Cedar Grove Respiratory And Nursing Center

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) to maintain a detailed record of receipts and accurate reconciliation of controlled medications for 7 of 7 Drug Enforcement Administration (DEA) 222 forms (a form used for ordering controlled substances)and b.) failed to ensure that controlled drugs are reconciled in accordance with facility policy and professional nursing standards on 1 of 5 SHIFT to SHIFT CONTROLLED MEDICATION COUNT LOG (B Unit, Cart #1). This deficient practice was evidenced by the following: A.) On 05/11/2023 at 09:22 AM, Surveyor #1 requested all of the DEA 222 forms for the last six (6) months from the Assistant Director of Nursing (ADON). The ADON provided Surveyor #1 with seven (7) DEA 222 forms. Surveyor #1 reviewed the DEA 222 forms and found seven of seven forms were not completed and accurately documented as follows: 1. DEA 222 form #221418084 was written on 12/22//22 and contained an order for 1 package of 20 Oxycodone IR (Immediate release) 5 milligram (mg), 1 package of 20…

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.

NJ Complaint: #NJ00160866 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow the prescriber's orders and accepted professional standards and principles by administering medications past the required time frame. The deficient practice was identified for 1 of 1 resident reviewed for being free of significant med errors. The deficient practice was evidenced by the following: A review of Resident #108's quarterly Minimum Data Set (an assessment tool) dated 02/27/2023, revealed that Resident #108 had a brief interview of mental status score of 15 which indicated he/she was cognitively intact. A review of Resident #108's physician's orders revealed the following orders but not limited to Digoxin tablet 250mcg (micrograms, medication used to manage and treat heart failure) one time a day and to hold for a heart rate greater than 60 beats per minute, lisinopril (medication used to treat high blood pressure) tablet 2.5mg (milligrams) one time a day, furosemide (medication used to manage and treat heart…

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 store a biological (Tubersol INJ [injection], used to aid in the diagnosis of tuberculosis infection [TB]) in accordance with the manufacturer's instructions. This deficient practice was identified in 1 of 5 medication carts inspected. On 05/11/2023 at 10:11 AM, the B-Wing Medication Cart #1 was inspected, by the surveyor, in the presence of Licensed Practical Nurse (LPN #1). Upon opening the bottom right-hand drawer, the surveyor observed an unopened box of house stock Tubersol INJ (Injectable) 5/0.1 ML (Milliters) manufactured by [company name]. A label affixed to the outside of the box indicated Refrigerate, Do Not Freeze, as well as an image of a refrigerator and the word REFRIGERATE written in bold letters next to the image. At the time of the observation, LPN #1 stated that she was unsure of how long the Tubersol had been in the drawer. On the same day at 10:53 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager (RN/UM #1) replied, in the fridge when…

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 provide all the items that were on the menu. This deficient practice occurred during one lunch meal that was observed in the main dining room and was evidenced by the following: 1. On 05/09/2023 at 11:48 AM, during the lunch meal in the main dining room, the surveyor observed 12 residents were present in the dining room. According to the menu, residents were to receive a slice of apple pie at the lunch meal on 05/09/2023. The surveyor observed 12/12 residents in the main dining room receive strawberry ice cream for dessert at the lunch meal instead of apple pie. The surveyor interviewed resident #39 during the lunch meal observation. Resident #39 stated to the surveyor when he pointed out that they were provided strawberry ice cream instead of apple pie, Sometimes we get a piece of cake that is pink and sometimes we get strawberry ice cream, but we never get strawberry shortcake. The surveyor then told the resident that the dessert for the lunch meal was apple pie on 05/09/2023.…

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

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide access to the call system while a resident was in bed. The deficient practice was identified for 1 of 1 resident (Resident #423) investigated under the Environment Task. On 05/03/2023 at 09:40 AM, during the initial tour of the facility, the surveyor observed Resident #423 asleep in bed. At that time, the surveyor observed the handheld call system on the floor adjacent to the bed. On 05/11/2023 at 09:56 AM, the surveyor observed Resident #423 awake in bed. At that time, the surveyor observed the handheld call system on the floor adjacent to the bed. On the same date at 10:00 AM, during an interview with the surveyor, Resident #423 said the handheld call system is on the floor sometimes and makes it difficult to get care. He/She stated that he/she leaves the door open so the staff can hear him/her. A review of Resident #423's Care Plan located in the Electronic Medical Record, revealed that he/she is at risk for falls. The Care Plan revealed an…

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 facility documentation, it was determined that the facility failed to develop a person-centered comprehensive care plan (CP) or develop a person-centered comprehensive care plan in a timely manner a) addressing the placement and care of hand mitts on left/right hands (Resident #23), b) addressing the use, care, cleaning and storage of a nebulizer (a machine that delivers aerosol medication into the lungs) (Resident #126), and c) failure to develop a hospice care plan in a timely manner for a resident enrolled and disenrolled in hospice services (Resident #69) . This deficient practice was observed for 3 of 33 residents reviewed and was evidenced by the following: a) On 2/11/2022 at 11:14 AM, the surveyor observed Resident #23 in bed, on a ventilator with a tracheostomy in place. At that time, the surveyor noted a left-hand Posey mitt in place, (Posey Mitts are used to help protect patients who are prone to disrupting medical treatment 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, and review of other facility documentation, it was determined that the facility failed to A) develop and implement a policy to track facility staff vaccination status to ensure all eligible staff were vaccinated by the required dates and B) follow their own policy for contingency plans by not ensuring unvaccinated staff wore an N 95 mask to mitigate the potential spread of COVID-19. This deficient practice was evidenced by the following: On 2/11/22 during entrance conference, the facility was asked to provide a matrix of the vaccination status of all their staff. The facility provided a sheet of paper, separated by department, and listed the number of total vaccinated and unvaccinated staff. The paper did not identify or specify which facility staff were vaccinated or unvaccinated. A.) A review of the facility provided matrix on 2/16/22, revealed 25 new hire employees from November of 2021 to February 2022. Of those 25 new hire employees, 8 are no longer on the schedule, 6 have pending exemptions, and 11 were unvaccinated. During an interview with…

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

Based on interview and record review, it was determined that the facility failed to refer Resident #14 to the appropriate state-designated authority for level II Preadmission Screening and Resident Review (PASARR) evaluation and determination. This deficient practice was identified for 1 of 4 residents reviewed for Level II PASARR. On 2/11/2022 at 2:21 PM the surveyor reviewed Resident #14's electronic and paper record. According to the admission record Resident #14 was admitted to the facility with the following diagnoses: injury of cauda equina (a sack of nerve roots at the lower end of the spinal cord), suicidal ideations, schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder), schizophrenia, major depressive disorder, and anxiety disorder. A further review of the medical record revealed a positive Level I screen for mental illness (MI) for the diagnoses of schizoaffective disorder and depression documented on PASARR Level I Screen, dated 10/20/2021. Further review of the Level I screen revealed that within…

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, review of the medical record and review of other facility documentation, it was determined that the facility failed to revise a care plan when there was a change in the medication regime for 1 of 33 sampled residents, (Resident # 58). This deficient practice was evidenced by the following: During the initial tour of the ventilatory unit on 2/11/22 at 10:40 AM, Resident #58 was observed lying in bed with their tracheostomy connected to a mechanical ventilator with their eyes closed. A review of the admission Record revealed Resident #58 was admitted to the facility with diagnoses including but not limited to; acute and chronic respiratory failure, and anoxic brain damage (lack of oxygen to the brain). A review of an Order Summary Report dated active orders as of 2/16/22, did not include an order for anticoagulant medication (a blood thinning medication). On 2/14/22 at 1:35 PM, the surveyor reviewed Resident #58's Care Plan that revealed a focus area of I am at risk for bleeding secondary to the use of anticoagulant therapy for Deep Vein Thrombosis…

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, review of the medical record, and other facility documentation it was determined that the facility failed to follow acceptable standards of clinical practice in accordance with the New Jersey Board of Nursing Statutes by not maintaining medication records that were complete with staff signatures for 2 of 33 residents reviewed (Resident # 9 and Resident #75). This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The nurse practice act for the State of New Jersey 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 regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing…

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 other pertinent facility documentation, the facility failed to ensure residents who are unable to carry out activities of daily living (ADL) received the necessary nail care to maintain proper grooming and personal hygiene. The deficient practice was observed for 2 out of 3 residents reviewed for Activities of Daily Living, (Resident #99 and Resident #92). The deficient practice was evidenced by the following: A) During the initial tour of the facility on 2/11/22 at 10:13 AM, surveyor #6 observed Resident #99 in their room. At that time, the surveyor observed Resident #99's fingernails on his/her right hand. The nails were chipped, long, and had unidentified matter underneath the nails. On 2/14/22 at 9:19 AM, surveyor #6 observed Resident #99 in their room and the fingernails on his/her right hand remained uncut and still contained matter underneath the nails. At that time, surveyor #6 observed that the left-hand fingernails also had unidentified matter…

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 pertinent facility documentation, it was determined that the facility failed to ensure a resident had physician's orders for ongoing care and protocols for a Foley catheter (tube inserted into the bladder to drain urine) for 1 of 3 residents reviewed for a Foley, (Resident #477). The deficient practice was evidenced by the following: During the initial tour of the facility on 2/11/22 at 10:34 AM, the surveyor observed Resident #477 in bed. A Foley catheter drainage bag was on the floor with a tube ascending towards the resident. A review of Resident #477's Electronic Medical Record (EMR) revealed under, Medical Diagnosis that he/she had a diagnosis of but not limited to, Focal Traumatic Brain Injury (localized damage to the brain from direct mechanical forces), and a Pressure Ulcer of Sacral Region. A review of the 5-Day Minimum Data Set (an assessment tool) dated for 1/29/22, revealed Resident #477 had an indwelling catheter. A review of the EMR under, Orders did not include any physician's orders for the Foley…

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 documentation, it was determined that the facility failed to accurately and consistently monitor an enteral tube feeding administration pump free water flush in accordance with physician's orders. This deficient practice was observed for 1 of 3 residents (Resident #149) reviewed for tube feeding and was evidenced by the following: On 2/11/2022 at 10:50 AM, during the initial tour of the facility, the surveyor observed Resident #149 lying in bed with the head of bed elevated. The surveyor observed the following from the enteral pump screen: Resident #149 was actively receiving a tube feed of Jevity 1.5 (a type of nutritional formula) infusing at 60 milliliters per hour (ml/hr). In addition, Resident #149 was receiving an autoflush (water flush) at 60 ml q (every) hour. The enteral water bag was labeled 2/10 and had a hang time of 6 PM. On 2/14/2022 at 8:49 AM, the surveyor observed Resident #149's in progress enteral feeding. The tube feed was infusing at 60 ml/hr via pump of Jevity 1.5 and the autoflush 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, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure respiratory equipment was stored properly when not in use, to reduce the risk of infection for 1 of 2 residents reviewed for respiratory equipment, (Resident #126). The deficient practice was evidenced as follows: On 2/11/2022 at 11:20 AM, during the initial tour of the B Unit, the surveyor observed a nebulizer machine on top of Resident #126's four drawered dresser. The dry nebulizer mask was exposed, connected to the dry medication cup, and the tubing was connected to the nebulizer machine. The mask was resting on top of a TV remote control, and a tan rolled bandage. The equipment was unlabeled and undated. During an interview at that time, the resident stated the nebulizer was for her to use when she got winded. The resident further stated that the nurse placed the nebulizer on the dresser. On 2/15/2022 at 09:42 AM, the surveyor observed a nebulizer machine on top of the resident's four drawered dresser. The dry nebulizer…

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 documentation, it was determined that the facility failed to document that topical pain medication was administered as ordered by the physician. This deficient practice was identified for 1 of 3 residents reviewed for pain management, (Resident #75) and was evidenced by the following: According to the admission Record, Resident #75 was admitted to the facility with diagnoses that included arthritis. A review of review the Order Summary Report revealed a physician's order dated 12/9/2021 for the resident to receive Voltaren Gel 1% (a topical pain medication) Apply to B/L (bilateral) knees topically two times a day for pain. A review of the electronic Treatment Administration Record (eTAR) for Resident #75 for January and February 2022, revealed the pain medication Voltaren Gel with scheduled administration times of 0900 (9:00 AM) and 2100 (9:00 PM). On the following dates and times, there was no documentation to indicate that the medication was administered as ordered on: 1/2/2022 at 2100 1/3/2022 at 0900 and 2100…

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 documentation, it was determined that the facility failed to consistently communicate with a contracted dialysis facility according to facility policy and procedure. This deficient practice was observed for 1 of 1 residents (Resident #50) reviewed for dialysis. This deficient practice was evidenced by the following: A review of an admission Minimum Data Set (MDS), an assessment tool dated 12/1/21, revealed Resident #50 had a Brief Interview for Mental Status score of 13/15, indicating that he/she was cognitively intact. According to section I of the MDS, Resident #50 had an active diagnosis of end stage renal disease and section O revealed that Resident #50 received dialysis while a resident. According to the Order Summary Report, Active Orders As Of: 2/22/2022, Resident #50 had an order, dated 11/26/2021 for: Dialysis treatment 3 times a week on M-W-F Pick-up at 800 am. On 2/17/2022 at 11:17 AM, the surveyor reviewed Resident #50's dialysis communication book for the period of 12/24/2021 up to and including…

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

Based on interview and review of other facility documentation, it was determined that the facility failed to ensure that all Certified Nursing Assistants (CNA) received 12 hours of mandatory education training, annually as required. This deficient practice was identified for 1 of 5 CNA files reviewed and was evidenced by the following: On 02/17/22 at 10:09 AM, the surveyor obtained and reviewed the performance evaluations and continuing education (CE) records of five randomly selected CNA staff members from the Assistant Director of Nursing (ADON). Upon review of the records, the surveyor noted the following: 1 of 5 Certified Nursing Assistants had no annual education for 2021. On 02/17/22 at 12:30 PM, the Infection Prevention Nurse (IPN) stated they did not have the required annual education for 1 of the 5 CNA's the surveyor requested for 2021. When asked who was responsible to make sure the required yearly education was completed, she stated she and the ADON were responsible to make sure it was completed. On 02/18/22 at 08:53 AM, the surveyor interviewed the ADON regarding the…

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

Based on interview, record review and review of other facility documentation, it was determined that the facility failed to follow the recommendation identified by the Consultant Pharmacist. This deficient practice was identified for 1 of 5 Residents (Resident #75) reviewed for unnecessary medications, psychotropic medications, and medication regimen review and was evidenced by the following: According to the admission Record, Resident #75 was admitted to the facility with diagnoses that included arthritis. A review of the Order Summary Report with active orders as of 2/17/2022, revealed a physician's order dated 12/9/2021 for the resident to receive Voltaren Gel 1% (a topical pain medication) Apply to B/L (bilateral) knees topically two times a day for pain. A review of the Consultant Pharmacist's Medication Regimen Review Active Recommendations Lacking Final Response dated 1/16/2022, indicated please update Voltaren gel order with number of grams to be applied. Upon review of the January and February 2022 Treatment Administration Record of Resident # 75 the facility did 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.

Based on observation, interview, record review, and review of other pertinent facility documents, it was determined the facility failed to A.) ensure a used syringe left in a plastic cup on a bedside table was placed into a puncture proof container, B.) ensure a peripheral venous catheter (PVC) (medical tube placed into a peripheral vein for venous access to administer intravenous medications) had a protective sterile cap (an antimicrobial impregnated plastic device) applied when it was not in use to prevent exposing the access device to the environment and C.) failed to maintain contact isolation for 3 of 6 residents reviewed for Infection Control (Resident #477, Resident #169 and Resident # 103). The deficient practice was evidenced by the following: A.) During the initial tour of the facility on 2/11/22 at 10:40 AM, surveyor #6 observed a used syringe with a depressed plunger placed inside a plastic cup on the bedside table in Resident #477's room. During an interview with surveyor #6 on 2/16/22 at 10:21 AM, Licensed Practical Nurse Unit Manager Nurse (LPNUM #2) revealed 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 observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to A.) implement a system to review antibiotic (medicine used against bacteria) use with the consultant pharmacist by failing to obtain monthly reports documenting potential areas of improvement, irregularities, and recommendations and B.) failed to implement ongoing education on the Antibiotic Stewardship Program (program to improve clinical outcomes and minimize harms by improving antibiotic prescribing). The deficient practice was evidenced by the following: During an interview with the surveyor on 2/16/22 at 10:21 AM, the Licensed Practical Nurse Unit Manager (LPNUM #2) revealed she is not sure what Antibiotic Stewardship is. LPNUM #2 revealed that when the facility obtains a new order for an antibiotic, there is nothing specific to do. During an interview with the surveyor on 2/16/22 at 1:01 PM, the Infection Prevention Nurse (IPN) stated she could not provide the consultant pharmacist monthly report. When the surveyor asked if 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.