Riverside Health And Rehabilitation Center LLC

COMPLAINT#: NJ0018543 Based on interview and review of pertinent documentation provided by the facility on 3/21/25 and 3/25/25, it was determined that the facility failed to implement the facility's Abuse, Neglect and Exploitation policy to ensure that existing staff received annual education for 1 of 2 employee files reviewed. This deficient practice was evidenced by the following: The surveyor reviewed the Social Worker Assistant's (SWA) employee file, which included a General Orientation Checklist for All Employees dated 12/15/09. The checklist indicated that the SWA had an in-service on Resident Neglect and Abuse as part of her orientation. The employee file did not contain any additional in-services regarding this topic. On 3/21/25 at 1:02 P.M., during an interview with the SWA, she stated that although she could not recall the exact date she received an in-service on Abuse and Neglect (A/N), she knew it had been over a year. On 3/21/25, at 3:18 P.M., during an interview with the Assistant Director of Nursing (ADON), she stated that all staff were to be in-service on A/N upon…

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

COMPLAINT#: NJ00184543 Based on interview, medical record review, and review of pertinent documentation provided by the facility on 3/21/25 and 3/25/25, it was determined that the facility failed to: a.) immediately initiate an investigation of an allegation of verbal abuse, and b.) implement the facility's Abuse, Neglect and Exploitation policy. This deficient practice was identified for 1 of 1 resident (Resident #2) reviewed for abuse and was evidenced by the following: Resident #2 was not at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record (AR) revealed that Resident #2 was admitted to the facility with diagnoses that included but were not limited to: paraplegia, acute pyelonephritis (a bacterial infection causing inflammation of the kidneys), anxiety, and depression. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/23/25, indicated that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that the resident's…

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 documents, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 11/18/2024 from 9:25 AM to 10:14 AM, the surveyor, accompanied by the Dietary Director (DD), and observed the following: 1.) In the refrigerator referred to as the reach in cooler, there were two egg salad sandwiches labeled with a use by date of 11/16/2024, but no made on date. The DD said that egg salad sandwiches should be discarded because sandwiches can cause illness. 2.) In the dry storage area, there were four bags of unopened marshmallows with a manufacture's expiration date of 07/2024. The DD said that marshmallows should be discarded because of the expiration date. 3.) In the overstock storage area, there were 70 cases (6 gallon per case) of water with a manufacture's expiration date of 07/31/2024. The DD said that the Licensed Nursing Home Administrator (LNHA) is aware of 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 observations and interviews on 11/20/2024 and 11/21/2024 in the presence of the Director of Maintenance (DOM), it was determined that the facility failed to ensure that the resident call bell system properly functioned by a.) ensuring the call bell system volume was set to a level to be heard and b.) devices used to identify call bell notifications were functioning properly. This deficient practice had the potential to affect all residents and was evidenced by the following: An observation at on 12/20/2024 at 12:55 PM revealed the call bell light outside of room [ROOM NUMBER] turned on when tested by the DOM, but there was no audible notification and the activation did not register at the nurse's station call bell annunciator. An observation at 1:00 PM revealed the call bell light outside of room [ROOM NUMBER] turned on when tested by the DOM, but there was no audible notification and the activation did not register at the nurse's station call bell annunciator. Additionally, visual notification of 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 On 11/18/2024 at 10:34 AM during the initial tour on the second floor in the low side shower room, Surveyor # 3 observed a trash can without a bag liner. The surveyor observed disposable gloves discarded in the whirlpool tub. The sharps bin on the wall was full and not emptied. The plastic lid indicated, Full. On 11/20/2024 at 10:09 AM in the second floor shower room, Surveyor # 3 observed the sharps bin still indicating, full. On 11/20/2024 at 10:10 AM in room [ROOM NUMBER], Surveyor # 3 observed the plastic on the foot board of Resident # 229's bed separated. Resident # 229 was asleep in the bed at that time. On 11/20/2024 at 10:13 AM, Surveyor # 3 observed the high side medication cart on the second floor. At that time, Surveyor # 3 observed hair tangled in the wheels of the cart. Surveyor # 3 observed residual stains and wrappers in the attached disposable glove holder on the side of the cart. On the same date at 10:15 AM, Surveyor # 3 observed the low side medication cart on the second floor. 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, record review, and review of pertinent facility documents it was determined that the facility staff failed to use appropriate infection control practices specifically by 1). failing to wear a gown when providing wound care, and 2). Performing hand hygiene for residents and staff during meal service. The deficient practice was identified for 1 of 1 (Resident # 22) residents reviewed for Pressure Ulcer/Injury, and 1 of 3 floors observed for dining. (4th Floor) The deficient practice was evidenced by the following: 1.) A review of Resident # 22's diagnoses located in the Electronical Medical Record (EMR), revealed a diagnosis of but not limited to a pressure ulcer of the sacral region. A review of Resident # 27's physician's orders located in the EMR revealed that he/she was receiving Collagen (a dressing that maintains a moist wound environment that fosters healing) applied every day shift for pressure ulcer. The order further revealed to cleanse sacrum with normal saline solution, apply collagen and cover with a bordered gauze dressing. On 11/22/2024…

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 other facility documentation it was determined that the facility failed to maintain an environment that protected and valued a residents' private space along with their personal property. This deficient practice was identified for 1 of 28 residents reviewed for Resident Rights (Resident #77). During initial tour of the Fourth Floor on 11/18/2024 at 10:55 AM, the surveyor observed a housekeeper wiping the inside of Resident #77's bedside drawer that was located across from the resident's bed. The surveyor immediately requested the assistance of the Registered Nurse Unit Manager (RN/UM#1) and upon the return to the resident's room, the surveyor and RN/UM#1 heard Resident #77 yell to the housekeeper to get out of the drawer and that they didn't give permission to go in there. The surveyor inquired if housekeeping has permission to go inside of resident's personal drawers. RN/UM #1 responded that they can open resident's drawers if the room was set to be carbolized…

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 maintain the call bell within reach for 1 of 28 sampled residents, (Resident #90). This deficient practice was evidenced by the following: On 11/18/2024 at 10:49 AM, upon initial tour of the Fourth Floor, the surveyor observed Resident #90's call bell on the floor under the bed. When asked about their call bell, Resident #90 was unsure where it was and if they had one. On 11/19/2024 at 11:17 AM, the surveyor observed the call bell on the floor underneath the resident's bed. On 11/20/2024 at 12:26 PM, the surveyor observed the call bell on the floor underneath the resident's bed. The surveyor reviewed the medical record for Resident #90. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: delusional disorder, psychotic disorder with delusions due to known physiological disorder and Diabetes Mellitus. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool…

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

Based on interview, record review and document review it was determined that the facility failed to maintain documentation and ensure that a complete and thorough investigation was conducted for residents that had a witnessed fall. This deficient practice was identified for 1 of 4 Residents (Resident #8) reviewed for accidents and was evidenced by the following: On 11/19/2024 at 12:PM, the surveyor requested all accidents and/or investigations during the timeframe of 10/14/2024 to 11/17/20204. The facility provided information related to Resident #8 sustaining a fall without injury on 11/9/2024. Upon review of the fall investigation titled, Witnessed Fall with Head Injury dated 11/9/2024 at 2:19 PM revealed under Incident Description: Heard a noise from the hall and got up to check and saw resident sitting on the floor. There was an aide sitting in the hallway and witness resident falling. Per aide resident's shoe came off while walking and she saw resident going on the floor and the back of [their] head hit the wall. The surveyor reviewed the medical record for Resident #8. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # 172764 Based on observation, interview, and record review it was determined that the facility failed to accurately assess the status of a resident in the Minimum Data Set (MDS), an assessment tool used to facilitate care. This deficient practice was identified for 2 of 31 residents (Residents #98 and #41) reviewed and was evidenced by the following: 1.On 11/21/2024 at11:49 AM, the surveyor observed Resident #98 with a Wander guard to his/her left ankle. According to the admission Record, Resident #98 was admitted to the facility with diagnoses including but not limited to dementia and cerebral vascular accident (stroke). Resident #98 had a Physician Order (PO) dated 04/10/24 to apply a Wander guard to the left ankle. A review of the April 2024, June 2024, and September 2024 Medication Administration Record reflected that the Wander guard was signed out as completed. A review of the Quarterly MDS dated [DATE] for Resident # 98 reflected under Section P0200 that the resident was coded as 0 indicating…

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 pertinent facility documentation, it was determined that the facility failed to develop a comprehensive person-centered care plan that includes measurable objectives to meet the resident's medical, nursing, mental, and psychosocial needs specifically by failing to include what the Care Plan focuses are related to. The deficient practice was identified for 2 of 3 residents (Resident # 124 & 21) reviewed for Development/Implementation of Care Plans. A review of Resident # 124's admission Record located in the Electronic Medical Record (EMR) revealed that he/she had a diagnoses including but not limited to Major Depression Disorder and Anxiety. A review of Resident # 124's Order Summary Report located in the EMR revealed that he/she had physician's orders including but not limited to bupropion (medication used to treat major depressive disorder), seroquel (medication used to treat bipolar disorder), and trazodone (medication used for depression). A review of Resident # 124's…

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

Based on interview, record review and document review it was determined that the facility failed to maintain thorough documentation following a witnessed fall according to professional standards of clinical practice. This deficient practice was identified for 1 of 4 Residents (Resident #8) reviewed for accidents and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: The practice of nursing as a licensed…

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 ensure that residents with indwelling urinary catheters received appropriate treatment and services to prevent urinary tract infections to the extent possible specifically by leaving the urinary catheter drainage bag in contact with the floor, unsecured to a bed, resting on top of a mattress while a resident was lying in bed, and failing to document whether the urinary catheter output was collected as ordered by the physician. The deficient practice was identified for 2 of 2 residents (Resident # 120 & 21). The deficient practice was evidenced by the following: A.) A review of Resident # 120's Electronic Medical Record (EMR) revealed a physician's order to maintain a 16 french/10 cubic centimeter catheter to OSD bag secondary to urinary retention related to neurogenic bladder. The EMR further revealed a physician's order to document catheter output every shift, every 8 hours…

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 facility documents, it was determined that the facility failed to properly store respiratory equipment, specifically a nebulizer, in accordance with professional standards of practice by leaving it unsecured, open to air. The deficient practiced was identified for 2 of 3 residents (Resident # 72 & 19) investigated under Respiratory Care. The deficient practice was evidenced by the following: A review of Resident # 72's Order Summary located in the Electronic Medical Record (EMR) revealed an order for, Oxygen Tubing Change: Please change oxygen tubing and Nebulizer mask weekly for infection prevention and patency. Label and date. On 11/19/2024 at 11:18 AM while in Resident # 72's room, the surveyor observed a nebulizer mask (mask used to deliver aerosolized medication to assist with breathing) in an opened drawer not secured in a bag and exposed to air. On 11/20/2024 at 10:03 AM while in Resident # 72's room, the surveyor observed the nebulizer tubing extending into a close drawer. No date was observed 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.

Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for 1 of 5 residents (Resident # 81). reviewed for medication management. The deficient practice was evidenced by the following: A review of the admission Record for Resident # 81 revealed the resident was admitted to the facility with diagnoses which included but were not limited to Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out daily tasks), and Protein-Calorie Malnutrition (a nutritional status in which poor intake of nutrients lead to changes in body composition and function). The facility-provided CP Recommendation dated 05/22/2024, indicated to clarify the Resident # 81's liquid Colace (medication used to soften stool) order to include concentration milligram/milliliter (mg/ml), dose (mg), and volume (10ml). The order needing clarifaction was written,…

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

Based on observation, interview, and review of documentation, it was determined that the facility failed to store, label, and date potentially hazardous food and maintain kitchen sanitation in a manner intended to limit the spread of food-borne illnesses. The deficient practice was evidenced by the following: On 08/28/23 at 09:55 AM, the surveyor entered the kitchen and toured with the Certified Dietary Manager (CDM). The surveyor observed several items throughout the kitchen that were not labeled properly to include a full case of bacon, several loaves of bread, boxes of tea bags, crackers in a yellow box, a bag of chips, and a metal container of grape jelly that was unlabeled. The jelly container contained peanut butter inside the jelly. The meat slicer was stored on the counter uncovered. The CDM made the observations alongside of the surveyor and confirmed the items should have been labeled,that separate spoons should have been used for the jelly and the peanut butter, and after the meat slicer was cleaned, it should have been covered. On the same day at 09:55 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint number: NJ00158868, NJ00159302, and NJ00158245 Based on observation, interview, and review of facility documentation it was determined the facility failed to maintain a clean, safe, and sanitary environment for the residents. This deficient practice was identified on the a.third and b.fourth floor of the facility and was evidenced by the following: a. On 08/29/23 12:09 PM, the surveyor toured the third-floor unit, the high and low side. During the tour the surveyor observed the following: In rooms 303, 304, 309, and 315 the surveyor observed cracks in the glass windows. The cracks were covered with silver tape; they were semi-private rooms. room [ROOM NUMBER] had brown substance spots on the floor which appeared dry. room [ROOM NUMBER] there was a nightstand with a broken door handing from the hinge. room [ROOM NUMBER] there was a four-drawer dresser and one of the drawers was missing from the dresser. On 08/31/23 at 11:58 AM, the surveyor went into the third-floor shower room and observed the…

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

Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to follow professional standards of nursing practice by incorrectly transcribing a physician's order for the appropriate dose of insulin medication. This deficient practice was identified for 9 out of 10 administered insulin doses for Unsampled Resident #1 observed during medication administration. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing a medical regimen as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey…

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 pertinent record review, it was determined that the facility failed to: 1.) ensure the accountability of the Narcotic Shift Count logs were completed in accordance with facility policy and 2.) accurately account for and document the administration of controlled medications. This deficient practice was identified on 3 of 3 medication carts and was evidenced by the following: 1. On 9/1/23 at 11:19 AM, the surveyor, in the presence of the Licensed Practical Nurse #1 (LPN #1) and a second surveyor, reviewed the narcotic logbook for the fourth floor's low side medication cart. The Record of Narcotic Count shift log revealed the following incomplete or blank sections: 8/1/23 - 7 AM incoming nurse and outgoing nurse signature and total number of narcotics remaining - cards, bottles, gels, and patches. 8/1/23 - 3 PM outgoing nurse signature and total number of narcotics remaining - cards, bottles, gels, and patches. 8/2/23 - 7 AM outgoing nurse signature 8/3/23 - 7 AM total number of narcotics remaining - patches. 8/26/23 - 11 PM total number of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to 1.) properly store medications including controlled substances, 2.) maintain clean and sanitary medication storage areas, and 3.) properly label opened multidose medications. This deficient practice was observed in 2 of 2 medication storage rooms and 3 of 3 medication carts reviewed for medication storage and labeling and was evidenced by the following: On [DATE] at 10:06 AM, the surveyor, in the presence of Licensed Practical Nurse Unit Manager #1 (LPN/UM #1) and a second surveyor, observed the fourth-floor medication storage room. The following observations were made: The medication storage refrigerator had a locking mechanism on the door which was left unlocked allowing the refrigerator door to be opened. In the refrigerator was a narcotic lock box which was secured to the inside of the refrigerator with a chain, had an unlocked hasp and padlock on the lid. Without the use of a key,…

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, review of medical records and other facility documentation, it was determined that the facility failed to promote dignity. This deficient practice was identified for 1 of 1 resident (Resident #287) reviewed for dignity. This deficient practice was evidenced by the following: On 08/09/22 at 7:18 AM, admission records revealed that Resident #287's family member had concerns about Resident #287's Texas catheter (a urine collection device that fits like a condom over the penis) was removed without his/her permission and Resident #287 was placed in a diaper the first night at the facility. On 09/11/23 at 12:15 PM, the surveyor reviewed Resident #287's Quarterly Minimum Data Set (MDS), an assessment tool revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated that the resident was cognitively intact. Further review of the admission record for Resident #287 revealed a progress note dated for 8/10/22 which stated, Patient also noted with texas catheter from ER, f/u to be done with MD for order to…

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

Based on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to promote and facilitate resident self-determination through support of resident choices to have personal needs allowance (PNA) and to have use of the laundry room during the evening hours and on the weekends. This deficient practice was identified for 6 of 6 residents. This deficient practice was evidenced by the following: On 08/31/23 at 10:30 AM, the resident council meeting was held and 6 out of 6 residents stated there was no PNA available in the evenings during the week and not available at all on the weekends, and the resident laundry room on the first floor was not available in the evenings during the week or on the weekends. On 08/31/23 at 02:09 PM, the surveyor interviewed the Administrator (Admin) and the Director of Nursing (DON) regarding the PNA and the Admin's response to the PNA was that PNA is available on the weekends and in the evenings. He stated that a locked box is kept at the front desk for the residents to be able to get…

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 the Annual Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 1 of 3 residents (Residents #51 ) reviewed for timing of assessments and was evidenced by the following: The Centers For Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual indicates that at a minimum, facilities are required to complete a comprehensive assessment for each resident not less than once every 12 months while a resident, where 12 months refers to a period within 366 days. This deficient practice was evidenced by the following: On 8/29/23 a review of the electronic health record (EHR) reflects that resident #51 was admitted to the facility in July 2017. The MDS schedule revealed the most recent MDS assessments completed were: Annual MDS 7/15/22 Quarterly MDS 10/14/22 Quarterly MDS 1/14/23 Quarterly MDS 4/13/23 The annual MDS due 7/13/23 for Resident # 51 was not completed nor…

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 resident observation, interview and record review, it was determined that the facility failed to complete a significant change in status assessment (SCSA) for a hospice resident. This deficient practice was identified for 1 of 1 residents (Resident #93) reviewed for hospice and was evidenced by the following: The Centers For Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual indicates that a SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The assessment reference date (ARD) must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). This deficient practice was evidenced by the following: On 08/29/23 at 11:25 AM, during the tour of the facility the surveyor observed Resident #93 in bed. At that time the resident was receiving care from a staff member who…

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

Based on observation, interview and record review it was determined the facility failed to implement a comprehensive care plan for Resident #23, 1 of 29 residents reviewed for care plans and was evidenced by the following: On 08/29/23 at 12:29 PM, during the initial tour of the facility Resident #23 told the surveyor that he/she fell out of bed about week ago because the bed is small, and they were used to a king-sized bed. The surveyor asked if there was a floor mat next to the bed at the time of the fall and resident said, I don't want a mat, I have rails on the side of the bed. Resident #23 denied any major injuries from falls and said he/she already had hip damage. On 09/06/23 at 10:00 AM, the surveyor observed Resident #23 in bed. The bed was in the low position. On 09/06/23 at 10:40 AM, the surveyor reviewed Resident #23 incidents/accidents which revealed the resident had falls on 10/4/22, 11/11/22, 11/23/22, 5/11/23 and 8/23/23. On 09/06/23 at 11:00 AM, the surveyor reviewed Resident #23 current care plan. The care plan had a focus of an actual fall related to poor impulse…

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 all medications were administered without an error of 5% or less. During the medication observation on 7/21/23, the survey team observed two (2) nurses administer medications to three (3) residents. There were 25 opportunities, and two (2) errors were observed which calculated a medication administration error rate of 8%. This deficient practice was identified for 1 of 3 residents (Unsampled Resident #1) that were administered medications by 1 of 2 nurses on the second-floor low side nursing unit. On 8/31/23 from 8:18 AM through 9:47 AM, the surveyor, in the presence of a second surveyor, during medication pass observation of the Licensed Practical Nurse (LPN) made the following observations: At 8:18 AM, a certified nursing assistant (CNA) was collecting eaten breakfast meal trays from resident rooms and placing on the tray cart in the hallway. The CNA informed the surveyor that breakfast was served to residents at approximately 7:50 AM that day. At 8:38…

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

Based on interview and document review of pertinent facility documentation, the facility failed to have the medical director present for two out of six Quality Assurance and Performance Improvement (QAPI) meetings as evidenced by the following: On 08/29/23 at 11:49 AM, the Director of Nursing (DON) provided the surveyor with six quarterly sign in sheets for the four most recent quarterly meetings which revealed: -Reporting Month of June 2022 Quality Assurance Performance Improvement (QAPI) Quarterly Meeting dated July 21, 2022, Medical Director's (MDs) signature was blank. - Reporting Month of December 2022/4th Quarter 2022 (QAPI) Sign In, the Medical Director's (MDs) signature was blank. During an interview on 09/01/23 at 12:56 PM, the DON stated the Medical Director did not attend the July 21, 2022 meeting and she did not attend the December 2022 meeting because she left the company. She furthered that the Medical Director should be attending the QAPI meetings. The Quality Assessment Performance Improvement Policy, implemented on 02/28/23 23 reflects that the committee shall…

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

Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to 1.) follow appropriate infection control practices and perform hand hygiene as indicated during a medication pass, and 2.) ensure respiratory equipment was kept in a clean and sanitary condition and stored properly to reduce the risk of infection. This deficient practice was identified for 1 of 3 residents reviewed for medication pass (Unsampled Resident #1), and for 1 of 1 resident reviewed for respiratory care (Resident #337). 1.) On 8/31/23 from 8:18 AM through 9:47 AM, the surveyor, in the presence of a second surveyor, during medication pass observation of Licensed Practical Nurse (LPN) made the following observations: At 8:18 AM a certified nursing assistant (CNA) was collecting breakfast meal trays from resident rooms and placing on the tray cart in the hallway. The CNA informed the surveyor that breakfast was served to residents at approximately 7:50 AM that day. At 8:38 AM, LPN prepared to obtain Unsampled Resident #1's vitals including blood pressure…

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.