Atlas Post Acute At Woodbury Country Club

Complaint NJ #171463 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were accurately implemented for 1 of 1 resident (Resident #20) reviewed for dining and was evidenced by the following: On 4/22/25 at 8:50 AM, the surveyor observed Resident #20 sitting upright in their bed with a breakfast tray on the overbed table. The resident's diet slip indicated a Western omelette, home-fried potatoes, margarine, two cold cereals, yogurt, coffee with cream and sugar. Instead of an omelet, the resident's breakfast tray included scrambled eggs, one cold cereal, and no yogurt. At that time, the surveyor interviewed the resident, who stated that occasionally the facility ran out of yogurt, and would not receive any. On 4/22/25 at 12:00 PM, the surveyor reviewed the medical record for Resident #20. A review of the admission Record, an admission summary, revealed that the Resident #20 had a diagnosis that included, diabetes mellitus and generalized anxiety disorder. A review of…

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

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to maintain proper infection control practices to prevent the spread of infection. This deficient practice was identified for 2 of 2 Licensed Practical Nurses (LPN #6, and #7) observed during the medication observation task and was evidenced by the following: On 4/17/2025 at 8:49 AM, the surveyor observed Licensed Practical Nurse (LPN #6) administer the medication to Resident #112. After administering the medication and performing hand hygiene, she went into an unsampled resident's room to assist the resident. She touched the resident's mattress, then proceeded to wash her hands. After washing her hands, she turned off the faucet with her bare hand. At that time, the surveyor interviewed LPN #6, who stated that she should have turned the faucet off with a dry paper towel. On 4/17/2025 at 9:49 AM, the surveyor observed LPN #7 administer medication to Resident #226, immediately following the administration, LPN #7 washed her hands then turned the faucet off 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY C#'s: NJ00177015 and NJ00180017. Based on interviews, record review, and review of the facility's policy, the facility failed to ensure documentation of controlled substance medications accurately reflected disposition and administration times in 3 of 28 residents (Resident (R)4, R23, and R24). The facility's failure placed residents who were ordered and administered controlled medications at risk of their controlled medications being misappropriated/diverted. This provided inaccurate documented evidence during the investigation of misappropriation/diversion events and/or allegations. Findings include: 1. Review of R4's undated admission Record, located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. Review of R4's physician Orders, located in the resident's EMR under the Orders tab revealed the resident was ordered alprazolam (a benzodiazepine used to treat anxiety and is a schedule 4 controlled medication) 2 MG [milligram] twice a day. Review of R4's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY C#'s: NJ00177015 and NJ00180017. Based on observations, interviews, and record review, it was determined that the facility failed to utilize the proper personal protective equipment (PPE) for residents on special droplet/contact precautions for 4 of 22 residents (Residents (R) 10, R11, R12, and R13) reviewed for COVID-19 out of a sample of 22 residents. The facility also failed to follow its COVID-19 Prevention, Response, and Reporting policy. This created the potential for the transmission of infection to staff and other residents. Findings include: 1. Review of R10's admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with a diagnosis of urinary tract infection. On 12/07/24, COVID-19 was added as a diagnosis. Review of R10's Prog Note tab revealed a Skilled Note, dated 12/07/24 at 10:34 PM, During the first shift, resident tested positive for covid. All isolation precautions put in place . A review of R10's Care Plan, located in…

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

Complaints: NJ00151851, NJ00153272, NJ00153799, NJ00156210, NJ00157166, NJ00157827 Based on interview and record review, the facility failed to ensure agency staff were competent in their duties before allowing them to work with residents. This had the potential to affect 115 of 115 residents who resided at the facility. Findings include: During an interview on 01/04/24 at 12:00 PM, Registered Nurse (RN) 1 stated sometimes the agency nurses working at the facility did not order medications as needed. RN1 reported that during June 2023, a resident had to be sent to the hospital for respiratory distress because the agency staff had not ordered a refill of their breathing treatment medication. During an interview on 01/04/24 at 8:37 AM, Licensed Practical Nurse (LPN) 7, who was an agency nurse, stated she did not receive any orientation to the facility prior to working there other than how to log into PCC (Point Click Care, the facility's electronic medical records system). LPN7 reported that 01/04/24 was her first day working at the facility. During an interview on 01/04/24 at 12:28…

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 interviews, record review, and review of the facility's Medical Director's Responsibilities policy, the facility failed to ensure the Medical Director was aware of serious occurrences in Freedom from Abuse, Neglect, and Exploitation, Quality of Care, and Pharmacy Services that resulted in actual harm and/or the likelihood for serious harm or death. The facility's failure had the potential to affect all 115 residents who resided at the facility. Findings include: During an interview on 01/04/24 at 12:50 PM, the Medical Director stated he was not aware of any issues with the facility procuring medications for residents as nothing had been brought up in QAPI or the facility's monthly meetings. The Medical Director stated it was his expectation if a resident was admitted during the day, the resident's medications would only take a few hours to arrive at the facility as the pharmacy was just a couple miles down the road. Cross Reference: F755-L The Medical Director stated related to R57's edema, the provider who was initially notified of the resident's concern should have…

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 Complaints: NJ00158123, NJ00158489, NJ00159800 Based on observations, interviews, record reviews, and review of the facility's policy, the facility failed to ensure resident records were complete and accurate for six residents (Resident (R) 64, R14, R63, R57, R58, and R15) of a total sample of 65 residents. The facility's failure to ensure nursing staff completely and accurately documented each residents clinical status placed all 115 residents of the facility at risk for serious unmet care needs. Findings include: 1. Review of R64's undated admission Record, provided by the facility, revealed the resident was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm (cancer) of lung, malignant neoplasm of brain, and malignant neoplasm of bone. Review of R64's Physician Orders, located in the resident's electronic medical record (EMR) under the Orders tab, revealed an order dated 01/04/24 at 9:00 PM for Lyrica [pain medication] Capsule 75 MG [milligram] give one capsule by mouth twice 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.

Based on interview and facility policy review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program that identified quality concerns, developed corrective actions, and monitored for adverse events related to pharmacy services, documentation, and call light response times. This had the potential to affect 115 of 115 residents who resided at the facility. Findings include: During an interview on 01/09/24 at 9:31 AM, the Regional Clinician (RC) confirmed she was speaking on behalf of the facility regarding the facility's QAPI program. The RC was asked how the QAPI program addressed the facility's pharmacy system. The RC stated if concerns were brought up, most likely the nursing department would be put in charge of putting a plan of improvement in place. The RC was asked what monitoring systems were in place for the pharmacy system. The RC stated the facility had clinical meetings Monday through Friday where they discussed notes from nursing, patient relations, lab results, and assessments to determine what to address. The RC stated concerns…

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 Complaints: NJ00156380, NJ00156776, NJ00157166, NJ00157827, NJ00159247, NJ00159405, NJ00161524, NJ00168545, NJ00168603 Based on observations, interview, and policy review, it was determined the facility failed to ensure a clean comfortable and homelike environment, this was evidenced by the facility failing to have an adequate supply of clean linens (towels, washcloths, flat sheets, fitted sheets, and gowns) available for resident use. Findings include: The facility had 124 beds and a census of 114 at the time of survey entrance. The 100 Hallway had 59 residents and the 200 Hallway had 55 residents based on facility census. Observation on 01/03/24 at 11:00 AM with the Housekeeping Director (HD) of the storage container located near the back door revealed: 10 dozen (120) towels. 10 dozen (120) washcloths. During an interview at this time the HD stated these supplies were new stock that were not yet in circulation; floor staff did not have access to this supply. Observation on 01/06/24 at 1:00 PM of the clean…

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 ensure grievances were addressed for two of 65 sampled residents (Resident (R) 62 and R21). The facility failed to document significant concerns as grievances; failed to address the concerns; failed to communicate resolution; and failed to assess resident/family satisfaction upon the conclusion of the grievance. Findings include: 1. Review of the admission Record in the electronic medical record (EMR) under the Profile tab revealed R62 was admitted to the facility on [DATE]. Review of the Diagnoses tab in the EMR under the Resident tab revealed R62's admission diagnoses included inguinal hernia with obstruction, covid-19, end stage renal disease, and type 2 diabetes mellitus. During an interview on 01/05/24 at 4:30 PM, Family Member (F)1 stated she was dissatisfied because R62 had not received adequate care since his admission to the facility. F1 stated she came to the facility on [DATE], the day after R62 was admitted , and she brought…

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: NJ00158720, NJ00159247, NJ00159405, NJ00161186 Based on interview, record review, and policy review, the facility failed to ensure three of 65 sampled residents (Residents (R)15, R3, and R4) reviewed for nutrition received nutritional care and services to maintain adequate parameters of nutritional status. R15 was not weighed, and a nutritional assessment was not completed; and for R15, R3, and R4 meal intake was not recorded or monitored. These failures placed residents at risk for undetected weight loss and dehydration. Findings include: Review of the Nutritional Management policy dated August 2023 revealed, A systematic approach is used to optimize each resident's nutritional status: a. Identifying and assessing each resident's nutritional status and risk factors, b. Evaluating/analyzing the assessment information. c. Developing and consistently implementing pertinent approaches. d. Monitoring the effectiveness of interventions and revising them as necessary . A comprehensive nutritional assessment…

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 Complaints: NJ00151851, NJ00153272, NJ00153799, NJ00156210, NJ00157166, NJ00157827, NJ00158123, NJ00158489, NJ00158720, NJ00158677, NJ00159247, NJ00159405, NJ00159679, NJ00159800, NJ00160123, NJ00161147, NJ00161524, NJ00162457, NJ00162827, NJ00162977, NJ00168603, NJ00169368 Based on observation, interview, record review, and policy review, the facility failed to ensure nursing department staffing was adequate in numbers and responsiveness to meet the needs of 17 out 65 sampled residents (Residents (R)59, R34, R35, R36, R14, R16, R18, R21, R20, R15, R62, R57, R42, R40, R44, R41, and R4). Staffing was inadequate to ensure residents' call lights were answered timely, residents were toileted timely, received medications timely, received meals timely, and were gotten up, dressed, and provided hygiene timely. This created the potential for residents' needs not to be met and for residents to decline and be neglected. Findings include: Review of the Nursing Services and Sufficient Staff policy dated November 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaints: NJ00158123, NJ00158489, NJ00158677, NJ00159247, NJ00159800 Based on observation, interview, record review, and facility policy review, the facility failed to ensure a medication error rate of less than 5%. Fifteen errors were made with a total of 47 opportunities for error, resulting in a 31.9% error rate. The errors involved two residents of five residents (Resident (R) R58 and R65) reviewed for medication administration out of a total sample of 65 residents. Fourteen medications, including insulin, were not administered to R58 within one hour of the scheduled time. Stiolto, a respiratory combination inhaler, was not administered to R65 due to the medication not being available. 1. Review of R58's electronic medical record (EMR), under the Profile tab, documented R58 was admitted on [DATE], with diagnoses including metabolic encephalopathy, type 2 diabetes mellitus, chronic obstructive pulmonary disease, atrial fibrillation, anemia, and diabetic neuropathy. Review of R58's admission Minimum Data Set…

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 Complaints: NJ00157166, NJ00162457 Based on observation, interview, and record review, the facility failed to ensure 15 residents, including seven sampled residents (Resident (R)18, R53, R47, R55, R49, R50, R51) and eight of 13 residents attending the group interview (R6, R42, R43, R40, R44, R57, R4, R41), were served a well-balanced diet taking into consideration the preferences of each resident. Residents' preferences were not served in accordance with their meal tickets. When residents contacted the dietary department for alternate selections staff did not consistently answer the phone, the selections were not consistently available, or the selections were not served. This created the potential for resident dissatisfaction and weight loss. Findings include: 1. During an interview on 01/03/23 at 10:19 AM, the Dietary Manager (DM) stated new residents were given a copy of the weekly menu in effect and the Always Available Menu at the time of admission. The DM stated residents were asked about their 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.

Complaints: NJ00153272, NJ00160123, NJ00161147, NJ00169368 Based on observation, interview, record review, and facility policy review, the facility failed to ensure the menus were followed for five residents (Resident (R) 46, R47, R51, R52, R54). Foods were not served in accordance with the menu for residents on renal, mechanical soft and pureed diets. Findings include: 1. Review of the undated Diet Master report provided by the facility on 01/03/24 and review of each resident's meal ticket dated 01/03/24 revealed: a. R46 was prescribed a regular, no added salt (NAS), liberalized renal diet with large portions. b. R47 was prescribed a ground diet. c. R51 was prescribed a puree diet. d. R52 was prescribed a regular liberalized renal, no concentrated sweets (NCS) diet. e. R54 was prescribed a puree NCS diet. 2. Kitchen and dining observations revealed R46, R47, R51, R52, and R54 were not served the correct foods in accordance with the menu: a. Review of the undated Week 1 Menu for lunch on 01/03/24 called for peppers and onions, two chicken tacos (with tortillas), salsa, sour cream,…

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 Complaints: NJ00157166, NJ00160123, NJ00162177, NJ00162457, NJ00162977 Based on observation, interview, record review, and review of facility policy, the facility failed to ensure food was palatable for ten residents including two sampled residents (Resident (R) 20 and R18) and eight of 13 residents attending the group interview (R44, R43, R41, R42, R57, R14, R40, R4) out of a total sample of 65 residents. Specifically, the food did not taste good, was not appetizing in appearance, and was not at a palatable temperature when residents received their meals. This created the potential for dissatisfaction and weight loss. Findings include: 1. During an interview on 01/05/24 at 10:29 AM, Family Member (F) 3 stated R20 did not like the food. F3 stated the food was, inedible . like dog food. F3 further stated the food was, awful and R20 would not eat it. Review of the undated admission Record provided by the facility revealed R20 was admitted to the facility on [DATE] with diagnoses including protein calorie…

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: NJ000168256 Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents' property was safeguarded from misappropriation for one of two residents (Resident (R) 30) reviewed for misappropriation of property out of a total sample of 65 residents. R30 returned to the facility to retrieve her personal belongings after she was emergently transferred to an acute care hospital; however, the facility could not locate the resident's belongings. Findings include: Review of R30's undated admission Record, provided by the facility, revealed the resident was admitted to the facility on [DATE] and discharged to an acute care hospital on [DATE]. Review of R30's nursing Progress Note, dated 09/12/23 and located in the resident's electronic medical record (EMR) under Progress Notes tab, revealed eMAR-Administration Note .Note Text: sent to ER [emergency room] for eval [evaluation]. Review of the EMR revealed no documentation after R30 was discharged to an acute care…

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 facility policy review, the facility failed to report an allegation of abuse to the required agencies within two hours for one resident (Resident (R) 38) and failed to report timely an allegation of misappropriation of resident property for one resident (R30) out of a total sample of 65 residents. The failure presented a potential for continued abuse and misappropriation of property for R38 and R30, respectively. Findings include: 1. Review of R38's admission Record, provided by the facility, revealed R38 was admitted to the facility on [DATE] with diagnoses that included surgical aftercare following surgery on the digestive system, ileostomy status, and other intestinal obstruction. Review of R38's Physician Orders, dated 12/06/23 and located under the Orders tab of the electronic medical record (EMR), revealed staff was to change R38's ostomy wafer and bag on the 11-7 shift. Review of R38's admission Minimum Data Set (MDS),located under the MDS tab of the EMR and with 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 interview, record review, and facility policy review, the facility failed to thoroughly investigate an allegation of abuse for one resident (Resident (R) 38) and an allegation of misappropriation of property for one resident (R30) out of a total sample of 65 residents. These failures increased the potential for additional allegations of abuse to go uninvestigated in a timely manner. Findings include: Review of R38's admission Record, provided by the facility, revealed R38 was admitted to the facility on [DATE] with diagnoses that included surgical aftercare following surgery on the digestive system, ileostomy status, and other intestinal obstruction. Review of R38's Physician Orders, dated 12/06/23 and located under the Orders tab of the electronic medical record (EMR), revealed orders to change R38's ostomy wafer and ostomy bag daily on the 11-7 shift. Review of R38's admission Minimum Data Set (MDS),located under the MDS tab of the EMR and with an assessment reference date (ARD) of 12/12/23, revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint: NJ00157215, NJ00157739, NJ00157827, NJ00158677, NJ00161186, NJ00161524, NJ00162977, NJ00167295, NJ00168545 Based on interview and record review, the facility failed to flush gastrostomy tube and provide oral nutrition supplements as ordered for resident (R16) out of a total sample of 65 residents. Findings include: Review of the undated admission Record provided by the facility revealed R16 was admitted to the facility on [DATE] with diagnoses including cancer of the tongue, protein calorie malnutrition, tracheostomy (incision into the windpipe opening a direct airway) status, and gastrostomy (artificial opening into the stomach for nutritional support) status. R16 was discharged on 09/25/23; his closed record was reviewed. Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/18/23 provided by the facility revealed R16's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R16 was 71 inches tall (5'11) and weighed 130…

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 : NJ00167295 Based on interview, record review, and policy review, the facility failed to ensure one out of one sampled residents reviewed for tracheostomy care and services (Resident (R)16) received consistent care and services as prescribed by the physician to address his tracheostomy and respiratory needs. Findings include: Review of the undated admission Record provided by the facility revealed R16 was admitted to the facility on [DATE] with diagnoses including cancer of the tongue and tracheostomy (incision into the windpipe opening a direct airway) status. R16 was discharged on 09/25/23; his closed record was reviewed. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/18/23, provided by the facility, revealed R16's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the Care Plan with a cancellation date of 09/25/23 and provided by the facility revealed a focus area of, I have a tracheostomy r/t [related…

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 document review, interview, and facility policy review, it was determined that the facility failed to ensure staff consistently monitored the refrigerator temperature for safe temperature ranges. This had the potential to affect all residents who received food from the kitchen. Findings included: A review of an undated facility policy titled, Food Safety Requirements, revealed, Food will be stored, prepared, distributed, and served in accordance with professional standards for food safety. The policy indicated Practices to maintain safe refrigerated storage include: i. Monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operation. During the initial tour of the kitchen on 04/10/2023 at 10:04 AM, it was noted the April 2023 Refrigerator/Freezer Temperature Log for the refrigerator had not been updated since 04/05/2023. During an interview on 04/10/2023 at 1:19 PM, the Dining Services Director said he expected his staff to ensure the temperature logs were up to date. New Jersey Administrative Code §…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to assess 1 (Resident #62) of 5 residents reviewed for self-administration of medication. Findings included: Review of a facility policy, titled, Self-Administration of Medication, revised February 2021, revealed, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The policy further indicated, 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan and 8. Self-administered medications are stored in a safe…

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, interviews, facility policy review, and the Centers or Medicare & Medicaid [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, it was determined the facility failed to encode and transmit a discharge Minimum Data Set (MDS) assessment for 1 (Resident #43) of 28 residents reviewed for MDS requirements. Findings included: Review of a facility policy titled, Resident Assessments, revised March 2022, revealed, A comprehensive assessment of every resident's needs is made at intervals designated by OBRA [Omnibus Budget Reconciliation Act] and PPS [Prospective Payment System] requirements. Further review of the policy revealed, 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews, including (7) Discharge assessment (return anticipated and return not anticipated). The facility policy indicated 2. The RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments. Review of the Centers 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, it was determined that the facility failed to provide care and treatment after a fall for 1 (Resident #281) of 3 residents. Specifically, the facility failed to conduct routine neurological examinations (neuro checks) for Resident #281 after a fall on 04/10/2022. Findings included: Review of the facility undated Neurological Check Flowsheet, revealed neuro checks should be completed every 15 minutes for one hour, then every 30 minutes for four hours, then every hour for two hours, then once per shift for a total of 72 hours. A review of an admission Record indicated the facility admitted Resident #281 with diagnoses that included chronic respiratory failure, chronic obstructive pulmonary disease, cardiomegaly, heart failure, muscle weakness, difficulty in walking, prepatellar bursitis of the left knee, and depressive disorder. Review of Resident #281's care plan initiated on 04/06/2022 revealed the resident was at risk for falls and had a fall on…

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

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to: a.) ensure that staff used the appropriate Personal Protective Equipment (PPE) when caring for newly admitted residents who were under observation for sign/symptoms of COVID-19 for 5 of 8 staff members observed for infection control practices on 2 of 2 units (100 Unit and 200 Unit); and, b.) clean and disinfected the equipment between residents and minimize the potential spread of infection to residents for 1 of 2 nurses observed during medication pass on 1 of 2 units (100 Unit). This deficient practice was evidenced by the following: 1. On 3/24/21 at 12:20 PM, the surveyor observed Resident #288's room with signage posted on the door frame indicating that the room was a COHORT 4 / Admit or Readmit room with a handwritten date of 3/26/2021. (COHORT 4 include new admissions/re-admissions who are not vaccinated and require 14 days quarantine). The sign reflected pictures of the Personal Protective Equipment (PPE) required in the room, which included: Gloves + Isolation…

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 properly handle potentially hazardous food and maintain the dry storage area in a safe and consistent manner to prevent food-borne illness. This deficient practice was evidenced by the following: On 03/24/21 from 9:01 AM until 9:59 AM, the surveyor, accompanied by the Dietary Director (DD), observed the following in the kitchen: 1. In the reach-in refrigerator, on the second shelf, a container of French vanilla creamer was not labeled or dated. The DD stated, There is a sticker, but no date. 2. In the dry storage area, there was a Rubbermaid bin with a dry bread-like substance with no label or date. The DD stated, I just put this stuff in there; and it should be labeled and dated. 3. In the dry storage area, on the second shelf, a box of plastic spoons and a box of plastic knives were opened and exposed. When asked if the boxes should be opened, the DD replied, No. 4. In the prep refrigerator, wrapped meat, which was identified as turkey bacon, was labeled use by 3/19/21. The DD stated,…

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.