River Front Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # 179036Based on record review, interviews, and policy review, the facility failed to develop a comprehensive care plan for one of two residents (Resident (R) 8) sampled for the use of a Life Vest, (a wearable defibrillator). Findings include: Review of the admission Record located under the Profile tab in the electronic medical record (EMR) revealed R8 was initially admitted on [DATE] and discharged to home on [DATE]. R8 had diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypertensive heart disease with heart failure, chronic atrial fibrillation, unspecified, and chronic diastolic (congestive) heart failure. Review of the Physician Orders located under the Orders tab in the EMR revealed R8 received an order for a Life Vest on 09/19/24. The order noted Change life vest battery every day shift. Life vest manufacturer [NAME] 1-8005433267serial # 58020305. Check [NAME] monitor for function and placement. Review of the 09/19/24…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ180849 Based on observations, interviews, and review of other facility documentation on 2/10/2025, it was determined that the facility failed to maintain a clean and homelike environment for the residents. This deficient practice was identified for 2 of 3 units, (Pavilion 2 and Pavilion 3) and was evidenced by the following: During a tour of the 2nd floor unit (Pavilion 2) on 2/10/2025 at 10:08 AM, the surveyor observed the following: 1.) Inside resident room [ROOM NUMBER], a brown stain on the ceiling tile and a build-up of dust and unknown debris in the heater vent. 2.) Inside resident room [ROOM NUMBER], four small holes in the wall behind the television for Bed-B and chipped paint on the walls. 3.) Inside resident room [ROOM NUMBER], two holes in the wall next to the bathroom door, a build-up of unknown debris in the heater vent, and chipped paint on the heater. 4.) Inside resident room [ROOM NUMBER], two holes in the wall behind the television for Bed B, a build-up of unknown debris 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.

Complaint # NJ 158956, 166158, 170632 Based on interview, and review of other facility documentation, it was determined the facility failed to ensure there was sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. This deficient practice was evidenced by the following: A review of the provided Facility Assessment dated March 2024 included .our approach to ensure adequate staff based on our resident population and their needs for care . for Certified Nurse Aides 1:8 Residents for days, 1:10 evenings, 1:14 nights, one Restorative Aide day shift weekdays and one Restorative Aide Day shift weekends. During resident Council meeting on 08/08/2024 at 11:00 AM, a resident stated nights are short staffed, and wait time is long. Only two were on 2nd floor last night. 2 of 5 residents stated they have waited 4 to 5 hours for an aide. A review of New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report for the following weeks weeks revealed the facility was deficient in CNA staffing for residents as follows: 1. For 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of the medical record, and review of pertinent facility records it was determined that the facility failed to follow through on recommendations made by the consultant pharmacist (CP) during their monthly medication regimen review (MRR) in a consistent and timely manner. This deficient practice was identified for 2 of 5 residents reviewed for unnecessary medications, (Resident #55 and Resident #89) and was evidenced by the following: The surveyor reviewed the facility policy on 08/13/2024 at 10:45 AM, titled Medication Regimen Review Policy NO: ROP-32, Reviewed: 6/2/2024. The following was revealed under POLICY: It is the facilities policy to provide a Medication regimen review (MRR) for all residents admitted to the nursing facility. The following was revealed under Policy Explanation and Compliance Guidelines: 1. Medication Regimen Review (MRR) is a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing…

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 handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: The surveyor reviewed a facility policy on 08/05/2024 at 12:02 PM, titled [company name] Dining Services Food Storage, undated. The following was revealed under Canned Fruits: Dented or bulging cans shall be placed on Damaged Goods Shelf and returned for credit. The following was revealed under Canned Vegetables: Dented or bulging cans shall be placed on Damaged Goods Shelf and returned for credit. The surveyor reviewed a facility policy on 08/05/2024 at 12:02 PM, titled [facility name] Dining Services Pots and Pans - Sanitizing Solution, undated. The following was revealed under the heading SANITATION OF EQUIPMENT: NOTE: Allow all items to air dry. Towels shall never be used for drying. When items are dry, store in proper storage area. 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.

Based on observation and interview, and review of other facility documentation, it was determined that the facility failed to ensure the transport of a non-ambulatory resident was provided in a manner to promote the dignity and respect of the resident. This deficient practice was identified for 1 of 32 residents reviewed for dignity, (Resident #27) and was evidenced by the following: A review of a facility policy titled Resident Rights, Created: 2/2024, revealed the following under Policy Explanation and Compliance Guidelines: 10. All residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. 11. The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. The following was revealed under the heading Resident rights: The resident has the right to a dignified existence, self-determination, and communication with and access to persons…

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/O # NJ 156940 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the facility in a clean and sanitary environment. This deficient practice was identified for 2 of 3 units, (Pavilion 2 and Pavilion 3) and was evidenced by the following: 1. On 08/13/2024 at 10:40 AM, a review of a facility policy titled Complete Room Cleaning dated 06/2024, revealed under the purpose section; The complete room cleaning schedule insures {sic} (ensures)that each resident room is discharge-cleaned on a monthly basis. Under the Patient Room section 3. Starting in a clockwise rotation from patient room door; clean polish, scrub, scrape, dust, disinfect, sweep, wipe and mop everything in the room including: . Check all the corners, ceiling and floors, Remove buildup on floor, dust mop and damp mop entire room. Under the Bathrooms section: . Toilet: scrub and disinfect toilet bowl. Use cleanser on interior of bowl only. Remove all stains and buildup.…

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 documentation, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives, timelines, and interventions to meet resident's medical and nursing needs for 1 out of 4 residents investigated for Respiratory Care. A review of a facility policy reviewed on 08/08/2024 at 11:05 AM, titled, Care Plan, dated June 2024, revealed the following statement, It is the policy of [facility name] that all residents admitted to the facility will have adequate person-centered care plans that provide for all their needs in a timely manner. Under Procedures, #1. Baseline Care Plans for all new admissions will be initiated within 48 hours of admission. Under #2. They will include initial goals, MD orders, medications, treatments, dietary orders, therapy orders, social service and PASARR recommendations. The deficient practice was evidenced by the following: On 08/05/2024 at 10:13 AM, the surveyor observed Resident #372 in his/her room, lying in bed…

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, review of the Electronic Medical Record (EMR), and review of other facility documentation, it was determined that the facility failed to ensure a resident had a Physician Order (PO) for transfer to the hospital. This deficient practice was identified for 2 of 2 residents reviewed for hospitalizations (Resident # 126 and Resident # 137) and was evidenced by the following: On 08/14/2024 at 9:52 AM, a review of the facility's Transfer or Discharge, Emergency policy dated revised June 2024, included, Should it become necessary to make an emergency transfer or discharge to a hospital . Notify the resident's attending physician; place order for transfer per attending physician/NP (nurse practitioner)/PA .(physician assistant) On 08/06/2024 at 11:42 AM, a review of the Electronic Medical Record (EMR) revealed the following: 1. A review of the admission record revealed Resident #126 was admitted to the facility with diagnoses including but not limited to: Conversion Disorder with Seizures or Convulsions. A review of a facility progress note (PN) dated 11/5/2023 revealed…

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 other facility documentation, it was determined that the facility failed to follow physician orders specifically to change the piston set (a device intended for medical purposes that consists of a calibrated hollow barrel and a movable plunger) every 24 hours for 1 of 3 residents reviewed for Tube Feeding, (Resident #54). This deficient practice was evidenced by the following: On 08/12/2024 at 12:10 PM, a review of a facility policy titled Enteral Tubes with a last revised date of 06/3/2024, revealed under the Procedure section: 16. Rinse Thoroughly with tap water and place in a labeled dry plastic bag to remain at bedside. *Change syringe and bag every 24 hours. During the initial tour of Pavilion 2 on 08/05/2024 at 10:58 AM, Resident # 54's piston set was observed on the bed side table. The bottled had the residents name and was dated 8/3/24. A review of the Electronic Medical Record on 08/06/2024 at 09:29 AM, revealed the following: Resident #54 was admitted with diagnoses including but not limited to: Multiple…

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 Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to ensure a resident who used Oxygen therapy at night, had a Physician Order. This deficient practice was identified for 1 of 4 residents reviewed for Respiratory Care (Resident #117) and was evidenced by the following: During the initial tour of the facility on 08/05/2024 at 10:29 AM, the surveyor observed oxygen tubing next to the resident in bed. The tubing was not dated. Resident #117 said he/she uses it at night. There was no observed oxygen sign outside the room. On 08/08/2024 at 01:10 PM, a review of a facility policy titled Oxygen Administration with a revised date of January 2024, revealed under the Policy section: Oxygen administration will be carried out only with a physician order. A review of the EMR on 08/05/2024 at 12:00 PM, revealed the following: According to the admission Record Resident #117 was admitted to the facility with diagnoses including but not limited to: Hypertensive heart Disease. 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, review of medical records and other facility documentation, it was determined that the facility failed to complete the dialysis communication book for a resident on dialysis (Resident #94). This deficient practice was identified for 1 of 1 residents reviewed for dialysis. The evidence was as follows: On 8/16/2024 at 12:00 PM the surveyor reviewed the facility's Dialysis Management (Hemodialysis) policy with a revised date of 6/2024 included . If Dialysis is provided at off-site Dialysis Center .Assure facility completed Dialysis communication form accompanies resident to dialysis on treatment days, to communicate resident information and coordinate care between Dialysis center and facility .Dialysis center personnel to complete Dialysis communication form and return and return to the facility . Upon return from Dialysis Center, review information provided on Dialysis communication form . On 8/7/24 at 11:18 AM the surveyor observed the Resident #94 in a wheelchair in their 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.

Cross Reference F867 Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to ensure: a) a discontinued and expired medication (pantoprazole, used to treat gastroesophogeal reflux disease /GERD, a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach) was removed from active inventory b) maintain an accurate accountability for controlled substances within the medication administration cart c) a controlled medication that was expired was removed from an automated medication dispensing system. This deficient practice was identified for 1 of 3 medication carts, and 1 of 1 automated medication dispensing system reviewed during the medication storage task. A review of the facility policy, Medication Administration (Reviewed 06/24) revealed the following: .Check the expiration date on medication label. A review of an undated facility policy, 6.0 Inventory Control of Drugs revealed the following: Controlled drugs are inventoried and documented under proper…

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.

Cross Reference F755 Based on observation, interview, and review of pertinent facility records, it was determined that the facility Quality Assessment and Performance Improvement (QAPI) committee failed to utilize the Facility Performance Improvement Plan (PIP) to follow the facility process to measure and utilize data for checking medication carts three times weekly for expired medications. This deficient practice was evidenced by the following: On 08/13/2024 at 09:51 AM, the surveyor reviewed the facility policy titled Quality Assurance Performance Improvement, Date Reviewed/Revised: 9/14/23. The following was revealed under Purpose: Our Quality Assurance and Performance Improvement Program (QAPI) represent our facility's commitment to continuous quality improvement. The program ensures a systematic performance evaluation, problem analysis, and implementation of improvement strategies to achieve our performance goals. The following was revealed at II. Guidelines for Governance and Leadership: a. Nursing and Facility Administration are responsible and accountable for developing,…

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 pertinent facility documentation, it was determined that the facility failed to a.)properly store and maintain both sterile and non-sterile medical supplies in a safe and sanitary manner and b.) ensure that laundry staff used the appropriate personal protective equipment while handling items that were likely contaminated with infectious bodily fluids. This deficient practice was identified for 2 of 2 medication storage rooms reviewed for the medication storage task and 1 of 1 laundry staff and was evidenced by the following: On 08/07/2024 at 9:41 AM, during the inspection of the Pavilion Three Medication Storage Room, in the presence of Licensed Practical Nurse Unit Manager (LPN/UM #1) the surveyor observed: three enema kits, two packages of heel booties, and a box of wound treatment supplies which included: a half filled box of fifty count 4 x 4 gauze pads, a fifteen count box of border gauze dressings, two rolls of gauze, and a roll of paper tape that were stored beneath the handwashing sink. LPN/UM #1 stated that Central Supply…

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 other pertinent documents, it was determined that the facility who had been in an active COVID-19 outbreak since 11/18/22, failed to: a) follow the facility policy and conduct complete and thorough contact tracing to prevent the spread of COVID-19 (a potentially, deadly virus) and b) implement measures to prevent the growth of Legionella (bacterium that causes legionnaires' disease, a type of pneumonia caused by legionella bacteria that spreads through mist such as through air conditioning units and can also occur in potable water) and other waterborne pathogens in the facility's water systems. This deficient practice was identified for 1 (one) of 1 (one) sampled COVID-19 positive resident (Resident #107) and a review of 1 (one) of 1(one) COVID-19 positive staff member (Certified Nursing Assistant (CNA) #4) and was evidenced by the following: Reference: Contact Tracing for COVID-19 Centers for Disease Control: https://www.cdc.gov/coronavirus/2019-ncov/php/contact-tracing/contact-tracing-plan/contact-tracing.html. Reference F886 a) On 12/07/22 at 9:30…

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, and review of pertinent documents, it was determined that the facility failed to: a) conduct immediate, comprehensive resident and staff COVID-19 (a potentially, deadly virus) testing upon the identification of a single positive resident or staff member in accordance with the facility policy b) ensure that comprehensive COVID-19 testing was completed and accurately documented during a COVID-19 outbreak that began on 11/18/22, in accordance with current Federal, State and Centers for Disease Control guidelines. This deficient practice was identified for 1 (one) of 1 (one) COVID-19 positive resident (Resident #107), 1 (one) of 1 (one) COVID-19 staff members (Certified Nursing Assistant (CNA #4) on 3 (three) of 3 (three) nursing units, and was evidenced by the following: Reference: Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements (Ref: QSO-20-38-NH)…

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 update the resident's comprehensive care plan in a timely manner. This deficient practice was identified for 2 of 34 residents (Residents #119 and #141) reviewed for care plans and was evidenced by the following: 1. On 12/07/22 at 12:00 PM, 12/08/22 at 10:14 AM and 12/09/22 at 12:30 PM, the surveyor observed the resident seated at a table in the dayroom. The surveyor observed that Resident #119 had a palm guard applied to the left hand at the time of each observation. According to the admission Record, Resident #119 was admitted with diagnoses which included, but were not limited to, contracture of the muscle to the left hand. Review of the Quarterly Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care, dated 09/12/22, reflected that Resident #119 was cognitively intact, required supervision with dressing including how the resident puts on, fastens, and takes off all items 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.

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 a.) accurately identify a wound type from first identification of the wound on 09/07/22 until 12/15/22 and b.) clarify the implementation of a diagnostic study recommended by a wound care consultant. This deficient practice was identified for 1 (one) of 2 (two) residents (Resident #15) reviewed for pressure ulcers and was evidenced by the following: On 12/07/22 at 10:54 AM, during initial tour, the surveyor observed Resident #15 sitting in a chair at his/her bedside. The resident was observed with an anti-pressure cushion on the wheelchair and an anti-pressure mattress on the bed. The surveyor interviewed the resident at that time and Resident #15 stated that he/she had a sore on the right foot and pointed to the planter (the arch of the foot) area of the right foot. The resident was washed and dressed and had socks on both feet. Review of the resident 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, review of the medical record and review of other facility documentation, it was determined that the facility failed to adequately monitor the target behaviors for the use of psychotropic medications (mood altering medications) for 2 of 5 residents (Resident #86 and #115) reviewed for mood/behavior. This deficient practice was evidenced by the following: 1. On 12/08/22 at 11:29 AM, the surveyor observed Resident #86 seated in a wheelchair in the dayroom while an activity was being held. On 12/08/22 at 12:23 PM, the surveyor reviewed Resident #86's electronic medical record (eMR). A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. A review of Resident #86's annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/16/22,…

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 interview, review of the medical record, and other facility documentation, it was determined that the facility failed to verify and accurately transcribe readmission medications. The deficient practice was identified for 1 of 5 residents (Resident #80) reviewed for unnecessary medications and was evidenced by the following: According to the admission Record, Resident #80 was admitted with diagnoses that included, but were not limited to, psychosis, anxiety disorder, and depression. Review of Resident #80's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 09/10/22, included the resident had a Brief Interview for Mental Status of 15, which indicated that the resident was cognitively intact. Further review of the MDS revealed the resident received antidepressant medication for the last 7 days. Review of the 07/28/22 psychiatric consult (psych consult) indicated to continue all current medications as prescribed, which included Duloxetine 90 mg daily for depression. The benefits outweigh the risk. Review of the Progress Notes…

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 handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 12/07/22 at 10:54 AM, the surveyor, in the presence of the Food Service Director (FSD), observed the following during the kitchen tour: 1. A stack of 18-inch sheet pans was stored on a multi-tiered cart. The surveyor observed the top sheet pans were wetnesting. When interviewed, the FSD stated the sheet pan should not have been stacked while wet. 2. In the dry storage room, an opened, undated container of beef base wrapped in plastic was stored on a shelf. When interviewed, the FSD stated the container should have been dated when opened. 3. In the dry storage room, a dented can with no labeled was stored on a shelf alongside undented cans. When interviewed, the surveyor observed the FSD remove the dented can from the rack and placed it on the shelve designated for the dented cans. 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 complete a resident assessment that accurately reflected the resident's status. This was identified during a review of the quarterly Minimum Data Set (MDS), an assessment tool to facilitate the management of care, for 1 of 31 residents reviewed (Resident #15). This deficient practice was evidenced by the following: On 12/07/22 at 10:54 AM, during tour, the surveyor observed Resident #15 sitting in a chair at bedside. The resident was observed with an anti-pressure cushion on the wheelchair and an anti-pressure mattress on the bed. The surveyor interviewed the resident at that time and Resident #15 stated that he/she had a sore on the right foot and pointed to the planter area of the right foot. The resident was washed and dressed and had socks on both feet. Review of the resident medical record revealed the following: Review of the admission Record (AR) reflected that Resident #15 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.

Based on interview, record review, and other pertinent facility documentation it was determined that the facility failed to a.) accurately document neuro checks (a nurse assessment to document an individual's neurological functions, motor and sensory response and level of consciousness) in accordance with professional standards of practice for one resident who sustained a fall b.) follow physician orders for the application of compression stockings. This deficient practice was identified for 1 of 5 residents (Resident #37) reviewed for hospitalizations and 1 of 1 (Resident #15) reviewed for edema (swelling) and 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 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…

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 the medical record and other facility documentation, it was determined that the facility failed to provide finger nail care to a resident that was dependent on the staff for hygiene for (one)1 of 31 residents (Residents #64). This deficient practice was evidenced by the following: According to the admission Record, Resident #64 was admitted to the facility with the diagnoses which included but was not limited to: vascular dementia, neuropathy, depression, and glaucoma. The quarterly Minimum Data Set (MDS), an assessment tool used facilitate the management of a resident's care, dated 09/13/22, indicated that Resident #64 had severe cognitive impairment and required extensive assistance with personal hygiene and total dependence on staff for bathing. On 12/07/22 at 11:00 AM, the surveyor observed Resident #64 sitting up in a chair in the resident's room and the surveyor observed that the resident's finger nails on bilateral hands were long, broken, and jagged. The resident was pleasant, however confused and unable to participate in an…

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

Based on observation, interview and review of other facility documents, it was determined that the facility failed to provide a sanitary environment for residents, staff and the public by failing to keep the garbage compacter area free of garbage and debris and failed to have the doors to the trash compactor closed for 1 of 1 trash compactor. This deficient practice was evidenced by the following: On 12/07/22 at 10:54 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and requested to see the outside garbage receptacle area. The surveyor observed a trash compactor (TC) on a cement pad. The surveyor further observed that both the left-side and right-side doors of the TC open exposing multiple trash bags inside. The surveyor further observed that the outside garbage receptacle area was littered with leaves, debris, used gloves, cans, cardboard boxes, milk and juice cartons. When interviewed at that time, the FSD stated that everyone was responsible for cleaning the garbage receptacle area and the lids and doors of the TC should be closed when not in use. 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.