Complete Care At Green Acres

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and document review, the facility failed to have a complete and accurate medical record for three out of 32 (Resident (R) 126, R164, and R191) sampled residents. This failure had the potential to adversely affect the care of these residents with inaccurate information in the medical record.Findings include: 1. Review of R126's undated Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated R126 was admitted to the facility on [DATE] with diagnoses that included heart failure, hypertension, and stroke. Review of R126's admission Minimum Data Set (MDS), located under the MDS tab in the EMR and with an Assessment Reference Date (ARD) of 06/04/25, indicated R126 had a Brief Interview of Mental Status (BIMS) score of five out of 15, which indicated R126 was severely cognitively impaired. Review of R126's Nursing Progress Notes, located under the Progress Note tab in the EMR, indicated on 07/17/25 at 2:49 PM, . During medication pass, patient noted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, policy review, and review of McGeer criteria, the facility failed to have an Antibiotic Stewardship Program that followed current standards of practice for prescribing an antibiotic for one of four residents (Resident (R) 99) reviewed for antibiotic stewardship out of total sample of 32. This failure had the potential to cause residents to be prescribed antibiotics that were potentially unnecessary.Findings include: Review of the facility's policy titled, Infection Surveillance, dated 09/01/2,4 indicated, A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections . The CDC's [Centers for Disease Control] National Healthcare Safety Network (NHSN) Long Term Care Criteria, updated McGeer criteria or other nationally-recognized [sic]…

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, and pertinent facility documentation on 07/09/2024, it was determined that the facility failed to ensure handwashing was performed according to their policy and acceptable standards of infection control practice according to the Centers for Disease Control and Prevention (CDC). This deficient practice was identified for 1 of 3 Employees (Certified Nursing Assistant #1 (CNA #1), observed for handwashing technique. This deficient practice was evidenced by the following: Reference: Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings, last reviewed 1/8/2021, Healthcare Providers, When and How to Perform Hand Hygiene, Techniques for Washing Hands with Soap and Water, recommends: When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your…

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 for two of three units (Rehabilitation unit and Secure unit) and five residents (Resident (R) 17, R196, R125, R2, R18) of 28 sampled residents revealed the food served was bland and residents did not receive salt, pepper, or Mrs. Dash to season their food after being served. Findings include: Review of R17's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/23 revealed R17 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R17 was cognitively intact. During the initial tour of the facility on 02/05/24 at 11:39 AM, R17 stated, The food doesn't have any taste, no spices in it at all. During an interview on 02/05/24 at 11:57 AM, R196 stated that the food was salty, especially the gravy. Review of R125's admission MDS with an ARD of 12/11/23 revealed a BIMS score of 13 of 15 which indicated that R125's cognition was intact. During an interview on 02/05/24 at 12:08 PM, R125's family member (F) 1 stated that the facility used to put salt, pepper packets, and butter 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, record review, interviews, and facility policy review, the facility failed to follow infection control procedures during a wound cleaning process, while delivering a meal tray to a resident in droplet isolation, and during room cleanings for residents in C-diff isolation for four of seven residents (Resident (R)86, R345, R134, and R194) reviewed for infection control standards of 28 sampled residents. Findings include: 1. Review of R86's undated admission Record located under the Profile tab in the electronic medical record (EMR) revealed R86 was readmitted to the facility on [DATE] with diagnoses of hypertension and peripheral vascular disease. Review of R86's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/15/23 revealed R86 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R86 was cognitively intact. During an observation of a dressing change to R86's sacral pressure ulcer on 02/08/24 at 10:59 AM, Licensed Practical 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 interview, document review, and facility policy review, the facility failed to notify the State Survey Agency (SSA) within 24 hours of an allegation of abuse, in which 12 tablets for one of one Resident (R) 191's oxycodone narcotic medication was removed from the medication's bingo card and replaced with another pill of similar size but a different color. The facility failed to notify the SSA until two days and 10 hours after the allegation of misappropriation of resident's property was brought to the Director of Nursing (DON)'s attention. Findings include: Review of the facility's investigative document, provided by the facility, revealed that on the Atrium unit on 07/25/23 at 7:00 AM, two nurses, Licensed Practical Nurse (LPN) 1 and LPN2, reported immediately to the DON that 12 tablets from R191's oxycodone bingo card had been removed and replaced with 12 tablets of similar size but different color. The back of the card showed that for 12 bubbles, the bubble had been sliced open, the oxycodone removed and replaced with another pill, then taped to close the bubble. 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, record review, and facility policy review, the facility failed to ensure the resident's baseline care plan contained the care and services required for two of two residents (Resident (R) 125 and R134) of 28 sampled residents, required upon admission to the facility. In addition, the facility failed to provide the summary of care to the resident and representative at the care plan meeting that was conducted after the admission Minimum Data Set (MDS) was completed. Findings include: 1. Review of R125's Face Sheet in the electronic medical record (EMR) under the Profile tab revealed R125 was admitted on [DATE]. During an observation and interview on 02/05/24 at 12:06 PM, R125 received oxygen through a nasal cannula. R125 stated that he didn't use oxygen at home but started using oxygen at the hospital and since being admitted to the facility. During an interview on 02/06/24 at 3:06 PM, Social Worker (SW) Long Term Care (LTC) printed R125's Baseline care plan and R125's admission MDS…

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 one observation, interview, record review, and facility policy review, the facility failed to ensure that residents who could not perform their own Activities of Daily Living (ADLs) regarding bathing and grooming was provided by facility staff for two of two residents (Residents (R)193 and R194) of 28 sampled residents. Findings include: 1. Review of R193's Face Sheet in the electronic medical record (EMR) under the Profile tab revealed R193 was admitted on [DATE]. No Minimum Data Set (MDS) information available. Observation and interview on 02/05/24 at 11:50 AM, revealed R193 had a full face of facial hair that was approximately half inch long and his fingernails were long with a dark substance underneath. Immediately at the time of this observation, Registered Nurse (RN) 1 entered the room and confirmed R193 should have been shaved and his nails trimmed. Review of R193's Care plan from the Care plan tab in the EMR with a date of 01/30/24, revealed a problem that R193 has an ADL self-care performance…

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 encourage and arrange transportation for two of two residents (Resident (R) 46 and R128) of 28 sampled residents to activities of their choosing. Findings include: 1. During an interview on 02/05/24 at 2:37 PM, R46 stated that he used to go to the second floor for activities, but he was told that they stopped first floor residents from mingling with second floor residents. R46 stated that he liked Bingo, and that he had not been able to go to Bingo on the second floor and that he missed that activity. Review of R46's Face Sheet in the electronic medical record (EMR) under the Profile tab revealed R46 was admitted to the facility on [DATE]. Review of R46's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/28/24 under the MDS tab in the EMR revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R46's cognition was intact. Review of the admission MDS section 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 Based on observation, interview, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least every thirty days for the first ninety days for new admissions or every sixty days after. This deficient practice was identified for 4 of 6 residents (Resident #3, #42, #49, and #66) during the Resident Council group meeting and evidenced by the following: On 11/8/21 at 10:01 AM, the surveyor conducted a resident group meeting with six residents who were alert and oriented and selected by the facility to attend the group meeting. Five of the six residents complained to the surveyor that they do not see their primary care physician (MD) or nurse practitioner (NP) regularly. Resident #42 stated that since admission, he/she has not seen their MD. On 11/8/21 at 11:03 AM, the Director of Nursing (DON) informed the surveyor that all MD and NP were conducting in-person visits for all…

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 the reconciliation and notification of the physician for the clarification of an enteral feeding order in accordance with professional standards of nursing practice. This deficient practice was identified for 1 of 24 resident reviewed for professional standards of nursing practice (Resident #359). Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The 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, interview, and review of facility documentation, it was determined that the facility failed to maintain kitchen equipment in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 11/5/21 at 11:17 AM, the surveyor conducted a follow-up kitchen visit with the Dietary Director (DD) and observed the cook taking lunch food temperatures at the steam table. The surveyor observed the white steam table attached cutting board was deeply pitted and discolored black and reddish. At this time, the DD stated that staff sanitize the cutting board prior to serving food. She was unable to respond when questioned if this cutting board should be used; when cutting boards should be replaced; or when the cutting boards were last replaced. The DD then showed the surveyor a small white cutting board that was pitted and discolored black. On 11/5/21 at 11:21 AM, the surveyor interviewed the Regional Dietary Director (RDD) who stated that cutting boards should be replaced when there were scratches or indentations because bacteria growth could…

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.