Avant Rehabilitation And Care Center

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) consistently complete the dialysis communication form and b.) maintain a resident's dialysis communication record. This deficient practice was identified for 1 of 2 residents reviewed for dialysis (Resident # 60), and was evidenced by the following: On 3/13/24 at 9:46 AM, the surveyor observed Resident #60 in bed in their room, who stated he/she went to dialysis on Mondays, Wednesdays, and Fridays. The surveyor reviewed the medical record for Resident #60. A review of the Resident Face Sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses which included end stage renal disease, diabetes mellitus with diabetic neuropathy (nerve damage), anemia( a low number of red blood cells), and chronic kidney disease. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 1/19/24, reflected a brief interview for mental status (BIMS) score of 14 out 15, which indicated an intact cognition. 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, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of the resident. This deficient practice was identified for 1 of 26 residents reviewed for accommodation of needs (Resident #37), and was evidenced by the following: On 3/13/24 at 10:58 AM, the surveyor observed Resident #37 in bed with their eyes open; the resident did not speak but responded to the surveyor's greeting with a smile and waved both arms. The surveyor observed the resident's call bell (a bell used to summon staff for assistance) was on the floor, not within his/her reach. On 3/15/24 at 11:43 AM, the surveyor observed Resident #37 in bed with the call bell tied to the lower aspect of the right side rail (bar positioned on the side of a bed to assist residents with mobility) not within his/her reach. On 3/19/24 at 9:47 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated the resident used their call bell to alert staff they needed assistance. At that time the surveyor accompanied by 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 ensure the accuracy of a re-admission nutrition assessment for a resident with significant weight loss. This deficient practice was identified for 1 of 4 residents reviewed for nutrition (Resident #60), and was evidenced by the following: On 3/13/24 at 9:46 AM, the surveyor observed Resident #60 in bed who stated he/she just finished breakfast and was still hungry. At this time, the surveyor observed the Licensed Practical Nurse (LPN) deliver the resident a sandwich. The surveyor reviewed the medical record for Resident #60. A review of the Resident Face Sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses which included end stage renal disease, diabetes mellitus with diabetic neuropathy (nerve damage cause by diabetes), anemia (low red blood cells), and chronic kidney disease. A review of the most recent 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.

Based on interview, review of Nurse Staffing Report sheets, and other pertinent facility documents, it was determined that the facility failed to ensure a Registered Nurse worked seven days a week for at least eight consecutive hours a day for 4 of 21 days reviewed. This deficient practice was evidenced by the following: During entrance conference on 3/13/24 at 10:45 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) how the facility's staff was, and the LNHA stated that staffing was good; that the facility primarily utilized agency staff for certified nursing aides (CNA). At this time, the surveyor requested the Nurse Staffing Report to be completed for the following weeks: 6/25/23 through 7/1/23; 7/2/23 through 7/8/23; 3/3/24 through 3/9/24. The surveyor reviewed the Nurse Staffing Reports which revealed there was no Registered Nurse (RN) to work eight consecutive hours on the following dates: 1. No RN on 6/25/23; the last RN was scheduled on the 3:00 PM to 11:00 PM (3-11) shift on 6/24/23. 2. No RN on 7/2/23; the last RN 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 observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures during a wound care treatment. This deficient practice was identified for 1 of 2 wound observations observed for 1 of 2 residents reviewed for pressure ulcer and injury (Resident #56), and was evidenced by the following: On 3/13/24 at 10:25 AM, the surveyor observed Resident #56 in bed with a pressure-relieving device who stated he/she had a wound on his/her bottom. The surveyor reviewed the medical record for Resident #56. A review of the Resident Face Sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement), dementia, diabetes mellitus, neuromuscular dysfunction of the bladder (lack of bladder control due to nerve damage), schizophrenia and a wound to the sacrum (lower portion of the spine near the pelvis). A review of the most recent 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 Based on observation, interview, record review, and review of pertinent facility documentation, the facility failed to implement their abuse policy to report a.) an allegation of sexual abuse between two residents, b.) verbal abuse between a staff member and a resident, c.) physical abuse by a resident against two other residents, and d.) an injury of unknown origin for two residents. This deficient practice was identified for 5 of 6 residents reviewed for abuse (Resident #10, #56, #63, #65, and #72) and 1 of 1 resident reviewed for hospitalization (#193), and was evidenced by the following: Refer to F600 and F684 a.) On 08/10/22, multiple staff members observed on the locked nursing unit, Resident #63, a registered sex offender, exit Resident #10's room. Resident #10 had intellectual disabilities and was dependent completely on staff for Activities of Daily Living (ADLs). Resident #63 was reported to be happy, bobbing their head side to side while smiling with feces on both of their hands. Certified Nursing…

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 document review, it was determined that the facility failed to provide sufficient nursing staff to ensure resident's highest practical wellbeing by failing to: a.) provide incontinence care on 1 of 3 units (unsampled resident), b.) provide psychiatric consultation per physician order for a resident who expressed suicidal ideation and feelings of loneliness for 1 of 3 residents reviewed for mood and behavior (Resident #63), c.) schedule a resident's appointment with their preferred cardiologist after a hospital visit for 1 of 5 residents who attended a Resident Council Meeting (unsampled resident), and d.) maintain the required minimum direct care staff-to-shift ratios as mandated by New Jersey State requirement, CHAPTER 112 (An Act related to staffing requirements for nursing homes and supplementing Title 30 of the Revised Statutes). The deficient practice was evidenced as follows: Refer to: F584, F740, F636, F638, and F882 a.) On 09/23/22 at 6:53 AM, Surveyor #1 went to the locked unit and observed the following: Resident #54,…

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 review of pertinent facility provided documentation, the facility failed to ensure that staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety, and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This deficient practice was evidenced by the following: On 10/07/22 at 11:48 AM, the surveyor interviewed the Interim Infection Preventionist (IIP) who had been the facility Educator prior to becoming the IIP regarding staff competencies. The IIP stated that she was only the Educator for a month and that she had been implementing the new computer system during that time. She added that the Director of Nursing (DON) and the Assistant DON (ADON) were the facility's educators and that the competency book would possibly be located in the DON's office. On 10/07/22 at 11:57 AM, the surveyor interviewed the second floor Unit Manager (UM) regarding staff competencies. The UM stated that she had occasionally given in-services to staff but that she had not…

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

Based on observation, interview, and 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 09/21/22 at 9:38 AM to 10:09 AM, the surveyor entered the facility kitchen and toured with the Food Service Director (FSD). On 09/21/22 at 9:41 AM, the surveyor observed the facility ice machine. The baffle area (the interior back of the basin in direct contact with the ice) located in the bucket with ice, contained black streaked debris, and accumulated debris above it. The FSD confirmed the ice machine was not clean. The FSD stated maintenance would come monthly to clean filters and the cover of the ice machine. On 09/21/22 at 9:54 AM, the surveyor observed 1/2 package of meatballs in the freezer, wrapped, but with no label and no use by date. The FSD stated the meatballs were good for 30 days. On 09/21/22 at 9:55 AM, the surveyor observed two frozen pie shells in plastic…

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 review of pertinent facility provided documents, it was determined that the facility failed to ensure the facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies was reviewed and updated, as necessary, and at least annually. This deficient practice was evidenced by the following: On 09/21/22 at 01:09 PM, during the entrance conference held with the facility administration, another surveyor requested a copy of the Facility Assessment (FA). On 9/22/22 at 2:28 PM, the Licensed Nursing Home Administrator (LNHA) provided the other surveyor with the FA. The FA was not signed or dated to indicate when the FA was conducted or reviewed. On 10/07/22 at 10:49 AM, the surveyor interviewed the LNHA regarding the FA. The LNHA stated that the FA should have been dated and signed. He then stated that it looked like the wrong one was given. He added that the corporate person had given it to him. He then added that it was in the binder for survey (binder which contains documents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review it was determined that the facility failed to ensure the Medical Director (MD) duties per the MD Job Description were implemented to ensure resident care policies and services were provided to all residents that were consistent with current professional standards of practice on 3 of 3 resident units. The deficient practice was evidenced by the following: Refer to: F600K, F609F, F610F, F684H, F835L, 838F, 850F, F865F, F867F, F880L, F886L, F888L During a recertification survey conducted on 10/12/22, the survey team identified multiple findings of Immediate Jeopardy which included, but were not limited to: The facility failed to ensure residents were free from sexual abuse after an allegation of sexual abuse involving (Resident #10), and b.) protect vulnerable residents from being verbally abused by staff (Resident #56). The Licensed Nursing Home Administrator (LNHA) failed to ensure policies, procedures and systems were developed and implemented to ensure immediate action 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 review of facility provided documentation, it was determined that the facility failed to have a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs. The deficient practice was evidenced by the following: On 10/11/22 at 01:00 PM, the surveyor asked the Regional Licensed Nursing Home Administrator (RLNHA) to view the written transfer agreement that the facility had with one or more hospitals. The RLNHA was unable to provide the surveyor a written transfer agreement. On 10/12/22 at 10:53 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) to view the written transfer agreement that the facility had with one or more hospitals. The LNHA stated that the agreement would be in the Emergency Preparedness (EP) manual. The LNHA then, in the presence of the surveyor, began looking through different binders that were not labeled as the EP manual. He then stated that the previous owner would have had the agreement. He stated that he was unable to locate it at this time. The LNHA then…

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 review of documentation, it was determined that the facility failed to employ a Social Worker (SW) with the required experience per facility policy and Centers for Medicare and Medicaid Services (CMS). This was identified for 1 of 1 SW employed and was evidenced by the following: On 09/27/22 at 12:31 PM, during an interview with a surveyor, the SW stated she had been in the position of Social Services Director (SSD) since March 2022. The SW stated some of her responsibilities included initial social services assessments, communication with residents and families, handling concerns such as any investigations, and interviewing anyone involved. The SW reiterated that she had started in March 2022 and added that this was her first job out of school, she had not been educated on this (her job), and had not been provided with clear direction to handle grievances. She stated that the Licensed Nursing Home Administrator (LNHA) had started in June 2022 and had trained her. The SW further stated she could not recall if she was provided a job description but, I'm going…

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 concerns identified during this survey that ended 10/12/2022, interviews and review of pertinent facility provided documentation, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to put forth a good faith attempt to identify and correct their own concerns related to infection prevention and control during an ongoing COVID-19 virus (an acute disease in humans caused by a Coronavirus) outbreak that began on 06/24/22. This deficient practice was identified during the standard survey and was evidenced by the following: Refer to F880L, F886L, F888L On 09/21/22 at 01:09 PM, during the entrance conference held with the facility administration, another surveyor requested information regarding the QAA (Quality assessment and assurance) committee and QAPI plan. The administration informed the survey team that the facility was presently in an outbreak of COVID-19 which began on 06/24/22. On 10/07/22 at 10:00 AM, the surveyor reviewed the facility provided Quality Assurance Meeting August 2022 minutes which included the following: Outbreak Plan: We…

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 concerns identified during the survey through interviews, and review of pertinent facility provided documents, it was determined that the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. This deficient practice was identified during the standard survey and was evidenced by the following: On 09/21/22 at 01:09 PM, during the entrance conference held with the facility administration, another surveyor requested information regarding the QAA (Quality assessment and assurance) committee and QAPI plan. On 10/07/22 at 10:00 AM, the surveyor reviewed facility provided Quality Assurance Meeting minutes for the last three meetings. There was no documented evidence in the minutes to confirm plans of action to correct identified quality deficiencies were implemented. On 10/07/22 at 11:29 AM, the other surveyor interviewed the Medical Director regarding the QAPI process. The Medical Director stated that she had been at the facility for more than…

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 pertinent documentation, it was determined that the facility failed to employ an Infection Preventionist (IP) who had completed specialized training in infection prevention and control per Centers for Medicare & Medicaid Services (CMS) guidance. This deficient practice was identified for 1 of 1 employees reviewed for IP and was evidenced by the following: On 09/21/22 at 1:08 PM, entrance conference was conducted with the facility Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). At that time, the surveyor was informed that the current position of IP was held by a Registered Nurse (RN) who had not completed the Center for Disease Control and Prevention (CDC) specialized training for infection prevention and control. On 09/22/22 at 1:54 PM, during an interview with the surveyor, the RN stated she had started as IP at the facility in July 2022 and had not completed her CDC training (IP). On 09/23/22 at 9:42 AM, during an interview with surveyors, the RN who was acting as the facility's IP stated she was new to the role of IP. The RN…

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 other pertinent facility documentation, it was determined that the facility failed to a.) notify in writing of residents' room changes for cognitively impaired residents and b.) develop facility policy for room changes in accordance with federal and state regulations. This deficient practice was identified for 2 of 3 residents reviewed for room changes (Resident #10 and #47) and was evidenced by the following: On 09/26/22 at 2:52 PM, the surveyor interviewed the Director of Social Services (DSS) who stated the process for a resident room change was the nurse or nurse's aide would inform her the resident's room needed to be changed. The DSS stated if a room was available, she talked to the resident directly as well as the roommate and then let the Director of Nursing (DON) or Assistant Director of Nursing (ADON) know a room would be changed. At this time, the surveyor requested a list of resident room changes from the past two months. On 09/27/22 at 12:35 PM, 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 document review, it was determined that the facility failed to maintain a clean and sanitary environment in the shower room on 1 of 3 units (second floor unit) and was evidenced by the following: On 09/21/22 at 11:55 AM, the surveyor in the presence of two other surveyors were touring the second floor of the facility. The surveyors entered the resident shower room and observed the following: Shower labeled C1 had a visibly stained blanket being used as a shower curtain and tied in a knot on the shower rod. The blanket was wet and lying on the base of the shower. The grout on the floor was blackened. There was an area below the shower handrail which was blackened and chipped. Shower labeled C2 had visibly darkened grout below the shower chair. There was an area below the shower handrail which was blackened and chipped. There was a blanket being utilized as a shower curtain. There was a dried washcloth left on the shower chair rail. On 09/21/22 at 12:04 PM, the surveyor asked the second floor Registered Nurse Unit Manager (RN UM) to join the…

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

Based on interview and record review, it was determined that the facility failed to complete a quarterly Minimum Data Set Assessment (MDS), an assessment tool, as required for 6 of 20 residents (Resident #8, #12, #13, #14, #26 and #34) system selected for MDS over 120 days and was evidenced by the following: On 9/27/22 at 11:52 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the MDS coordinator resigned about three weeks ago and that the Regional MDS coordinator was now responsible for completing the MDS. The DON further stated that the Regional MDS coordinator was only in the facility, once in a while but usually communicated via email. The surveyor asked the DON how often the MDS should be completed. The DON replied, quarterly, annually, and for changes in the resident's condition. On 9/28/22 at 1:02 PM, the surveyor interviewed the Regional MDS Coordinator who stated that she had been the facility's Regional MDS coordinator since August 1, 2021, and the in-house facility MDS coordinator for about five weeks. The MDS coordinator stated that she was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to develop and revise a person-centered comprehensive care plan to: a.) address a resident's aggressive and inappropriate behavior (Resident #63); b.) specify supervision required for residents at risk for falls (Resident #24 and #13); and c.) update the care plan, identify steps to be implemented to manage the behavior of residents with history of sexual assault and prevent them from attempting to engage in inappropriate sexual behavior (Resident #63 and #8), for 4 of 35 residents reviewed for person-centered care plans. Findings included: Refer F600 a. On 09/21/22 at 10:40 AM, Surveyor #1 toured the 300's locked unit and observed Resident #63 lying in bed; he/she was awake and alert. He/she reported to the surveyor that he/she had a headache, the surveyor left the room and informed the nurse. Surveyor #1 reviewed Resident #63's medical record on 09/27/22 which revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed follow the facility policy for fall prevention, and to ensure: a.) interventions in place to prevent accidents were consistently implemented, and b.) residents at risk for falls received adequate supervision to prevent falls. This deficient practice was identified for 2 of 5 of five residents (Resident #13 and #24) reviewed for accidents and was evidenced by the following: On 09/21/22 at 10:15 AM, the surveyor observed Resident #13 in a low bed and his/her face was discolored. Resident #13 had bruises on the facial area. Resident #13 was alert and was calling out mommy continuously. On 09/21/22 at 11:30 AM, the surveyor returned to the room and observed that Resident #13 remained in bed. Resident #13 was able to hold a conversation for a brief period of time and denied being in pain. On 09/22/22 at 1:02 PM, the surveyor observed Resident #13 in bed. A Certified Nursing Assistant (CNA #1) was in the room assisting Resident #13 with the lunch…

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 pertinent documentation, it was determined that the facility failed to document the amount of fluid administered by nursing for 1 of 2 residents (Resident #69) reviewed for fluid restriction while on hemodialysis (HD -the process of purifying the blood of a person whose kidneys are not working normally). This deficient practice was evidenced by the following: On 09/21/22 at 10:41 AM, the surveyor observed Resident #69 sitting in a chair by the window in his/her room. Resident #69 stated he/she was on HD and there was an access in their right arm. On 09/26/22 at 11:03 AM, the surveyor observed Resident #69 in their room eating ice chips out of a pink water pitcher. Resident #69 stated that he/she had HD that day and would be picked up at 1 PM. The resident further stated he/she was not on any fluid restrictions. He/she stated they would eat before he/she would leave. The surveyor asked again if anyone ever told him/her to restrict fluids. The resident stated, I don't have any fluid restrictions, I can have what I want. 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 observations, interviews, and review of other pertinent facility documentation, it was determined that the facility failed to provide psychiatric consultation for a resident who expressed suicidal ideation and feelings of loneliness as ordered by the physician in April of 2022. This deficient practice was identified for 1 of 3 residents reviewed for mood and behavior (Resident #63) and was evidenced by the following: On 09/27/22 at 09:57 AM, the surveyor interviewed Temporary Nursing Aide (TNA) #1, who stated the facility's locked unit was for residents who had a tendency to wander off of a unit, had dementia, and more aggressive behaviors. TNA #1 continued Resident #63 was a resident on the unit who usually stayed in their room or in the hallway and went outside to smoke cigarettes. TNA #1 stated the resident had no behaviors, but there was an incident last month where Resident #63 was observed exiting a resident of the opposite sex's room. Resident #63 had not had a tendency to wander, and the incident was reported to the nurse. On 09/27/22 at 10:30 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 provide pharmaceutical services in accordance with professional standards to ensure: a.) a medication was removed from active inventory after being discontinued in July 2022 for one (1) of three (3) medication carts inspected; and b.) expired medications were removed from emergency (back-up) supply box for 1 of 1 back up supply box. This deficient practice was evidenced by the following: 1.) On 09/26/22 at 11:58 AM, the surveyor inspected the Low side medication cart on the third floor in the presence of the Licensed Practical Nurse (LPN #1). The surveyor found one bingo card (a multidose card containing individually packaged medication) of Divalproex sodium (Depakote) extended release (ER; used for epilepsy and, or acute bipolar mania) 250 milligrams (mg) with Unsampled Resident #393's name crossed off with a marker and Resident #48's name had been handwritten in. The bingo card was dated 07/19/22, labeled 1 of 1. The bingo card found was opened with 13 tablets remaining. At that time,…

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 properly label, date and discard expired biologicals in 2 of 3 medication carts, and 1 of 2 medication rooms inspected on the second floor unit. This deficient practice was evidenced by the following: On 09/26/22 at 10:10 AM, the surveyor, in the presence of the second floor Registered Nurse/Unit Manager (RN/UM), observed the following items in the High side unit medication cart (second floor): -one unlabeled inhaler [no Resident's name and unmarked with open date] of Ventolin HFA (albuterol oral inhaler; a medication used to help in breathing) 90 micrograms (mcg) per actuation. -one unlabeled bottle [no Resident's name] of Linzess (linaclotide; a medication used to treat chronic constipation or chronic irritable bowel syndrome) 145 milligrams (mg). During an interview with the surveyor at that time, the RN/UM stated that each medication should have been in a bag or a box and labeled with the Resident's name on the medication to avoid medication administration…

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 documentation, it was determined that the facility failed to promote dignity by failing to ensure: a.) a resident who required assistance at meals and foods in bowls was provided , and b.) a resident was provided with priviacy during dressing. This deficient practice occurred for 2 of 19 residents reviewed (Resident #7) and (Resident #54) and was evidenced by the following: a. ) During observation of the lunch meal on 09/23/22 at 12:30 PM, the surveyor observed Resident #7 seated at a table eating lunch. Resident #7 spilled all the food on his/her shirt and was observed picking up the food with his/her hands from the shirt to eat. Two staff members (TNA #1 and CNA #2) were observed in the dayroom assisting the residents. The surveyor observed TNA #1 who poured the remaining food from Resident #7's shirt on their plate and was about to serve the resident the food collected when the surveyor stopped her and asked her to call the kitchen for more food. 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.

Based on interview and record review, it was determined that the facility failed to complete a comprehensive Minimum Data Set Assessment (MDS), an assessment tool, as required for 2 of 20 residents (Resident #10 and #248), system selected for MDS over 120 days and was evidenced by the following: On 9/27/22 at 11:52 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the MDS coordinator resigned about three weeks ago and that the Regional MDS coordinator was now responsible for completing the MDS assessments. The DON further stated that the Regional MDS coordinator was only in the facility, once in a while but usually communicated via email. The surveyor asked the DON how often the MDS assessments should be completed. The DON replied, quarterly, annually and for changes in the resident's condition. On 9/28/22 at 1:02 PM, the surveyor interviewed the Regional MDS Coordinator who stated that she had been the facility's Regional MDS coordinator since August 1, 2021, and the in-house facility MDS coordinator for about five weeks. The MDS coordinator stated that she…

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 document review it was determined that the facility failed to implement revised interventions to prevent recurrent falls for a resident who had a history of falls and sustained a fall without injury on 01/11/23. The deficient practice occurred for 1 of 4 Residents reviewed for incidents (Resident #9) during a re-visit survey conducted on 01/26/23 and was evidenced by the following: On 01/26/23 at 8:43 AM, the Director of Nursing (DON) informed the surveyor team that there had been four investigations/ Reportable Events since 12/05/22. The surveyor reviewed the medical record for Resident #9 which revealed: A Resident Face Sheet which indicated the resident had diagnoses which include, but were not limited to, vascular dementia, unspecified severity, with behavioral disturbance, essential hypertension and chronic ischemic heart disease. An Nursing Progress Note, dated 01/17/23 at 11:12 AM, revealed 01/22/2023 CNA approached writer stating resident is on the floor on the floor…

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 provide residents with the care needed to meet the resident's assessed needs. This deficient practice was identified for 2 of 19 residents reviewed for care, (Resident #48 and #54) was evidenced by the following: On 09/21/22 at 10:20 AM, during the initial tour of the locked 300's unit, the surveyor observed Resident #48 in their room, the room had a strong odor of urine. Flies were noted in the room, the mattress was yellow stained. On 09/21/22 at 11:00 AM, an interview with LPN # 6 assigned to the 300's unit low side, revealed that all residents on the low side were confused, they defecated and urinated on the floor and wandered from room to room. The LPN could not comment if Resident #48 was on a toileting program or what had been done to address the behavior. On 09/21/22 at 11:01 AM, the surveyor interviewed the Housekeeping staff assigned to the 300's Unit, she stated that she reported to work at 7:00 AM daily, her role was to remove the trash, clean the dining room, the nursing…

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 pertinent facility documentation, it was determined that the facility failed to provide appropriate services for a resident with contractures by failing to ensure: a.) appropriate interventions were in place for a resident with contractures, and b.) a resident with limited range of motion received appropriate services in accordance with person centered care plan to prevent further contractures, and c.) interventions were appropriately documented as administered for resident with limited range of motion for 1 of 4 residents (Resident #20) reviewed for position/mobility. This deficient practice was evidenced by the following: On 09/22/22 at 12:43 PM, the surveyor observed Resident #20 seated in a chair. Resident #20 had contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of both hands. The surveyor did not observe any devices including a hand roll in either of Resident #20's hands. The surveyor attempted to interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #NJ00155999 Based on observation, interview, and other facility documentation, it was determined that the facility failed to maintain complete, accurate, and readily accessible medical records. This deficient practice was identified for (a) 1 of 4 residents closed medical records reviewed (Resident #194), and (b) 1 of 35 Sampled residents reviewed (Resident #8). The deficient practice was evidenced by the following: a) On 09/27/22 at 11:47 AM, the surveyor requested Resident #194's closed records from the Medical Records department. On 09/28/22 at 12:02 PM, the surveyor interviewed the Unit Clerk/ Medical Records (UC/MR) who explained her process. She stated she thinned the paper charts, closed charts, and sent data to other physicians when needed. She informed the surveyor that the electronic Medical Record (eMR) started in May 2022. A review of the eMR under admission Discharge Transfer (ADT) reflected Resident #194 was admitted to the facility on [DATE] and discharged on 05/13/22. On 10/04/2022 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, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer a resident a Pneumococcal Vaccine. This deficient practice was identified for 1 of 5 residents reviewed for immunization status (Resident #11). The deficient practice was evidenced by the following: On 09/26/22 at 9:18 AM, the surveyor reviewed Resident #11's medical record which revealed the following information: Review of the Resident Face Sheet Record (an admission summary) revealed that Resident # 11 had been admitted to the facility with diagnoses which included but were not limited to dementia, acute embolism, thrombosis of lower extremities and an International Classification of Diseases, 10th Revision (ICD-10; a diagnostic and procedure coding system) of Z28.39 other under immunization (is for reporting when a patient is not current on other, non-COVID vaccines). Review of the most recent quarterly Minimum Data Set (MDS - an assessment tool), dated 08/12/22,…

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 pertinent facility documents, it was determined that the facility failed to offer a resident a COVID-19 Immunization. This deficient practice was identified for 1 of 5 residents reviewed for immunization (Resident #11). The deficient practice was evidenced by the following: On 09/26/22 09:18 AM, the surveyor reviewed Resident #11's medical record which revealed the following information: Review of the Resident Face Sheet Record (an admission summary) revealed that Resident # 11 had been admitted to the facility with diagnoses which included but were not limited to dementia, acute embolism, thrombosis of lower extremities and an International Classification of Diseases, 10th Revision (ICD-10; a diagnostic and procedure coding system) of Z28.39 other under immunization (is for reporting when a patient is not current on other, non-COVID vaccines). Review of Resident #11's active Care Plan (CP) printed on 10/03/22 did not reveal any focus, goals, or interventions for vaccinations. Review of Resident #11's electronic Medical…

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 document review, it was determined that the facility failed to ensure corridors were equipped with firmly secured handrails on 1 of 3 floors (second floor) and was evidenced by the following: On 09/21/22 at 12:21 PM, the surveyor in the presence of a second surveyor was touring the second floor and observed the handrails from the elevator door located in front of the second floor conference room to be unsecure. The surveyors observed the handrail from the elevator to the corner of the low side corridor was visibly leaning outward. The surveyor was able to touch the handrail and it was observed to have almost completely separated from where it was screwed into the wall. The surveyors observed the attached corner handrail, that was meant to hold two handrails together, which was visibly partially separated from the two handrails causing another handrail on the low side corridor to become unsecured. The surveyors next observed the handrail from the elevator towards the high side corridor was visibly leaning outward with a corner handrail piece which…

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.