Optima Care Fountains

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that the device used to identify call device notifications were functioning properly for 1 of 7 units.This deficient practice was evidenced by the following: On [DATE] at 11:00 AM, the surveyor observed the call light was on outside the resident's room [ROOM NUMBER], but there was no audible sound. The surveyor observed unit 12's call light system machine in unit 12's nursing station had no audible sounds, and no button lights were on. On the same day, the surveyor observed another call light was on outside of another room in unit 12, but there was still no audible sound, and no lights were on in the nurses' station call light system machine. On [DATE] at 11:18 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated that the call light and sound were off in the nurses' station, but she had informed the maintenance department about the call light…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility documentation, it was determined that the facility failed to ensure handrails were secure and intact on 2 of 7 resident units. This deficient practice was evidenced by the following:1. On 2/13/2026 at 10:19 AM, the surveyor toured unit 8, 2nd floor and observed the following: -a handrail located across from emergency exit door, near the pay phone, next to room [ROOM NUMBER], was coming loose away from the wall. On 2/13/2026 10:24 AM, the surveyor interviewed the Certified Nursing Aide (CNA) on the unit, who stated if something was broken, she would report it to the nurse, who would then notify maintenance. She stated she was unaware of the loose handrail. On 2/13/2026 at 10:32 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) #1, for unit 8. LPN #1 stated if something was broken, he would call maintenance and enter it into the maintenance logbook (MLB). LPN #1 provided the surveyor with the MLB. A review of the MLB from October to present did…

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#NJ183884Based on interviews, medical record review and pertinent facility documents reviewed on 7/18/2025 and 7/21/2025, it was determined that facility staff failed develop and implement an oxygen Care Plan (CP) with appropriate interventions for a resident (Resident #2) receiving oxygen. This deficient practice was identified for 1 of 3 residents reviewed for CP and was evidenced by the following: Review of the Electronic Medical Record (EMR) was as follows:According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to Parkinson's, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, and Atrial Flutter.A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/18/2024, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 5/15, which indicated the resident was moderately cognitively impaired.A review of Resident #2's Order Summary Report (OSR), revealed an order for…

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

Complaint #NJ183644Based on interviews, medical record review and pertinent facility documents reviewed on 7/18/2025 and 7/21/2025, it was determined that facility staff facility failed to maintain a complete and accurate medical record (MR) for 1 (Resident # 3) of 11 sampled residents. This deficient practice is evident by the following:According to the facility admission Record (AR), Resident #3 was admitted to the facility with the following diagnoses which included but not limited to: Atrial Fibrillation, Anogenital Warts, Hypertension, Diabetes Mellitus, and Nontraumatic Intracerebral Hemorrhage.A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/17/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 14/15, which indicated that the resident's cognitive function was intact.A review of Resident #3's Care Plan (CP), initiated 11/6/2024, included a focus, Resident #3 has Cerebral Vascular Accident (Stroke) r/t Hemorrhage. Interventions included but were not limited to, Monitor/document residents…

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 #: NJ00182050 Based on interviews, review of medical records, and other pertinent facility documentation on 1/16/2025 and 1/17/2025, it was determined that the facility failed to: a.) administer medications as prescribed within the appropriate medication administration timeframe and b.) notify the physician when a medication was not available for administration. The facility also failed to follow its policy titled Medication Administration Policy. This deficient practice was identified for 2 of 3 residents reviewed for medication administration documentation. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses that included but were not limited to: Parkinson's Disease, Unspecified Dementia, and Unspecified Depression. A review of Resident #1's Minimum Data Set (MDS), an assessment tool dated 10/12/2024, revealed a Brief Interview of Mental Status (BIMS) of 14 out of 15, which indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ00182050 Based on interviews, medical record review, and review of other pertinent facility documents on 1/16/2025 and 1/17/2025 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. This deficient practice was identified for 3 of 3 residents reviewed for ADL documentation. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses that included but were not limited to: Parkinson's Disease, Unspecified Dementia, and Unspecified Depression. A review of Resident #1's Minimum Data Set (MDS), an assessment tool dated 10/12/2024, revealed a Brief Interview of Mental Status (BIMS) of 14 out of 15, which indicated the resident's cognition was intact. The MDS further revealed that the resident was independent with toileting hygiene and dressing but requires…

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 facility policy review, the facility failed to maintain proper food holding temperatures. This had the potential to affect 273 of 273 residents who ate food from the kitchen. This failure had the potential to cause food borne illness in the facility. Findings include: Review of the facility's policy and procedure for Holding Hot Food Prior to Service, last revised 04/20/2022, revealed, . It is the policy of this facility to hold hot food at acceptable temperature range prior to service . Upon removal from the oven or stove, cooked meats are to be kept at an internal temperature of 140 degrees or higher in a steamtable, or suitable device . During the noon meal preparation on 10/16/24 at 11:30 AM., food for the meal was removed from the oven, temperatures were obtained, and the food was placed on the steam table. The food temperatures when removed from the oven were: Seasoned chicken thighs- 160 degrees Fahrenheit (F). Italian green beans - 200 degrees F. Carrots - 170 degrees F. The meal trays were prepared and then loaded onto…

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, the facility failed to inform three of three residents and/or their responsible parties (Resident (R) 380, R112, and R265) reviewed for arbitration agreements out of a total sample of 45 of their right to rescind the arbitration agreement within 30 calendar days and their right to not be required to enter into a binding arbitration agreement as a condition of admission. Findings include: Review of the facility's undated admission Agreement revealed in section 9. Miscellaneous Category G, Disputes, Any controversy, dispute or disagreement arising out of or in connection with this Agreement, the breach thereof, or the subject matter thereof including Facility's obligation thereof shall be settled by binding arbitration, which shall be conducted in Jersey City, New Jersey in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Arbitration, and which to the extent of the subject matter of the arbitration shall be binding not only on all the parties to this Agreement, but on any other…

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, the facility failed to ensure their arbitration agreement informed three of three residents and/or their responsible parties (Resident (R) 380, R112, and R265) reviewed for arbitration agreements out of a total sample of 45 of their right to the selection of a neutral arbitrator agreed upon by both parties. The agreement also failed to inform the residents and/or their representatives of their right to select a venue for arbitration that was convenient to both parties. Findings include: Review of a copy of the facility's undated admission Agreement revealed in section 9. Miscellaneous Category G, Disputes, Any controversy, dispute or disagreement arising out of or in connection with this Agreement, the breach thereof, or the subject matter thereof including Facility's obligation thereof shall be settled by binding arbitration, which shall be conducted in Jersey City, New Jersey in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Arbitration, and which to the extent 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.

Based on interview, observation, and facility policy review, the facility failed to provide information on how to file an anonymous grievance for seven of seven residents (Residents (R) 23, R44, R117, R140, R152, R177, and R200) reviewed for the grievance process out of a total sample of 45. The failure had the potential to affect residents' ability to safely report concerns without fear of retaliation. Findings include: Review of the facility's policy titled, Resident and Family Grievances, revised 10/16/24, revealed, . It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal . A grievance may be filed anonymously. Anonymous grievance may be filed using the Compliance Hotline and/or complaint/grievance boxes located throughout the facility . During the initial tour of the facility, a poster recording the number for the facility's Compliance Hotline was observed posted near the administrative office. No complaint/grievance boxes were observed in the facility.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, review of facility reported incidents (FRI), and review of facility policy, the facility failed to protect the residents' right to be free from physical abuse by other residents for five (Resident (R) 262, R426, R424, R66, and R128) of eight residents reviewed for abuse out of a total sample of 45 residents. R262 scratched R76 on the face with a broken comb; R426 pulled R424's hair; and R140 struck R142, R66, and R128 with his hand. The facility's failure to protect residents from abuse placed resident at continued risk of harm. Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, reviewed 07/2024, indicated, It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. 1. a. Review of R262's admission Record, located under the Profile…

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, review of facility reported incidents (FRI), and review of facility policy, the facility failed to ensure allegations of resident-to-resident abuse involving four of eight residents (Resident (R) 262, R76, R426, and R424) reviewed for abuse out of a total sample of 45 were reported to the state agency (SA) within two hours of knowledge of the alleged incidents. This failure had the possibility of negatively impacting all 277 residents currently residing in the facility. Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, reviewed 07/2024, indicated, . Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency (SA), adult protective services (APS) and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than two hours after the allegation is made, if the events that cause…

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, review of facility reported incidents (FRI), and review of facility policy, the facility failed to ensure allegations of resident-to-resident abuse involving four of eight residents (Resident (R) 262, R76, R426, and R424) reviewed for abuse out of a total sample of 45 were thoroughly investigated. The failure to thoroughly investigate allegations of abuse had the potential to cause other residents to be at risk of abuse. Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, reviewed 07/2024, indicated, . Investigation of alleged abuse, neglect and exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: . 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations . 6. Providing…

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, the facility failed to provide written information regarding the facility's bed-hold policy for six of nine residents (Resident (R) 75, R111, R127, R209, R90, and R186) reviewed for hospitalization out of a total sample of 45. The failure had the potential to cause confusion for residents planning on returning to the facility. Findings include: Review of the facility's policy titled, readmission To Facility, revised 07/2023, indicated, It is the policy of this facility to protect the resident's rights to readmission by initiating a bed-hold and permitting each resident to return to the facility after they are hospitalized or placed on therapeutic leave, regardless of payment source . Procedure: 1. The facility will initiate a bed-hold and permit residents to return to the facility and resume residence after they are hospitalized or placed on therapeutic leave . 4. Residents who seek to return to the facility within the bed-hold period in the state plan are allowed to return…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and test tray sample, the facility failed to provide food that was palatable, flavorful and at proper temperature for nine of nine residents (Resident (R) 111, R162, R117, R23, R44, R140, R152, R177, and R200) reviewed for food palatability. This failure had the potential for residents who disliked a meal to experience nutritional problems or dissatisfaction with their meals. Findings include: Review of the facility's policy and procedure for Holding Hot Food Prior to Service, last revised 04/20/2022, revealed, . It is the policy of this facility to hold hot food at acceptable temperature range prior to service . Upon removal from the oven or stove, cooked meats are to be kept at an internal temperature of 140 degrees or higher in a steamtable, or suitable device . 1. Review of R111's admission Record, located under the Profile tab in the EMR, indicated that R111 was re-admitted to the facility on [DATE] with a diagnosis of dysphagia. Review of R111's quarterly…

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

Based on record review, interviews, and observations, the facility failed to maintain documentation and demonstrated evidence of its' ongoing Quality Assessment and Performance Improvement (QAPI) program. This failure had the potential to negatively affect 277 of 277 residents who resided at the facility. Findings include: Review of the facility's policy titled, QAPI Plan Quality Assessment and Performance Improvement, updated 04/01/24, indicated, . Optima Care Fountains maintains a coordinated quality assessment and assurance program which integrates the review activities of all nursing home programs and services to enhance the quality of life and resident care and treatment. The purpose of the QAPI at Optima Care Fountains is to take a proactive approach to continually improving the way we care for and engage with our residents, caregivers, and other partners. To do this we study, plan, analyze, and validate specific areas of improvement for positive resident care outcomes. This will allow us to realize our Vision and carry out our Mission Statement. The QAPI will meet monthly.…

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

Based on interviews and record reviews, the facility failed to obtain feedback, use data, and take action to conduct systematic investigations and analyses of underlying causes or contributing factors of problems affecting facility-wide processes. Specifically, the facility failed to use feedback and data from resident council meetings to address food palatability concerns. This failure had the potential to affect the nutritional status of 273 of 273 residents who ate food from the kitchen. Findings include: Review of the facility's policy titled, QAPI Plan Quality Assessment and Performance Improvement, updated 04/01/24, indicated, Optima Care Fountains maintains a coordinated quality assessment and assurance program which integrates the review activities of all nursing home programs and services to enhance the quality of life and resident care and treatment. The purpose of the QAPI at Optima Care Fountains is to take a proactive approach to continually improving the way we care for and engage with our residents, caregivers, and other partners. To do this we study, plan, analyze,…

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, policy review, and record review, the facility failed to ensure one of 45 (Resident (R) 26) sampled residents observed while dining were treated with dignity. Specifically, staff failed to sit while feeding R265. This failure had the potential to cause residents to feel undignified. Findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, revised 07/2023, revealed, . It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . Review of R265's admission Record, found in the electronic medical record (EMR) Profile tab, showed a facility admission date of 08/14/24 with diagnoses that included acute stroke with right-sided weakness and aphasia. Review 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, record review, and facility policy review, the facility failed to ensure personal privacy during care for two of 47 (Resident (R) 75 and R110) residents observed. This had the potential to cause embarrassment or shame for the residents. Findings include: Review of the facility's policy titled, Resident Privacy and Confidentiality, dated 07/2023, revealed, . During the delivery of personal care and services, staff must remove residents from public view, pull privacy curtains or close doors, and provide clothing or draping to prevent exposure of body parts . 1. Review of R75's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R75 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to embolism, chronic congestive heart failure, and Alzheimer's dementia. Review of R75's significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/26/24, revealed R75 had a Brief Interview…

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 policy review, the facility failed to ensure one of one public bathrooms (Unit 12 public bathroom) observed for concerns was free of insects and was maintained in a sanitary manner. This had the potential to cause the spread of infection by disease-causing organisms. Findings include: Review of the facility's policy titled, Resident Environment, dated 09/2022, revealed, . Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior . During an interview on10/16/24 at 12:55 PM, the Director of Housekeeping (HKSP) stated the facility's pest management company came every two weeks and sprayed to prevent insects for the entire campus. HKSP stated this treatment would take two days to complete, and if there were any issues with pests, it would be documented at each nurses' station which areas might require attention. Review of the facility's pest control sheets for September 2024 revealed no documentation of roaches on Unit 12. During a confidential interview on 10/16/24 at 4:35 PM, a family…

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 policy review, the facility failed to ensure interventions to aid in the healing of pressure ulcers were implemented as per the plan of care for one of five residents (Resident (R) 157) reviewed for pressure ulcers out of a total sample of 45. This failure had the potential to contribute to delayed healing of the resident's pressure ulcer. Findings include: Review of the facility's policy titled, Pressure Injury Prevention Policy, dated 07/2023, revealed, . Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used . Review of R157's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R157 was admitted to the facility on [DATE] with diagnoses that included stroke, impaired thought process, and anxiety. Review of R157's Care Plan, dated 05/06/24 and located under the Care Plan tab of the EMR, revealed R157 had a pressure ulcer to her right heel.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that two residents (Resident (R) 110 and R76) from a sample of 45 residents had a way of making sure that medications were secured. This failure has the potential to expose residents to hazards of unsecure medications. Findings include: Review of the facility's policy titled, Medication Administration Policy, dated 03/2023, indicated, It is the policy of this facility to ensure that facility staff follows the guidelines for a safe, timely and accurate administration of resident medications. Procedure . The licensed nurse is responsible to . Assures medications are not left unattended. Keeps medications secured in a locked area or in visible control at all times . 1. Review of R110's admission Record, located under the Profile tab of the electronic medical record (EMR), indicated that R110 was re-admitted to the facility on [DATE] with diagnoses that included corneal edema. Review of R110's Order Summary…

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, interview, and review of facility policy, the facility failed to ensure staff donned the appropriate personal protective equipment (PPE) when providing direct care to two of 13 residents (Resident (R) 110 and R157) on Enhanced Barrier Precautions (EBP) out of a total sample of 48. This failure could promote the spread of multi-drug-resistant organisms throughout the facility. Findings include: Review of the facility's policy titled, Enhanced Barrier Precautions, dated 04/01/24, revealed, . All staff must wear gloves and gowns during high-contact activities for residents identified. Examples of high-contact activities are: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device are or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. Wound care: any skin opening requiring a dressing . 1. Review of R110's admission Record, located under the Profile tab of the EMR, revealed R110…

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

Based on interview and record review, it was determined that the facility failed to ensure that the resident's primary physician reviewed, signed and dated the monthly physician orders (PO) to ensure that the resident's current medical regimen was appropriate. This deficient practice was observed for 17 of 35 residents. Resident #202, #239, #29, #30, #53, #137, #157, #245, #257, #165, #236, #58, #148, #152, #146, #127, and #111 were reviewed and found that for several months physicians did not sign resident's monthly POs. This deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) for the residents listed above which revealed that the resident's primary physician had not physically signed the Order Summary Reports (monthly physician's orders) located in the residents' chart. In addition, there were no electronic signatures under the physician's orders for the following residents: 1. On 11/16/22, during the review of Resident #202's hybrid medical records, the surveyor observed that the resident's physician had not…

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

Based on observation, interview, and record review, it was determined that the facility failed to ensure proper use of personal protective equipment (PPE) for staff in accordance with the Centers for Disease Control and Prevention guidelines for infection control. This deficient practice was evidenced by the following: 1. On 11/14/22 at 11:21 AM, the surveyor observed the unit 2 Licensed Practical Nurse, Unit Manager (LPN UM) wearing an N 95 mask (a respirator mask) with both of the yellow straps cut and tied behind her ears. The LPN UM stated that she was fit tested to wear this N 95 mask but that it felt too tight to wear so she cut the straps and tied them so the straps go behind her ears. 2. On 11/14/22 at 11:29 AM, the surveyor observed a unit 2 Housekeeper (HK) wearing an N 95 mask on top of a surgical mask. The HK stated that the N 95 mask causes her to have marks on her skin so she wore the surgical mask under it. She stated that she was fit tested for this N 95 mask and had in-services but thought that it was okay to wear the surgical mask under the N 95 mask. 3. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined that the facility failed to maintain professional standards of nursing practice by not following a physician's order for 2 of 10 sampled residents, Resident #94 and #204. 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 casefinding; 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. 1. On 11/15/22 at 9:20 AM, the surveyor interviewed Resident #94 at bedside. Resident #94 stated they are a Diabetic and their blood sugars have not been taken in a long time but use to be taken…

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 residents were weighed monthly in accordance with physician's orders and facility policy. This deficient practice was identified for 2 of 11 residents, Residents #154 and #127 reviewed for nutrition. The deficient practice was evidenced by the following: 1. On 11/14/22 at 12:18 PM, the surveyor observed Resident #154 lying in bed on a pressure relieving mattress. Resident #154 responded to conversation in English and Spanish (main language). Resident #154 appeared comfortable, awake and alert. The surveyor reviewed the resident's hybrid paper and electronic medical record (EMR). The surveyor reviewed the admission Record (A one-page summary of important information about a resident) belonging to Resident #154. Resident #154 was admitted to the facility with diagnoses that included but were not limited to Hypothyroidism (when the thyroid gland doesn't produce enough thyroid hormone), Hyperlipidemia (high levels of fat in the blood), and Diabetes Mellitus. 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, interview, and record review, it was determined that the facility failed to maintain respiratory equipment in a sanitary manner for a resident who was receiving continuous oxygen (O2) and utilizing a BiPap machine (helps push air into your lungs). The deficient practice was identified for 1 of 2 residents (Resident #202) reviewed for respiratory care. This deficient practice was evidenced by the following: On 11/14/22 at 11:35 AM, the surveyor observed Resident #202 laying on bed with O2 in use via a nasal cannula (n/c) set at 2 liters per minute (LPM) attached to the humidified O2 concentrator (a medical device used for delivering O2). The surveyor observed the oxygen tubing was touching the floor. The nurse assigned to Resident #202 was brought inside the room and during the interview, the nurse stated that the oxygen tubing must not be touching the floor. On 11/15/22 at 10:45 AM, the surveyor observed Resident #202 laying on bed with O2 in use via n/c at 2 LPM attached to the humidified…

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 (CNA) on an annual basis. This deficient practice occurred with 5 of 5 CNAs whose personnel records were reviewed and was evidenced by the following: 1. According to data provided by the facility, CNA #1 was hired at the facility on 11/8/16. When reviewed, there were no current annual performance evaluations available in CNA #1's personnel file. When interviewed by the surveyor on 11/23/22 at 1:30 p.m., the Director of Nurses (DON) stated that CNA #1 was due for having her performance reviewed. The DON could not explain why there had been no annual performance evaluations conducted with CNA #1. 2. According to data provided by the facility, CNA #2 was hired at the facility on 11/7/05. When reviewed, there were no current performance evaluations in her personnel file. When interviewed by the surveyor on 11/23/22 at 1:30 p.m., the DON stated that CNA #2 was due for having her performance reviewed. The DON could not explain why there had been…

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, it was determined that the facility failed to label multidose medication containers with the open date. This was found in 1 of 9 medication carts inspected. The deficient practice was evidenced by the following: On 11/16/22 at 11:45 AM the surveyor inspected the Unit 11 medication cart in the presence of the Registered Nurse (RN) who was assigned to the cart. The following multidose medication containers were open and not dated with the open date: Latanoprost ophthalmic solution 2.5 ml multidose bottle Risperdal oral solution 10 ml multidose vial 1 mg/1 ml. Haldol 10 ml multidose vial 5 mg/1 ml. The RN stated the medications should have been dated when they were opened. The RN discarded the medications. On 11/16/22 at 11:30 AM the surveyor reviewed the facility's policy and procedure which was titled Medication Storage with a review date of 7/24/22. The policy included the statement Medications are labeled & dated upon opening, PPD vials/Insulin/Multidose vials. On 11/17/22 at 10:00 AM the surveyor discussed the labeling concern with the Director…

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.