pressure), and Peripheral vascular disease. The 5/7/21 Comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate care…

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 follow appropriate measures to prevent and control the spread of infection for: a) hand hygiene for safe food handling during dishwashing and b) multiple residents' usage of a landline telephone in the unit day room. The deficient practices were evidenced by the following: 1. On 8/10/21 at 11:10 AM, the surveyor observed a Food Service Worker (FSW#1) on the dirty side of the dish machine and FSW #2 on the clean side of the dish machine. FSW #2 was observed leaving the clean side of the dish washer and with ungloved hands, he took a crate with three soiled insulated plastic containers and placed them on the dirty side of the dish machine. Then, without washing his hands or putting on gloves, FSW #2 went back to the clean side of the dish machine and picked up a crate containing cleaned insulted soup bowls and placed them on top of a cart with other cleaned crates of insulated soup bowls. The surveyor stopped FSW #2 and asked what should have been done before picking up a crate of clean…

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.