Trenton Gardens Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review it was determined that the facility failed to ensure a comprehensive, data-driven Quality Assurance Program (QAPI) was implemented and sustained during leadership transition and focused on resident outcomes and quality of life to ensure for an ongoing infestation of cockroaches that was documented as observed on the 3rd floor beginning 6/1/24, and affected 3 of 3 resident units.The deficient practice was evidenced by the following:Refer to 584F, 925F, and 880F The surveyors observed cockroaches during the following observations:- On 12/2/25 at 8:05 AM, Surveyor #1 entered Resident #135's room with two Certified Nurse Aides (CNA's) to observe incontinence care. While in the room with the CNAs the surveyor observed a brownish cockroach type bug crawling on the wall. Upon inquiry, the CNA's informed the surveyor that the facility had roaches. -On 12/04/25 at 12:30 PM, Surveyor #2 and #4 observed Resident #31's room. Resident #31 allowed the surveyors to observe…

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 document review it was determined the facility failed to develop and implement an infection prevention and control program (IPCP) to limit the potential transmission of bacteria during a facility wide infestation of cockroaches, ensuring clean linens were protected from pests, and ensure water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems were developed and implemented.The deficient practice affected all residents who resided on 3 of 3 resident units and was evidenced by the following: Reference: Guidelines for Environmental Infection Control in Health- Care Facilities; Recommendations of CDC (Centers for Disease Control) and the Healthcare Infection Control Practices Advisory Committee; 2003; Updated July 2019. Refer to F584 and F925Fa. On 12/2/25, Surveyor #1 conducted an initial tour of the facility on the second floor, and observed the following:At 7:49 AM, a food cart…

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 # NJ 2587050Based on observation, interview and review of pertinent documents it was determined that the facility failed to ensure the ice machines were maintained in a clean and sanitary manner, and per manufacturers' instructions. The deficient practice was identified for 3 of 3 ice machines located on the 2nd, 3rd and 4th floor resident units, and was evidenced by the following: On 12/2/25, Surveyor #1 conducted an initial tour of the facility on the second floor, and observed the following:At 7:36 AM, the ice machine located in the resident dining room, had a plastic type ice chute that was heavily soiled inside with white and black colored substances. The drain cover had a rust like build and the molding around the ice machine was peeling off.On 12/2/25 at 8:45 AM, Surveyor #2, conducted an initial tour of the facility on the third floor and observed the following:The ice machine located in the resident dining room had blackened areas inside the ice chute, and the area also had blackened discolored embedded areas where the ice chute attached to the machine and where 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 Based on observation, interview and document review it was determined that the facility failed to have an effective pest management program to irradicate an infestation of German cockroaches. The deficient practice occurred on 3 of 3 resident units and was evidenced by the following:Refer to 584F and 880F On 12/2/25 at 8:05 AM, Surveyor #1 entered Resident #135's room with two Certified Nurse Aides (CNA's) to observe incontinence care. The bathroom floor was covered with various debris, which included used plastic bags, a broken toilet seat was also observed on the floor. While in the room with the CNAs the surveyor observed a brownish cockroach type bug crawling on the wall. Upon inquiry, the CNA's informed the surveyor that the facility had roaches. The surveyor then asked the CNA's what the protocol was if staff observed cockroaches. The staff informed the surveyor that they would enter their observations into the pest control book which was located at the nurses' station and they would also notify the…

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

Based on observation, interview and document review, it was determined that the facility failed to ensure a system was in ensure annual competency evaluations were completed for Certified Nurse Aides (CNAs) and they were educated based on the outcome, and a system was in place to ensure CNAs were provided with at least 12 hours of education per their annual date of employment. The deficient practice was evidenced by the following: On 12/10/25 at 11:03 AM, the surveyor reviewed the provided in-service education for 5 randomly selected CNAs for the 2024 to 2025 year, which revealed that the in-service education was a sign-off list and did not obtain an hourly audit of education training. On 12/10/25 at 1:11 PM, the surveyor interviewed the Director of Nursing who confirmed that there was no system in place to document the amount of hourly training and/or performance evaluations for the requested CNAs. The DON could only provide checklists for the CNAs without any specifics related to the amount of training. On 12/11/25 at 10:15 AM, the surveyor interviewed the Assistant Director of…

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

Based on interview, and review of facility documentation, it was determined that the facility failed to ensure that a Certified Nurse Aide (CNA) received at least 12 hours of mandatory in-service training for 5 of 5 CNAs education reviewed. This deficient practice was evidenced by the following: On 12/10/25 at 11:03 AM, the surveyor reviewed the provided in-service education for 5 randomly selected CNAs for the 2024 to 2025 year, which revealed that the in-service education was a sign-off list and did not obtain an hourly audit of education training. On 12/10/25 at 1:11 PM, the surveyor interviewed the Director of Nursing who confirmed that there was no system in place to document the hourly training and/or performance evaluations for the requested CNAs. The DON and could only provide checklists for the CNAs.On 12/10/2025 at 1:15 PM, the surveyor interviewed the Human Resources Director (HRD) who confirmed there were no competencies for the staff, and for the CNA education, there was a trifold bulletin board used with no documentation regarding any hourly training provided to CNAs.…

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 #s NJ 388773, NJ 2573609, NJ 2595473, NJ 263559, NJ 2591993Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that residents who were dependent on staff for care were provided with a) routine and appropriate incontinence care and b) provided with care to maintain their fingernails in a clean manner. This deficient practice was identified for 3 of 4 residents reviewed for Activities of Daily Living (Resident #11, #81 and Resident #135. The deficient practice was evidenced by the following: 1. On 12/02/25 at 7:50 AM the surveyor observed Resident # 11 lying in bed, the resident was awake and alert and the surveyor further observed that the resident's fingernails were long and jagged with a black substance underneath all of the nails.On 12/04/25 at 8:25 AM, the surveyor again observed Resident #11's fingernails were not cleaned trimmed. During an interview with the surveyor, the resident stated, I would like…

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 provide the required Skilled Nursing Facility (SNF) Notice of Medicare Non-Coverage (NOMNC) for 1 of 2 residents (Resident #114) reviewed for change in insurance coverage status and remained in the facility. This deficient practice was evidenced by the following:On 12/09/25 at 9:09 AM, the Social Worker returned 2 of 3 requested beneficiary forms to the surveyor and stated, I don't have Resident #114, they didn't have a beneficiary form completed, as the resident had a guardian. The Social Worker stated that she should have informed the guardian regarding Medicare coverage ending but she did not, and stated, it fell through the cracks. On 12/09/25 at 9:11 AM, the surveyor reviewed the SNF Beneficiary Protection Notification Review (BPNR) forms for Resident #114, provided by the facility. The facility had a change in insurance coverage status and remained in the facility. The resident's last covered day for Medicare Part A Services was 9/15/25. Resident #114's SNF NOMNC form did not have a signature…

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 Intake NJ #2594199Based on interview, record review and review of pertinent documentation, it was determined that the facility failed to ensure an allegation of misappropriation of property was investigated. The deficient practice was identified for 1 of 1 sampled resident (Resident #154) reviewed for misappropriation property and was evidenced by the following:On 12/09/25 at 12:00 PM the surveyor reviewed Resident #154's medical record which revealed the following:The diagnoses included but not limited to; Schizoaffective disorder, Bipolar type (mental health disorder), Epilepsy (seizure disorder) and Hemiplegia (loss of voluntary movement on one side). A review of the Significant Change Minimum Data Set, an assessment tool, dated 9/29/25, indicated the resident had a Brief Interview for Mental Status score of 13 out of 15, which indicated the resident was cognitively intact. On 12/10/25 at 1:21 PM, the surveyor interviewed the Director of Nursing (DON) regarding what accommodations were in place to ensure Resident #154's safekeeping of valuables. The DON stated that if 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 Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA Form 222) were completed with sufficient detail to enable accurate reconciliation of controlled-dangerous substances (narcotic medications, that due to their high potential for abuse, are tracked with a degree of detail and attention)medications ordered and received for 1 of 6 forms provided, and the facility failed to ensure medications were administered to a resident according to standards of practice (Resident #121). The evidence was as follows: a. On 12/11/2025 at 10:57 AM the surveyor reviewed the facility provided DEA 222 forms which revealed on one of the six provided forms Part 5, had not been completed upon receipt of the medications from the provider pharmacy as instructed on the reverse of the ordering form. The forms were as follows: Order form # 230236684 dated…

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 # 388773Based on interviews, record reviews and reviews of other facility documentation, the facility failed to ensure that staff received behavioral health training to assist them in coping effectively with residents who had maladaptive behavior of being disruptive, cursing and spitting at staff. This deficient practice was identified for 1 of 2 residents reviewed for behavior, Resident #157, and was evidenced by the following:A review of a Facility Reportable Event Record (RER). dated 2/13/25 revealed a Narrative: Resident #157 picked up a piece of cake that the aide (Certified Nurse Aide) was going to give to another resident, and the aide explained that the cake was not for Resident #157, and took a bite out of the cake and spit it at the aide, and gestured to hit the aide, who then raised a hand to protect herself. Another aide was present when Resident #157 stated you hit me, the supervisor was called, the police and Crisis.On 12/5/25 at 10:00 AM, the surveyor reviewed the medical record for…

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

Complaint #2620207Based on interviews and review of other pertinent facility documentation on 10/07/2025 and 10/14/2025, it was determined that the facility failed to: a.) ensure that the facility-wide assessment (FA) evaluated its resident population and b.) identified the resources needed to provide the necessary care and services required for residents admitted with a history or current use of, tobacco or drug and alcohol abuse. This deficient practice had the potential to affect all residents and was evidenced by the following:Refer to F689A review of the facility's Facility Assessment provided by the Director of Nursing (DON), indicated that the assessment was completed on 05/03/2025. A further review of the facility's FA did not include any documentation that addressed the resident population that was admitted to the facility with a history or current use of, tobacco or drug and alcohol abuse.During a joint interview with the DON, the Consultant DON, and the Consultant Administrator on 10/14/2025 at 2:14 P.M., the DON stated that the FA was a snapshot of residents that…

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 #: NJ185458Based on interviews, medical record reviews, and review of other pertinent facility documentation on 5/8/25, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) and the administrative staff failed to ensure resident safety and well-being by failing to A) prevent illicit drugs from entering the facility and drug overdose incidents from occurring, B) ensure a thorough investigation was completed for a staff to resident sexual abuse allegation involving Resident #3 and multiple drug overdoses that occurred in the facility involving Resident #6, and C) ensure that the police and the New Jersey Department of Health (NJDOH) were notified of any drug overdoses that occurred in the facility. The deficient practice was evidenced by the following:A review of the facility's undated job description titled Administrator revealed under Purpose of Your Job Description, The primary purpose of your position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standard guidelines, and regulations…

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 #: NJ182907, NJ185458, NJ186028 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 5/7/25, 5/8/25, and 5/9/25 it was determined that the facility failed to: a.) report a to the New Jersey Department of Health (NJDOH) on 10/12/24 when Resident #15 was observed to have bruising, swelling and a scratch to her/his face. b.) report to law enforcement when a resident (Resident #2) reported witnessing an alleged sexual abuse between Licensed Practical Nurse (LPN #1) and another resident (Resident #3), and c.) report a staff to resident verbal abuse allegation involving LPN #7 and Resident #1 to the NJDOH in a timely manner. The facility also failed to follow its policy titled Abuse, Resident Behavior and Facility Practice. The deficient practice was evidenced by the following: A.) According to the facility's Grievance/Concern Communication Form, filled out by the Director of Nursing (DON), with an event date of 10/14/24, revealed under Description of concern, This writer met with Resident #15 this date. Nursing reported he/she had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ182907, NJ186028 Based on interviews, medical records reviews, and review of other pertinent facility documentation on 5/7/25, 5/8/25, and 5/9/25 it was determined that the facility failed to complete thorough investigations when A) Resident #15 was observed to have bruising, swelling and a scratch to her/his face. B) when a resident reported witnessing an alleged sexual abuse between another resident (Resident #3) and the Licensed Practical Nurse (LPN #1). The facility also failed to ensure its policy titled Abuse, Resident Behavior and Facility Practice was implemented for the alleged physical abuse and alleged sexual abuse allegations. 1. On 10/12/24 at approximately 8:30 P.M, the Unit Manager (UM) was notified by LPN #6 that Resident #15 had a scratch on his/her face. LPN #6 reported that Resident #8 left the room that he/she shared with Resident #15 cursing and stating he/she had punched the resident (Resident #15). The DON failed to conduct a thorough investigation. The DON stated that…

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 # NJ 185458, NJ179424 Based on observations, interviews, and review of other facility documentation on 5/7/2025, it was determined that the facility failed to maintain a clean and homelike environment for the residents. The deficient practice was identified for 2 of 3 units, (floor 2 and floor 4) and was evidenced by the following: During a tour of the 2nd floor unit on 5/7/2025 at 11:08 AM, the surveyor observed the following: 1. Inside 2nd floor Central Bath, sink filled with isolation gown, black pad, wash sponge, and grey basin. 2. Inside 2nd floor Central Bath, shower bed noted to have hair clippings, toilet paper, shaving cream can, a covered razor, a shampoo and a lotion bottle on it. 3. Inside 2nd floor Central Bath, visible water on the floor outside of the shower stall and in the shower stall. 4. Inside 2nd floor Central Bath 1st stall, noted to have a brown hard substance to left outer dividing wall corner where the silver molding is missing. 5. Inside 2nd floor Central Bath 1st stall, brown, green, and black colored substance on bottom left corner of the shower…

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 #NJ184250 Based on interview and record review it was determined that the facility failed to appropriately discharge a resident from the facility. This deficient practice was identified for 1 of 18 residents who was discharged without a 30-day discharge notice. This deficient practice was evidenced by the following: According to Resident #16's admission Record (AR), the resident was admitted with diagnoses that included but were not limited to: Polyneuropathy, Bipolar, Chronic PTSD, Frontotemporal Neurodegenerative Disorder, Neuroleptic Induced Parkinsonism. According to the Minimum Data Set (MDS), an assessment tool dated 1/27/25, Resident #16 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. On 5/8/25 at 12:26 P.M, during an interview with the Social Worker (SW #2) she stated, Resident #16 had an incident with her/his roommate which led to a physical fight. Resident #16 didn't return back to the facility because it was domestic violence, and the roommate didn't want her/him back. Resident #16'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.

C#175920 Based on interviews, medical record reviews, and other pertinent facility documentation on 5/7/2024, 5/8/2024, and 5/9/2024, it was determined that the facility failed to follow a Physician's Order (POs) for a treatment to the Resident's (Resident #5) wound. The facility also failed to follow its policies titled P&P Physician Order and Medication Administration Policy and Protocol. This deficient practice was identified for 1 of 18 residents and was evidenced by the following: Reference: The practice of nursing as a Licensed Practical Nurse is defined as performing tasks, and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a Registered Nurse, or otherwise legally authorized Physician or Dentist. A review of the Electronic Medical Record (EMR) was as follows: According to the admission Record (AR), Resident #5 was admitted to the facility with diagnoses which included but were not limited to:…

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

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store, label, and date potentially hazardous foods to prevent food-borne illness; b.) discard potentially hazardous foods past their date of expiration; and c.) maintain storage areas in a sanitary manner. This deficient practice was evidenced by the following: On 5/2/24 at 8:49 AM, the surveyor with the Dietary Director (DD) toured the kitchen and observed the following: 1. The handwashing sink had no paper towels. The DD acknowledged there should be paper towels by the sink at all times. 2. In the walk-in refrigerator, one gallon of ranch dressing dated opened 3/30/24. The rim of the bottle, lid, and outside of the container all contained ranch dressing spillage. The DD acknowledged the bottle should have been cleaned after use to prevent bacterial growth. 3. In the walk-in refrigerator, one opened jug of salsa dated received 1/18/24. The was no opened date, and the packaging indicated best within seven to ten days after opening. 4. In the walk-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 observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) perform hand hygiene during and after medication administration; b.) perform hand hygiene before and after serving residents meals; and c.) maintain enhanced barrier precautions to maintain infection control standards. This deficient practice was identified on 2 of 3 nursing units (Second and Third Floor), and was evidenced by the following: 1. On 5/8/24 at 10:29 AM, the surveyor observed Unit Manager/Licensed Practical Nurse (UM/LPN #1) perform tracheostomy (a small surgical opening that is made through the front of the neck into the windpipe) care on Resident #47 and observed the following: UM/LPN #1 performed hand hygiene with soap and water lathering outside the flow of running water for thirteen seconds and put on a pair of gloves. UM/LPN #1 then cleaned the bedside table and removed the pair of gloves, and performed hand hygiene with soap and water lathering outside the flow 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 documents it was determined that the facility failed to ensure the smoking policy was followed to screen and assess a resident for the ability to safely smoke cigarettes. The deficient practice occurred for 1 of 5 residents reviewed for accidents (Resident #127) and was evidenced by the following: On 4/30/24 at 10:18 AM, during the entrance conference, the facility provided a Smoking Policy and Procedure and the Smoking Schedule which revealed that Resident #127 was listed as smoking during shift #1 from 9:00 AM-9:10 AM, 10:30 AM-10:40 AM, 2:00 PM-2:10 PM, 5:00 PM-5:10 AM. On 5/2/24 at 8:40 AM, Resident #127 was observed self-propelling from the designated smoking area onto the elevator. On 5/2/24 at 8:59 AM, the surveyor reviewed the electronic medical record (EMR) which revealed the most recent signed Smoking assessment dated [DATE] indicated 1. Is Resident a Smoker, and No was checked off. A review of the admission Record for Resident #127 revealed…

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 documentation, it was determined that the facility failed to ensure safe and appetizing temperatures of food for 3 of 4 entree meals observed on 1 of 3 nursing units (Third Floor). This deficient practice was evidenced by the following: On 5/3/24 at 10:07 AM, the surveyor conducted a Resident Council meeting which included four residents (Resident #13, #27, #46, and #48). Resident #46 stated lunch and dinner were served cold and in takeout containers and not on hot plates since February of 2024. On 5/8/24 at 11:32 AM, the surveyor informed the Dietary Director (DD) they wanted to observe the lunch meal for the day including food temperatures. The surveyor asked the [NAME] to calibrate two thermometers in their presence; which the [NAME] completed using an ice bath, and the thermometers reached 32 degrees Fahrenheit (F). On 5/8/24 at 11:33 AM, the surveyor observed the [NAME] using one of the thermometers calibrated to 32 F and took the following temperatures for the lunch meal: Barbecue chicken 178 F Scalloped…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of other pertinent documentation, it was determined that the facility failed to a.) inform and offer educational material regarding advance directives (written instruction including but not limited to living will, medication restrictions, and treatment restriction for the provision of healthcare when an individual is incapacitated) with a resident's legal representative, and b.) ensure life-sustaining treatment wishes were reviewed with the residents or their representatives and documented consistently within the medical record. This deficient practice was identified for 2 of 2 residents (Resident #96 and #62) reviewed for advance care planning and directives and was evidenced by the following: On [DATE] at 9:12 AM, the surveyor observed Resident #96 in a recliner chair in the 3rd unit day room. The surveyor attempted to talk to the resident, but the resident did not respond. The surveyor reviewed the medical record for Resident #96. A review 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 observation, interview, record review and review of other documentation, it was determined that the facility failed to implement a Care Plan (CP) intervention for a resident with an actual fall. This deficient practice was identified for 1 of 4 residents (Resident #96) reviewed for falls and was evidenced by the following: On 4/5/22 at 9:12 AM, the surveyor observed Resident #96 in a recliner chair in the 3rd floor day room. The surveyor attempted to interview the resident, but the resident did not respond. On 4/6/22 at 8:52 AM, the surveyor observed Resident #96 awake lying in bed. The bed was in the low position, there was a foot cushion at the foot board, a perimeter cover (a mattress cover used for fall prevention) on the mattress, but no floor mats. The surveyor noted there were no floor mats in the room. On 4/11/22 at 8:15 AM, the surveyor observed Resident #96 awake and calm lying in bed. The bed was in the low position and there were no floor mats down by either side of the bed or in the room 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 observations, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to update and revise the Care Plan (CP) for 1 of 4 residents (Resident #112) reviewed for falls and 1 of 1 resident (Resident #31) reviewed for urinary tract infections (UTI). This deficient practice was evidenced by the following: 1. On 3/31/22 at 10:20 AM, the surveyor observed Resident #112 in his/her room in bed with the head of the bed elevated and knees bent with call bell within reach. The surveyor attempted to interview the resident, and the resident shook their head yes to surveyor, however resident did not respond verbally to the surveyor's questions. On 4/1/22 at 12:17 PM, the surveyor observed the resident in bed, dressed in socks on their feet, head of bed elevated and knees bent. Again, the surveyor attempted to interview the resident, but the resident did not respond to surveyor's greetings, only shook their head. The surveyor observed a high back wheelchair in…

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

Based on observation, interview, and record review, it was determined that the facility failed to ensure Peridex (a prescribed germicidal mouthwash) was administered and documented in accordance with professional standards of practice. This deficient practice was identified for 1 of 27 (Resident #39) sampled residents reviewed for medication management and was evidenced by the following: On 4/1/22 at 9:58 AM, the surveyor observed Resident #39 lying in bed asleep. At that time, the surveyor observed a graduated unit dose cup (used to administer medications) containing a light blue liquid on the resident's bedside table. At that time, the surveyor was unable to locate the nurse assigned to Resident #39. On 4/1/22 at 10:02 AM, the surveyor observed an ancillary staff walk through the hallway who informed the surveyor that she would call the unit manager (UM) to the resident's room. At that time, the Registered Nurse/Unit Manager (RN/UM) walked into Resident #39's room and stated she was unable to identify the light blue liquid in the graduated unit dose cup but would look at the…

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

Based on observation, interview, and record review it was determined that the facility failed to ensure an adaptive cup was provided to a resident during meal service. This deficient practice was identified for 1 of 4 residents (Resident #62) reviewed for nutrition and the evidence was as follows: On 3/31/22 at 10:00 AM, the surveyor observed Resident #62 seated in a wheelchair using their feet to propel themselves to the Nurse's Station. The resident then asked the nurse at the Nurse's Station to change their lunch meal to pork roll, French fries, and ginger ale. The surveyor observed both of the resident's hands appeared to be contracted. On 3/31/22 at 12:17 PM, the surveyor observed Resident #62 in their room with their lunch tray. The resident's pork roll and French fries were on a scoop dish (adaptive dish with raised sides to aide in feeding) and the resident was using a standard fork and knife to cut the pork roll. There was also a can of ginger ale, a foam cup of coffee, a foam cup of iced tea, and a small carton of milk. There was no observed adaptive equipment for liquids.…

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

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to maintain kitchen equipment and store/maintain food items to prevent microbial growth. This deficient practice was evidenced by: On 4/13/22 at 11:13 AM, the surveyor in the presence of the Food Service Director (FSD) conducted a follow-up kitchen tour and observed the following: 1. In the three compartment sink, the sink designated as the sanitizing sink, a black residue in the drain and a brown discoloration in the corner of the the sink. The FSD used a clean paper towel to wipe off the black residue in the drain which transferred onto the paper towel. The FSD stated the sanitizing chemical does that to stainless steel of the sink. The FSD further stated the three compartment sink was cleaned after every shift, and then he stated twice a day. The FSD confirmed there were no documentation for the sink cleaning. 2. At 11:31 AM, the surveyor observed an uncovered large multi-gallon garbage receptacle (trash can) without a lid which was halfway full of various trash…

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 documentation, it was determined that the facility failed to track and securely document the COVID-19 vaccination status for all staff, both direct facility hires and contracted hires/outside vendors. The deficient practice was evidenced by the following: Reference: Centers for Medicare and Medicaid Services (CMS) QSO-22-07 ALL, dated 12/28/21, included the following: Within 30 days after issuance of this memorandum 2, if a facility demonstrates that: Policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or patient or resident contact are vaccinated for COVID-19; and 100% of staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is compliant under the rule; or Less than 100% of all staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted…

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.