Venetian Care & Rehabilitation Center, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, facility document review, facility policy review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure pressure ulcer prevention measures were in place for two residents out of four reviewed (Resident (R) 116 and R3) for pressure ulcers out of a total sample of 35 residents. This had the potential for the residents to develop pressure ulcers and/or worsen current pressure ulcers.Findings include: Review of the RAI manual, dated 10/2024 and located at Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual | CMS, revealed .The items in this section document the risk, presence, appearance, and change of pressure ulcers/injuries. This section also notes other skin ulcers, wounds, or lesions, and documents some treatment categories related to skin injury or avoiding injury. It is important to recognize and evaluate each resident's risk factors and to identify and evaluate all areas at risk of constant pressure. A complete…

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 ensure interventions were in place for one of one resident (Resident (R) 56) out of two residents reviewed for range of motion (ROM) out of a total sample of 35 residents. This had the potential for the residents contracture to worsen. Findings include: Review of R56's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility 05/02/22 and had diagnoses including dementia, contracture, muscle weakness, and osteoarthritis. Review of R56's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/20/25 and located under the MDS tab of the EMR, revealed she was rarely/never able to make herself understood and severely impaired cognition. R56 did not have limited ROM. Review of R56's Care Plan, dated 06/27/25 and located under the Care Plan tab of the EMR, revealed she was dependent on staff for assistance with activities of daily living. The Care Plan did not address R56'shand contracture or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and facility policy review, the facility failed to provide respiratory care per standards of practice for one of two sampled residents (Resident (R)142) reviewed for respiratory care out of a total sample of 35 residents. Specifically, the facility failed to ensure respiratory equipment (Ambu-bag) was accessible. The failure had the potential for the resident to have respiratory issues and unmet care needs.Findings include: Review of a facility policy titled Tracheostomy Care dated 06/25/25 failed to address the importance of an Ambu-bag to be stored by a resident, who has a trach, at bedside. Review of R142's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R142's EMR titled Care Plan located under the Care Plan tab dated 09/06/25 indicated the resident had a tracheostomy related to respiratory failure and that the resident required emergency equipment at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure the physician responded to the consultant pharmacist medication reviews for one resident (Resident (R7) out of five reviewed for unnecessary medications in a total sample of 35 residents. This failure placed the resident at risk of receiving unnecessary medications.Findings include: Review of the facility policy titled, Medication Regimen Reviews (MRR), dated July 2025, revealed, .A licensed pharmacist reviews the medication regiment of each resident at least monthly.The purpose of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication.Upon receiving the MRR, the attending physician reviews and responds to the report. The physician documents in the resident's medical record that the pharmacist's recommendations have been reviewed and what (if any) actions were taken to address them.If the physician does not provide a timely or adequate response, or the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of facility policy, the facility failed to ensure the medical record was complete and accurate for three residents (Residents (R)7, R64, and R70) out of total sample of 35 residents reviewed. This failure had the potential for the resident's health status not be accurate, complete, and possibly create unmet care needs.Findings include: Review of the facility policy titled, Charting and Documentation, dated July 2017 revealed, .Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R7 was admitted to the facility with a diagnosis that included major depressive disorder. Review of the 04/22/25 Comprehensive Care Plan located in the Care Plan tab of the EMR revealed, I use anti-psychotic medication [a class of medications used to treat psychotic disorders, such as schizophrenia and bipolar…

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, and policy review, the facility failed to ensure a potential allegation of physical abuse by staff was reported timely to the Director of Nursing (DON) and to the State Survey Agency (SSA) when a resident sustained an injury during a transfer from the wheelchair to the bed for one of three residents (Resident (R) 2) reviewed for abuse out of 22 sample residents. This failure increased the risk of other vulnerable residents being physically abused.Review of R2's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R2 was admitted to the facility on [DATE].Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/25, located in the EMR under the MDS tab, revealed R2's Brief Interview for Mental Status (BIMS) score was three out of 15 which indicated she was severely cognitively impaired. The MDS revealed she required substantial/maximal assistance with chair/bed-to-chair transfers and had…

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

Based on interviews, record review, and policy review, the facility failed to protect a resident during an investigation of a potential allegation of physical abuse by staff when a resident sustained an injury during a transfer from the wheelchair to the bed by two nursing aides for one of three residents (Resident (R) 2) reviewed for abuse out of 22 sample residents. This failure increased the risk of other vulnerable residents being physically abused.Review of R2's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R2 was admitted to the facility in 04/15.Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/25, located in the EMR under the MDS tab, revealed R2's Brief Interview for Mental Status (BIMS) score was three out of 15 which indicated he/she was severely cognitively impaired. The MDS revealed he/she required substantial/maximal assistance with chair/bed-to-chair transfers and had impairment on both sides of the lower extremities.Review of the facility's Reportable Event…

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 review, the facility failed to prevent an injury during an improper transfer for one of three residents (Resident (R) 2) reviewed for abuse out of 22 sample residents. This failure increased the risk of residents experiencing injuries during transfers.Review of R2's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R2 was admitted to the facility in 04/15.Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/25, located in the EMR under the MDS tab, revealed R2's Brief Interview for Mental Status (BIMS) score was three out of 15 which indicated he/she was severely cognitively impaired. The MDS revealed he/she required substantial/maximal assistance with chair/bed-to-chair transfers and had impairment on both sides of the lower extremities.Review of R2's Care Plan, dated 07/22/15 and located in the EMR under the Care Plan tab, revealed a focus of R2 wanting to assist with surface to surface transfers and requiring extensive assistance with surface transfers…

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, and policy review, the facility failed to ensure nursing staff received ordered medications from the pharmacy for residents for one out of 22 sample residents (Resident (R) 16). This failure had the potential for residents not to receive their ordered medications and could result in negative outcomes. Review of the facility's policy titled Accepting Delivery of Medications, revised November 2022, revealed Policy Statement 1. All staff follow a consistent procedure in accepting medications. 2. Any errors noted in receiving medications are brought to the attention of the pharmacist and director of nursing services. Policy Interpretation and Implementation 1. A nurse accepts each medication delivery. 2. Before signing to accept the delivery, the nurse reconciles the medications in the package with the delivery ticket/order receipt. Review of R16's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed she was admitted on 08/24…

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

Based on observations, interviews, record review, and policy review, the facility failed to ensure nursing staff stored medications not administered to residents in the locked medication cart not at bedside for one out of 22 sampled residents (Resident (R) 16) observed during the medication administration. This failure had the potential for wandering residents to self-administer other residents' medications. Review of R16's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed he/she was admitted in 08/24 with a diagnosis of epilepsy. Review of R16's Physician's Orders, dated 08/13/25 and located in the EMR under the Orders tab, revealed an order for polyethylene glycol 3350 powder give 17 grams by mouth one time a day for constipation mix with 6-8 ounces (oz.) of water or juice and an order for Phenobarbital oral elixir 20 milligrams (MG)/5 milliliters (ML) give 11.3 ML by mouth every 12 hours for seizures. Review of Registered Nurse (RN) 4's Medication Administration Competency, dated 08/13/25, revealed she completed 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 observations, interviews, and policy review, the facility failed to ensure staff perform hand hygiene after serving and assisting residents with setting up their meals for one out of 22 sample residents (Resident (R) 22) observed during the lunch meal. This failure had the potential to cause cross contamination and spread germs to vulnerable residents. During an observation on the fourth floor in the common area on 08/19/25 at 12:19 PM, Recreation Aide (RA) 2 placed R21's meal tray on the table, removed the plate cover, lids on the cups, and then used the fork to cut up the food without performing hand hygiene afterward. Next, RA2 walked to the food cart and picked up another food tray and placed it in front of R22. During an interview on 08/19/25 at 12:23 PM, RA2 confirmed she did not perform hand hygiene after setting up R21's food tray and stated she was not told to sanitize or wash her hands after setting up the food trays for the residents, but it would be an infection control issue. During an interview on 08/19/25 at 12:49 PM, the Assistant Director of Nursing (ADON),…

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 #: 186850 Based on interviews and medical record review (MR) and other pertinent facility documentation on 6/4/25, it was determined that facility failed to thoroughly investigate an allegation of abuse for 1 of 4 residents (Resident #4). This deficient practice was evidenced by the following: According to the admission Record (AR) Resident #4 was admitted with diagnoses including but not limited to: Visual Loss, Presence of Artificial Eye, Unspecified Hearing Loss, and Anxiety Disorder. A review of the Minimum Data Set (MDS), an assessment tool dated 3/30/25, revealed that Resident #4 had a Brief Interview of Mental Status (BIMS) score of 15, indicating that Resident #4 was cognitively intact, and was Supervision/Touch assistance with ADLs (Activities of Daily Living), independent with transfers and continent of bowel and bladder. During an interview with the Surveyor on 6/4/25 at 12:30 P.M., Resident #4 stated that they were not able to remember the date or the exact time but stated that sometime after supper that someone came in the room and pulled down their pants.…

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, and pertinent facility documents it was determined that the facility failed to maintain the designated emergency supply of water needed for residents in the event of a loss of normal water supply. This deficient practice was evidenced by the following: On 3/25/24 at 09:00 AM, the survey team entered the facility and was made aware by the Licensed Nursing Home Administrator (LNHA) that the facility was licensed for 180 beds and the facility census was 123 (the number of residents who currently resided at the facility). On 03/25/24 at 10:10 AM, the surveyor toured the kitchen with the facility's Food Service Director (FSD) and the Regional FSD. During the initial tour, the surveyor was escorted to a storage room which contained the emergency water and food supply. In the presence of the surveyor and the facility's FSD, the regional FSD stated that he had 22 cases of emergency water which contained 6 gallons of water per case. He stated that there was a total of 132 gallons 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 observations, interviews, record review and other facility documentation, it was determined that the facility failed to complete weekly skin evaluations for 3 of 3 residents (Resident #5, #49 and #86) reviewed for pressure ulcers. This deficient practice was evidenced by the following: 1.On 03/25/24 at 11:10 AM, during initial tour of the 4th floor, the surveyor observed Resident #5 in bed. The surveyor attempted to interview the resident but he/she was unable to answer the surveyor's questions. A review of Resident #5's Electronic Medical Record (EMR) revealed the following: According to the admission Record, Resident #5 was admitted to the facility with diagnoses that included but were not limited to: Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and Epilepsy, (a brain condition that causes recurring seizures) Unspecified, Not Intractable, without Status Epilepticus. The Quarterly Minimum Data Set…

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, record review, and review of facility documentation, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure that a.) staff followed a Physician Orders (PO) for the administration of an insulin medication for 1 of 1 resident (Resident #96) reviewed for the management of insulin, b.) medications were observed as accurately and timely administered to one (1) of five (5) residents, (Resident #54) reviewed for medication administration, and c.) to ensure an accurate inventory of controlled medications (narcotic medications) dispensed from the facility's automated medication dispensing system (AMDS) located on the 2nd floor nursing unit. The deficient practices were 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…

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

Based on observation, interviews, and record review, it was determined that the facility failed to provide nail care to a resident who required extensive assistance from staff for Activities of Daily Living (ADL). This deficient practice was identified for 1 of 7 residents (Resident #13) reviewed for ADL care. The deficient practice was evidenced by the following: On 03/25/24 at 10:28 AM, during the initial tour of the facility, the surveyor observed Resident #13 in bed, with his/her right hand from middle finger to pinky finger closed into a fist and the index finger pointing out with an elongated thickened non-smooth nail. The surveyor was not able to observe the resident's right hand nails from the middle finger to pinky finger. Resident #13's left hand had long nails on the thumb, index finger and the pinky finger. The third and fourth fingernails had jagged appearance. The surveyor reviewed the medical records for Resident #13. A review of the admission Record face sheet reflected Resident #13 was admitted to the facility with diagnoses which included, but were not limited 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 observation, interviews, record review and review of other relevant facility documentation, it was determined that the facility failed to obtain and carry out an order to discontinue a Peripheral Intravenous line (IV [In a vein]) and to maintain the site according to professional standards of practice. The deficient practice was identified for one of one residents (Resident #326) reviewed for IV therapy. The deficient practice was evidenced by the following: On 3/26/24 at 11:43 AM, the surveyor observed the resident's left forearm (region of the upper limb between the elbow and the wrist) with an IV line in place. The IV line was covered by a transparent dressing. The tape holding the dressing to the skin was peeling off. The surveyor noted the IV line was not dated or initialed. There were no medications or fluids infusing through the IV line during this observation. A review of the admission record (an admission summary) revealed that the Resident #326 was admitted to the facility with the follow diagnoses, which included but not limited to; Urinary tract infection (UTI…

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.

NJ #159787 Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of foods served to the residents. This deficient practice was identified for 5 of 5 residents interviewed during the Resident Council meeting and confirmed during the lunchtime meal service on 04/05/24 for 1 of 3 nursing units (2nd Floor unit) tested for food temperatures and was evidenced by the following: On 03/27/24 at 10:51 AM, the surveyor met with five residents for a resident council meeting. Three out of five residents resided on the 3rd floor. Two out of five residents resided on the 4th floor. Five of five residents agreed that the food trays were not warm. On 04/05/24 at 11:14 AM, the surveyor calibrated a state issued digital thermometer via the ice bath method to 32 degrees Fahrenheit (F) in the presence of the survey team. On 04/05/24 at 12:24 PM, the surveyor observed the lunch truck arrive to the 2nd floor. The Assistant Director of Nursing (ADON) met the food truck. A regular diet…

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 review of pertinent facility documents, it was determined that the facility failed to ensure foods were provided in accordance with physician's orders and resident preferences identified in their plan of care. This deficient practice was identified for 2 of 4 residents reviewed for nutrition (Resident #114 and #120). This deficient practice was evidenced by the following: 1. On 3/27/24 at 10:57 AM, the surveyor observed Resident #114 seated in a wheelchair at a table in the dining area drinking water. On 3/28/24 at 12:18 PM, the surveyor observed the resident's lunch tray. The meal ticket indicated the tray items should have included four ounces (oz.) of red bean chili, a creamy peanut butter and jelly sandwich, a ½ cup of Fortified mashed potatoes, a ½ cup of green peas, one piece of cornbread, six oz. chicken orzo soup, one serving of a low-sugar house shake, ½ cup of fruit cup, one vanilla ice cream, a four oz. cranberry juice, eight oz. of whole milk and…

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

Based on facility staff interviews and review of other facility documentation, it was determined that the facility failed to ensure that the designated Infection Preventionist (IP) had completed specialized training in infection prevention and control and was qualified by certification and experience for 1 of 1 staff member reviewed in accordance with the facility job description, Center for Medicare and Medicaid Services (CMS) and New Jersey State guidelines. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health Executive Directive No 20-026-1 dated October 20, 2020, revealed the following: ii. Required Core Practices for Infection Prevention and Control: Facilities are required to have one or more individuals with training in infection prevention and control employed or contracted on a full-time basis or part-time basis to provide on-site management of the Infection Prevention and Control (IPC) program. The requirements of this Directive may be fulfilled by: a. An individual certified by the Certification Board of Infection…

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

Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to complete weekly weights and consistently monitor a resident with a history of weight loss. This deficient practice was identified for 1 of 6 residents (Resident #15) reviewed for nutrition and was evidenced by the following: On 09/19/22 at 12:37 PM, the surveyor observed Resident #15 sitting up in bed with a lunch tray positioned on the overbed table. The resident was pleasantly confused and was observed feeding self without difficulty. The surveyor observed that the resident ate approximately 25% of the lunch meal. When interviewed, the resident stated the meal was alright and that he/she did not want anything else to eat. According to the admission Record, Resident #15 was admitted with diagnoses which included, but were not limited to, Chronic Obstructive Pulmonary Disease (a group of diseases that cause airflow blockage and breathing-related problems), muscle weakness, and need for assistance with personal care. Review of the Quarterly Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to a.) document the size and type of resident's tracheostomy tube on the resident's Care Plan (CP) and b.) obtain a physician order for oxygen and include oxygen use and care on a CP. This deficient practice was identified for 2 of 3 residents (Residents #89 and #120) reviewed for respiratory care and was evidenced by the following: According to the admission Record reflected that the resident was admitted to the facility with the diagnoses which included, but were not limited to, Cerebral Infarction (stroke, Infarction refers to death of tissue), aphasia (comprehension and communication (reading, speaking, or writing)) disorder resulting from damage or injury to the specific area in the brain), tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe for artificial airway), and hemiplegia (paralysis of one side of the body). The annual Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to consistently monitor and manage a resident's pain consistent with professional standards of practice or develop a comprehensive person-centered care plan for 1 of 4 residents who exhibited signs and symptoms of pain, Resident # 55. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the…

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

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to a.) coordinate medication administration times and accuchecks (blood sugar monitoring) with scheduled renal dialysis days, b.) identify and monitor the dialysis access site, c.) consistently maintain ongoing complete communication notes between the facility and the dialysis center, and d.) implement a person-centered care plan for a resident on renal dialysis. This deficient practice was identified for 1 of 4 residents (Resident #107) reviewed for dialysis and was evidenced by the following: On 09/16/22 at 10:25 AM during initial facility tour, Resident #107 was not in the room. The surveyor interviewed the Licensed Practical Nurse (LPN) who was outside in the hallway and indicated that she was assigned to Resident # 107 today however the resident was out to dialysis. The LPN stated that the resident went out to dialysis on Monday, Wednesday, and Friday from approximately 5:00 AM and returned to the facility at approximately 10:00 AM or 11:00 AM 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.

Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to follow professional standards of nursing practice by not clarifying medication orders in timely manner for 1 of 4 residents (Resident #127) reviewed for tube feeding. This deficient practice was evidenced by the following: On 09/19/22 at 12:18 PM, the surveyor observed Resident #127 in bed with the head of bed elevated. The resident had no facial grimacing and showed no signs or symptoms of distress or discomfort. According to the admission Record, Resident #127 was admitted with diagnoses which included but were not limited to acute respiratory failure, dysphagia (difficulties swallowing), aphasia (loss of ability to understand or express speech) and gastrostomy status (surgical operation for making an opening in the stomach) (peg tube.) Review of Resident #127's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 09/02/22, indicated the resident had a feeding tube and that the resident received 51% or more of…

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

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 09/16/22 at 10:00 AM, the surveyor, in the presence of the Food Service Director (FSD) and Ambassador of Dietary Services (ADS), observed the following during the kitchen tour: 1. A food service worker (FSW) was observed walking in the kitchen with a blue baseball cap with hair sticking out the back. When interviewed, the FSD stated the FSW's hair should be covered. 2. A stack of uncovered coffee filters was stored directly on the shelf and a second stack of uncovered coffee filters was stored in a bin containing coffee packets. When interviewed, the FSD stated the stacks of coffee filters should be stored in plastic. 3. A stack of uncovered plastic lids was stored directly on the shelf and a second stack of uncovered plastic lids was stored directly on the shelf behind the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) utilize an infection assessment tool for 4 of 4 residents (Resident #124, #127, #487, and #488) prescribed antibiotic medications in the facility, and b.) monitor and review actual antibiotic use according to the facility's Antibiotic Stewardship Program. This deficient practice was evidenced by the following: Review of the Antibiotic Stewardship Meeting Minutes, dated 07/26/22, provided by the Infection Preventionist (IP), revealed a section titled Discussion with the following listed below it: Antibiotic Stewardship Program Goals, Antibiotic Use Reports, Antibiotic Resistance Reports, Newly Diagnosed Infection Report, C Difficile Report (Outcome Measure Review), and Antibiotic Prescription Review. However, the only documents attached to the meeting minutes were Infection Control Logs of the residents who were on antibiotics during the month of July 2022. There were no reviews or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set, an assessment tool used to facility the management of care, to identify that the resident was on renal dialysis. This deficient practice was identified for 1 of 4 residents (Resident #107) reviewed for dialysis and was evidenced by the following: On 09/16/22 at 10:25 AM during initial facility tour, Resident #107 was not in the room. The surveyor interviewed the Licensed Practical Nurse (LPN), who was assigned to Resident # 107. The LPN stated that the resident went out to dialysis on Monday, Wednesday, and Friday from approximately 5:00 AM and returned to the facility at approximately 10:00 AM or 11:00 AM in the morning. Review of the admission Record reflected that Resident #107 was admitted to the facility with diagnoses which included, but were not limited to, end stage renal (kidney) disease (ESRD). Review of the admission Minimum Data…

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

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to consistently revise and/or update resident care plans for 1 of 4 residents (Resident #58) reviewed for pain. This deficient practice was evidenced by the following: On 09/16/22 at 10:03 AM, the surveyor observed Resident #58 in bed with the head of the bed elevated. When interviewed at that time, Resident #58 stated that he/she was always in pain. According to the admission Record, Resident #58 was admitted with diagnoses that included, but were not limited to, aftercare following explantation (revision) of knee joint prosthesis, infection, and inflammatory reaction due to internal left knee, and pain in the left knee. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 08/03/22, revealed staff identified Resident #58 as cognitively intact, with range of motion impairment on one side of the lower extremity (hip, knee, ankle, foot) and the resident received scheduled pain medication…

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 consistently document in the Medication Administration Record (MAR). This deficient practice was identified for 1 of 5 residents (Resident #58) reviewed for unnecessary medications and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The nurse practice act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as…

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 staff delivered meal trays to the correct residents. This deficient practice was identified for 2 of 2 residents observed during lunch meal services (Resident #34 and #36) and was evidenced by the following: On 09/19/22 at 12:27 PM, the surveyor observed Resident #36 lying in bed with his/her lunch meal tray on the overbed table. Resident #36 stated they had finished their partially eaten lunch and needed assistance to bring the Styrofoam cup filled with water closer. On 09/19/22 at 12:29 PM, the surveyor observed Resident #36's roommate, Resident #34, walking around in the room. Resident #34 used a walker and walked towards the meal tray on the overbed table. The surveyor tried to get the attention of Resident #34, but the resident did not acknowledge the surveyor. At that time, the surveyor observed the meal ticket for Resident #34 was for Resident #36. On 09/19/22 at 12:49 PM, the surveyor brought the Assistant Director of Nursing (ADON) into the room the 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.

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that an indwelling urinary catheter drainage bag (urine collection bag) was stored in a way to prevent the spread of infection. This deficient practice was identified for 1 of 3 residents reviewed for the use of indwelling urinary catheters (Resident #56) and was evidenced by the following: According to the admission Record, Resident #56 had diagnoses that included, but were not limited to: encounter for attention to other openings of urinary tract. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/29/2022 , revealed the resident had a Brief Interview for Mental Status (BIMS) of 15/15 which indicated that the resident was cognitively intact. Further review of the MDS revealed the resident had a urinary indwelling catheter. On 09/16/22 at 11:00 AM, the surveyor observed Resident #56's drainage bag hanging from the bed in a privacy bag and the catheter piece used to empty…

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 a) identify that medications were not scheduled to accommodate a resident's dialysis schedule during the monthly CP medication review and b.) act on or respond to recommendations made by the Consultant Pharmacist (CP) in a timely manner . This deficient practice was identified for 2 of 6 residents reviewed for medication regimen review (MRR) (Residents #107 and #583) and was evidenced by the following: 1.) On 09/16/22 at 10:25 AM during initial facility tour, Resident #107 was not in the room. The surveyor interviewed the Licensed Practical Nurse (LPN #2) who was outside in the hallway and indicated that she was providing care for Resident #107 today who was out to dialysis. The surveyor was unable to interview the resident currently. The LPN #2 stated that the resident goes out to dialysis on Monday, Wednesday, and Friday from approximately 5:00 AM and returned to the facility at approximately 10:00 AM or 11:00 AM in the morning. The LPN #2 further stated that the resident had an AV shunt (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.