Christian Health Care Center

Based on observation, interview, review of the medical records and other facility documentation, it was determined that the facility failed to, a.) provide adequate monitoring for the use of psychoactive medications (meds) for 1 of 6 residents reviewed for psychotropic meds (Resident #371) and b.) ensure that the resident did not receive an unnecessary medication (med) by duplicate and incomplete med orders, for 1 out 3 residents, (Resident #374), observed during the med pass observation.The deficient practice was evidenced by: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician…

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

Based on the interview and review of facility documentation, it was determined that the facility failed to ensure that facility wide assessment included the resources required to establish policies and procedures a.) to ensure water management was included and b.) for the management of emergency food and water supply in order to meet the requirements and needs of all residents in the facility. This failure had the potential to affect all 277 residents who currently live in the facility. This deficient practice was evidenced by the following: During the entrance conference on 9/30/24 at 10:16 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) a copy of the facility's assessment. Both the LNHA and DON stated that the facility's census (the number of residents currently under the care of a specific facility) was 277. A review of the facility's Facility Wide Assessment (FWA) with a date of July 2024 that was provided by the DON on 9/30/24 at 01:31 PM did not include information about the facility's emergency food and water…

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 a review of facility provided documents, it was determined that the facility failed to consistently respond to issues and concerns presented during resident council meetings and resident questionnaires obtained from residents in lieu of a formalized resident council meeting for two (2) of three (3) resident council minutes reviewed. This deficient practice was evidenced by the following: According to the Heritage Manor East (HME) Resident Council Meeting Minutes that was provided by the Director of Nursing (DON) revealed: 1. July 18, 2024 at 02:30 PM -Staff in attendance: Director of Activities (DoA), Director of Food and Nutrition Services (DFNS), Assistant Director of Nursing (ADON), Social Worker (SW), Activities Assistant #1 (AA#1), and Activities Director (AD). -Residents in attendance: 18 -Dietary Committee Meeting: residents would like to know could the supper be served at 5:45 PM instead of arriving at 6:00 PM? Residents would prefer it earlier, if possible. The DFNS will discuss…

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 and a review of facility provided documents, it was determined that the facility failed to provide Saturday mail and package delivery services to residents. This deficient practice was identified for seven (7) of seven (7) residents interviewed during the resident council group meeting (Residents #10, #48, #167, #173, #212, #218, and 232) and was evidenced by the following: During the resident council meeting conducted by the surveyor on 10/02/24 at 10:29 AM with Residents #10, #48, #167, #173, #212, #218, and #232, the surveyor asked the residents if they received mail on Saturdays. All residents stated that there was no mail or packages on Saturdays because the mail room was closed. On that same date and time, Resident #212 informed the surveyor that a couple of weeks ago the resident had a delivery from an outside vendor [name of company] that was returned which the resident had known because the resident's representative told them. Resident #212 stated that they notified the Social Worker about it and the reason it was returned was because the packages were…

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 REPEAT DEFICIENCY Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure: a.) the resident's oxygen (O2) tubing was dated for two (2) of five (5) residents, Residents #9 and #38, b.) a physician's order for O2 and SPO2 (saturation of peripheral oxygen) monitoring was administered as ordered for two (2) of five (5) residents, Resident #9 and #124, and c.) proper storage of O2 cannula and tubing for one (1) of five (5) residents, Resident #157, reviewed for respiratory care, according to standards of clinical practice and facility policy and procedure. 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 and potential physical and emotional health problems, through…

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 the facility failed to ensure accurate documentation and review of a resident's advance directives for one (1) of five (5) residents (Resident #253) reviewed. This deficient practice was evidenced by the following: The surveyor reviewed the hybrid (electronic and paper) medical records of Resident #253. The Resident Face Sheet (a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to, dementia, spondylosis (degeneration of the bones and disks in the neck), and type 2 diabetes mellitus. A comprehensive Minimum Data Set (MDS) assessment, a tool to facilitate the management of care, dated [DATE], indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #253 scored a 09 out of 15, which indicated the resident had moderate cognitive impairment. A physician's order (PO) dated…

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 pertinent facility documentation, 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, for four (4) of 38 residents, (Residents #15, #153, #194, and #253) reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: According to the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual October 2024, for Use Effective October 1, 2024, revealed: Section C Cognitive Patterns: C0100: Should Brief Interview for Mental Status Be Conducted? Coding Instructions o Code 1, yes: if the interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available. Section J Health Conditions: J1900: Number of Falls Since Admission/Entry or Reentry or Prior…

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

Based on observation, interview, and record review it was determined the facility failed to consistently follow standards of clinical practice with regards to ensuring completion of neuro (neurological) checks after a resident had a fall for one (1) of three (3) residents (Resident #415) reviewed for falls. 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 and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of…

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

Based on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to provide appropriate interventions, implement interventions, and ensure that interventions to prevent further falls were documented and monitored for one (1) of three (3) residents, Resident #153, reviewed for incident and accident. This deficient practice was evidenced by the following: On 9/30/24 at 11:29 AM, the surveyor observed Resident #153 was not in their room. The room was observed with a bed alarm on top of the nightstand table and a low bed. The bed had a regular mattress [not specialized]. The surveyor reviewed the medical records of Resident #153 and revealed the following: The Resident Face Sheet (an admission summary) showed that the resident was admitted to the facility with a diagnosis that included but was not limited to Alzheimer's disease unspecified, dementia in other diseases classified elsewhere, muscle weakness (generalized), other sequelae of cerebral infarction (stroke), and repeated falls. A review of the provided Matrix for…

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

Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to ensure a.) complete documentation of supplemental intake, for residents identified as at risk for malnutrition according to the physician's order and care plan interventions for two (2) of four (4) residents, Residents #90 and #124, and b.) monitored weight according to the physician order for one (1) of four (4) residents, Resident #124, reviewed for nutrition. This deficient practice was evidenced by the following: 1. On 10/03/24 at 10:46 AM, the surveyor observed Resident #90 sitting up in bed, alert and verbally responsive. The resident stated that they would lose weight, gain weight back, and lose weight again. The resident stated recently they had a good appetite and did receive supplement drinks that they usually consumed. The resident had no concerns with their care. The surveyor reviewed the paper and electronic medical record (EMR) of Resident #90. The Resident Face Sheet (FS; a summary of important information about…

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 monitor enteral tube feeding administration to assure the total volume administered was in accordance with physician's orders. This deficient practice was identified for two (2) of two (2) residents (Residents #157 and #230), reviewed for enteral tube feeding. This deficient practice was evidenced by the following: During an initial tour on 9/30/24 at 11:48 AM, Surveyor #1 (S#1) observed Resident #157 in bed, with their head of bed elevated. The surveyor observed there was a tube feeding (TF) pump and a pistol syringe hung on the pole, which was inside a plastic bag. The resident was not receiving TF at that time. On 10/03/24 at 11:07 AM, Surveyor #2 (S#2) observed Resident #157 sitting in chair. The surveyor observed the TF pump next to resident's chair. The resident was not receiving TF at the time. S#2 reviewed the paper and electronic medical record of Resident #157: The Resident Face Sheet (RFS; an admission summary) reflected that Resident #157 was admitted to the facility 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 observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident's routine pain level assessment was being completed and documented according to the facility's policy and standards of practice. This deficient practice was identified for one (1) of one (1) resident reviewed for pain management (Resident #253), and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. On 9/30/24 at 10:18 AM, the surveyor observed Resident #253 lying in bed, alert and…

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 pertinent facility documentation, it was determined that the facility failed to provide care and services in accordance with professional standards clinical practice with regards to: a.) clarify and follow a physician's order (PO) for midodrine medication, and b) document the consumed fluid intake for a resident with a PO for fluid restrictions. This deficient practice was observed for one (1) of one (1) resident reviewed for dialysis care and services, Resident #188. 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 and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed…

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 #: NJ170023 and NJ172045 Based on interview, record review, and review of pertinent facility documentation, it was determined the facility failed to ensure sufficient nursing staff and ensure call bells were answered timely without waiting a long period of time for two (2) of (2) two residents (Residents #463 and #513). This deficient practice was evidenced by the following: 1. Surveyor #1 (S#1) reviewed the Alarm Average Response Time Report for Heritage Manor [NAME] 327-336 bed, from 02/20/24-3/15/24 for Resident #463, who was admitted to room [ROOM NUMBER]W. For room [ROOM NUMBER]-W, the section under Report Detail reflected the following dates and response times (>15 minutes): 3/14/24 at 05:15 PM response time was 17 minutes (mins) and 32 seconds (secs) 3/12/24 at 10:17 PM response time was 18 mins and 19 secs 3/12/24 at 09:51 PM response time was 23 mins and 11 secs 3/11/24 at 11:19 PM response time was 16 mins and 21 secs 3/10/24 at 10:46 PM response time was 24 mins and 58 secs 3/10/24 at 06:55…

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.

REPEAT DEFICIENCY Based on interviews, record review, and a review of pertinent facility documents, it was determined that the facility failed to identify the irregularity with regard to the physician's order for one (1) of 38 residents, Resident #12 reviewed for medication in accordance with facility's practice and policy. This deficient practice was evidenced by the following: On 9/30/24 at 11:46 AM, Surveyor #1 (S#1) observed Resident #12 inside their room near the door seated in a wheelchair. The surveyor reviewed the medical records of Resident #12 and revealed: According to the Resident Face Sheet (an admission summary), the resident was admitted to the facility with diagnoses that included but were not limited to Barrette's esophagus without dysplasia (a change in the cellular structure of your esophagus [a tubular, elongated organ of the digestive system which connects the pharynx to the stomach] lining), gastro-esophageal reflux disease without esophagitis (a type of GERD that does not involve inflammation of the esophagus), and heartburn (burning pain or discomfort in the…

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

Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to ensure that all medications were administered with an error rate of less than 5%. During the medication administration observation conducted on 10/02/24, the surveyor observed four (4) nurses administer meds to five (5) residents. There were twenty-eight (28) opportunities, and two (2) errors were observed which resulted in a medication error rate of 7.14%. This deficient practice was identified for one (1) of five (5) residents observed (unsampled resident), which was administered by one (1) of four (4) nurses. This deficient practice was evidenced by the following: According to the manufacturer's specifications for Carbidopa/Levodopa (Sinemet) (a medication used to treat Parkinson's disease), administration of Iron (a mineral supplement) or Iron containing products with Sinemet may reduce the amount of Levodopa available in the body. According to clinical documentation and accepted practice, Calcium (a mineral supplement) may reduce the absorption…

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.

REPEAT DEFICIENCY Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) ensure that the staff donned (put on) the appropriate personal protective equipment (PPE) prior to providing care to a high contact care resident room that required an Enhanced Barrier Precautions (EBP) for one (1) of two (2) residents, Resident #58, reviewed for pressure ulcer and b.) follow appropriate infection control practices by having direct care staff knowledgeable about identifying residents who require direct care, and when staff to use PPE, this deficient practice was identified for two (2) of three (3) Certified Nursing Aides, according to facility's policy and practice. This deficient practice was evidenced by the following: 1. During on an initial tour on 9/30/24 at 11:26 AM, Surveyor #1(S#1) observed Resident #58 lying in their bed, with oxygen in use at 2 LPM (Liters per minute). On 10/03/24 at 11:57 AM, S#2 observed an orange-colored round sticker [dot] next to resident's name on the name plate, which 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 interview and record review, it was determined that the facility failed to accurately complete and timely transmit the Minimum Data Set (MDS) for 6 of 36 residents reviewed, Residents #171, #71, #39, #45, #54, #223, and was evidenced by the following: On 6/13/23 at 10:45 AM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS up to 14 days of the assessment being completed. After transmitting the MDS, a quality measure to enable a facility to monitor resident's decline and progress is generated. The following residents were identified for MDS timely transition issues: 1. Resident #171 was identified to have a Quarterly MDS (Q/MDS) with Assessment Reference Date (ARD) of 3/24/23 and was due to be transmitted no later than 4/21/23. The MDS was not transmitted until 6/13/23. 2. Resident #71 was identified to…

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 carry out a comprehensive care plan (CP) for 1 of 42 residents reviewed for the fulfillment of a care plan, Resident #30. This deficient practice was evidenced by the following: On 6/6/23 at 10:10 AM, the surveyor observed Resident #30 in bed with a floor mat on the left side of the bed, between the resident and their roommate. The resident's bed was in a position equal to their roommate. On 6/7/23 at 11:25 AM, the surveyor observed Resident #30 in bed with a floor mat on the left side of the bed, between the resident and their roommate. The resident's bed was in a position equal to their roommate. The surveyor reviewed the resident's hybrid medical chart which included a review of a paper as well as computerized medical chart. Review of the Face Sheet (FS), a one-page summary of important information about a patient that documented the resident's diagnosis as well as the diagnosis tab, which included but was not limited to Alzheimer's Disease, Dementia, Unspecified Fracture of lower end…

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 a.) follow a physician's order (PO) for administering medications, b.) document the daily weights in accordance with the PO and c.) document the consumed fluid intake for a resident with a PO for fluid restrictions. This deficient practice was observed for 1 of 39 residents reviewed for physician order accuracy, Resident #503. This deficient practice was evidence by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. On 6/1/23 at 10:52 AM, Resident #503 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 medical records, it was determined that the facility failed to follow physician orders related to the use of continuous oxygen (O2) for 2 of 4 residents, Resident #40, and #236 who both had compromised breathing status conditions. This deficient practice was evidenced by: 1. On 6/6/23 at 10:05 AM, the surveyor interviewed Resident #40 who was seated in a wheelchair, in the dining area eating breakfast. Resident #40 was noted receiving O2 delivered through a nasal cannula (NC-plastic prongs attached to a tube, inserted into the nostrils that oxygen flows through) utilizing a concentrator (an oxygen delivery system) at 4 Liters per minute (LPM). The surveyor reviewed the resident's hybrid medical chart which included a review of a paper as well as computerized medical chart. Review of the Face Sheet (FS) (a one-page summary of important information about the patient) that documented the resident's diagnosis which included but was not limited to Chronic Obstructive Pulmonary Disease with exacerbation, Pulmonary Fibrosis, and…

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 a resident's medication times were adjusted to accommodate their dialysis schedule for 1 of 2 residents (Resident #503) reviewed for dialysis. This deficient practice was evidenced by the following: On 6/1/23 at 10:52 AM, Resident #503 was observed sitting in their room in a wheelchair. Resident #503 appropriately responded to the surveyor. The resident was observed receiving oxygen (O2) via a nasal cannula controlled by a concentrator set at 2 liters per minute (LPM). Resident #503 informed the surveyor that they were scheduled for dialysis on Mondays, Wednesdays, and Fridays. Review of Resident #503's hybrid (computerized and paper) clinical medical records revealed: A review of the Resident #503's Face Sheet (a one-page summary of important information about the patient) that documented the resident's diagnosis which included but was not limited to End Stage Renal Disease, Dependence on dialysis, Chronic Respiratory…

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 Consultant Pharmacist (CP) failed to identify and notify the facility of possible medication irregularities. These irregularities were identified for 2 of 42 residents reviewed for CP medication evaluation, Resident #30, and Resident #503. The deficient practice was evidenced by the following: 1. On 6/6/23 at 10:18 AM, the surveyor observed Resident #30 in bed receiving care from a Certified Nursing Assistant in their room. The surveyor reviewed the resident's hybrid chart which included a review of a paper as well as computerized medical chart. Review of the Face Sheet (FS), a one-page summary of important information about a patient that documented the resident's diagnosis as well as the diagnosis tab, which included but was not limited to Dysphagia (difficulty or discomfort in swallowing) and Rheumatoid arthritis. Review of Resident #30's Physician's orders (PO) presented an active order, Medications may be crushed as permitted by manufacturer and administered together to decrease resident discomfort,…

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 facility polices it was determined that the facility failed to maintain proper kitchen sanitation practices, maintain the kitchen equipment in a clean and sanitary manner, and properly label and date potentially hazardous foods in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was evidenced by the following: On 5/31/23 from 9:49 AM through 10:45 AM, the surveyors completed the initial tour with the Senior Food Service Director (SFSD) and the Executive Chef (EC) and observed the following: 1. The dietary aide (DA) used a Hydrion (Brand of strip to test chemicals in the water) testing strip to test the sanitizing solution of the 3-compartment sink. The testing strip was compared to the color-coded concentration guide, which showed a reading higher than 400 parts per million (ppm). The DA stated the sanitizing solution should be between 200-400 ppm. A reading over 400 PPM indicates that there is too much…

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 follow appropriate measures to prevent and control the spread of infection by not wearing the proper personal protective equipment (PPE) while taking care of a resident with an active COVID 19 infection. The deficient practice was evidenced by the following: On 6/1/23 at 10:32 AM, prior to the initial tour, the facility's Director of Quality/Acting Assistant Director of Nursing (DQ/AADON) provided a copy of the resident's list of names who had active diagnosis of COVID 19 and were placed on a droplet precautions which included Resident #222. On 6/1/23 at 11:32 AM, during the initial tour of the nursing units, the surveyor observed a sign indicating Droplet precaution on Resident #222's door of their room. There was also another sign titled, Cohort One Sequence for Donning PPE that included directions for, 3. Put on N-95 and 4. Put on eye protection On 6/1/23 at 11:35 AM, the surveyor observed a Certified Nursing Assistant (CNA) who was inside Resident #222's room, open the door and…

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.