Complete Care At Wayne Hills Rehab & Resp Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure the accuracy of the Minimum Data Set (resident assessment) related to an antipsychotic medication for one of 27 residents (Resident (R) 75) reviewed creating an inaccurate assessment of the resident's psychological status.Findings include:Review of the admission Record located in the electronic medical record (EMR) under the Profile tab revealed R75 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included dementia and schizophrenia.Review of the Physician's Orders located in the EMR under the Orders tab revealed R75 was prescribed quetiapine fumarate (an antipsychotic medication) 50 milligrams (mg) by mouth two times a day for schizophrenia on 09/16/25. Review of the Medication Administration Record (MAR) located in the EMR under the Orders tab, for the month of October 2025, revealed R75 received the antipsychotic medication twice a day as prescribed.Review of the MAR 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 observation, record review, and interviews, the facility failed to develop and implement a comprehensive care plan for three of 27 residents (Resident (R) 11, R8, and R65) reviewed. Specifically, the facility failed to develop an individualized activity care plan for R11 creating the potential for individual interests to not be identified; failed to develop an individualized care plan for R8 related to her seizure disorder creating the potential for staff to not respond as needed; and failed to develop an individualized care plan for R65's preference for daily showers creating the potential for showers to be missed.Findings include:1. Review of the admission Record located under the Profile tab in the electronic medical record (EMR) revealed R11 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, anxiety disorder, and major depressive disorder.Review of the quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD)…

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 interviews, record review, and policy review, the facility failed to ensure the Fall Care Plan was updated to include interventions to prevent falls after a resident had a fall with major injury for one (Resident (R) 13) of five residents reviewed for falls in a total sample of 27 residents. This failure placed the residents at risk for unmet care needs.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R13 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a complex mental illness with a major mood disorder) and ataxic gait (abnormal walking characterized by clumsy, staggering, and an uncoordinated walk).Review of the Medical Diagnosis list located in the Diagnosis tab of the EMR revealed, Displaced Fracture of Head of Left Radius, Subsequent Encounter for Closed Fracture with Routine Healing, dated 09/11/25.Review of a significant change Minimum Data Set (MDS) located in the MDS tab…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and policy review, the facility failed to provide activities to meet the interests or needs of two of 27 residents (Resident (R) 11 and R8) reviewed. The failures created the potential for in-room visits to occur without the residents' individual interests or choice.Findings include:.1. Review of the admission Record located under the Profile tab in the electronic medical record (EMR) revealed R11 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, anxiety disorder, and major depressive disorder.Review of the quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 09/04/25 revealed a Brief Interview for Mental Status (BIMS) without a score, which indicated R11 was unable to complete the assessment.Review of the 09/09/25 revised comprehensive Care Plan located under the Care Plan tab in the EMR revealed an R11 has impaired communication due to diagnosis of anoxic brain…

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, and interview, the facility failed to ensure a resident's room was free of accident hazards for one of 27 sampled residents (Resident (R)8). Specifically, the facility failed to respond timely to a water leak which reached electrical cords to the ventilator, bed, and enteral feeding pump of the resident. This failure had the potential to cause injury or equipment failure. Findings include:Review of R8's admission Record located under the Profile tab in the electronic medical record (EMR) indicated R8 was originally admitted to the facility on [DATE] with the diagnoses of dependence on respirator (ventilator) status and acute and chronic respiratory failure.Review of R8's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 07/21/25 revealed R8 was severely cognitively impaired. R8 had ventilator assistance for breathing and a tube feeding.During an observation on 12/02/25 at 12:45 PM, water from the back 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.

Based on observation, record review, interviews, and policy review, the facility failed to ensure a physician order and consent was obtained for bed rail use for one of one resident (Resident (R) 65) reviewed for bed rails out of 27 sample residents. This failure had the potential to affect safety for all residents who had bed rails. Findings include: Review of the admission Record located under the Profile tab of the electronic medical record (EMR) revealed an admission date on 08/15/24 with diagnoses which included hemiplegia (paralysis on one side of the body) and hemiparesis (one sided muscle weakness) affecting left dominant side. Review of the admission Nursing Comprehensive Assessment, dated 08/15/24, and located under the Assessments tab of the EMR, revealed the resident was assessed for bed rail usage, to include proper fit, no gaps between the rails and mattress, and alternatives attemptedReview of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/11/25 and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and policy review, the facility failed to ensure medications were administered in accordance with infection control measures for one (Resident (R) 108) of six residents reviewed in a total sample of 27. This failure placed residents at risk of cross-contamination.Findings included.Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R108 was admitted to the facility on [DATE] with a diagnosis of cerebral palsy (brain disorder at birth), respiratory failure, and was ventilator dependent. During an observation on 12/02/25 at 8:59 AM, Registered Nurse (RN) 1 entered R108's room with medications that were placed in four different medication cups for administering through a gastrostomy tube (G-tube-a tube inserted into the stomach to allow for nutrition and medications). RN1 then placed the four cups on an overbed table. She did not use a barrier, nor did she clean the table prior to placing the cups on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ00176749 Based on interviews and a review of the medical records and other facility documentation, it was determined that the facility staff failed to report an allegation of sexual abuse made by a resident (Resident #2) to the New Jersey Department of Health (NJDOH) as required. This deficient practice was identified for 1 of 4 residents (Resident #2) and was evidenced by the following: The surveyor reviewed Resident #2's medical record on 09/10/2024. The admission Record reflected the Resident #2 was admitted to the facility with medical diagnoses which included but not limited to: Type 2 Diabetes, Acute and Chronic Respiratory Failure, Morbid Obesity, Tracheostomy Status, Hypertension, Anxiety Disorder, Chronic Obstructive Pulmonary Disorder, and Other Seizures. Review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 5/29/24, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated severely impaired cognition. 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 Complaint #: NJ00176749 Survey Dates: 09/10/2024 Census: 85 Sample Size: 4 Based on interviews and a review of the medical records and other facility documentation, it was determined that the facility staff failed to investigate an alleged incident of sexual abuse made by a resident (Resident #2) to the New Jersey Department of Health (NJDOH) as required. This deficient practice was identified for 1 of 4 residents (Resident #2) and was evidenced by the following: The surveyor reviewed Resident #2's medical record on 09/10/2024. The admission Record reflected the Resident #2 was admitted to the facility with medical diagnoses which included but not limited to: Type 2 Diabetes, Acute and Chronic Respiratory Failure, Morbid Obesity, Tracheostomy Status, Hypertension, Anxiety Disorder, Chronic Obstructive Pulmonary Disorder, and Other Seizures. Review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 5/29/24, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 0…

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 the interview and record review, it was determined that the facility failed to ensure that the resident's primary physicians a.) signed and dated monthly physician orders and b.) wrote physician progress notes every other month alternating with the nurse practitioner. The deficient practice was observed for 10 of 20 residents (Resident #38, 37, 45, 72, 74, 16, 41, 63, 1, and 78) reviewed and occurred over a 6-month period. The deficient practice was evidenced by the following: 1. A review of the hybrid medical record for Resident #38 revealed the physician electronically signed monthly physician orders for the month of March 2024. There were no other monthly physician orders signed within the past 6 months. Additionally, there were no monthly progress notes written by the physician in the previous 6 months. 2. A review of the hybrid medical record for Resident #37 revealed the physician electronically signed the March 2024 monthly physician orders. There were no other signed monthly physician orders in the past 6 months. Additionally, there were no monthly physician…

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 the interview and record review, it was determined that the facility failed to complete and submit electronically the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment and in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for 1 of 20 residents (Residents #136). This deficient practice was evidenced by the following: On 05/14/24, at 9:41 AM, the surveyor observed Resident #63 lying in bed watching television. The resident was able to answer the surveyor's inquiry. Resident #63's electronic medical record (eMR) revealed the following information: According to the admission Record (an admission summary) (AR), Resident #63 was admitted to the facility with diagnoses that included but were not limited to urinary tract infections. The Quarterly Minimum Data Set (QMDS), dated [DATE], indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interview and record review, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, in accordance with the federal guidelines for 2 of 20 residents (Resident #63, and #85) reviewed for the accuracy of MDS coding. The deficient practice was evidenced by the following: 1. On 5/14/24, at 9:41 AM, the surveyor observed Resident #63 lying in bed watching television, able to answer the surveyor's inquiry. The resident stated that they had a bowel movement at least once daily and had no problem. Resident #63's electronic Medical Record (eMR) revealed the following information: According to the admission Record (an admission summary) (AR), Resident #63 was admitted to the facility with diagnoses that included but were not limited to urinary tract infections. The Quarterly Minimum Data Set (QMDS), dated [DATE], indicated that the facility assessed the resident's cognitive status using a Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to maintain the nursing professional standard of clinical practices by not accurately documenting the bowel elimination status of 1 of the 20 residents (Resident #63) who had been reviewed for urinary catheter. 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 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 licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced by the following: On 5/14/24, at 9:41 AM, the surveyor observed Resident #63 lying in bed watching television, able to answer the surveyor's inquiry.…

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 pertinent provided facility documents, it was determined that the facility failed to ensure that oxygen care and services were provided according to the standard of clinical practice in one (1) of (1) residents observed for respiratory care. The deficient practice was evidenced by the following: On 5/15/24 at 11:34 AM, the surveyor interviewed Resident #85. During the interview, the surveyor observed that the resident was receiving oxygen by a nasal cannula (a tube attached to an oxygen source that delivers oxygen to the resident via the nostrils). The surveyor observed that the nasal cannula was not positioned in the nostrils of the resident and was located to the left of the resident's nose, on the cheek. Further observation of the oxygen supply tubing revealed that it was attached to a central wall supply and there were no other markings on the tubing or nasal cannula denoting when the tubing and nasal cannula was applied. The resident stated that they are feeling okay with no concerns. On 5/16/24 at 12:55 PM, the surveyor…

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

Complaint NJ # 167624 Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to follow Centers for Disease Control (CDC) guidance and implement infection control practices to mitigate the spread of multiple multi-drug resistant organisms (MDROs) during an outbreak which began on 09/15/23. The facility failed to: a) implement infection control surveillance per facility policy for MDROs- Carbapenem-Resistant Acinetobacter Baumannii (CRAB-bacteria resistant to nearly all antibiotics and difficult to control and irradicate from the environment), and Candida Auris (CA- a dangerous fungus that can be difficult to identify and treat), and b) staff donned (put on) the required personal protective equipment (PPE) prior to entry to a resident room who was on Transmission Based Precautions. This deficient practice was identified on 1 of 2 resident units, for 2 of 2 employees observed in TBP resident rooms and was evidenced by the following: Reference: https://www.cdc.gov/hai/pdfs/cre/crab-handout-v7-508.pdf…

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 records, it was determined that the facility failed to ensure an accurate inventory of controlled medications (narcotic medications) dispensed from the facility's automated medication dispensing system (AMDS). The deficient practice was observed on the automatic medication dispensing system located on the South Wing nursing office and evidenced by the following: On 2/18/22 at 10:05 AM, the surveyor reviewed the facility's DEA 222 forms and asked the Regional Clinical Specialist (RCS) a Registered nurse if he could provide the surveyor signed off logs showing that narcotics are being accounted for in the facility's AMDS. On 2/18/22 at 11:55 AM, the Licensed Nursing Home Administrator (LNHA) told the surveyor team that the Assistant Director of Nursing (ADON) were unable to locate the accountability form for the controlled medications accountability for the month of February 2022. On 2/18/22 at 12:05 PM, the surveyor in the presence of the LNHA was brought to the Nursing office on the South wing nursing unit which contained 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 the facility failed to follow accepted standards of infection control to reduce the spread of infection as observed for 2 of 2 Licensed Practical Nurses (LPN #1 and LPN #2) and 3 of 3 Housekeepers (HK #1, HK #2, and HK #3). The deficient practice is evidenced by the following. 1. On 2/16/22 at 11:00 AM the surveyor observed LPN #1 perform a pressure ulcer treatment on Resident #42. The surveyor and LPN #1 reviewed the physician's order on the electronic record - cleanse sacral pressure ulcer with normal saline solution, pat dry, pack wound with calcium alginate and cover with a dry dressing daily and as needed if soiled, initiated 12/25/21. LPN #1 stated the resident had a stage 4 (full thickness) pressure ulcer on the sacrum. LPN #1 performed hand hygiene, donned gloves, and sanitized the over bed table with an antiseptic wipe. LPN #1 removed her gloves and, without performing hand hygiene, assembled supplies for the treatment. LPN #1 entered the resident's room, donned gloves, and began the treatment. LPN #1…

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 maintain professional standards of clinical practice by failing to document injection sites on the electronic Medication Administration Record (eMAR) for 1 of 18 residents (Resident #70) reviewed. The 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 states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as 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 record review, it was determined that the facility failed to ensure that oxygen therapy was administered to a resident in accordance with physician's orders. This was found with 2 of 6 residents reviewed, Resident #63 and Resident #61. The deficient practice was evidenced by the following: 1. On 2/11/22 at 11:00 AM, the surveyor observed Resident #63 walking from the bathroom to sit on bed. The surveyor observed Resident #63 putting on a tracheostomy collar over the tracheostomy (a surgical opening in the windpipe). The tracheostomy collar delivered the oxygen to the resident via the tracheostomy. The resident stated that he/she was encouraged to keep the oxygen on. The surveyor reviewed the electronic medical record (EMR) of Resident #63 which revealed the following: According to the Resident Face Sheet, Resident #63 was admitted with diagnoses that included Respiratory Failure and Chronic Obstructive Pulmonary Disease. The Annual 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 observation, interview, and record review, it was determined the facility failed to consistently assess a resident upon return from the dialysis center. The deficient practice was observed for 1 resident, #74, of 1 reviewed for dialysis and is evidenced by the following. On 2/11/22 at 1:08 PM, the surveyor observed the resident in bed with eyes closed. The resident was discharged from the facility on 2/14/22. On 2/15/22 at 9:54 AM, the surveyor interviewed the unit Licensed Practical Nurse (LPN). The LPN stated the pre dialysis resident assessment was documented on the top of the Nursing Facility/Dialysis Center Communication Record (a paper which travels with the resident to and from the dialysis clinic). She stated the post dialysis assessment is documented in the electronic medical record nursing progress notes. On 2/15/22 at 10:07 AM, the surveyor interviewed the Registered Nurse Unit Manager (RNUM). The RNUM stated there is no hard documented resident assessment performed after the resident returned from the dialysis center. There is no specific place for it on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 3 of 6 medication carts inspected. This deficient practice was evidenced by the following: On [DATE] at 10:20 AM, the surveyor inspected the East wing medication cart #1 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened bottle of Glucose testing solution and an opened Anoro Ellipta Inhaler that were not dated. The surveyor interviewed LPN #1 who stated that once a bottle of Glucose testing solution and an Anoro Ellipta inhaler are opened they should have been dated. On [DATE] at 11:15 AM, the surveyor inspected the East wing medication cart #2 in the presence of LPN #2. The surveyor observed an opened Humalog insulin vial that had an opened date of [DATE] and was expired. The surveyor also observed a Levemir insulin pen that was in a bag with another resident's name and that was label for Basaglar insulin pen. The surveyor also…

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 policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, b.) failed to sanitize and air-dry steam table pans in a manner to prevent microbial growth and c.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 2/14/22 at 9:47 AM, in the presence of the Dietary Supervisor and Regional Food Service Director, the surveyor observed the following: 1. In the food preparation area, on a shelf over top of the convection ovens, the surveyor observed three full sized sheet pans which were stacked with water between them. 2. The surveyor observed two of three red sprinkler caps and fire suppression poles above the cook top area, which were soiled with gray colored dust-like particles. 3. In the dry storage area, the surveyor observed a random sampling of dented cans which…

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