CareOne At Hanover Township

Based on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure a.) provision of routine medication for administration (Resident #267) b.) accurate administration of medication for Resident #3, c.) documentation of removal of a controlled dangerous substance (narcotic; with high potential for drug diversion) medication from inventory, maintained accountability, and accurate reconciliation of Resident #43 and #50's narcotic medications, that was identified during the medication storage inspection of 2 of 2 medication carts. The deficient practice was evidenced by the following: On 4/14/25 at 8:13 AM, the surveyor observed Licensed Practical Nurse (LPN #1) begin to prepare 8 medications for Resident #267. The medications included a physician's order of 550 milligrams (mg) Rifamaxin (Xifaxan), give 1 tablet by mouth two (2) times a day for hepatic encephalopathy (a brain dysfunction caused by liver dysfunction). The order was…

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

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of the resident and ensure that the side rail padding was in place. This deficient practice was identified for 1 of 19 residents reviewed for accommodation of needs (Resident #52), and was evidenced by the following: On 4/16/25 at 10:18 AM, the surveyor observed Resident #52 in bed, with his/her eyes open. Resident #52 did not respond to the surveyor's greeting. The surveyor observed that the resident's call bell (a bell used to summon staff for assistance) was not visible. The surveyor also observed that the resident's padding to the right upper half siderail was not placed correctly and was hanging down onto the floor. The surveyor reviewed the medical record for Resident #52. A review of the admission Record reflected that Resident #52 was admitted to the facility with diagnoses that included but were not limited to; epilepsy, diabetes mellitus, and cognitive communication deficit. A review of the Physician Order Summary…

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

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a safe, clean, and homelike environment. This deficient practice was identified for 2 of 19 residents (Resident # 18 and # 19) and was evidenced by the following: 1.On 4/15/25 at 11:35 AM, during an interview with the surveyor, Resident #18 stated his/her privacy curtain was soiled, and it was very upsetting as this was his/her home and that he/she liked things to be nice and clean. At that time, the surveyor observed that the privacy curtain was soiled with several brown stains. The surveyor reviewed the medical record for Resident #18. A review of the admission Record reflected Resident #18 was admitted to the facility with diagnoses that included but were not limited to; diabetes mellitus and repeated falls. The quarterly Minimum Data Set (MDS), an assessment tool, dated 1/19/25, reflected the resident had a brief interview for mental status score of 13 out of 15, which indicated that the resident's cognition was intact. On 4/15/25 at 11:40 AM, 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 accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 4 of 19 residents, (Resident #6, #14, #37 and #66). This deficient practice was by the following: Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 10/26/24, included the following. The CDC recommended administration of pneumococcal conjugate vaccine (PCV20 or PCV21) at least 1 year for all adults 50 years or older who have received PCV 13 only at any age. 1. On 4/13/25 at 11:07 AM, during the initial tour, the surveyor observed the resident in bed. The resident revealed to the surveyor that they had lived in the facility for about a year, felt depressed at times, and did not like to join activities. The surveyor reviewed Resident #14's medical record. The admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and policy review, the facility failed to update one resident's (R)47) status by completing a significant change Minimum Data Set (MDS) assessment when R47 was admitted to hospice care on 01/05/24. This failure affected one of five residents reviewed for MDS assessment concerns, in a sample of 28 residents. Findings include: Review of R47's Face sheet found in the Profile tab of the Electronic Medical Record (EMR) revealed R47 was admitted to the facility on [DATE] with diagnosis of malignant cystic neoplasm (bladder cancer). Review of R47's quarterly MDS with an assessment reference date (ARD) of 2/18/23 documented that R47 had a Brief Interview for Mental Status score of 13 out of 15, which indicated mild cognitive impairment. Review of R47's EMR physician's order dated 01/03/24 revealed admit R47 to hospice care. Review of the hospice note dated 01/05/24 found in the MISC tab in the EMR revealed that on 01/05/24, hospice service was initiated by Ascend Hospice. 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.

Based on observation, record review, interviews, review of facility policy, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure three residents (Resident (R)4, R14, and R17) out of 28 sampled residents had an accurate Minimum Data Set (MDS) assessment. Findings include: 1. Observation on 01/24/24 at 4:00PM revealed R4 had a nephrostomy tube draining yellow urine in the right flank area. Review of R4's admission Record located in the electronic medical record (EMR) tab Profile revealed the resident was admitted to the facility with diagnoses that included calculus (stone) of the ureter and multiple sclerosis. Review of R4's Physician's Orders dated January 2024 located in the EMR tab Orders revealed right nephrostomy tube monitor site every shift. Review of R4's quarterly MDS with an Assessment Reference Date (ARD) 11/02/23 located in the resident's EMR tab MDS revealed the nephrostomy tube was not listed in the MDS section for appliances in bladder and bowel. 2. Review of R14's admission Record located in the EMR tab Profile revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to revised/update care plans for two Residents (R )39 and R74 from a sample of 28 residents. The facility failed revised R39's care plan to reflect a fall with a significant injury and R74's care plan regarding tracheotomy care. Findings include: 1. Review of R39's admission Record located in the electronic medical record (EMR) Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included anoxic brain syndrome, cognitive communication deficit, dementia, major depressive disorder, and history of falls. Review of R39's Nursing Notes dated 03/02/23 located in the EMR Progress notes tab revealed the resident was readmitted to facility following surgical repair of femur fracture. Review of R39's Care Plan with a revision date of 02/20/23 located in the EMR Care Plan tab did not reflect the resident's fall with a hip fracture that required surgical intervention. Interview on 01/25/24 at 2:30PM, the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to update the physician's orders to accurately reflect the respiratory care and services for one resident (R)74 of three residents reviewed for respiratory care and services in the sample of 28 residents Findings include: Review of R74's Face sheet found in the Profile tab of the Electronic Medical Record (EMR) revealed R74 was admitted to the facility on [DATE] with diagnoses including respiratory failure with hypoxia and cerebral infarction, Review of R74's admission Minimum Data Set (MDS) assessment revealed when he was admitted R74 was unable to communicate so there was no BIMS score for cognition and was dependent on a tracheostomy (trach) collar when admitted . Review of R74's undated Order Summary Report found in the Order tab of the EMR revealed R74 was admitted on O2 [oxygen] via aerosolized trach mask at 35% and 10LPM (liters per minute) of oxygen every shift for TDRF (trach dependent respiratory failure). Keep an extra #8 Shiley [brand 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 interview, record review and document review, the facility failed to explain to residents the binding arbitration agreement and failed to inform the resident of the right to rescind the agreement within thirty calendar days for three (Resident (R) 224, R225, and R226) of three residents reviewed for arbitration agreement in a total sample of 28 residents. Findings include: Review of an undated copy of admission Agreement, provided to the survey team by the Administrator, with the following, Dispute Resolution and Arbitration embedded, indicated, Any controversy or claim arising out of or relating to this agreement and brought by the resident, his/her personal representative, heirs, attorneys or the responsible party shall be submitted to binding arbitration by a single arbitrator selected and administered pursuant to the commercial arbitration rules of the American Arbitration Association. A claim shall be waived and forever barred if, on the date the demand for arbitration is received, the claim (if…

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 medical records and other pertinent facility documentation, it was determined that the facility failed to: a.) initiate a timely and through investigation for two injuries of unknown origin, and b.) ensure the facility policy for Investigating Injuries and Abuse Investigation and Reporting 1 of 3 residents (Resident #7) reviewed for investigations. The deficient practice was evidenced by the following: On 08/30/21 at 9:48 AM, the surveyor observed Resident #7 lying in bed. The resident was alert and was confused. The surveyor observed a black-blue discoloration located on the left forehead. Upon surveyor interview, Resident # 7 was unable to describe how the black and blue discoloration occurred to his/her left forehead. The surveyor reviewed the resident's electronic medical record (EMR) which revealed the following: The admission Record (AR) indicated that Resident #7 was admitted to the facility with the diagnoses which included, but was not limited to, pulmonary fibrosis (a condition in which the lungs become scarred over time),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of medical records, it was determined that the facility failed to provide physician ordered treatments, consistent with professional standards of clinical practice. This deficient practice was identified for 2 of 17 residents reviewed (Residents #34 and #23) and was evidenced by the following: Reference: New Jersey Statutes, 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 well being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to provide a safe environment to prevent the potential spread of infection by failing a.) to utilize the proper personal protective equipment (PPE) for residents on transmission-based precautions (TBP) for 4 of 5 (Resident #39, #210, #311, #29) resident reviewed for TBP, and b.) to adhere to infection control practices for hand hygiene to prevent the spread of infection during observation of a wound care treatment for 1 of 1 (Resident #29) reviewed. This deficient practice was evidenced by the following: A. 1.) On 08/30/21 at 9:24 AM, the facility informed the survey team that residents who were positive for COVID-19 were located on the first floor in a Red Zone area. The facility further stated the PPE required in the COVID-19 Red Zone were a reusable PPE gown, N95 mask with a surgical mask on top of it, and eye protection. On 08/30/21 at 10:08 AM, during tour, 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 2. During the initial tour on 08/30/21 at 9:30 AM, the surveyor observed Resident #18 in bed, with oxygen in place. The Oxygen was connected to a device delivering humidified air via nasal cannula. The setting on the device was 2 liters. The humidifier bottle was almost empty and had a sticker dated 07/24/21. The connected tubing was not labeled or dated. On 08/31/21 at 7:40 AM the surveyor observed Resident #18 sitting in the room, Resident #18 told the surveyor that she had a bad night and had to use the oxygen almost all night. On 09/01/21 at 9:25 AM, the surveyor observed Resident #18 sitting in a chair in the room eating breakfast. The Oxygen tubing was noted on the bed underneath the pillows, not labeled or dated. The sticker on the humidifier bottle still dated 07/24/21. A review of Resident #18's clinical record revealed the following: Resident #18 was admitted to the facility with diagnoses which included shortness of breath, Acute kidney failure, diabetes mellitus and asthma. On the most recent Minimum…

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 ensure that medications received from residents, specifically a controlled schedule IV drug, were verified and accounted for daily by incoming and outgoing staff. This deficient practice was identified for 1 of the 3 medication carts reviewed and was evidenced by the following: During the Medication Pass Administration observation on 08/31/21 at 9:30 AM, the surveyor conducted a narcotic count with the Registered Nurse (RN ) responsible for the medication cart on the high side. The surveyor observed 2 bottles of medication stored in the locked narcotic compartment. The medication was labeled as Tramadol 50 milligrams (mg) and Klonopin 0.5 mg. The medication belonged to Resident #10 who still resided at the facility and were brought to the facility by the resident on admission. The declining inventory count was accurate for the Klonopin. The count was 25 and verified with the RN. The nurse had been using the Klonopin received from home when the Klonopin from the facility pharmacy had not…

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