Troy Hills Center

Based on interviews, record review, and a review of pertinent facility documents, it was determined that the facility failed to identify the irregularity with regard to medications with parameters for 5 of 5 residents reviewed, Residents #24, #43, #53, #57, and #82 in accordance with facility's practice and policy. This deficient practice was evidenced by the following: 1. On 11/19/24 at 11:50 AM, the surveyor reviewed the paper and electronic medical record (EMR) of Resident #53. The admission Record (AR; a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to, hypertension (high blood pressure), and rheumatoid arthritis. A quarterly Minimum Data Set (qMDS), assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 11/05/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #53 scored a 15 out of 15, which indicated the resident was cognitive intact. A physician's order (PO) dated 9/04/22…

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 properly store medication for 2 of 3 medication storage areas and 2 of 2 medication refrigerators inspected according to facility's policy and standard 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 states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as 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 observations, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that the resident's call light was readily accessible within reach. The deficient practice was identified for 1 of 3 residents, Resident #79, reviewed for accommodation of needs and limited range of motion (ROM). This deficient practice was evidenced by the following: On 11/18/24 at 10:43 AM, the surveyor observed Resident #79 resting in bed and their right arm was elevated on the pillow. The surveyor greeted the resident, and the resident elevated their head of bed with the controller. The resident was unable to speak much at the time of observation. The surveyor observed resident's call bell wrapped around the side rails on resident's right side of bed. The resident was unable to reach it. On 11/20/24 at 11:42 AM, the surveyor observed the resident in their bed and the call bell was wrapped around the right side and the end of the call bell was hung on the right side of the bed. Resident #79's right arm was elevated on the pillow. 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 interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure reference checks were completed for 2 out of 10 newly hired staff (Staff #2 and #6) prior to their start date of employment. This deficient practice was evidenced by the following: The surveyor reviewed ten randomly selected new employee files. The review for reference checks for 2 of the 10 new employees revealed the following: -Staff #2's file, a Licensed Nursing Home Administrator (LNHA) who was hired on 7/03/23, revealed no reference checks in their file. -Staff #6's file, a Nursing Assistant (NA) who was hired on 9/27/24, revealed no reference check in their file. On 11/25/24 at 12:20 PM, during an interview with the surveyor, the Staffing Coordinator (SC) stated minimum of 2 reference checks were required before the date of hire. SC further stated the recruiter was responsible to check the reference checks and then SC would double check the files. In the presence of the surveyor, the SC checked the employee files and acknowledged that the 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 the interview, record review, and review of other facility provided documents, it was determined that the facility failed to report an allegation of Abuse/Neglect to the New Jersey Department of Health (NJDOH) in the required timeframe for 1 of 4 sampled residents, Resident #45, reviewed for abuse. This deficient practice was evidenced by the following: On 11/19/24 at 01:39 PM, the surveyor reviewed the last three months' resident council minutes that were provided by the Licensed Nursing Home Administrator (LNHA) and revealed: -8/15/24: Council Members in Attendance: 10 Compliments/Ideas/Preferences/Concerns/Suggestions: Nursing: A resident awoke another resident and tried to get into their bed. The complainant resident asked the other resident to leave and would not. The complainant's roommate stayed with the complainant until nursing came, and not the first time the resident visited the complainant's room. Further review of the facility-provided resident council meeting minutes revealed that there was no resolution or follow-through with the above concerns on the 8/15/24…

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

REPEAT DEFICIENCY Based on observation, interview, record review, and review of other pertinent facility provided documentation, the facility failed to a.) ensure accurate documentation of treatment administration and follow wound consultant recommendations for 1 of 1 resident, Resident #15, reviewed for pressure ulcer, b.) follow a PO with regard to vital signs for 1 of 24 residents, Resident #68, and c.) clarify the physician's order with regard to pain medication for 1 of 24 residents, Resident #80, according to the standard 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 states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to maintain professional standards of nursing practice by not following a.) a physician's order for the application of a splint to right wrist, and b.) document in the Treatment Administration Record for 1 of 3 residents, Resident #68, reviewed for limited range of motion (ROM). The deficient practice was evidenced by the following: On 11/18/24 at 10:30 AM, during an initial tour, the surveyor observed Resident #68 resting in their bed while watching television, with no splint in use. The surveyor observed a picture of right hand in a splint that was posted on their room wall with instructions, indicating Right hand- Apply daily with a.m. (morning) care. Remove after 8 hours. Later on, the surveyor observed resident sitting in their wheelchair (w/c) in atrium from 12:20 PM until 02:20 PM. The surveyor did not observe resident's right wrist splint on. On 11/19/24 at 12:58 PM, the…

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

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the necessary respiratory care and services of residents that were receiving oxygen, according to the standard of clinical practice and the facility's policy and procedure, specifically a.) clarify the physician's order for as needed (PRN) oxygen and document the use of PRN oxygen therapy for 1 of 3 residents, Resident #33 and b.) that respiratory equipment was stored in accordance with facility policy and infection control measures for 1 of two 3 residents reviewed for respiratory care, Resident #80. 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 states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health…

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 pertinent documents, it was determined that the facility failed to complete post dialysis communication record assessments upon the resident's return from the dialysis center for 1 of one 1 resident, Resident #24, reviewed for dialysis services. The deficient practice was evidenced by the following: On 11/18/24 at 12:05 PM, the surveyor observed Resident #24 was not in their room. The Registered Nurse (RN) assigned to care for Resident #24 stated the resident was at dialysis. The surveyor reviewed the electronic medical record of Resident #24. The admission Record (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to, end stage renal [kidney] disease, dependence on renal dialysis, hypertension (high blood pressure) and atrial fibrillation (an irregular, often rapid heart rate). A comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/10/24, indicated the facility assessed the…

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

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to post the accurate Nursing Home Resident Care Staffing Report daily for 2 of 7 days. This failure could affect the knowledge of the availability of staff to care for the residents, resident representative, and visitors. This deficient practice was evidenced by the following: On 11/18/24 at 9:10 AM, upon entry into the facility, Surveyor #1 (S#1) observed a posted Nursing Home Resident Care Staffing Report (NHRCSR) that was posted in the reception area of the lobby, dated 11/18/24 Day Shift, 7 AM-3 PM. The NHRCSR reflected current census of 98 that included 10 CNAs (Certified Nursing Aides) with staff to resident ratio of 1 CNA:9.8 Residents. On 11/18/24 at 10:04 AM, during entrance conference, the Licensed Nursing Home Administrator (LNHA) informed S#1 that the census (total number of residents) was 97. S#1 requested for Daily Census (DC) and Daily Staffing Sheets [DSS] (to reflect total number of staff that actually worked). A review of DC and DSS dated…

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

Based on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to adequately monitor target behaviors for the use of a psychotropic medication for 1 of 5 residents (Resident #53) reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 11/18/24 at 12:10 PM, the surveyor observed Resident #53 lying in bed with their head of the bed elevated. The resident was alert, oriented, pleasant, and conversant. On 11/19/24 at 11:50 AM, the surveyor reviewed the paper and electronic medical record (EMR) of Resident #53. The admission Record (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to, hypertension (high blood pressure), depression, rheumatoid arthritis, and anxiety disorder. A quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/05/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status…

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 pertinent facility documentation it was determined that the facility failed to ensure meals were served at safe and appetizing temperatures for 1 of 4 nursing units (Wing 2), during the lunch meal service on 11/22/24. This deficient practice was evidenced by the following: On 11/18/24 at 12:10 PM, the surveyor observed Resident #53 resting in their room. The resident was alert, oriented and verbally responsive. The resident stated the staff were nice and helpful. The surveyor asked Resident #53 about the food served at the facility. The resident stated that sometimes the food was cold when received. A review of last three months of resident council minutes revealed: In September 2024, residents reported food was not always hot by the time it was served to their room. In October 2024, residents reported coffee not being hot in dining room. A review of grievances from August 2024 to November 2024 included the following: In August 2024, there was one (1) grievance related to resident concern that food was always cold. In…

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, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to follow appropriate hand hygiene, and use of personal protective equipment (PPE) for 2 of 7 staff (Housekeeper and non-certified Nursing Aide) and follow appropriate infection control practices when performing high contact care activities in an enhanced barrier precaution (EBP) to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . Before moving from work on a soiled body site to a clean body site on the same patient . After touching…

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 document review, it was determined that the facility failed to ensure sufficient nursing staff was in place to ensure resident's highest practicable well-being was maintained by failing to ensure: a.) appropriate incontinence care was provided for 6 of 6 residents reviewed (Resident #35, #57, #88, #45, #59, #88) on 2 of 4 resident Wings (Wing 1 and Wing 3), b.) residents were provided with nail care and hygiene services for 3 of 5 residents (Resident #57, #45, #88) reviewed on 2 of 4 resident Wings (Wing 1 and Wing 3), and c.) appropriate nursing and related services required for a resident who required assistance with meals for 2 of 5 residents reviewed (Resident #35 and #88), on 2 of 4 resident Wings (Wing 1 and Wing 3) to meet the residents individual needs. This deficient practice has the potential to affect all residents and was evidenced by the following: Refer to: F677 and F689 On 02/08/2023 at 8:50 AM, the surveyor toured the 3rd Wing of the with staff and observed the following: 1. The surveyor entered Resident #35's room…

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 evaluate the performance of all Certified Nursing Assistants (CNAs) on an annual basis. This deficient practice occurred with 5 of the 5 CNAs whose personnel records were reviewed and was evidenced by the following: On 02/22/2023 at 12:40 PM, the surveyor reviewed the employee files of 5 randomly selected CNAs which were provided by the facility. The surveyor identified the following: CNA #1 had a hire date of 05/04/2015. According to the CNA #1's personnel record, the last documented performance appraisal was 09/22/2020. There were no annual performance reviews conducted within the past year. CNA #2 had a hire date of 02/27/1996. According to the CNA #2's personnel record, the last documented performance appraisal was 09/18/2020. There were no annual performance reviews conducted within the past year. CNA #3 had a hire date of 10/12/2010. According to the CNA #3's personnel record, the last documented performance appraisal was 09/18/2020. There were no annual performance reviews conducted within 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 document review, it was determined that the facility failed to ensure a.) that the kitchen environment, equipment and resident meal service items were maintained in a clean and sanitary manner, b.) a walk in refrigeration unit maintained appropriate food temperatures, c.) a commercial dishwashing machine was operated within manufactures specifications, d.) food temperatures were consistently monitored, e.) hair restraints were consistently worn, and e.)food items were consistently labeled and dated with a use by date to limit the spread of infection and potential food borne illness. The deficient practice was evidenced by the following: On 02/08/23 at 8:51 AM through 9:25 AM, the surveyor conducted an initial tour of the kitchen. The surveyor observed the [NAME] wearing a surgical mask under his nose and facial hair was protruding out the side of his mask. The [NAME] was not wearing a facial restraint. There were two additional dietary workers in the kitchen who informed 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 interview, record review and review of other pertinent documentation, it was determined that the facility failed to follow facility policy and ensure the implementation of a comprehensive antibiotic stewardship program (ASP). This deficient practice was identified during a review for 3 of 3 months of the facility Infection Control Monthly Line Listing tracking forms (December 2022, January 2023, and February 2023). The deficient practice was evidenced by the following: On 02/08/23 at 11:12 AM during entrance conference, the Licensed Nursing Home Administrator (LNHA) stated that the facility was in a current outbreak of COVID-19. A review of the facility provided line list revealed the outbreak began 10/23/22. On 02/10/23 at 2:48 PM, the ADON IP provided Surveyor #1 with Infection Control Monthly Line Listing forms for December 2022, January 2023, and February 2023 up to 02/10/23. A review of the Infection Control Monthly Line Listing form revealed the following information to be documented: Name; Room #; admit date ; Date onset; HAI (healthcare acquired)/C (community…

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

Based on observation, interview and document review, it was determined that that facility failed to ensure that contracted facility departments received training and competencies in accordance with the Facility Assessment, and to ensure facility policies and procedures for infection control standards were met. This deficient practice affected 4 of 4 Resident Wings and was evidenced by the following: On 02/08/23 at 11:12 AM, during the facility entrance conference the Licensed Nursing Home Administrator (LNHA) provided a copy of the Facility Assessment Tool (Tool), dated 03/22/22. The Tool revealed staff training/education and competencies, 3.4. Describe the staff training/education and the competencies that are necessary to provide the level and types of support and care needed for your resident population. Include staff certification requirements as applicable. Potential data sources include hiring, education, training, competency instruction, and testing policies. At facility staff members are provided with training and education beginning with the new hire orientation and regular…

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 documentation, it was determined that the facility failed to update comprehensive patient-centered care plans for: a.) a resident with suicidal ideation, b.) a resident on a hypotensive medication, and c.) a resident with a diagnosis of pneumonia requiring antibiotics. This deficient practice was identified for 3 of 23 residents (Resident #71, #95, and #26) reviewed for Care Planning (CP) and was evidenced by the following: a.) On 02/09/23 at 8:21 AM, the surveyor observed Resident #71 sitting on the side of the bed reading the newspaper. The surveyor observed the resident's urinary catheter collection bag was not in a privacy bag. At that time, the Registered Nurse (RN) was outside the room in the hallway with the surveyor and stated the resident had behaviors including taking the urinary collection bag out of the privacy bag. A review of the medical records for Resident #71's included an admission Record which revealed the resident was…

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 follow professional standards of clinical practice with respect to a.) medication administration and documentation, b. ) follow the facility's policy/protocol on discarding controlled substances, and c. ) follow standards of clinical practice and executing orders as prescribed by the physician. The deficient practice was identified for 4 of 8 residents during medication pass observation (4 unsampled residents); 1 of 6 residents (Resident #95) reviewed for medication parameters; and 3 of 3 sampled residents reviewed for care (Resident # 315, #88 and Resident #95). The 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 states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or…

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 documents, it was determined that the facility failed to provide personal hygiene and provide timely assistance for 6 of 6 residents (Resident #1, #35, #45, #66, #88 and Resident #57) reviewed who required assistance with Activities of Daily Living (ADLs). The deficient practice was evidenced by the following: On 02/08/2023 at 8:50 AM, the surveyor toured the 3rd Wing of the with staff and observed the following: 1.The surveyor entered Resident #35's room with a Certified Nurse Aide (CNA). Resident #35 was observed in bed resting. The CNA informed the resident of the task and the CNA proceeded to turn the resident over. The surveyor, along with the CNA observed that Resident #35 was soaked with urine and was wearing two incontinence briefs. The breakfast tray was noted on the bedside table that was untouched. On 02/08/23 at 09:10 AM, during an interview with the CNA, she stated that the facility was shorthanded. She further added…

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

Based on observation, interview and document review it was determine that the facility failed to provided meals at acceptable temperatures for 2 of 4 residents interviewed during a resident council meeting and for 4 of 4 items sampled during a test tray observation. The deficient practice was evidenced by the following: On 02/14/23 10:33 AM, a surveyor conducted a resident meeting with four residents, and 2 of 4 residents stated that the food served would sit on the meal trays too long and would then be cold because there were not enough Certified Nurse Aides to give out the meal trays. On 02/15/23 at 11:37 AM to 12:08 PM, the surveyor entered the kitchen and observed the tray line in progress for the lunch meal. The surveyor observed the tray line while next to a Dietary Staff worker (DS #1) who was opposite the Cook. The surveyor selected a hot dog, cheese pizza, puree hot dog and four ounces of milk from the tray line and posted menu. The food temperatures had been recorded by the [NAME] and reviewed by the surveyor which revealed: hot dog 194 degrees Fahrenheit (F), puree hot…

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

Based on interview, record review and review of pertinent documents it was determined that the facility failed to complete and document a thorough investigation regarding bruises of unknown origin sustained on a cognitively impaired resident. This deficient practice occurred for 1 of 1 resident (Resident #92) reviewed for abuse and was evidenced by the following: On 02/14/23 at 8:46 AM, the surveyor observed Resident #92 seated in a chair next to the bed. Resident #92 was alert but unable to answer questions asked by the surveyor. Resident #92 was confused and unable to proceed with the interview. On 02/14/23 at 8:59 AM, the surveyor observed a Certified Nurse Aide (CNA) who was assigned to Resident #92, enter the resident's room with a meal tray. Plastic utensils were observed on the resident's meal tray and the surveyor inquired to the CNA about the plastic utensil use. The CNA stated that she did not know and they don't want [him/her] to hurt [him/herself]. On 02/14/23 at 1:21 PM, the surveyor was in Resident #92's room and observed the Business Office Manager (BOM) enter 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, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure the facility policy was followed to ensure appropriate care was provided for a resident who required tracheal suctioning for a tracheostomy tube (a surgically inserted tube into the neck to help a person breathe). The deficient practice occurred for 1 of 1 resident reviewed (Resident #57) for tracheostomy care and was evidenced by the following: On 02/13/23 at 10:56 AM, the surveyor attempted to complete an observation of Resident #57. The resident was not in the room, and the staff informed the surveyor that the resident had been transferred to the hospital and was admitted with pneumonia. On 02/23/23 at 9:00 AM, the surveyor reviewed Resident #57's medical record. Record review revealed Resident #57 was readmitted from the hospital on [DATE]. The diagnoses from the readmission included, but was not limited to; acute respiratory failure with hypoxia and COVID-19. 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 ensure: a.) the reconciliation, accountability, and notification of the physician for the use of a hand splint in accordance with professional standards of nursing practice. and b.) a resident-designated insulin vial was not shared with another resident during a medication pass observation. This deficient practice was identified for 2 of 18 residents reviewed for professional standards of nursing practice (Resident #20 and Resident #50). Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized…

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 a.) a discontinued medication used to treat high potassium levels in the blood were removed from active inventory and b.) expired over-the-counter stock medications were removed from active inventory from a unit refrigerator, a medication cart and the central supply storage area. This deficient practice was identified for 1 of 3 medication refrigerators (Wing 1), 1 of 2 medication carts (Wing 3) and 1 of 1 central supply storage areas that were inspected. The evidence was as follows: On 10/15/20 at 10:12 AM, two surveyors and the Registered Nurse/Unit Manager (RN/UM) of Wing 1 and 2, inspected the Wing 1 medication refrigerator. The surveyors observed an opened bottle of Acidophilus Probiotic 1 billion unit (a dietary supplement) capsules with an expiration date of 4/2020 in the refrigerator. The RN/UM stated that there were no residents currently on that medication and the expired Acidophilus Probiotic bottle should have been removed and discarded. The RN/UM then took 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 pertinent facility documents, it was determined that the facility failed to: a.) ensure the appropriate timing and technique of performing hand hygiene while providing care and wound care to a resident to prevent infection for 1 of 2 residents reviewed for pressure ulcers (Resident #56), and b.) surveil/trend their infection rates since July 2020. This deficient practice was evidenced by the following: 1. The surveyor reviewed the facility's Hand Hygiene policy reviewed 11/15/19 which included, that hand hygiene should be performed Before patient care; before an aseptic procedure; after any contact with blood or other body fluids, even if gloves are worn; after patient care; after contact with the patient's environment. Hand hygiene techniques included, To wash hands with soap and water: wet hands with warm (not hot) water, apply soap to hands, and rub hands vigorously outside the stream of water for 20 seconds covering all surfaces of the hands and fingers. Rinse hands with warm water and dry thoroughly with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident had a.) a call bell placed within reach, and b.) the appropriate call bell for his/her assessed functioning level. This deficient practice was identified for 1 of 18 residents reviewed (Resident #56), and was evidenced by the following: On 10/14/20 at 11:24 AM, the surveyor observed Resident #56 in bed, and the resident's left arm was bent toward the chest and he/she had a hand roll in the left hand. The surveyor observed that the button call bell was wrapped around the left side rail of the bed, hanging toward the floor and out of reach for the resident. The resident informed the surveyor that he/she currently had to communicate a need to the nurse. The surveyor asked the resident about the call bell and the surveyor observed the resident reach with his/her right arm in an attempt to reach the call bell hanging toward the floor on the resident's left side, but the resident was unable to reach it.…

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

Based on observation, interview and record review, it was determined that the facility failed to ensure: a.) infection control procedures were followed while performing tracheostomy care, b.) the resident was assessed for cardiac and respiratory status prior to tracheostomy suctioning in accordance with the physician order, c.) the tracheostomy suction tubing was pre-lubricated to prevented irritation, d.) the physician orders and care plan reflected the resident's current tracheostomy size, and e.) that the resident was explained of the suctioning procedure prior to passing the suctioning catheter. This deficient practice was identified for 1 of 1 residents reviewed with a tracheostomy (Resident #12). The evidence was as follows: On 10/19/20 at 9:25 AM, two surveyors observed Resident #12 in bed, awake and smiling and appeared comfortable. The resident had a tracheostomy (a tube inserted into the anterior neck/windpipe allowing air to enter the lungs), and was receiving humidified supplemental oxygen by way of a trachesotomy collar. Upon closer observation of the tracheostomy…

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.