Aster Creek Nursing And Rehabilitation Center

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 a.) discard potentially hazardous foods past their date of expiration; b.) ensure potentially hazardous foods were stored at least six inches from the floor; c.) maintain multiuse food-contact surface cutting boards in a manner to prevent microbial growth; d.) maintain kitchen and storage areas in a sanitary manner; and e.) perform hand hygiene to prevent food borne illness. This deficient practice was evidenced by the following: Upon arrival to the facility on [DATE] at 8:45 AM, the surveyor observed eight boxes of bread that were delivered and placed directly on the ground in the parking lot. The bread boxes were stacked in two piles with two boxes directly on the pavement. On 10/1/24 at 8:50 AM, the surveyor accompanied by the Acting Director of Nursing (ADON) exited the facility and observed the bread delivery on the ground. The ADON confirmed food should not be stored directly on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain residents' living environment in a clean, comfortable, homelike manner. This deficient practice was identified on 1 of 2 nursing units reviewed for environment (300 unit), and was evidenced by the following: 1. On 10/1/23 at 12:24 PM, during initial tour of the facility, the surveyor entered onto a ramp that led to the 300 nursing unit, and observed the following: 1. The handrail on right side of wall going up the ramp had three areas where it was not connected to itself, which left a gap in the system where the metal framing was exposed. This presented a safety hazard for residents that were unsteady on their feet. 2. The wallpaper was peeling and bubbling throughout the entire entrance to the 300 nursing unit. 3. The threshold that connected the ramp to the 300 nursing unit corridor had tile removed, missing and uneven elevations in areas presenting a tripping hazard. 4. 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 and interview, it was determined that the facility failed to properly dispose and maintain waste in garbage dumpster areas. This deficient practice was identified for 1 of 1 garbage disposal areas, and the facility was previously cited for this during their last standard survey on 9/1/23. The evidence was as follows: On 10/1/24 at 10:46 AM, the surveyor and the Food Service Director (FSD) toured the facility's outside garbage disposal area and observed the following: 1. The cardboard dumpster had no lid and garbage debris was around it. The FSD stated the facility was trying to get the company to replace the lid. 2. The other three dumpsters had paper and food waste around it. 3. A storage container in the area had food and paper debris, wooden boards, and an unidentifiable large object around it. 4. The wooded area along the dumpster area had trash including food product, paper waste, broken wooden boards, and a mattress. 5. The fence along the inside of the garbage area had three pallets leaning against it, and the fence along the outside had an accumulation…

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 review of pertinent facility documents, it was determined that the facility failed to revise an individual comprehensive care plan for a resident with a history of falls at the facility. This deficient practice was identified for 1 of 1 resident reviewed for falls (Resident #53), and was evidenced by the following: On 10/1/24 at 10:17 AM, during the initial tour of the facility, the surveyor observed Resident #53 in bed with blankets over their head. On 10/2/24 at 11:30 AM, the surveyor observed Resident #53 in bed. Resident #53 told the surveyor that they liked to stay in bed and they ate meals in their room. The surveyor asked the resident if they had any history of falling, and the resident said yes, but did not say if they were every injured during a fall. The surveyor observed no fall mats. On 10/2/24 at 12:15 PM, the surveyor reviewed the medical record for Resident #53. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with medical diagnoses which included but not…

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

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident who smoked cigarettes was assessed for safety. The deficient practice was identified for 1 of 5 residents reviewed for accidents (Resident #25), and was evidenced by the following: On 10/1/24 at 10:28 AM, during initial tour of the facility, the surveyor observed Resident #25 in their room watching television. Resident #25 stated that they were a smoker and went outside to smoke at 9:00 AM, 1:00 PM, and 4:00 PM. The resident also stated that the activities staff held on to their cigarettes and lighter. On 10/1/24 at 12:26 PM, the surveyor reviewed the medical record for Resident #25. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses including but not limited to; hypertension (high blood pressure), depression, and hyperlipidemia (abnormally high levels of lipids or fats in the blood). A review of the most recent comprehensive 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.

Based on observations, interview, and review of pertinent facility documentation, it was determined that the facility failed to label, date, and initial a resident's oxygen tubing. This deficient practice was identified in 1 of 1 residents reviewed for respiratory therapy (Resident #49), and was evidenced by the following: On 10/1/24 at 10:07 AM, during initial tour of the facility, Resident #49 approached the surveyor in the main dining room on the second floor. During the observation, the resident had a walker and a portable oxygen tank. The tubing that supplied the oxygen that went from the resident to the tank did not have a date. The surveyor then entered the resident's room with the resident, and the resident had an oxygen concentrator (a medical device that separates nitrogen from the air around you so you can breathe up to 95 % pure oxygen) in the room. The concentrator had oxygen tubing that went from the concentrator and into a bag. The resident told surveyor that they wore that when in bed. On 10/1/24 at 10:37 AM, the surveyor observed Resident #49 in the bed. 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 pertinent facility documents, it was determined that the facility failed to use appropriate hand hygiene and proper disinfection while providing wound care to a resident. The deficient practice was observed for 1 of 1 residents reviewed for pressure ulcers/injury (Resident #8), and was evidenced by the following: On 10/1/24 at 10:40 AM, during initial tour of the facility, the surveyor observed Resident #8 sleeping in their bed. The surveyor observed the resident wearing bilateral heel protectors. On 10/2/24 at 10:08 AM, the surveyor reviewed the medical record for Resident #8. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses including but not limited to; acute respiratory failure with hypercapnia (a condition where you do not have enough oxygen in the tissues in your body), metabolic encephalopathy (short- or long-term change in how your brain functions), and muscle weakness. A review of the most recent comprehensive 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.

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) store, label, and date potentially hazardous foods to prevent food-borne illness, b.) air dry kitchen equipment in a manner to prevent microbial growth, c.) maintain kitchen equipment in a sanitary manner, d.) maintain proper kitchen sanitation practices. This deficient practice was evidenced by the following. On 08/22/23 at 9:35 AM, the surveyor, in the presence of the Food Service Director (FSD), toured the kitchen and observed the following: 1. In the reach-in refrigerator, sliced yellow American cheese wrapped in clear plastic that was not dated or labeled with a used-by date. The FSD stated that the staff should have labeled and dated when the cheese was sliced. Ten cupcakes in a store-bought plastic container were not labeled or dated. The FSD stated that the cupcakes were from the recreation department and should not have stored them there. The FSD discarded the cupcakes. 2. On the front of the stove, underneath the grill top, there was a buildup 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 that the facility failed to treat each resident with respect and dignity in a manner that promotes his/her quality of life. This deficient practice was identified for one (1) of 19 residents (Resident #27) reviewed for resident rights. This deficient practice was evidenced by the following: On 8/24/2023 at 10:32 AM, the surveyor observed Resident #27 seated in their wheelchair across from the nurse's station. Resident #27 asked the Acting Licensed Practical Nurse Unit Manager (LPN UM #1) if they can have their medication. LPN UM #1 responded that they would notify their nurse when they returned from break. Resident #27 stated to LPN UM #1 that there was a medication error and they did not receive their medication in the morning and wanted it now. LPN UM #1 sternly directed Resident #27 to go to their room. Resident #27 responded, you don't have a right to speak with me like that. At that time, LPN UM #1 again stated they would notify their nurse and transported the resident from the nursing station to 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 8/22/23 at 9:35 AM, the surveyor, in the presence of the Food Service Director (FSD), toured the kitchen and the designated garbage area and observed the following: There were three dumpsters in the designated area for the facility's garbage. All three lids were opened and several garbage bags were filled with trash on the ground near the dumpsters. There was debris around all the dumpsters, and behind one of the dumpsters, there was furniture such as mattresses, frames for the beds, overbed tables, and dressers. The Food Service Director (FSD) stated that the housekeeping department was responsible for keeping the area clean. On 8/23/23 at 8:55 AM, the surveyor toured the garbage area in the presence of the FSD. The furniture was in one of the dumpsters, and there…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to maintain medical records accurately and completely in accordance with acceptable standards and practice by not documenting pertinent clinical documentation on the resident's medical record for a resident who had a change in condition. This was identified for 1 of 18 residents (Resident #68) reviewed and was evidenced by the following. a.) According to Resident #68's medical record, the resident was admitted to the facility with the diagnoses which included but not limited to hypertension (high blood pressure), obstructive uropathy (retention of urine), and cerebral infarction (stroke). The significant change Minimum Data Set (MDS-a assessment that facilitates a resident's care) dated 06/12/23, indicated that the resident had moderate cognitive impairment and required expensive assistance with activities of daily living (ADL's) On 08/23/23/ at 10:00 AM, the surveyor…

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: a.) assess and obtain a physician's order (PO) for the self-administration of oxygen; b.) label, date, and initial oxygen tubing c.) Care Plan for the self-administration of oxygen and d.) ensure oxygen tubing, equipment, and BiPAP masks were stored in accordance to professional standards of practice. This deficient practice was identified for 1 of 3 residents reviewed for respiratory care (Resident #13) and was evidenced by the following. On 6/8/21 at 11:04 AM, the surveyor observed Resident #13 sitting in his/her room. The resident was receiving oxygen via nasal cannula (NC; a tube used to deliver oxygen via the nostrils) connected to an oxygen concentrator (a machine used to pull room air through a filter to remove the nitrogen to make the oxygen more concentrated) set at three liters per minute (3 lpm). The surveyor also observed a BiPAP machine (non-invasive ventilation therapy system used to facilitate breathing) that was not in use with an uncovered mask and tubing connected 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, interview and review of facility provided documentation, the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficient practice was evidenced by the following: Reference: NJ State requirement, CHAPTER 112. An Act concerning staffing requirements for nursing homes and supplementing Title 30 of the Revised Statutes. Be It Enacted by the Senate and General Assembly of the State of New Jersey: C.30:13-18 Minimum staffing requirements for nursing homes effective 2/1/21. 1. a. Notwithstanding any other staffing requirements as may be established by law, every nursing home as defined in section 2 of P.L.1976, c.120 (C.30:13-2) or licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall maintain the following minimum direct care staff -to-resident ratios: (1) one certified nurse aide to every eight residents for the day shift; (2) one direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be certified nurse…

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 pertinent facility documentation, it was determined that the facility failed to a.) maintain proper infection control practices for donning (putting on) the appropriate Personal Protective Equipment (PPE) prior to entering an isolation room to prevent the transmission of infection and b.) maintain appropriate hand hygiene practices in accordance with the Center for Disease Control . This deficient practice was identified for 1 of 2 nursing units (400), and for 2 of 2 residents (Resident #202 and Resident #203) on the Persons Under Investigation (PUI; for possible COVID-19 infection) unit and for observed hand hygiene in the kitchen. This was evidenced by the following: 1. On 06/09/21 at 12:15 PM the surveyor observed two Certified Nursing Aides (CNA), CNA #1 and CNA#2 delivering lunch trays to two residents on the PUI (400) unit. CNA#1 entered Resident #202's isolation room without donning the required PPE, wearing only a surgical mask. CNA#1 had not donned a gown, gloves, N95 (respirator) mask and eye protection posted…

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.