Complete Care at Voorhees, LLC

Complaint #: NJ00174162 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) provide nail care to a resident who required assistance with the activities of daily living (ADL) and b.) implement the comprehensive care plan. This deficient practice was identified for 1 of 8 residents (Resident #118) reviewed for activities of daily living. This deficient practice was evidenced as follows: 1.) On 1/7/25 at 11:07 AM, during an incontinence tour, while accompanied by Licensed Practical Nurse/Unit Manager (LPN) #1 and Certified Nurse Assistant (CNA) #2, the surveyor observed Resident #118 bilateral (b/l) lower legs with multiple blister-like areas containing some dried blood. The LPN/UM#1 stated that the resident scratches themselves. Resident #118's fingernails were observed to be medium in length and contained reddish-brown blood-like residue under multiple fingernails and thick brown fecal-like matter under their right thumb. A review of the admission Record, an admission summary, revealed the resident 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.

Complaint #: NJ172440 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that resident dietary preferences were accurately identified and implemented for 4 of 21 residents (Resident #20, #39, #107, and #275) reviewed for dining and was evidenced by the following: On 1/3/25 at 10:00 AM, during a surveyor-conducted resident council meeting, 4 out of 4 residents (Residents #6, #60, #71 and #98) stated that condiments such as cream, sugar, mustard, and mayonnaise would not be on the meal trays and that the facility did not honor food preferences on their meal tickets. The residents also stated that when they ask for a substitute food item than what was on their meal ticket, it can take a long time for another meal tray, or they don't get it at all. 1. On 1/3/25 at 11:36 AM, the surveyor observed Resident #107 seated in a wheelchair in his/her room. The resident stated that his/her meal ticket listed no bread, no citrus, and no tomato, but received bread on his/her meal tray. On 1/3/25 at 1:02 PM, 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 record review and interview, the facility failed to provide a fully completed Form CMS-10055 (Centers for Medicaid and Medicare Services) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to include the cost of continued services for three of three residents (Resident (R) 388, R389, and R57) reviewed for liability notices out of a total sample of 41 residents. This failure prevents the resident or responsible party the ability to make an informed decision related to the cost of continued services. Findings include: 1. Review of the beneficiary notice provided by the facility revealed R389 was admitted to Medicare Part A Skilled Services on 02/15/23. The last covered day of Part A Skilled Services was 04/12/23. The SNFABN was issued on 04/04/23 by the Social Services Director (SSD) to the responsible party. In the section labeled . F. Estimated Cost . the SSD did not put a cost. This failure to include the estimated cost prevented the resident representative from making an informed decision about continuing to receive physical and occupational services. 2. Review…

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 facility policy review, the facility failed to ensure food was palatable for nine out of 41 sampled residents (Residents (R)28, R102, R40, R60, R119, R189, R89, R188, R97), for 27 residents residing on the 200 unit, and for six residents who attended the resident council interview out of 146 total residents who resided in the facility. Findings include: 1. Interviews with seven residents revealed concerns with food palatability: a. During an interview on 09/26/23 at 11:08 AM, R28 stated she had been served a moldy peanut butter and jelly sandwich. R28 stated the food was not good and the food was cold (when it should be hot). Review of R28's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/30/23 in the electronic medical record (EMR) under the MDS tab revealed R28 had intact cognition with a Brief Interview for Mental Status Score (BIMS) of 15 out of 15 (score of 13 - 15 indicates intact cognition). b. During an interview on 09/25/23 at 9:50 AM, R189 stated the food was terrible and the coffee and food…

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 facility policy review, the facility failed to ensure meals were served at regular times comparable to those in the community, failed to ensure there was not more than a 14-hour lapse between dinner and breakfast the next morning, and failed to ensure a substantial evening snack was offered to residents. In addition, the greater than 14-hour timeframe between dinner and breakfast the next day, had not been approved by the resident group. These failures had the potential to affect 142 out of 146 residents (four residents received nutrition via tube feeding.) Findings include: 1. Review of the undated Truck Delivery Log provided by the facility revealed there were nine carts (trucks) that delivered food to residents. The first meal cart was delivered to Unit Five at 7:36 AM, lunch was delivered at 11:36 AM, and dinner was delivered at 4:24 PM. The time span from dinner to breakfast was greater than 15 hours. The last meal cart was delivered to Unit Four dayroom two at 8:24 AM, lunch was delivered at 12:30 PM, and dinner was delivered…

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

Based on observations, interview, record review, and facility policy review, the facility failed to ensure the kitchen dish room, floor, countertops, and wall behind the dish machine was maintained in a sanitary condition creating the potential for the spread of foodborne illness for 142 out of 146 residents who resided in the facility (four received nutrition via tube feeding). In addition, the facility failed to adhere to proper hand hygiene when serving meals to residents on the secured unit during food delivery to the adjoining dining rooms and the resident's individual rooms. Findings include: 1. During the initial tour of the kitchen with the Dietary Director (DD) on 09/25/23 from 10:14 AM to 10:43 AM, the following concerns were noted: a. The garbage can in the handwashing area had a foot operated pedal which opened the garbage can. After the surveyor washed her hands and operated the foot pedal, the top interior surface of the garbage can lid was observed to be covered (approximately a third of the lid) with a green/black fuzzy substance. This would have been visible every…

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 facility policy review, the facility failed to ensure the antibiotic screening documentation was completed for the use of antibiotics including identifying trends and implementing protocols to monitor the antibiotic use, measure the effectiveness of the antibiotics, and create an action plan to lower the use of antibiotics that did not meet the screening criteria for R91 and all residents receiving antibiotics with the potential to affect any residents who have taken antibiotics. Findings include: 1. Review of August 2023 Infection Log revealed there were five residents who received antibiotics for urinary tract infections. All five residents received a complete course of antibiotics as ordered. All five of them did not meet the antibiotic criteria. Review of the Order Listing Report, provided on paper and dated 09/29/23, revealed 17 residents had antibiotics in the month of September. There was no documentation in the electronic medical record (EMR) or in the Infection Preventionist's (IP) paper documents for any of the 17 residents 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interview, and facility policy review, the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four (Resident (R) 288, R41, R72, and R240) of seven residents reviewed for bed rail use of 41 sample residents. These failures had the potential to cause risk of entrapment or injury due to use of bed rails for these four residents. Findings include: 1. Review of R288's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including: ataxia (poor balance), Alzheimer's disease with agitation, muscle weakness, abnormal posture, and delirium. Review of R288's significant change Minimum Data Set (MDS) assessment under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 08/01/23, revealed she was unable to complete 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 record review, interview, and facility policy review, the facility failed to maintain the proper Advance Directive after one (Resident (R) 112) out of five residents reviewed for advance directives in a total sample of 41 residents. The facility's failure had the potential to prevent the residents from having their wishes granted for advance directives. Findings include: Review of R112's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed R112 was admitted to the facility on [DATE] with diagnoses that included Trigeminal neuralgia, altered mental status, unspecified severe protein calorie malnutrition. Review of R112's Advance Directive, located in the EMR under the Miscellaneous tab, revealed R112 was documented as a Do Not Resuscitate (DNR). Review of R112's Orders, dated 02/18/23 and located in the EMR under the Orders tab, revealed a DNR code status order. Review of R112's New Jersey Universal Transfer Form, dated 06/28/23 and located in the EMR under 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 record review, staff interviews, and facility policy review, the facility failed to protect the rights of one (Resident (R) 121) of five residents reviewed for abuse of 41 sample residents to be free from physical abuse by another resident (R44). This failure had the potential to cause physical injury and/or psychological harm to R121. Findings include: A. Review of R121's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including dementia with psychotic disturbance and agitation, anxiety, depression, mood disorder, and psychosis. R121 resided on the secure dementia care unit. Review of R121's quarterly Minimum Data Set (MDS) assessment under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 02/12/23, revealed she was unable to complete the Brief Interview for Mental Status (BIMS) and was assessed by staff with memory problems and severely impaired cognition. R121 was rarely/never able…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and facility policy review, the facility failed to develop policies and procedures that identified abuse, including resident-to-resident abuse, in order to prohibit and prevent abuse for one (Resident (R) 121 of five residents reviewed for abuse of 41 sample residents. This failure had the potential to cause physical injury and/or psychological harm to R121. Findings include: Review of R121's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including dementia with psychotic disturbance and agitation, anxiety, depression, mood disorder, and psychosis. R121 resided on the secure dementia care unit. Review of R44's admission Record under the Profile tab of the EMR revealed she was admitted to the facility on [DATE] with diagnoses including subdural hemorrhage, hemiplegia, depression, anxiety, mood disorder, stroke, and dementia. She resided in the secure dementia care unit.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review, the facility failed to ensure the comprehensive Care Plan was revised to reflect resident-specific information regarding behavioral symptoms and activities of daily living (ADL) assistance for two (Resident (R) 119 and R288) of 41 sample residents. These failures had the potential to lead to unmet behavioral and/or ADL needs for these two residents due to a lack of care-planned interventions. Findings include: 1. Review of R119's admission Record located in the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] and re-admitted on [DATE]. R119 had diagnoses including Alzheimer's disease with behavioral disturbance, cognitive communication deficit, muscle weakness, major depressive disorder, anxiety disorder, and repeated falls. Review of R119's quarterly Minimum Data Set (MDS) assessment located in the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 08/05/23, revealed he scored…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and facility policy review, the facility failed to ensure a newly identified area of skin breakdown was assessed and treated in a timely manner for one (Resident (R) 121) of five residents reviewed for pressure ulcers of 41 sample residents. This failure had the potential to cause further deterioration or infection of R121's wound. Findings include: Review of R121's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including dementia with psychotic disturbance and agitation, hip fracture, osteoarthritis, and type one diabetes. Review of R121's quarterly Minimum Data Set (MDS) assessment under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 09/12/23, revealed she was unable to complete the Brief Interview for Mental Status (BIMS) and was assessed by staff with memory problems and severely impaired cognition. R121 was rarely/never able to make herself…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure one out of six residents (Resident (R)62) reviewed for falls out of a total sample of 41 residents was adequately supervised resulting in a fall out of bed while the Certified Nursing Assistant (CNA) went to the bathroom to get supplies. Findings include: Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R62 was admitted to the facility on [DATE]. R62's diagnoses included malnutrition, cerebral palsy, epilepsy, aphasia (language disorder with the inability to communicate), unspecified intellectual disabilities, spastic quadriplegic cerebral palsy, and contractures of multiple sites. Review of R62's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/03/23 in the EMR under the MDS tab revealed R62 was severely impaired in decision making, did not speak, was rarely or never understood, and was rarely or never understood by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure one of two residents (Resident (R)62), reviewed for tube feeding out of a total sample of 41 residents, had head of bed elevated high enough while the tube feeding was being administered, which placed the resident at risk for aspiration (when something such as food or liquid enters the airway or lungs). Findings include: Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R62 was admitted to the facility on [DATE]. R62's diagnoses included malnutrition, cerebral palsy, epilepsy, aphasia (language disorder with the inability to communicate), unspecified intellectual disabilities, spastic quadriplegic cerebral palsy, and contractures of multiple sites. Review of R62's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/03/23 in the EMR under the MDS tab revealed R62 was severely impaired in decision making, did not speak, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and facility policy review the facility failed to ensure appropriate use of side rails through routine assessments for three (Residents (R) R72, R240, and R288) of 16 residents reviewed for accidents of 41 sample residents. Findings include: 1. R72's admission Record, dated 09/29/23 and found in the electronic medical record (EMR) under the Profile Tab, revealed the resident was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, type 2 diabetes, and hemiplegia and hemiparesis following a stroke. R72's admission Minimum Data Set (MDS) assessment, dated 07/05/23 and found in the EMR under the MDS Tab, revealed a Brief Interview for Mental Status (BIMS) assessment score of seven out of 15 (severely cognitively impaired). The assessment indicated the resident required extensive assistance from staff to complete all of his activities of daily living (ADLs), including transfers in and out of bed, and indicated bed rails were not in use for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to ensure dates of newly identified wound and bed rail assessments were accurately reflected for two (Resident (R) 121 and R238) of 41 sample residents. This failure had the potential to cause further deterioration or infection of R121's wound or risk of entrapment or injury from side rail use for R238. Findings include: 1. Review of R121's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including: dementia with psychotic disturbance and agitation, hip fracture, osteoarthritis, and type one diabetes. Review of R121's quarterly Minimum Data Set (MDS) assessment under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 09/12/23, revealed she was unable to complete the Brief Interview for Mental Status (BIMS) and was assessed by staff with memory problems and severely impaired cognition. She was at risk for 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.

Based on interview, record review, and review of other facility documents, it was determined that the consultant pharmacist failed to respond to a medication-related irregularity in a timely and complete manner. This deficient practice was identified for 1 of 5 residents (Resident #55) reviewed for unnecessary medications and was evidenced by the following: On 05/27/22, the surveyor obtained and reviewed copies of the Consultant Pharmacist's (CP) Monthly Report. (A CP's note is a report of any medication-related irregularity or recommendation that needs to be addressed by the physician.) Review of the Consultant Pharmacist's Monthly Report, dated 04/28/22, revealed a recommendation to, Please update PRN Glucagon to include parameters. (Glucagon is a hormone that works within the body to control blood sugar levels. A medication form of the hormone is typically given when a blood sugar (BS) level is too low to maintain the normal biological functions of the body. Its use is implemented in conjunction with a parameter, a numerical or other measurable factor forming a condition 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.

Based on interview, record review, and review of other facility documents, it was determined that the facility failed to a.) accurately transcribe a physician's order and b.) ensure that the resident received the psychotropic medication in accordance with the psychiatric recommendation. This deficient practice was identified for 1 of 5 residents (Resident #87) reviewed for unnecessary medications and was evidenced by the following: According to the admission Record, Resident #87 was admitted to the facility with diagnoses that included, but were not limited to, Major Depressive Disorder and generalized Anxiety Disorder. 1. Review of the Psychiatric Evaluation dated 03/11/22 revealed Resident #87's current mediation orders for Ativan (an antianxiety medication) 0.5 mg (abbreviation for milligram) every six hours PRN (as needed) times 14 days for diagnosis Anxiety and Lexapro (an antidepressant medication) 10 mg daily for diagnosis Depression. After the psychiatrist evaluated the resident, the Plan was to Extend PRN Ativan order for an additional 30 days as a bridge therapy 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.

Based on observation, interview and document review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner. This deficient practice was evidenced by the following: On 05/19/22 from 11:00 AM to 11:22 AM, the surveyor, accompanied by the Food Service Director (FSD), Executive Chef (EC), and District Manager in Training observed the following in the kitchen: 1. A stand up mixer on top of a wheeled cart was covered with a clear plastic bag. The mixer was cleaned and sanitized. Upon removal of the plastic cover, the surveyor observed unidentified debris and dead flies in the base of the bowl, which is a food contact surface. On 06/03/22 during a follow up interview, the EC stated, We haven't used this in two years. We put plastic wrap over the bowl to protect it. 2. The surveyor opened the lid to the bulk ice machine. The surveyor observed unidentified black debris on the white drip plate which was above the ice supply. The surveyor then obtained a paper towel and wiped the drip plate. The paper towel 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, record review and review of other facility documents, it was determined that the facility failed to obtain a physician's order for the use of bed siderails. This deficient practice was observed for 1 of 2 residents (Resident #14) reviewed for position/mobility 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 states: The practice of nursing as a licensed practical nurse is…

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 facility documents, it was determined that the facility failed to follow a physician's order to offload a resident's heels. The deficient practice was observed for 1 of 3 residents (Resident #6) investigated for Pressure Ulcer/Injury and was evidenced by the following: On 05/19/22 at 11:03 AM, during the initial tour, the surveyor observed Resident #6 in bed. Resident #6's legs appeared to be contracted. At this time, the surveyor observed a heel boot (a cushion that protects the heels by relieving excess heel pressure from ulcers and pressure injuries) on the nightstand. On the same date at 11:20 AM, the surveyor observed no off-loading support was in place on Resident #6's heels. On 05/23/22 at 8:39 AM, the surveyor observed Resident #6 in bed. The resident did not have heel boots on or off-loading support for his/her heels. On 5/24/22 at 11:23 AM, the surveyor observed Resident #6 in bed. The resident did not have heel boots on or…

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 facility documents, it was determined that the facility failed to follow a physician's order for the application of a palm protector to the left hand for one resident. This deficient practice was identified for Resident #9, 1 of 2 residents reviewed for limited range of motion and was evidenced by the following: On 05/23/22 at 11:59 AM and 1:06 PM, on 05/24/22 at 10:27 AM and 1:17 PM, on 05/25/22 at 8:05 AM, on 06/01/22 at 8:30 AM and 11:15 AM, and on 06/02/22 at 10:46 AM, the surveyor observed Resident #9 lying in bed with the head of the bed elevated. The surveyor observed the resident's left hand was closed with the fingertips touching the resident's palm with no palm protector in place. The surveyor further observed the resident was nonverbal, confused and could not follow directions to open his/her hand. According to the admission Record, Resident #9 was admitted to the facility with diagnoses that included, but were not limited to, contracture of the left hand. Review of the Quarterly Minimum Data Set (MDS),…

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

Based on observation, interview, and record review, it was determined that the facility failed to a.) follow a physician's order for floor mats to the floor while in bed and b.) follow fall prevention interventions as written on the resident's plan of care for a resident that was identified as a higher risk for falls. The deficient practice was identified for 1 of 4 residents reviewed for accidents (Resident #100) and was evidenced by the following: 1. During a tour of the facility on 05/19/22 at 12:10 PM, the surveyor observed Resident #100 with his/her eyes closed in bed, with the head of the bed slightly elevated. The surveyor further observed a blue mattress propped against the wall under the window. The surveyor did not observe floor mats on either side of the resident's bed. According to the Face Sheet, Resident #100 was admitted to the facility with diagnoses that included: Alzheimer's disease, dementia, muscle weakness, lack of coordination and unsteadiness on feet. Review of a Significant Change in Status Minimum Data Set (MDS), an assessment tool used to facilitate 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.