Autumn Lake Healthcare At Salem County

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure that an accurate Preadmission Screening and Resident Review (PASARR) Level I assessment was completed after admission for one resident (Resident (R)8) out of 33 sampled residents. This failure increased the risk for the resident not receiving specialized services as determined by a Level II prompted by a Level I that indicated mental illness.Findings include:Review of R8's ''admission Record,'' located in the ''Profile'' tab of the EMR, revealed R8 admitted to the facility on [DATE] with diagnoses including major depressive disorder, bipolar disorder, post-traumatic stress disorder and other schizophrenia. Review of R8's annual ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 07/21/25 revealed a score of 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. Review of the Facility Reportable Investigation dated 06/01/25 revealed he was physically aggressive towards another…

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, record review, and policy review, the facility failed to ensure the medical staff documented the correct indication for the use of an antipsychotic medication and instead documented a diagnosis of Schizophrenia in the medical record for one resident (Resident (R) 6) out of five residents reviewed for unnecessary medications out of a total sample of 33 residents. This failure had the potential to cause psychological distress and impact treatment.Findings include:Review of R6's admission Record located in the electronic medical record (EMR) under the Profile tab revealed he was admitted to the facility on [DATE] with diagnoses including Post-Traumatic Stress Disorder (PTSD).Review of the Care Plan tab revealed a focus area, [R6] uses psychotropic medications r/t [related to] mood disorder dated 04/02/25. The Care Plan did not reflect a diagnosis of schizophrenia.Review of a General Nurses Note dated 04/07/25 and located in the EMR under the Progress Notes tab revealed R6 was sent to a hospital…

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, the facility failed to provide wound treatments as ordered by the physician for one (Resident (R) 80) of 33 sampled residentsFindings include: Review of R80's admission Record located in the electronic medical record (EMR) under the Admission tab revealed R80 was admitted to the facility on [DATE] with diagnoses including cellulitis of other sites and type 2 diabetes mellitus with other circulatory complications. During an observation and interview on 08/04/25 at 11:15 AM, revealed R80 had an ace bandage on his lower right leg. R80 stated the bandage had not been changed since 08/01/25 and it was supposed to be changed daily. During an observation and interview on 08/04/25 at 11:23 AM, Licensed Practical Nurse (LPN1) revealed R80 had a white bandage under an ace bandage dated 08/01 with LPN1's initials. LPN1 also stated she did wound care on R80's lower right leg on 08/01/25. She further stated R80's wound care was supposed to be done daily. Review of 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, record review, interviews, and policy review, the facility failed to ensure a resident utilizing supplemental oxygen (Resident (R) 65) had orders and a plan of care for its use and a resident (R31) had clean oxygen concentrator filters out of two residents reviewed for oxygen use out of a total sample of 33 residents. This failure had the potential to cause impaired respiratory function.Findings include: 1.Review of R65's admission Record located in the electronic medical record (EMR) under the Profile tab revealed she was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia (low oxygen levels), acute pulmonary edema (fluid in the lungs), pleural effusion (fluid between the lung and chest wall), and heart failure. Review of the hospital Discharge summary dated [DATE] and located under the Misc tab of the EMR revealed: Patient received incentive spirometry, . and we weaned O2 [oxygen] as tolerated. Patient has been weaned from 4L [liters] to 1L,…

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 record review, interview, and policy review, the facility failed to ensure documentation of assessment prior to, and upon return from, dialysis and failed to ensure communication forms were used between the facility and the dialysis center for one of one resident reviewed for dialysis (Resident (R) 2) out of 33 sampled residents. This had the potential to affect the health of residents receiving dialysis.Findings include:Review of R2's admission Record located in the electronic medical record (EMR) under the Profile tab revealed she was admitted to the facility on [DATE] with diagnoses including end stage renal disease and dependence on renal dialysis.Review of the Care Plan tab revealed a focus area, [R2] needs hemodialysis renal failure dated 03/04/24 with interventions including to check the thrill and bruit (dialysis access site) per protocol, observe/document/report any peripheral edema, any signs of infection to the access site, and any bleeding. Review of the Order Summary Report revealed orders…

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, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails and that assessments were completed for the risk of entrapment for one of four residents (Resident (R)59) reviewed for side rails out of 33 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment.Findings include: Review of R59's admission Record located in the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder and cognitive communication deficit. Review of R59's annual Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 07/09/25, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating no cognitive impairment. Review of R59's Care Plan, located under the Care Plan tab of the EMR 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure a medication was ordered upon admission from the hospital for one resident (Resident (R) 113) out of a total sample of 33 residents. This failure increased the risk that the resident would have unrelieved pain.Findings include:Review of R113's admission Record located in the electronic medical record (EMR) under the Profile tab revealed she was admitted to the facility on [DATE] with diagnoses including spondylosis (degenerative changes of the spine) and encounter for other orthopedic aftercare (surgery).Review of R113's hospital Discharge Documentation dated 10/17/24 and provided by the facility from the resident's paper chart revealed she underwent fusion of the spine (back surgery) on 10/08/24 and 10/14/24. R113 had an unplanned cage migration (movement of hardware used during the surgeries, which can cause pain) on 10/15/24. Discharge medications included acetaminophen 1000mg every six hours as needed (PRN) for mild pain 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: 2569972Based on interviews, medical record review, and review of other pertinent facility documents on 7/28/2025, it was determined that the facility failed to notify a resident's physician of a low blood sugar result, and to follow facility policy titled Notification of Changes. This deficient practice was identified for (Resident #7), 1 of 3 residents reviewed and was evidenced by the following:A review of the closed Electronic Medical Record (EMR) was as follows:According to the admission Record (AR), Resident #7 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Diabetes, Hypertension, and Chronic Pain Syndrome. The resident was discharged from the facility on 12/30/2024. According to the Minimum Data Set (MDS), an assessment tool dated 12/30/2024, Resident #7 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating the resident's cognition was intact. A review of Resident #7's Order Summary Report (OSR) included 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 interviews, medical record reviews, and review of other pertinent facility documentation on 7/28/2025, it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the residents. Also, the facility failed to follow its policy titled ADL Documentation Policy. This deficient practice was identified for 3 of 4 residents reviewed for ADL documentation. This deficient practice was evidenced by the following:1.According to the admission Record (AR), Resident #3 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Quadriplegia (paralysis of all four limbs), Acute Respiratory Failure, and Dysphagia (difficulty swallowing).According to the Minimum Data Set (MDS), an assessment tool dated 5/15/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating the resident's cognition was intact. A review of Resident #3's DSR…

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 #: NJ00179130 Based on interviews, medical record review, and review of other pertinent facility documents on 11/07/2024 and 11/08/2024, it was determined that the facility failed to develop a Care Plan (CP) for a resident that had a diagnosis of Diabetes (high blood sugar levels) and was admitted to the facility with elongated(long) toenails. The facility also failed to follow its policy titled Care Plans, Comprehensive Person-Centered. This deficient practice was identified for 1 of 7 residents (Resident #2) reviewed for care plans. This deficient practice was evidenced by the following: According to the admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to, Diabetes, Major Depressive Disorder, and Unspecified Dementia (general decline in cognitive abilities that affects a person's ability to perform everyday activities). A review of Resident #2's most recent Quarterly Minimum Data Set (MDS), an assessment tool dated 10/27/2024…

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 #: NJ179130 Based on interviews, medical record review, and review of other pertinent facility documents on 11/07/2024 and 11/08/2024, it was determined that the facility failed to follow standards of clinical practice regarding a.) ensuring a resident was seen by the Podiatrist in a timely manner, b.)ensuring a resident care plan (CP) was developed for a resident that had a diagnosis of Diabetes and was admitted to the facility with elongated (long) toenails, and c.) immediate notification to the Physician of abnormal urine culture results. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed and evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health…

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 #: NJ00179130 Based on interviews, medical record review, and review of other pertinent facility documents on 11/07/2024 and 11/08/2024, it was determined that the facility failed to provide foot care and services for a resident that had a diagnosis of Diabetes (high blood sugar levels) and was admitted to the facility with elongated (long) toenails on 01/18/2024 and was not seen by a Podiatrist until 10/07/2024. The facility also failed to follow its policy titled Podiatry Services. This deficient practice was identified for 1 of 1 resident (Resident #2) reviewed for foot care. This deficient practice was evidence by the following: According to the admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to, Diabetes, Major Depressive Disorder, and Unspecified Dementia (general decline in cognitive abilities that affects a person's ability to perform everyday activities). A review of Resident #2's most recent Quarterly Minimum Data…

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 #: NJ00179130 Based on interviews, medical record review, and review of other pertinent facility documents on 11/07/2024 and 11/08/2024, it was determined that the facility failed to promptly notify the Physician of an abnormal urine culture result. The facility also failed to follow its policy titled Laboratory Services and Reporting. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for laboratory results. This deficient practice was evidenced by the following: According to the admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to, Diabetes (high blood sugar levels), Major Depressive Disorder, and Unspecified Dementia (general decline in cognitive abilities that affects a person's ability to perform everyday activities). A review of Resident #2's most recent Quarterly Minimum Data Set (MDS), an assessment tool dated 10/27/2024 revealed that the resident had a Brief Interview for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of facility documentation, it was determined the facility failed to maintain a comfortable and homelike environment for 3 resident rooms (room numbers 211, 212, and 213) on the C/D unit of the facility. The evidence of this deficient practice includes: 1. During the initial tour of the unit on 03/04/24 at 11:32 AM, in room [ROOM NUMBER], the surveyor observed the side table missing the middle drawer handle, the walls behind and next to the bed with gouges, the opposite wall with scratches and missing paint, the closets with scratches and missing laminate on the edges exposing the raw edge, and the closet drawer handle hanging perpendicular to the drawer. In the bathroom, the surveyor observed a brown discolored ceiling tile, a black bucket under the bathroom sink with water in it, and water on the floor under the sink. 2. On 03/04/24 at 11:40 AM, in room [ROOM NUMBER], the surveyor observed that the bottom of the window blind was broken in half. The resident stated that…

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

Based on observation, interview, and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On 03/04/24 from 09:54 to 11:03 AM, the surveyor toured the kitchen in the presence of the Dietary Director (DD) and observed the following: 1. On a metal rack in the walk-in refrigerator, there were two boxes marked raw chicken drumsticks that were resting on a parchment paper lined metal tray and the paper was marked pull with no date. The DD acknowledged there was no pull date and stated that it was important that expired food was not served, and that the box should have had a label with a pulled and use by date. 2. There was a box marked fresh leaf lettuce with a sticker dated 2/15/24. The lettuce was wilted, dry, had brown edges and there was black lettuce…

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 facility documentation, it was determined that the facility failed to follow appropriate infection control practices and perform hand hygiene as indicated during meal tray pass observed in the Main Dining area. The deficient practice was evidenced as follows: On 03/04/24 at 12:07 PM, the surveyor observed the following: The Licensed Practical Nurse (LPN) was standing at Resident #19's table, and with her bare hands, she opened a packet of powder, emptied the powder into a cup of white liquid and mixed it with a spoon with her left hand. With her right hand she removed a phone from her pocket and touched the phone screen then placed it back into her pocket. The LPN continued to stir the liquid with her left hand and added more powder from the packet with her right hand then continued to stir. The LPN then moved the cup onto the resident's tray and placed the spoon on the tray. The LPN returned to the food cart area and placed her hands in her pockets. She then approached the food cart, removed a food tray, and placed it in front 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 review of electronic medical records and other pertinent facility documentation, it was determined that the facility failed to follow professional standards of clinical practice with respect to obtaining a diagnosis for the use of an antibiotic intravenous medication for 1 of 1 residents (Resident #184) reviewed for antibiotics. 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 licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. According to the admission Record, Resident #184 was admitted to the facility in March of 2024. The resident did not have a comprehensive…

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 # 155679, 165123, and 168629 Based on interviews, review of electronic medical records, and review of other pertinent facility documents, it was determined that the facility failed to a.) obtain a physician order for the treatment of a skin tear that was obtained during a fall and b.) update a resident's Care Plan (CP) with fall prevention interventions after the resident fell on [DATE]. This was deficient practice was identified for 1 of 5 residents (Resident #334) reviewed for accidents and was evidenced by the following: According to the admission Record (AR), Resident #334 was admitted to the facility with the diagnoses that included, but were not limited to, osteomyelitis (infection of the bone), sepsis (occurs when your immune system has a dangerous reaction to an infection), and malignant neoplasm of the brain. The admission Minimum Data Set (MDS), an assessment tool that facilitates a resident's care, dated 09/07/23, reflected that the resident was cognitively impaired and had a history 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, record review, and review of facility documents, it was determined that the facility failed to a.) ensure an indwelling urinary catheter drainage bag did not touch the floor and b.) ensure the urinary catheter drainage bag was kept below the level of the bladder for 1 of 3 residents (Resident #67) reviewed for urinary catheter. This deficient practice was evidenced by the following: On 03/04/24 at 9:58 AM, the surveyor observed Resident #67 lying in bed. The resident had a urinary catheter (a tube placed in the body to empty urine) with a drainage bag secured to the bed. The bottom of the urinary catheter drainage bag was touching the floor. According to the admission Record, Resident #67 had diagnoses which included, but were not limited to, retention of urine. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 01/08/24, included the resident had a Brief Interview for Mental Status score of 15, which indicated the resident's cognition was intact. Further review of the MDS included 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 other pertinent facility documents, it was determined that the facility failed to label and dispose of medications in accordance with accepted professional principles for 1 of 1 residents (Resident #184) reviewed for antibiotic therapy. This deficient practice was evidenced by the following: According to the admission Record, Resident #184 was admitted to the facility in March of 2024. The resident did not have a comprehensive Minimum Data Set (MDS) completed at this time. The admission assessment (AA) indicated that Resident #184 was admitted to the facility with intravenous (IV) antibiotic therapy and rehabilitation. The AA indicated that the resident had the diagnoses of cellulitis and that the resident had a single lumen peripherally inserted central catheter (PICC) located in the right upper arm. On 03/04/24 at 10:47 AM, during tour, the surveyor observed a sign posted on the resident's door indicating that the resident was on transmission-based- precautions/contact isolation. The sign also indicated that to enter the room you must…

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# 168629 Based on interview and review of medical records and other facility documents, it was determined that the facility failed to maintain an accurately documented and complete medical record for 1 of 22 reviewed (Resident #334). This deficient practice was evidenced by the following: According to the admission Record (AR), Resident #334 was admitted to the facility with diagnoses that included, but were not limited to osteomyelitis (infection of the bone), sepsis (occurs when your immune system has a dangerous reaction to an infection), and malignant neoplasm of the brain. The admission Minimum Data Set (MDS), an assessment tool that facilitates a resident's care, dated 09/07/23, reflected that the resident was cognitively impaired and had a history of falls prior to admission to the facility. The resident was unable to be interviewed as he/she was not currently a resident in the facility. On 03/03/24 at 11:48 AM, the surveyor reviewed the facility's fall investigation and fall incident report, dated 10/08/23, which revealed the following information: According 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 interview and record review, it was determined that the facility failed to act on or respond to, comments made by the Pharmacist Consultant in a timely manner. This deficient practice was identified for 1 of 7 residents (Resident #31) reviewed for unnecessary medications and was evidenced by the following: According to the Pharmacist Consultant's Therapeutic Suggestions dated 07/26/21, the Pharmacist Consultant (PC) made a recommendation for Resident #31 As per CMS guidelines, is a taper of Zoloft [an antidepressant medication] indicated? If a taper of this medication is contraindicated, include the rationale in your response to this request. A review of the Order Summary Report for Active Orders as of 07/01/2021 revealed that Resident #31 had an order dated 01/12/21 for Sertraline HCL (Zoloft) 100 mg daily, an anti-depressant. A review of the 07/21, 08/21, 09/21, 10/21, and 11/21 Medication Administration Records (MAR) revealed Resident #31 received the medication daily. A review of the 12/21 MAR revealed that Resident #31 received the medication on 12/01/21, 12/02/21,…

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 11/29/21 at 9:52 AM, the surveyor, in the presence of the Food Service Director (FSD), observed the following during the kitchen tour: 1. In the dessert refrigerator, an undated turkey and cheese sandwich wrapped in clear plastic was stored on a shelf. 2. In the dessert refrigerator, an undated styrofoam cup containing dessert and an undated styrofoam cup containing lemonade was stored on a shelf. 3. In the dessert refrigerator, an opened bottle of ginger ale was stored on a shelf. 4. In the dessert refrigerator, an opened and undated bottle of water was stored on a shelf. 5. In the dessert refrigerator, an undated food platter wrapped in a plactic bag was stored on a shelf. When interviewed, the FSD stated that staff was suppose to label and date all personal items when stored 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 Based on interview and record review, it was determined that the facility failed to a.) consistently monitor fluid restriction instructions in accordance with the physician's order and professional standards of care for 1 of 2 residents (Resident #56) reviewed for dementia care and b.) clarify conflicting physician orders for 1 of 5 residents (Resident #18) reviewed for unnecessary medications. 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 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 physician 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.

Based on observation, interview, and record review, it was determined that the facility failed to follow an active physician's order to apply bilateral heel protectors (a cushioned pressure relieving device for heels) (heel protectors) while in bed. This deficient practice was identified for Resident #56, 1 of 2 residents reviewed for pressure ulcers and Resident #24, 1 of 1 resident reviewed for positioning and mobility and was evidenced by the following: On 12/01/21 at 10:58 AM, Surveyor #1 observed Resident #56 asleep with the head of bed elevated. Surveyor #1 observed that the resident had a heel protector applied to the left foot and no heel protector on the right foot. Surveyor #1 further observed a heel protector on the resident's wheelchair which was positioned near the resident's closet. According to the admission Record, Resident #56 had diagnoses that included, but were not limited to: dementia, diabetes, and heart failure. Review of the Quarterly Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 10/21/21, revealed the resident had…

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.