The Center For Rehab & Nursing Washington Township

Complaint #: NJ184057 Based on observation, interview, review of the Electronic Medical Record (EMR) and review of other facility documentation on 03/05/2025 and 03/05/2025, it was determined that the facility failed to update and revise a resident's care plan, specifically for a newly identified wound, for 1 of 1 resident reviewed for comprehensive person-centered care plans, (Resident #4). This deficient practice was evidenced by the following: A review of the admission Record (an admission summary) reflected that Resident #4 was admitted to the facility with diagnoses that included but were not limited to: Anemia (low healthy red blood cells and hemoglobin), Depression (feeling of sadness), and Muscle Weakness. A review of the admission Minimum Data Set, an assessment tool used to facilitate the management of care dated 01/12/2025, reflected that the resident had a Brief Interview for Mental Status score of 14 out of 15, indicating that the resident was cognitively intact. Section M0100 revealed no pressure ulcer. A review of Resident #4's Care Plan (CP) initiated on 01/06/2025…

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 #: NJ184057 Based on observation, interview, and review of pertinent facility documents on 03/05/2025 and 03/05/2025, it was determined that the facility failed to: a.) ensure the treatment cart was secured during wound care observation, b.) initial, date, and time a dressing prior to applying on a resident (R#4) in accordance with professional standards of clinical practice. The facility also failed to follow its policies titled Storage of Medications and Wound Care This deficient practice was identified for 1 of 1 resident observed for wound care. 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…

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#: NJ182815 Based on observations, interviews, and review of other facility documentation on 3/5/2025, it was determined that the facility failed to: a.) ensure that food items were dated, b.) ensure outdated food items were discarded, and c.) ensure refrigerator temperatures in the kitchen were completed to prevent foodborne illnesses. This deficient practice was evidenced by the following: On 3/5/2025 from 10:08 AM to 10:40 AM, the surveyor, accompanied by the Dietary Director (DD), observed the following during a tour of the kitchen: 1. On the bread rack, the surveyor observed: - an unopened loaf of sliced rye sandwich bread with a use by date of 2/22/25. - an opened gluten free white wide slice bread with a use by date of 2/11/25. -an opened bag of 8 English muffins with no label and no expiration date. 2. The surveyor observed a temperature log sheet outside the walk-in refrigerator that had a blank space for 3/4/2025, for PM temperatures. 3. The surveyor and DD entered the walk-in refrigerator that contained milk and juice. The surveyor observed a cart in the walk-in…

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

Complaint #: NJ184057 Based on observation, interview, and review of pertinent facility documents on 3/5/2025 and 3/6/2025, it was determined that the facility staff failed to maintain appropriate infection control practices specifically by not properly discarding an opened pack of unused 4x4 gauze after a wound care observation to prevent the potential spread of infection in accordance with the Center for Disease and Control prevention guidelines and Standards of Clinical Practice. The facility staff failed to follow their policy titled Infection Prevention and Control Program. This defiant practice was identified during 1 of 1 wound care observation. On 3/5/2025 at 12:00 P.M., the surveyor observed the Registered Nurse (RN#1) complete a wound care treatment. Upon completion of the wound care, RN#1 was observed gathering and returned an opened pack of unused 4x4 gauze and placed it in the treatment cart. On 03/05/2025 at 12:45 P.M., during an interview with RN#1, she stated the opened pack of unused 4x4 gauze from the resident's room should have been discarded and not placed in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ182815 Based on observations and interviews on 3/5/2025 and 3/6/2025, it was determined that the facility failed to ensure their wireless call bell system communicated calls directly to the staff. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses that included but were not limited to: fracture of unspecified part of neck of left femur, sarcoidosis (an inflammatory disease of the lungs and lymph nodes), and hypertension. A review of resident #1's Minimum Data Set (MDS), an assessment tool dated 2/28/2025, revealed a Brief Interview of mental Status (BIMS) score of 13 out of 15, which indicated the resident's cognition was intact. The MDS further revealed the resident was dependent for toileting hygiene. On 3/5/2025 at 11:21 AM, the surveyor interviewed Resident # 1 in the presence of the resident's family member. The resident stated he /she was admitted to the facility several weeks ago.…

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 #'s: 168276, 169388, 173735 and 174353 Based on observation, interview, record review, and document review, it was determined that the facility failed to provide sufficient nursing staff to ensure all residents reached their highest practical wellbeing by failing to: a) provide timely incontinence care to 1 out of 4 residents (Resident #47) reviewed for Activities of Daily Living, and (b) sufficient nursing staff for 5 of 5 weeks of staffing prior to the recertification survey date of 11/22/24. The deficient practice was evidenced by the following: Refer to S0560 1.) On 11/19/24 at 11:04 AM, the surveyor observed the resident #47 lying in bed with his/her eyes closed. observed resident in bed. The surveyor observed the resident's family member at the bedside. The family member repositioned Resident #47 and showed the surveyor Resietn #47 incontinence brief which was saturated with urine and urine had leaked onto the cloth underpad. The resident's family meember stated that the resident was usually washed, dressed, and up in their wheelchair by this time. At 11:08AM, 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 handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was identified in the facility's kitchen and 5 of 5 pantries designated for resident food, and was evidenced by the following: On 11/88/24 from 9:16 AM to 10:26 AM, the surveyor, accompanied by the Food Service Director (FSD) toured the kitchen and observed the following: In the Walk-in Freezer: 1. one box containing French toast inside a plastic bag that was not closed and the French toast was open to the air. 2.One 10-pound box of veggie burgers inside a plastic bag that was not closed, and the burgers were open to the air. At that time, the FSD stated that the French toast and the veggie burgers should be closed and wrapped. On 11/19/24 at 9:32 AM, the surveyor accompanied by the Licensed Practical Nurse (LPN #1) observed the following in the 200-unit pantry: a) the freezer did not contain a thermometer b) 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 facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of garbage and debris. This deficient practice was evidenced by the following: On 11/18/14 at 10:06 AM, during initial kitchen tour with the Food Service Director (FSD), the surveyor observed the trash company at the dumpster area. The surveyor observed the debris, trash, leaves around the enclosed dumpster area. The dumpster area included four (4) blue dumpsters and one (1) black dumpster container for used oil. The surveyor observed five (5) black trash bags lying directly on the ground next to the first dumpster and one (1) black trash bag lying directly on ground next to third dumpster. At that time, the surveyor, in the presence of the FSD, interviewed the driver of the trash company who stated that he had just moved the (5) black trash bags that were lying in front of the dumpster directly on the ground to the side of the dumpster so he…

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 record review, it was determined that the facility failed to ensure that the residents' dining experience was provided in a manner to promote dignity and respect of the residents. This deficient practice was identified in 1 of 6 dining areas observed, (the Activities room) and was evidenced by the following: On 11/19/24 at 11:59 AM, the surveyor observed dining on the first-floor activities room. The surveyor observed two (2) residents (Resident #22 and Resident #94) sitting at the same table. Resident #94 had their lunch tray and was eating. Resident #22 had not received their lunch tray. At that time, the surveyor interviewed a Licensed Practical Nurse (LPN # 2) who stated that residents who were seated at the same table should have been served their lunch at the same time. At 12:02 PM, LPN #2 stated that she had called the kitchen to obtain Resident #22's lunch tray. At that time, the surveyor observed Resident #22 take a piece of brownie from Resident # 94's plate and ate it. Then, Resident #94 tried to feed a forkful of broccoli 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, medical record review, and review of other facility documentation, it was determined that the facility failed to document a resident's life-sustaining treatment preference on the physician's orders. This deficient practice was identified for one (1) of one (1) resident (Resident #52) reviewed for advanced directives and was evidenced by the following: On 11/18/24 at 11:18 AM, the surveyor reviewed the medical record for Resident #52. There was no documented evidence of the resident's code status. A review of the admission Record, (an admission summary) revealed the resident was admitted to the facility with diagnoses which included: heart failure, depression, obstructive sleep apnea, atrial fibrillation, hyperlipidemia, and hypertensive chronic kidney disease. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool, dated 11/3/24, included the resident had a Brief Interview Mental Status (BIMS) score of 13 out of 15, which indicated the resident's cognition was intact. On 11/20/24 at 11:25 AM, the surveyor interviewed the Registered…

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 #NJ169388 Based on interview, record review, and review of facility documents, it was determined that the facility failed to report an allegation of staff to resident abuse to the New Jersey Department of Health and the Office of the Ombudsman in a timely manner in accordance with state and federal requirements and the facility policy. This deficient practice was identified for 1 of 1 resident (Resident #199) reviewed for abuse and was evidenced by the following: Refer to F610 A review of the admission Record (an admission summary), revealed the resident had diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, recurrent, moderate, generalized anxiety disorder, mild cognitive impairment of uncertain or unknown etiology, unspecified urinary incontinence, and morbid (severe) obesity due to excess calories. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool, dated 12/10/23, included the resident had a Brief Interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #NJ169388 Based on interview, record review, and review of facility documents, it was determined that the facility failed to conduct a timely and thorough investigation in accordance with the facility policy for an allegation of staff to resident abuse. This deficient practice was identified for 1 of 1 resident (Resident #199) reviewed for abuse and was evidenced by the following: Refer to F609 On 11/18/24 at 10:27 AM, the surveyor reviewed the closed medical record for Resident #199. A review of the admission Record (an admission summary), revealed the resident had diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, recurrent, moderate, generalized anxiety disorder, mild cognitive impairment of uncertain or unknown etiology, unspecified urinary incontinence, and morbid (severe) obesity due to excess calories. A review of the resident's quarterly Minimum Data Set (MDS), 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ173651 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to revise a resident's individual comprehensive care plan after a resident developed contractures for 1 of 2 residents (Resident #2) reviewed for limited range of motion. This deficient practice was evidenced by the following: On 11/17/24 at 10:16 AM, the surveyor observed Resident #2 lying in bed. The resident's left hand appeared contracted. On 11/18/24 at 10:24 AM, the surveyor reviewed the medical record for Resident #2. A review of the admission Record (an admission summary), revealed the resident had diagnoses which included: unspecified dementia, major depressive disorder, generalized anxiety disorder, insomnia, and muscle weakness. A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 10/23/24, included the resident had a Brief Interview for Mental Status score of 3 out of 15 which indicated the resident's cognition was severely…

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 #: NJ173651 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide nail care to a resident who was unable to carry out activities of daily living (ADL) for 1 of 4 residents (Resident #2) reviewed for ADL care. This deficient practice was evidenced by the following: On 11/18/24 at 10:54 AM, the surveyor observed Resident #2 lying in bed. The resident's left hand appeared contracted and the fingernail on the resident's left middle finger was long in length and jagged. On 11/18/24 at 10:24 AM, the surveyor reviewed the medical record for Resident #2. A review of the admission Record (an admission summary), revealed the resident had diagnoses which included: unspecified dementia, major depressive disorder, generalized anxiety disorder, insomnia, and muscle weakness. A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 10/23/24, included the resident had a Brief Interview for Mental Status score of 3 out of 15 which indicated the resident's cognition was severely…

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 #: NJ173651 and NJ174353 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide a resident with meaningful activities that reflected the resident's preferences for 1 of 1 resident (Resident #2) reviewed for activities. This deficient practice was evidenced by the following: On 10/18/24 at 10:24 AM, the surveyor reviewed the medical record for Resident #2. A review of the admission Record (an admission summary), revealed the resident had diagnoses which included: unspecified dementia, major depressive disorder, generalized anxiety disorder, insomnia, and muscle weakness. A review of the comprehensive Minimum Data Set (MDS), an assessment tool, dated 4/25/24, included the resident had a Brief Interview for Mental Status score of 3 out of 15 which indicated the resident's cognition was severely impaired. Further review of the MDS revealed it was important for the resident to do things with groups of people and that the resident was dependent on staff for all activities of daily living (ADLs). A…

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

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to: a.) notify the physician of an injury sustained by a resident, b.) obtain a physician's order for a wound treatment, and c.) document a skin assessment in accordance with the facility policy and professional standards of nursing practice. This deficient practice was identified for 1 of 1 resident (Resident #78) reviewed for skin conditions 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 and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New…

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 #: NJ173651 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure floor mats were in place for 1 of 2 residents (Resident #2) reviewed for falls. This deficient practice was evidenced by: On 10/17/24 at 10:16 AM and 10/18/24 at 10:54 AM, the surveyor observed Resident #2 lying in bed. On both observations, there were no floor mats on either side of the resident's bed. On 10/18/24 at 10:24 AM, the surveyor reviewed the medical record for Resident #2. A review of the admission Record (an admission summary), revealed the resident had diagnoses which included: unspecified dementia, major depressive disorder, generalized anxiety disorder, insomnia, and muscle weakness. A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 10/23/24, included the resident had a Brief Interview for Mental Status score of 3 out of 15 which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident was dependent on staff for all activities of daily…

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

REPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed a.) to provide a continuous positive airway pressure (CPAP- a machine used to keep breathing airways open during sleep) to accommodate the respiratory needs of a resident upon admission to the facility, b.) ensure the CPAP was stored in accordance with professional standards when not in use, and c.) ensure the individualized comprehensive care plan included CPAP therapy. This deficient practice was identified for 1 of 3 residents reviewed for respiratory care (Resident #52), and the evidence was as follows: On 11/17/24 at 11:10 AM, during the initial tour, Resident #52 was observed sitting upright in the wheelchair with their eyes closed. At that time, the surveyor observed a CPAP machine and face mask on top of the nightstand and the face mask was not properly stored inside a plastic bag. A review of the admission Record (an admission summary), revealed the resident was admitted to the facility with diagnoses which included: heart failure,…

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

Based on observation, interview, and review of facility documents, it was determined that the facility failed to ensure that the daily Nursing Home Resident Care Staffing Report was posted and displayed in a place that was readily accessible to be viewed by both residents and the general public as indicated on the report. This deficient practice was identified on 5 of 5 nursing units and was evidenced by the following: On 11/18/24 at 9:37 AM, the surveyor observed the facility's Nursing Home Resident Care Staffing Report posted on the receptionist's desk in the front main lobby. A pass code was required to be entered into a keypad on the wall to gain access to the locked double doors that led to the nursing units. The surveyor toured the facility and did not observe the daily Nursing Home Resident Care Staffing Report posted on any of the five nursing units. On 11/21/24 at 2:10 PM, when the surveyor asked the Director of Nursing (DON) where the staffing report was posted she stated that it was posted at both entrances to the facility. When asked if the staffing report was available…

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 follow appropriate infection control practices during the provision of a wound treatment. This deficient practice was observed for 1 of 1 nurse (400 Unit) observed during the provision of wound care to 1 of 1 resident (Resident #62) and was evidenced by the following: On 11/17/24 at 11:24 AM, the surveyor observed Resident #62 lying in bed on an air mattress. On 11/18/24 at 12:27 PM, the surveyor reviewed the medical record for Resident #62. A review of the admission Record (an admission summary), revealed the resident had diagnoses which included: osteomyelitis (a bone infection), unspecified, type 2 (two) diabetes mellitus with diabetic chronic kidney disease, muscle weakness (generalized), need for assistance with personal care and pressure ulcer of sacral region, Stage 4 (four) (Full thickness tissue loss with exposed bone, tendon or muscle). A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool, dated 10/31/24, included…

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

Based on observation, interview, and review of documentation, it was determined that the facility failed to store, label, and date potentially hazardous food, and maintain kitchen sanitation in a manner intended to limit the spread of food-borne illnesses. The deficient practice was evidenced by the following: On 08/02/23 at 9:50 AM, the surveyor entered the facility kitchen and toured with the Food Service Director (FSD). The surveyor observed 3 crates of milk that had no expiration dates printed on each milk. The FSD confirmed there were 75 milk cartons in each crate for a total of 225 milk cartons that had no expiration dates and confirmed the facility uses the First in, First out method and the dates should have been checked upon delivery before being stored in the refrigerator. On that same day at 10:16 AM, the surveyor observed 4 packs of bread on the countertop that were all unlabeled. The FSD stated the bread was brought out to be used today. There were 2 bags of partially used hamburger buns, 1 pack of partially used hot dog buns, and another bag was found on the bread rack…

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, review of medical records and other facility documentation, it was determined that the facility failed to follow professional standards of nursing practice by a.) not obtaining a physician's order for a negative pressure wound therapy (NPWT) machine setting prior to application. This deficient practice was identified for 1 of 1 residents (Resident #188) reviewed for skin conditions, b.) not clarifying physician orders for 1 of 4 residents reviewed for medication administration, (Resident # 56), and c.) not completing weekly skin assessments as ordered by the physician for 9 of 21 residents reviewed (Resident #38, #12, #8, #69, #78, #97, #68, #37, and #89) 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 state: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential…

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 document review, it was determined that the facility failed to provide documented evidence that Quality Assessment and Assurance (QAA) meetings were held with the required members in attendance for the past four quarters. On 08/04/23 at 1:45 PM, the surveyor requested all quarterly sign-in sheets for QAA meetings for the past four quarters. The Licensed Nursing Home Administrator (LNHA) stated that there were no sign-in sheets or proof of attendance as staff attended the meetings remotely via ZOOM (online platform). The LNHA further stated that since the facility recently changed ownership, she no longer had access to her emails and was unable to furnish the surveyor with documented evidence of staff meeting attendance or topics that were discussed. The LNHA stated that if the lack of documentation resulted in a deficient practice so be it, as she did not have access to any type of proof of QAA meeting attendance. On 08/14/23 at 10:07 AM, the surveyor interviewed the LNHA who stated that she began working at the facility in September of 2022. The LNHA stated…

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 pertinent facility records it was determined that the facility failed to implement infection control protocols in a manner that would decrease the possibility of the spread of infection by a.) not performing hand hygiene in accordance with the Center for Disease Control and Prevention and facility policy during wound care and b.) during the distribution of resident meal trays. This was observed for a.) 1 of 1 residents (Resident #68) reviewed for wound care and b.) 5 of 7 nursing staff observed on 2 of 4 nursing units during resident meal pass. This deficient practice was evidenced by the following: a.) On 8/2/23 at 10:57 AM, the surveyor observed Resident #68 in their room sitting in a wheelchair while being visited by a family member. The family member introduced themselves to the surveyor as the resident's daughter-in-law (family member) and informed the surveyor that they are the resident's caregiver at home prior to admission to this facility. They further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to provide privacy and promote dignity during resident assessment. This deficient practice was identified for 1 of 1 resident (Resident #24) reviewed for dignity. This deficient practice was evidenced by the following: On 08/07/23 at 12:53 PM, the surveyor entered the dining room and observed the Nurse Practitioner ask Resident #24 several questions regarding his/her health and then bent down to examine Resident 24's feet. This was done in the dining room in the presence of other residents and staff and while Resident #24 was sitting at the table eating lunch directly across from another resident. The surveyor interviewed the Nurse Practitioner who confirmed that Resident #24 should not have been examined in the dining room and should have been seen in his/her room for privacy but the NP did not want to disturb his/her lunch. According to the admission Record Resident #24 was…

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

Based on interview and record review, it was determined that the facility failed to issue the proper required Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN) for 2 of 3 residents (#107, #86) reviewed for facility change notifications. This deficient practice was evidenced by the following: On 08/04/23 at 1:24 PM, the Director of Nursing (DON) provided the surveyor with a list of residents who were discharged from the facility within the last six months and should have received Beneficiary Notices. The surveyor reviewed two of the residents (#107, #86) listed who were discharged from a Medicare Part A (helps cover skilled nursing facility care including rehabilitation services) stay at the facility and were documented as having a discontinuation of their Medicare Part A insurance payment to the facility. Resident #107 was admitted to the facility in April of 2023. The last documented day of coverage for Medicare Part A service was on 05/01/23. The facility did not present the resident with the proper required SNFABN form to notify them of the termination of…

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

Based on observation, interview, and record review it was determined the facility failed to conduct a new Preadmission Screening and Resident Review (PASARR) level 1 assessment after a resident was newly diagnosed with a mental illness. This deficient practice was identified in 1 of 2 residents reviewed for PASARRs (Resident #42) and was evidenced by the following: On 08/06/23 at 10:00 AM, the surveyor reviewed the resident's Preadmission Screening and Resident Review (PASARR) level 1 (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) which was negative, meaning the resident did not have any mental illness diagnoses or changes. At the same time, the surveyor reviewed the admission Minimum Data Set, an assessment tool (MDS), dated 2021. Under the diagnoses section I, the surveyor noted that the resident did not have any mental or psychiatric diagnosis. Resident #42 was admitted to the facility in April 2021. Review of the resident's most recent MDS indicated the resident had medical diagnosis which included, but…

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

Based on observation, interview, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan. This deficient practice was identified for 1 of 22 residents reviewed for resident-centered care plans (Resident #69), and was evidenced by the following: On 8/2/23 at 11:09 AM the surveyor observed Resident #69 in his/her room with the left fingers contracted. Resident #69 asked where the brace for his/her hand was and stated the staff usually place it on the left hand. On 8/03/23 at 09:04 AM the surveyor observed Resident #69 with left fingers contracted and no brace observed on the left hand. Subsequent observations made on 8/4/23 at 11:14 AM, 8/7/23 at 12:47 AM, and 8/8/23 at 10:45 AM of Resident #69 with no brace on the left hand. The surveyor reviewed Resident #69's medical record which revealed that the resident was admitted to the facility with diagnoses that included but was not limited to hemiparesis (muscle weakness) following a stroke. The surveyor reviewed Resident #69's care plans dated 1/29/20 which include that this resident…

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

Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed a.) to provide a CPAP (continuous positive airway pressure, a machine used to keep breathing airways open during sleep) to accommodate the respiratory needs of a resident and b.) to follow the physician's order (PO) and provide the correct setting on the oxygen (O2) machine to accommodate the respiratory needs of a resident. This deficient practice was identified for 2 of 24 residents reviewed (Resident #188 and #89). This deficient practice was evidenced by the following: On 08/07/23 at 1:12 PM, the surveyor observed Resident #188 who was seated on the side of the bed. The resident voiced concern that there had been a delay in receipt of a CPAP machine that was allegedly ordered upon the resident's admission to the facility. Review of the admission Record (an admission summary) revealed that the resident was admitted to the facility in July of 2023 with diagnosis which included but were not limited to: Obstructive sleep apnea (intermittent airway…

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 #NJ00166725 Based on record review and interview it was determined the facility failed to ensure that received medications were appropriately labeled and dated by the providing pharmacy and to check medication expiration dates prior to administering a medication. This deficient practice was identified in 1 of 1 resident reviewed for intravenous nutrition (Resident #288) and was evidenced by the following: On [DATE] at 10:04 AM, the surveyor reviewed Resident #288 Electronic Medical Record (EMR) which revealed Resident#288 was admitted to the facility on [DATE] at 06:40 PM from an acute care facility. Review of the Physician Orders (POS) indicated the resident was ordered nothing by mouth (no eating or drinking) and had an order for Total Parenteral Nutrition (TPN) which was total intravenous nutrition, to be infused at 100 milliliters per hour intravenously in the evening daily for until a total of 1800 milliliters was infused. The TPN was ordered by the physician and sent to the outside pharmacy 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 review of facility documentation it was determined the facility failed to document behaviors on a resident receiving psychotropic medications. This deficient practice was observed for 1 of 2 residents reviewed for behaviors (Resident #42) and was evidenced by the following: On 08/02/23 at 1:00 PM, the surveyor observed Resident #42 sitting in the dayroom being assisted with lunch. On 08/07/23 at11:42 AM, the surveyor reviewed the physician orders which showed the resident was prescribed Risperidone, an antipsychotic, Paxil, an antidepressant, and Trazadone an antidepressant and sedative. Resident #42 was admitted to the facility in 2021. Medical diagnoses included, but not limited to hypertension (high blood pressure), failure to thrive, and arthritis of the left hip. Review of the most recent quarterly Minimum Data Set (MDS), an assessment tool revealed the resident had a Brief Interview of Mental Status of 99, meaning the resident could not respond to the cognitive…

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 policy, it was determined that the facility failed to a.) properly secure a wound treatment cart containing medications while unattended during wound care for 1 of 1 resident (Resident #68) reviewed for wound care, and b.) store medications according to facility policy. This deficient practice was evidenced by the following: a. On 8/2/23 at 10:57 AM, the surveyor observed Resident #68 in their room sitting in a wheelchair while being visited by a family member. The family member introduced themselves to the surveyor as the resident's daughter-in-law (family member) and informed the surveyor that they are the resident's caregiver at home prior to admission to this facility. They further informed the surveyor that the resident had an ulcer on (his/her) bottom. On 8/3/23 at 12:12 PM, the surveyor observed Resident #68 being wheeled back to their room in a wheelchair by the family member. Once back in the resident's room, the family member informed the surveyor that the resident's wound is most likely a pressure ulcer but was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in the facility's name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. (2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services or supplies 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.