BERLIN REHABILITATION AND HEALTHCARE CENTER

100 LONG-A-COMING LANE, BERLIN, NJ 08009 (856) 322-3600
For profit - Corporation 128 Beds MARQUIS HEALTH SERVICES Data: November 2025 1 Immediate Jeopardy citation
Trust Grade
38/100
#175 of 344 in NJ
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Last Inspection: May 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Berlin Rehabilitation and Healthcare Center has received a Trust Grade of F, indicating poor overall performance and significant concerns regarding care quality. In New Jersey, it ranks #175 out of 344 facilities, placing it in the bottom half, and #8 out of 20 in Camden County, meaning only seven local options are worse. The facility is showing signs of improvement, with reported issues decreasing from 10 in 2023 to 3 in 2025. Staffing is average with a rating of 3 out of 5 stars, and turnover is at 47%, which is similar to the state average. However, it has incurred $57,944 in fines, which is concerning as it is higher than 83% of facilities in New Jersey. While RN coverage is average, the facility has experienced critical incidents, such as a cognitively impaired resident managing to elope from the building, raising serious safety concerns. Additionally, there have been issues with pressure ulcer management for residents, indicating lapses in timely care interventions. Food service has also been a problem, with reports of inadequate meal options not meeting nutritional standards. Overall, families should weigh these strengths and weaknesses carefully when considering this facility for their loved ones.

Trust Score
F
38/100
In New Jersey
#175/344
Top 50%
Safety Record
High Risk
Review needed
Inspections
Getting Better
10 → 3 violations
Staff Stability
⚠ Watch
47% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties
⚠ Watch
$57,944 in fines. Higher than 83% of New Jersey facilities, suggesting repeated compliance issues.
Skilled Nurses
○ Average
Each resident gets 40 minutes of Registered Nurse (RN) attention daily — about average for New Jersey. RNs are the most trained staff who monitor for health changes.
Violations
⚠ Watch
14 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 10 issues
2025: 3 issues

The Good

  • 5-Star Quality Measures · Strong clinical quality outcomes
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

3-Star Overall Rating

Near New Jersey average (3.3)

Meets federal standards, typical of most facilities

Staff Turnover: 47%

Near New Jersey avg (46%)

Higher turnover may affect care consistency

Federal Fines: $57,944

Above median ($33,413)

Moderate penalties - review what triggered them

Chain: MARQUIS HEALTH SERVICES

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 14 deficiencies on record

1 life-threatening 1 actual harm
Aug 2025 1 deficiency 1 IJ
CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of medical records, and other pertinent facility documentation on [DATE], it was determined that the...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of medical records, and other pertinent facility documentation on [DATE], it was determined that the facility failed to provide adequate supervision to a cognitively impaired resident (Resident #2) with a known history of elopement who eloped from the facility on [DATE]. The deficient practice was identified for 1of 3 residents (Resident #2).The resident had a history of exiting their unit on [DATE]. On [DATE] at approximately 6:01 P.M., Resident #2, while wearing a wander guard (security bracelet), left their unit on the second-floor and exited the facility through the main lobby front door. Staff became aware that the resident was missing from their unit when another nurse informed Resident #2's Licensed Practical Nurse (LPN #1) that when a staff member was coming into the facility, he saw someone that looked like Resident #2 on the road. At that time, LPN #1 looked for Resident #2 in their room, but could not find them. LPN #1 and other staff members went outside to search for the resident. Resident #2 was found approximately thirty minutes later, while walking with a walker on a nearby busy four-lane highway, and brought back to the facility at approximately 6:49 P.M.The facility's failure to provide adequate supervision to a cognitively impaired resident who was at risk for elopement and eloped posed a likelihood of serious harm, injury, impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation which ran from [DATE] at 6:01 P.M., when Resident #1 eloped from the facility out of the main entrance doors until [DATE] at 6:49 P.M., when the resident was located by staff and brought back to the facility. The IJ was Past Non-Compliance (PNC).The facility's Administration was notified on the IJ on [DATE] at 6:28 P.M. The facility submitted an acceptable Removal Plan on [DATE].The facility was back in compliance when the facility addressed the situation by locating the resident and immediately assessing them for injury upon return to the facility. Resident #2 was placed on one-to-one (1:1) monitoring; their care plan was revised; and the functioning of their wander guard was verified. The facility completed a head count to verify all residents were accounted for; conducted a house sweep using an interim elopement/wandering risk evaluation to check other residents for elopement risk; educated all staff on interventions to prevent elopement; and verified all binders that identified residents at risk for elopement were accurate and placed at the nurses' stations and the front desk. The Elopement/Missing Person policy was reviewed, and the Receptionist and off-shift staff were educated on the process for incoming and departing visitors. The Regional Plant Operations inspected doors and wander guard functionality; the door lock system was reviewed, and the timer was adjusted; adjustment was made to the frequency/sensitivity for the wander guard bracelet; and the front door system was switched to alert the front door's operator with a push/release mode only. The surveyor verified the completion of the Removal Plan was [DATE], during the on-site visit on [DATE], and determined the IJ was PNC.The evidence was as follows: A review of the facility's policy titled Wander Management and Prevention Updated-[DATE], under Policy Statement Indicated: The facility will maintain the safety of residents who wander and/or are at risk for elopement. Under Policy Interpretation and Implementation 4. The wander management system device will be used in conjunction with other resident-specific interventions for the management of unsafe wandering. 5b. Wander management system devices will be checked for functionality daily by nursing staff. 7. Doors with wander management system alarms will be checked for functionality daily by maintenance staff/designee. 8. Identified issues with wander management system alarms will be immediately addressed.A review of the facility's policy titled Wandering and Elopements under Policy Interpretation and Implementation 2. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the resident from leaving in a courteous manner; b. get help from other staff members in the immediate vicinity, if necessary and c. Instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises. According to the Facility Reportable Event Record (FRE) dated [DATE], Resident #2 exited the second-floor nursing unit and eloped out of the facility through the facility's first floor lobby door on [DATE] at 6:01 P.M.According to the FRE, the Receptionist on duty at the time confirmed that she observed Resident #2 exit the building through the main front door but thought the resident was a visitor because the resident wore a [NAME] straw hat and was using a rollator. The FRE indicated that at around 6:22 P.M., a staff member who was returning to facility from his dinner break informed the nurse on the first-floor unit that he saw a person with a rollator (walker) outside the facility that looked familiar, like a resident. Staff then looked for Resident #2 in their room but could not locate the resident. A code yellow was called, and a search was initiated for the resident.The Summary and Conclusion of the FRE indicated that staff found Resident #2 on the road and returned the resident to facility at 6:49 P.M., and that the resident's vital signs, pain and skin evaluation were completed, and no ill effects noted; and that facility placed Resident #2 on 1:1 monitoring. According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to: Parkinson's Disease, traumatic subdural hemorrhage, and seizures.According to the quarterly Minimum Data Set (MDS), an assessment tool dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated the resident's cognition was moderately impaired. The MDS also indicated that Resident #2 had an elopement alarm order, and that the resident walked with set-up assistance using a walker.The surveyor reviewed Resident #2's Progress Notes (PN) dated [DATE] at 2:29 P.M., Note Text: Late entry for [DATE], written by the DON: The PN revealed that staff was notified that Resident #2 left the building and that the staff immediately responded by going to search for the resident. The PN further stated that staff found the resident and brought them back to the facility, and that the resident's family and the physician were notified.According to Resident #2's Care Plan (CP) with an initiated date of [DATE], Resident #2 was at actual/potential risk for elopement. The CP also reflects exit seeking behaviors that was initiated on [DATE], with an intervention to maintain wander guard's placement and function. The CP also revealed the following interventions: photograph in elopement book - initiated on [DATE], monitor for resident's desire to leave facility - initiated on [DATE], and 1:1 observation initiated [DATE].On [DATE] at 10:23 A.M., the surveyor conducted a telephone interview with the Receptionist, who was on duty at the facility's front entrance on [DATE]. The Receptionist stated that on [DATE], she observed a person going through the front entrance maybe around 6:00 P.M., wearing a straw hat with brims covering their face and using a walker. She stated she thought the person was a visitor because she did not see their face. The Receptionist stated she was familiar with Resident #2, and added that the resident wanders, and had a wander guard. The Receptionist stated that they had a binder at the front desk for residents at risk for elopement with each resident's name, room number and their pictures in the binder. When asked if she checked the binder, she said she tried to make it a habit to check the binder and that they received information when the binder was updated. The Receptionist further stated she did not hear the alarm go off on the day Resident #2 eloped through the facility's front lobby entrance.On [DATE] at 10:55 A.M., during an interview with the surveyor, LPN #2, who was assigned to Resident #2, stated LPN #1 informed her that she received a phone call from the nurse downstairs who informed her that a staff reported he saw someone walking down the street that looked like they might be a resident at the facility, but he was unsure. LPN #2 stated that she immediately went to check Resident #2's room and bathroom and didn't see Resident #2. She then called code yellow (code for missing person), and all staff members searched the rooms and bathrooms on the unit but could not find the resident. LPN #2 further stated that there was no alarm sounding at the time of their search, and that some of the staff members drove down the road where the DON and other staff found Resident #2 on [busy four-lane highway]. She stated that Resident #2 was then brought back to the facility and assessed. LPN #2 confirmed that the resident was at risk for elopement and had a wander guard which was checked every shift for placement and function. When asked if she checked Resident #2's wander guard during her shift, she replied, she did, it was present at the time she checked during their 5:00 P.M. medication administration. She further stated the alarm normally went off if residents who had a wander guard attempted to leave the unit, and that staff must respond and reset the alarm. When asked if she knew how Resident #2 eloped, she replied if a resident with a wander guard went on the elevator, the alarm sounded, and the elevator would not go down or close. LPN #2 further stated that on [DATE], the day the resident eloped, none of that happened; no alarms were sounding.On [DATE] at 12:35 P.M., during an interview with the Maintenance Director, he stated that maintenance did daily testing on the wander guard alarm system (using a device called a wander guard tester) to ensure it was functioning. He stated that all testing for the wander guard alarm system was conducted on the morning of [DATE], and was functional.On [DATE] at 1:23 P.M., during a telephone interview with the surveyor, the Certified Nursing Assistant (CNA #1) assigned to Resident #2, stated that he last saw Resident #2 after he picked up their dinner tray from their room around 6:00 P.M. on [DATE]. CNA #1 stated that a few minutes later, he heard a code yellow called and they all started to search for the resident. CNA #1 further stated that they searched rooms, bathrooms and everywhere and could not find Resident #2. According to CNA #1, if the resident had a wander guard, once they entered the elevator, it triggered the alarm system, and they must respond. CNA #1 stated that on the day the resident eloped, there was no alarm sounding. When asked if he observed Resident #2 leave the unit, CNA #1 replied, no, I did not see the resident leave, neither did I hear any alarms going off.On [DATE] at 1:44 P.M., during an interview with LPN #1, she stated that she received a phone call from the nurse on the first-floor who stated that a CNA (CNA #2), who was returning from their break, saw a person that might be a resident outside of the facility. LPN #1 stated that she immediately checked Resident #2's room and bathroom, and the resident was not there. LPN #1 noticed the resident's wheelchair was present, but their walker was missing. A code yellow was activated. LPN #1 further stated that while they were searching for the resident, she received a phone call that the DON and another staff member that they had located Resident #2 at the corner of [four lane highway], two turns from the facility. LPN #1 stated that she went to the location to get the resident and that she noticed the resident had their wander guard on their ankle. LPN #1 stated the expectations was that if a resident had a wander guard and tried to elope, the elevator should alarm, and all other alarms should be sounding for the safety of the resident. When asked if the alarm sounded on the day Resident #2 eloped, she replied, no, I did not hear the alarm or elevator sounding that day. Even though I was in the back hall, I should hear the alarms sounding. LPN #1 stated that if a resident with a wander guard eloped, they would be at risk for harm, injury, or death and that Resident #2 could have gotten injured or died from the elopement.On [DATE] at 2:49 P.M., during an interview with the DON, in the presence of the Licensed Nursing Home Administrator (LNHA), the DON confirmed that on [DATE], a CNA (CNA #2) returning from their break at approximately 6:22P.M., observed someone who looked familiar to him adjacent the building. CNA #2 notified his nurse, who called the second-floor nurse, who called code yellow, initiated a search and notified her. The DON stated that she was with Resident #2 at 6:32 P.M., and they returned the resident to the building around 6:49P.M., and assessed the resident. The DON stated that the Receptionist noticed Resident #2, whom she thought was visitor, leave the facility through the front entrance. The DON stated that they observed the resident on a screenshot camera footage leaving the building at approximately 6:01 P.M. The DON confirmed she observed the wander guard on the resident's left lower extremity. The DON further stated that it was important for a resident at risk for elopement to have a functional wander guard in place for their safety, and that the wander guard function and placement was checked every shift. The expectation was that if a resident had a wander guard, our system should be sounding if the resident attempted to elope. She further stated there were binders at each nurse's station and at the front desk with pictures and names of residents at risk for elopement.The surveyor interviewed the LNHA on [DATE] at 2:49 P.M. The LNHA stated that the maintenance staff checked the alarm system daily to ensure it was functional. The LNHA added that it was important to ensure the system was functioning and the alarm will sound to alert staff to residents at risk for elopement. When asked if the system was triggered when Resident #2 eloped, he stated they did not know if the system was triggered for Resident #2. The LNHA stated that the expectation was that the system should trigger and alert staff if a resident with a wander guard attempted to elope. The facility was unsure how Resident #2 left the building since all the systems were functioning on the day Resident #2 eloped. The LNHA did not provide any other information as to how Resident #2 left from their unit (second floor) and exited out of the facility with their wander guard on [DATE] at approximately 6:01 P.M. The LNHA stated they did not know how Resident #2 exited the second-floor to the first-floor and then to the front door entrance. They only had video footage of the resident leaving through the front entrance. The LNHA in the presence of the DON both agreed that if a resident at risk for elopement left the building unsupervised, there could be a potential for harm, injury, or death to the resident.The facility submitted an acceptable Removal Plan (RP) on [DATE] at 12:00 P.M., indicating the actions the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: the facility located the resident and immediately assessed them for injury upon return to the facility. Resident #2 was placed on one-to-one (1:1) monitoring; their care plan was revised; and the functioning of their wander guard was verified. The facility completed a head count to verify all residents were accounted for; conducted a house sweep using an interim elopement/wandering risk evaluation to check other residents for elopement risk; educated all staff on interventions to prevent elopement; and verified all binders that identified residents at risk for elopement were accurate and placed at the nurses' stations and the front desk. The Elopement/Missing Person policy was reviewed, and the Receptionist and off-shift staff were educated on the process for incoming and departing visitors. The Regional Plant Operations inspected doors and wander guard functionality; the door lock system was reviewed, and the timer was adjusted; adjustment was made to the frequency/sensitivity for the wander guard bracelet; and the front door system was switched to alert the front door's operator with a push/release mode only. The facility self-corrected the deficient practice, and it was determined that the IJ was PNC. The facility corrected their non-compliance on [DATE]. The surveyor verified the implementation of the Removal Plan on-site on [DATE].NJAC 8:39-27.1 (a)
May 2025 1 deficiency
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected most or all residents

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) the facility's four week cycle menus were consistently nutrition...

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Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) the facility's four week cycle menus were consistently nutritionally adequate for fruit, protein, and starch servings in accordance with the facility provided Diet Manual and nationally accredited standards, b.) standardized recipes were readily available and followed, and c.) that all listed menu items were consistently provided at meals (Resident's #1, #28, #44, #81 and #88). This deficient practice was identified by surveyors during meal rounds on 3 of 3 units and was supported by 5 of 5 residents that attended the Resident Council Meeting on 5/20/25 (Resident's #8, #15, #50, #56 and #58). The deficient practice was evidenced by the following: On 5/19/25 at 8:13 PM, the surveyor interviewed Resident #44 who stated they ordered a grilled cheese sandwich for breakfast from the Always Available Menu, and was told that the kitchen had no bread. On 5/20/25 at 10:32 AM, the surveyor conducted a resident council meeting with five residents. They stated that both the quality and the quantity of food provided at meals was poor. They stated that over the weekend they were served ravioli and were supposed to receive eight but only received four. They stated that bread was not available on Sunday. They stated when they received chicken on a bun for a meal it used to be a real chicken breast and now it was a processed patty. They stated they attended Food Committee Meetings conducted by the Food Service Director (FSD); however, concerns were not resolved and we have to hear about the budget. On 5/20/25 at 12:22 PM, the surveyor observed lunch service in the Hickory dining room. Bread was not served for the regular or alternate meal but was posted on the menu and meal tickets. On 5/20/24 at 12:24 PM, another surveyor observed lunch service in the Hickory dining room. Bread was not served for the regular or alternate meal but was posted on the menu and meal tickets. On 5/20/25 at 12:42 PM, another surveyor observed lunch service on the Evergreen unit. The surveyor observed a table with four residents, three of which had meals with no bread served. The fourth had a sandwich. During lunch meal rounds, the surveyor observed lunch for Resident's #1, #28, #81 and #88 on the same unit. Bread or roll with butter, was indicated on all four of their meal tickets. None of the four residents were served bread. On 5/20/25 at 1:10 PM, the surveyor interviewed the Infection Preventionist, who stated when lunch trays were served staff should verify the residents name and ensure the correct diet consistency was served. She was unable to speak to how the staff ensured the residents received items indicted on the meal ticket. On 5/20/25 at 1:43 PM, the Licensed Nursing Home Administrator (LNHA) stated that when menu items were not checked off on a meal ticket, the resident should have received the main meal items which should have included bread. Shortly after, the FSD entered the conference room. He stated there was a dietary aide position that checked meal trays for accuracy before they were delivered. He could not speak to why bread was not served and stated he would have to investigate this. These interviews were conducted in the presence of the survey team. On 5/21/25 at 12:13 PM, the surveyor observed lunch service in the Hickory dining room. The surveyor observed 19 residents receive four ravioli with red sauce, mixed vegetable and half a slice of bread on a plate. In addition, the surveyor observed a resident who received double portions served eight ravioli, mixed vegetables and a full slice of bread. On 5/21/25 at 12:24 PM, another surveyor observed Resident # 44 at lunch. The resident's plate had four ravioli with red sauce and a sprinkle of parmesan cheese, vegetables and a half slice of bread. The meal ticket indicated 1 slice of Ravioli Bake, and 1 slice of Pound Cake. There was no pound cake on the tray. On 5/21/25 at 12:38 PM, another surveyor observed lunch service in the Hickory dining room. The surveyor observed Resident #58's plate, which had four ravioli with red sauce, mixed vegetables and a half slice of bread. The resident ordered the alternate meal as a substitute which was a chef's salad (lettuce, tomato, wedges of hard-boiled egg, cubed ham and shredded cheddar cheese) and a slice of bread. No side starch was observed. On 5/21/25 at 1:45 PM, the surveyor interviewed the Regional Dietary Manager (RDM) from the contracted food service company, in the presence of the survey team. The surveyors were provided with sample trays for the regular and alternate meals that were served for lunch. He acknowledged that the amount of ravioli served was a greater portion than the residents received. There were 10 ravioli with red sauce. In addition, the RDM stated the ravioli bake was typically served as a square and was prepared with mozzarella cheese. The surveyors were visually unable to detect any mozzarella cheese in the meal. In addition, two surveyors tasted the ravioli bake in the presence of the RDM and survey team and did not taste mozzarella cheese. The plate provided to the surveyors had a full slice of bread and the RDM could not speak to why a half slice was served to the residents. The RDM also observed the alternate meal and acknowledged that a side starch was not served with the meal and should have been included on the menu. On 5/22/25 at 10:50 AM, the LNHA provided the surveyor with requested food invoices. The surveyor reviewed and compared food invoices to the menu. On 5/22/25 at 1:34 PM, the surveyor interviewed the Registered Dietitian (RD), who could not speak to the required amount of protein to be served at lunch and dinner. He was also unable to speak to the amount of fruit servings that should be served daily. On 5/22/25 at 1:44 PM, the surveyor conducted multiple interviews in the presence of an additional surveyor as well the FSD, the RDM, the Regional Director of Dining Services (RDDS) and the LNHA. The surveyor inquired how many meatballs were served when on the menu. The RDDS stated if the meatballs were one ounce each, three would be served because they typically served three ounces of protein at lunch and dinner. The FSD, RDM, and the RDDS could not speak to how many grams of protein were in three ounces of protein (21 grams). The surveyor inquired how many ravioli were served when on the menu. The FSD stated 8 to 10. The surveyor inquired how many slices of cheese were used to make a cheese sandwich or grilled cheese sandwich. The FSD stated, three slices. When asked, the FSD, RDM, and the RDDS could not speak to how many servings of fruit should be served daily. The RDM and DSSD stated bread fish were served when breaded fish or pub style fish were on the menu. The FSD, RDM, and the RDDS stated a chicken patty was served when a chicken patty sandwich was on the menu. The DSSD stated that when pizza was on the menu, they used frozen premade pizza. During this same interview, the surveyor inquired what the portion size 1 slice of Ravioli Bake, which was indicated on the menu, was equivalent to. The RDM stated that information was on the recipe. The surveyor had reviewed the recipe prior to the interview. That recipe included cottage cheese and mozzarella cheese be added to the ravioli and red sauce. The recipes were not readily available prior to surveyor inquiry. The surveyor the interviewed the full time [NAME] who prepared the Ravioli Bake. The [NAME] stated, he did not add cottage cheese and that he used mozzarella cheese and cheddar cheese; neither of which were observed during lunch meal rounds nor on the sample plate provided to surveyors. During that same interview, the FSD could not speak to why bread was not served at lunch on 5/20/25. The surveyor then interviewed the dietary aide responsible for ensuring bread was served that day who stated, I missed it. The FSD stated there was a dietary aide who checked the meal trays prior to delivery to ensure all items were served per the menu and meal ticket. The dietary aide could not speak to why bread was not served. During that same interview, the FSD stated he conducted Food Committee Meetings, and some concerns residents voiced included they wanted more fresh fruit, and they liked plain vegetables verses mixed. He stated he revised the menus based on their requests and that the purpose of the meetings was to ensure residents received food items they liked. On 5/22/25 at 3:01 PM, the survey team met with the Administrative team (Regional Director of Operations, the Regional Director of Clinical Services, the LNHA and the Director of Nursing [DON]). At this time, food concerns were presented. The LNHA acknowledged that he was surprised the FSD had not investigated why bread was not served at lunch on 5/20/25. The LNHA stated the FSD was responsible to ensure menus were followed, that tray service was accurate and that residents received what they want. On 5/23/25 at 11:35 AM, the survey team met with the Administrative team. The LNHA acknowledged the food concerns, and no additional information was provided related to the amount of fruit servings that should be provided. A review of the Diet Manual with a revised date 9/11/23 and signed/approved by facility staff on 8/20/24, indicated the following. - 3-4 servings of fruit were the minimum daily amount (page 29). - 2-3 servings of protein were the minimum daily amount (page 29). - Each lunch and dinner meal included a protein, vegetable, starch and bread (page 30). - A portion of protein on a Regular diet was 3 ounces (page 31). A review of the Food Committee Council Meeting Minutes dated 2/18/25, indicated the residents disliked the breaded fish, requested more fresh fruit, and did not like the mixed vegetables. The facility's response was to bread fresh fish from scratch. A review of the Food Committee Council Meeting Minutes dated 3/27/25, indicated a concern from the previous meeting was tray accuracy and that dietary aides received training and guidance, and random tray checks and resident interviews would continue to ensure improvement. A review of the Resident Food Committee minutes dated 4/15/25, indicated residents requested more fresh fruits. A review of the facility provided a.) four-week cycle menus (posted dates 5/18/25 - 6/14/25), b.) the menu spreadsheets with portion sizes, c.) recipes, d.) nutritional information for premade products, e.) Diet Manual, f.) Always Available Menu, and g.) staff interviews; the following was determined: -25 out of 28 days the facility did not serve the minimum amount of fruit servings per day. -18 out of 56 lunch and dinner meals offered did not meet the minimum amount of high biological value protein (proteins of high biological value, also known as complete proteins, are those that contain all the essential amino acids in the appropriate proportions that the body needs to carry out its functions optimally) required. -4 out of 9 main meal substitutes offered on the Always Available Menu, did not meet the minimum amount of high biological value protein required. A review of an undated policy Accuracy and Quality of Tray Line Service, included that all meals should be checked for accuracy by the food service staff and by the staff that serve the resident their meal. It also included that the FSD or designee was responsible to ensure all foods needed for each meal were present for service. In addition, it included that meals should be checked for accuracy verse the menu and the spreadsheets (portion sizes), and any problems with accuracy should be resolved immediately. A review of an undated policy Portion Control, included residents should receive the appropriate portions as indicated on the menus. It also included that standardized recipes should be used. A review of the policy Meal Service Accuracy, with a revised date of 1/3/25 included that meal service accuracy referred to all components of a meal being prepared and provided to a resident correctly. It also included that meals should be provided in accordance with posted menus with accurate portion sizes served. In addition, the policy included that the quality of the food should be satisfactory. A review of an undated/unsigned job description for Dietary Aide (DA) from [name redacted], included the responsibility of assistance in preparation of meals according to planned menus, following guidelines and portion control. In addition, a DA was responsible to ensure residents trays are accurate. A review of an undated/unsigned job description for Dietary [NAME] (DC) from [name redacted], included the responsibility to ensure meals meet dietary requirements and were prepared and cooked according to planned menus. A review of an undated/unsigned job description for FSD from [name redacted], included the responsibility of managing, supervising and directing the food service staff. It also included the responsibility of planning and implementing menus that are well-received by the residents and featured seasonal menu items. NJAC 8:39-17.1 (b), 17.4 (a) (1) (3) (c) (e)
Feb 2025 1 deficiency
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to follow Enhanced Barrier Preca...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to follow Enhanced Barrier Precautions (EBP) during wound care and failed to follow proper hand hygiene practices during wound care for two of three residents (Residents (R) 11 and R12) reviewed for pressure ulcers out of 19 sampled residents. This failure had the potential to cause cross contamination and cause a wound infection. Findings include: 1. Review of the Centers for Disease Control and Prevention (CDC) CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/24, accessed at https://www.cdc.gov/infection-control/hcp/core-practices/ on 02/26/25, revealed . Core Practices Table . Core Practice Category 5a. Hand Hygiene References and resources: 3, 7, 11 . 2. Use an alcohol-based hand rub or wash with soap and water for the following clinical indications: .c. Before moving from work on a soiled body site to a clean body site on the same patient .f. Immediately after glove removal. Review of R11's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R11 was admitted to the facility on [DATE] with a diagnosis of a pressure ulcer of right buttock, stage IV. Review of R11's Physician's Orders, dated 02/26/25, located in the EMR under the Orders tab, revealed an order to apply to right medial gluteus topically every night shift for wound care cleanse pressure ulcer with acetic solution 0.25%. Apply collagen sprinkles then calcium alginate. Cover with silicone foam dressing. Done daily and as needed (PRN) till discontinued. Observation on 02/26/25 at 11:05 AM of R11's wound care revealed LPN4 poured acetic solution on approximately eight gauzes, picked up several in her gloved hands, wiped the inside of the right medial gluteus pressure ulcer several times with the soaked gauze, discarded the gauze in the trash can next to the foot of the bed, and then packed the wound with calcium alginate without performing hand hygiene and donning new gloves. Continued observation revealed LPN4 handed the Nurse Educator a couple of soaked gauze, the Nurse Educator cleansed the inside of R6's pressure ulcer with the soaked gauze, the Nurse Educator held the calcium alginate in place with her gloved hands while LPN4 applied the adhesive dressing and then the Nurse Educator discarded her gloves and performed hand hygiene. During an interview on 02/26/25 at 11:31 AM, LPN4 verified she should have removed the gloves and performed hand hygiene after cleansing the pressure ulcer and then applied the treatment because it could cause cross contamination and infect the wound. LPN4 stated she had been trained in wound care and completed the wound care competency in January 2025. During an interview on 02/26/25 at 11:34 AM, the Nurse Educator confirmed she should have changed her gloves and performed hand hygiene after cleansing R11's pressure ulcer. The Nurse Educator also stated she worked three days a week and trained the staff on wound care and observed them performing wound care. During an interview on 02/26/25 at 11:40 AM, the Director of Nursing (DON) stated she expected staff to remove their gloves and perform hand hygiene after cleansing the wound and then applying the treatment to the wound. The DON stated the wound care policy and competency did not address changing gloves and performing hand hygiene when moving from dirty to clean body site, but it was a standard of practice to prevent infection to the wound. During an interview on 02/26/25 at 11:52 AM, the Infection Preventionist (IP) stated staff should discard and apply new gloves and perform hand hygiene after cleansing the pressure ulcer and then applying treatment to the pressure ulcer. Review of Licensed Practical Nurse (LPN) 4's Wound Care Competency, dated 01/23/25, provided by the facility, revealed LPN4 demonstrated competency in wound care. 2. Review of the facility's policy titled, Enhanced Barrier Precautions, dated August 2022 and provided by the facility, revealed Policy Statement Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation .2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact activity (as opposed to before entering the room) . 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: .h. wound care (any skin opening requiring a dressing) . 9. Staff are trained prior to caring for residents on EBPs. 10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. 11. PPE is available outside of the resident rooms . Review of Review of R12's undated admission Record, located in the EMR under the Profile tab, revealed R12 was admitted to the facility on [DATE] with a diagnosis of osteoarthritis of the hip and knee. Review of R12's Physician's Orders, dated 02/26/25, located in the EMR under the Orders tab, revealed an order to apply coccyx topically every day shift for wound care cleanse with acetic acid (may use sterile water if acetic acid is not available), apply collagen sprinkles to wound bed top with calcium alginate and cover with bordered gauze daily. Review of R12's Interim Skin Check, dated 02/06/25, revealed R12 had a pressure injury noted to the sacrum that measured 2 centimeters (CM) length x 1.4 CM width x 1.0 CM depth. Review of a facility's in service training record titled Enhanced Barrier Precautions (EBP), dated 03/22/24, provided by the facility, revealed LPN7 and the Nurse Educator were trained by the IP to wear gloves and a gown for the following high-contact resident care activities such as wound care: any skin opening requiring a dressing. Observation on 02/26/24 at 10:40 AM of R12's wound care revealed LPN7, and the Nurse Educator washed their hands and then applied gloves prior to initiating wound care, however, they did not wear a gown during wound care. Continued observation revealed an enhanced barrier precautions stop sign posted on the outside of R12's door frame that stated . Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities. everyone must: . Wound Care: . Moreover, observation revealed a PPE cart on the floor below the EBP sign posted on the outside of the door frame. During an interview on 02/26/25 at 10:57 AM, LPN7 confirmed she did not put on a gown prior to initiating R12's wound care. LPN7 stated she forgot to put on the gown even though the EBP sign was posted on the outside of R12's door and the PPE cart was located below the sign on the floor which was stocked with gowns. LPN7 stated EBP were ordered for this resident to prevent the spread of MDROs. During an interview on 02/26/25 at 10:58 AM, the Nurse Educator confirmed she did not wear a gown, and she assisted LPN7 with R12's wound care. The Nurse Educator stated she had been trained on EBP last year and should have put on the gown before she touched R12's coccyx wound. During an interview on 02/26/25 at 11:36 AM, the DON stated she expected staff to wear a gown and gloves when performing wound care. The DON also stated EBP was used to prevent exposure to infections during high contact activities such as wound care. During an interview on 02/26/25 at 11:47 AM, the IP stated she posted the EBP sign on the outside of resident's room door and the PPE cart in the hallway near the door upon admission of a resident with a pressure ulcer, indwelling catheter, etc. The IP also stated that newly admitted residents could have MDROs so the appropriate PPE should be worn to prevent the spread of it to others. The IP also indicated that she trained new staff during orientation and existing staff on EBP.
Dec 2023 10 deficiencies 1 Harm
SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ00166442 Based on interviews, review of closed medical records and other facility documentation, it was determined that the fa...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ00166442 Based on interviews, review of closed medical records and other facility documentation, it was determined that the facility failed to consistently implement timely interventions in adherence with the facility pressure injury prevention policy and the resident's care plan to promote skin integrity and prevent the development of moisture-associated skin damage (MASD) of both the right and left buttocks, a deep tissue injury (DTI, an injury of the underlying tissue below the skin's surface that results from prolonged pressure) of the left lateral heel and an unstageable pressure ulcer of the right lateral ankle. This deficient practice was identified for 1 of 2 residents (Resident #172) reviewed for pressure ulcer management. This deficient practice was evidenced by the following: Refer to F 677 Reference: Pressure Ulcer stages defined by the National Pressure Ulcer Advisory Panel (NPUAP): https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf NPUAP Pressure Injury Stages The updated staging system includes the following definitions: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate (interaction between skin temperature and moisture at skin surface), nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema (redness), which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD, caused by prolonged exposure to moisture), including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole, undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Review of the admission Record revealed that Resident #172 was admitted to the facility with diagnosis which included but were not limited to: Fracture of unspecified part of the neck of right femur (upper bone of the leg, the head forms a ball and socket joint with the hip), unspecified diastolic congestive heart failure (condition in left chamber of heart with reduced amount of blood pumped out to the body), need for assistance with personal care, and muscle wasting and atrophy (waste away), not elsewhere classified, multiple sites. Review of Resident #172's admission assessment dated [DATE], indicated the resident's skin was intact with no abnormalities. Further review of the assessment indicated to initiate Potential for Skin Breakdown care plan with a focus of, I have skin breakdown and/or potential for skin breakdown . Interventions: Apply barrier cream after incontinence care, Document skin checks weekly and PRN (as needed) ., I need moisturizer applied to my skin as needed .I need reminding/assistance to turn/reposition at least every two hours, more often as needed or requested, Notify nurse immediately of any skin changes: redness, blisters, bruises, discoloration, etc. noted during care. Goal: I will be at reduced risk for skin breakdown daily through the review date. Review of Resident #172's admission Minimum Data Set (MDS), an assessment tool dated 06/27/23, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Further review of the MDS revealed that the resident required extensive assistance of one person for bed mobility, transfers, toilet use and personal hygiene. Review of Section H of the MDS, for Bladder and Bowel, revealed that the resident was always incontinent of urine and frequently incontinent of bowel. Review of Section M of the MDS, for Skin Conditions, indicated the resident was at risk for developing pressure ulcers/injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin in persons with limited ability to change position) and had no unhealed pressure ulcers/injuries. A review of Resident #172's Comprehensive Care Plan initiated on 06/20/23, with a focus area for ADL (assistance of daily living) self-care performance deficit related to deconditioning status post hospitalization. The goal outlined that the resident would be at reduced risk for complications of self-care performance deficit and impaired mobility daily through the review date (Target date 10/11/23). Interventions included: Provide skin inspection daily during care. Observe for redness, open areas, scratches, cuts, bruises, etc. (etcetera, used at the end of a list to indicate that further, similar items were included) and report changes to Nurse. A review of Care Plan initiated on 06/30/23, with a focus area for urinary incontinence related to physical limitations. Goals included: I will not have skin breakdown due to incontinence through the review date (Target date 10/11/23). Interventions included: Establish voiding patterns, Apply moisture barrier cream to buttocks and peri-area with incontinence care as needed, Observe buttocks, peri-area, and groin during care for possible skin problems. Notify nurse of changes, redness, rashes, open areas, etc. Review of the Order Summary Report revealed the following Physician's Orders (PO): - A PO dated 6/20/23, for Pressure redistribution/reducing mattress every shift, Pressure reducing cushion every shift, and Consult Wound Care services for evaluation and treatment as needed. -A PO dated 06/20/23, Weekly skin checks on shower day: Friday on 3-11 shift, every evening shift every Friday. Must complete Weekly Skin Check Evaluation. -A PO dated 06/21/23, Fluid Restriction (recommendation made by the doctor to prevent fluid from building up in the body): 1500 ml (milliliters) Total in 24 hrs (hours): Nursing: 600 ml/24 hr, (240 ml on 7-3 (supplement), 180 ml on 3-11, 180 ml on 11-7); Dietary: 900 ml/24 hr (420 ml @ (at) Breakfast, 240 ml @Lunch, 240 ml @Dinner) every shift. Further review of the PO's revealed that no supplement was ordered. -A PO dated 06/22/23, for CBC with diff (complete blood count with differential, a blood test used to look at overall health and find a wide range of conditions including anemia (deficiency of red blood cells or of hemoglobin (a red protein responsible for transporting oxygen in the blood) and white blood cells (fight infection), basic metabolic panel (BMP, basic metabolic panel, a test that measures eight different substances in your blood which includes: calcium level (mineral in blood needed for strong bones and bodily functions), carbon dioxide (determines kidney or lung function), chloride (electrolyte that helps control amount of fluids), creatinine (test done to determine kidney function), glucose (provides an estimate of blood sugar levels), potassium (mineral that helps nerves and muscles communicate), sodium (an electrolyte that helps nerves and muscles work) and urea nitrogen (a waste product that develops when your body breaks down protein in foods eaten that forms in the liver and travels through the blood to the kidneys) one time only for edema (a condition characterized by an excess of watery fluid collection in the tissues or cavities of the body), mg (magnesium, mineral), and phos (phosphorous, mineral). One time only for Eliquis (a drug used to prevent and treat blood clots) until 06/26/23 . -A PO dated 06/23/23, for BMP. - A PO dated 6/23/23, for Ace bandage wrap b/l [bilatereral] legs knee to feet in the morning for edema. - A PO dated 06/26/23, Remove Ace bandage wraps from b/l lower legs and feet QHS (at bedtime) for edema. -A PO dated 06/27/23, CBC with diff, bmp on 7/3. -A PO dated 06/30/23, Fluid Restriction: 1500 ml (milliliters) Total in 24 hrs (hours): Nursing: 600 ml/24 hr, (240 ml on 7-3 (supplement), 180 ml on 3-11, 180 ml on 11-7); Dietary: 900 ml/24 hr (420 ml @ (at) Breakfast, 240 ml @Lunch, 240 ml @Dinner) every shift. Further review of the PO's revealed that no supplement was ordered. - A PO dated 07/09/23, to cleanse right buttock with nss (normal saline solution), pat dry, apply zinc mix with collagen powder and cover with a DSD (dry, sterile, dressing) every day. - A PO dated 07/18/23, to Cleanse right buttock with nss, pat dry, apply zinc mix with collagen powder. Leave open to air every day and evening shift. -A PO dated 07/19/23, to Cleanse b/l buttocks with gentle soap and water after peri-care, pat dry, apply zinc mix with collagen powder. Leave open to air every day and evening shift. -A PO dated 07/19/23, CBC w diff, BMP, Mag (magnesium), Phos (phosphorous), Pro BNP (Brain natriuretic peptide, is a test that measures levels of protein called BNP that is made by the heart and blood vessels, high levels may indicate heart failure). One time only for monitoring. -A PO dated 07/24/23, Wound care consult, DTI left heel, open right lateral malleoulus wound and right hand wound. - A PO dated 07/24/23, to off load b/l heels. B/l waffle boots to off load heels while in bed. -A PO dated 07/24/23, Off load b/l heels. B/l waffle boots to off load heels while in bed. Every shift for DTI (deep tissue injury). -A PO dated 07/25/23, for a CBC, BMP, Mag, Phos, and liver function panel (provides information about the status of the liver and includes: albumin (a protein produced in the liver that plays an important role in keeping fluid from leaking into the tissues) bilirubin (yellowish pigment made up from the break down old red blood cells), and liver enzymes (provides information about the state of a person's liver). -A PO dated 07/25/23, Pro BNP one time only until 07/26/23. - A PO dated 07/26/23, for Pro Stat (protein supplement) two times a day for wound healing 30 ml by mouth. May provide Liquacel (alternate protein supplement) if unavailable. -A PO dated 07/26/23, to Cleanse right lateral ankle cleans with NSS, apply medi honey fiber to wound bed, apply Skin prep (liquid film-forming protective barrier dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) to peri wound, cover with bordered foam dressing daily. -A PO dated 07/26/23, to Apply skin prep to left lateral heel every day and every evening shift. -A PO dated 07/27/23, for Right lateral ankle, b/l buttocks. Apply Skin Prep to left lateral heel, Right dorsal hand one time a day for train (sic.) family on wound care for discharge. Review of the resident's June and July 2023 Treatment Administration Record (TAR) reflected the above corresponding physician's orders and the treatments were implemented as ordered. Review of a Weekly Skin Check dated 07/08/23, revealed that the resident had a new skin impairment noted, Skin Tear, right buttock, with no other skin impairments noted. Review of a Physiatry Note, titled, Physical Medicine and Rehabilitation Consultation dated 06/26/23 at 11:05 PM, revealed CC (chief complaint): Leg edema, right leg pain with movement. Plan included: .Apply ACE wraps every morning and remove ACE wraps every evening. NO ACE WRAPS OVERNIGHT. Inspect skin carefully after removing ACE wraps daily. Please start ACE wrap at ankles. Including foot in ACE wrap will reduce pedal edema. Review of a Physical Medicine and Rehabilitation Follow Up note dated 07/07/23 at 4:35 PM, revealed the following: CC (chief complaint) Right femur fracture. .Continue with daily application of ACE wraps every morning and removal of ACE wraps every evening. NO ACE WRAPS OVERNIGHT. Inspect skin carefully after removing ACE wraps daily. Please start ACE wrap base of toes. Do NOT start ACE wrap at ankles. Including foot in ACE wrap will reduce pedal (foot) edema. Avoid overly tight wrapping . Review of a Physical Medicine and Rehabilitation Follow Up note dated 07/24/23 at 11:35 AM, revealed the following: Right femur fracture, ambulatory dysfunction, left heel DTI .Pt. noted to have left heel DTI. Also, with right malleoulus (the bony protuberance on either side of the ankle) open wound . Plan: .off load b/l heels. Wound care consult. Review of a Health Status Note (HSN) dated 07/09/23 at 11:20 AM, (19 days after the resident was admitted to the facility), revealed the resident's skin on the right buttock was macerated (softening and breaking down of skin from prolonged exposure to moisture) and noted with small bleeding during am care. A new daily/prn (as needed) Tx (treatment) was put in place to cleanse with nss (normal saline solution), apply collagen powder mix with zinc and cover DSD (dry, sterile, dressing). Will encourage frequent turning and repositioning while in bed and frequent incontinent (sic.) care. Review of a Health Status Note dated 07/24/23 at 2:47 PM by the Registered Nurse (RN) revealed the following: Notified by Physiatry that patient had new skin issues. Upon investigation, Patient with a Left Heel DTI 1 x 1 purple in color with intact skin, and a right ankle opening-A 3 cm long opening with a 1 cm opening at the distal end. Patient wearing TEDS (compression stockings) with +3 edema to b/l BE (sic). When suggested patient return to bed and elevate feet, patient became mad and stated he/she does not like to be in the bed. He/She gets up in the morning and stays up until bed. Patient unsure how he/she acquired opening. Daughter at bedside and stated they were already aware of both skin issues. MD (Medical Doctor) made aware with order to cover Open ankle wound and for a wound consult. Patient to be seen on wound rounds. Review of a Nutrition Note dated 07/26/23 at 12:45 PM, revealed, Per most recent WOCN (Wound Ostomy Continence Nurse) documentation resident with unstageable pressure to right ankle Discussed increased nutritional needs r/t (related to) wound healing. Recommend prostat BID (twice a day), multivitamin, vit c (vitamin c), and zinc. Resident reports .discharge Friday. Gave recommendations for home nutrition for wound healing. On 11/20/23 at 1:14 PM, the surveyor requested to view all investigations that pertained to Resident #172. The Director of Nursing (DON) provided the surveyor with three (3) Full QA (Quality Assurance) Reports dated 07/11/23, 07/20/23, and 07/24/23 all of which pertained to skin issues. Review of the 07/11/23, incident report revealed an acute onset of MASD to bilateral (b/l) buttocks was identified with a root cause analysis of due to incontinence puts resident at risk for MASD. Review of the 07/20/23, incident report indicated a skin tear that measured 3 cm (centimeter) x 1 cm after the resident hit their hand when transferred from bed to chair. Review of the 07/24/23, incident report indicated that a house acquired pressure ulcer(s) was identified and was documented as a left heel DTI that measured 1 cm x 1 cm (intact skin) and a right lateral ankle open wound that measured 3 cm x 1 cm. Review of the problem statement portion of the incident revealed that the resident had + [plus] 3 b/l le [lower extremity] edema (swelling caused by too much fluid trapped in the body's tissues) as patient liked to sit in wheelchair all day. The Registered Nurse (RN) documented in the Investigative statement portion of the incident that she was notified by Physiatry (a doctor who specialized in physical medicine and rehabilitation) that patient had new skin issues. Upon investigation, patient with a left heel DTI 1 x 1 purple in color with intact skin and a right ankle opening with a 1 cm opening at distal end. Patient wore TEDS Stocking (compression stockings) with +3 edema to b/l BE (sic.) .Patient to be seen on wound rounds. There was no documented evidence in the resident's medical record including the Care Plan or Progress Notes the resident's preference to remain in the wheelchair all day as described by the RN. Further review of the medical record including physician's orders revealed there was no physician's orders for TEDS Stockings as documented by the RN in the 07/24/23, incident report and Health Status Note dated 07/24/23 at 2:47 PM, that was written by the RN. Review of the Wound Care Consultant documentation dated 07/11/23, revealed the following: Wound 1: Right buttock-MASD, Wound Type: dermatitis (condition of skin in which it becomes red, swollen, sore, with small blisters resulting from direct irritation of the skin with external agent). Wound status: unknown. Pain level 4 out of 10, Measurements (not specified) L (length) X W (width) X D (depth): 5 x 2 x 0.1, area (sq cm) 10, volume (cm3), no tunnels, Exudate amount: low, Exudate type: serous (clear), Wound Margin: poorly defined. Periwound (surrounding skin): erythematous (redness) Tissue exposed: partial thickness. Treatment recommendations: The plan for the dermatitis is to cleanse the area with soap and water. Primary dressing: 1. Zinc Oxide cream. Secondary Dressing: 1. Collagen Sprinkles. This treatment will be done every shift for one week. Today's treatment will be performed by the wound care team and other care performed by the staff of the facility. Wound 2: Left buttock-MASD. Wound Type: dermatitis. Wound status: unknown. Pain level 4 out of 10. Measurements: 4 x 2 x 0.1, Area 8, volume: 0.80, no tunnels. Exudate amount: low. Exudate type: serous. Wound Margin: poorly defined. Periwound: denuded (strip of its covering). Tissue Exposed: Partial Thickness. Treatment Recommendations: The plan for the dermatitis is to cleanse the area with Soap and Water. Primary Dressing: 1. Zinc oxide cream Secondary Dressing: 1. Collagen Sprinkles. This treatment will be done every shift for one week. Today's treatment will be performed by the wound care team and other care performed by the staff of the facility. Provider Comments: Patient is seen with an MASD to the right and left buttocks, both measured in a cluster of three, noted with 100% dermis and erythema. Both treatments are the same with the following instructions: Cleanse with soap and water. Apply 1:1 mixture of zinc + collagen powder every shift and as needed. Leave open to air. .The patient's BMI (body mass index, value derived from the mass and height of a person) is greater than 25 which suggests they are overweight. Recommend implementing a nutritional care plan per facility policy. Review of the Wound Care Consultant Documentation dated 07/18/23, revealed the following: Wound 1: Right buttock MASD, Wound Type: Dermatitis. Wound Status: improving. Pain level: 2 out of 10. Measurements: 2 x 2 x 0.1, Area: 4, Volume: 0.40, Tunnels: 0, Exudate amount: low. Exudate type: serous, Wound Margin: well defined. Periwound: normal. Tissue exposed: partial thickness. Treatment Recommendations: The plan for the dermatitis is to cleans the area with soap and water. Primary Dressing: 1. Zinc oxide cream. Secondary Dressing: 1. Collagen Sprinkles. This treatment will be done every shift for one week. Today's treatment will be performed by the wound care team and other care performed by the staff of the facility. Wound Number 2: Left buttock: MASD. Wound Type: Dermatitis. Wound Status: improving. Pain level 2 out of 10. Measurements: 1 x 0.5 x 0.1, Area 0.5, Volume 0.05, Tunnels: 0, Exudate amount: low. Exudate Type: serous. Wound Margin: well defined. Periwound: normal. Tissue Exposed: partial thickness. Treatment recommendations: The plan for the dermatitis is to cleanse with area with soap and water. Primary Dressing: 1. Zinc oxide cream Secondary Dressing: 1. Collagen Sprinkles. This treatment will be done every shift for one week. Today's treatment will be performed by the wound care team and other care performed by the staff of the facilty. Provider Comments: Left and right buttock MASD improving, noted smaller in size with 100% dermis. Recommend continuing same tx (treatment) and leaving it OTA (open to air). Review of the Wound Care Consultant documentation dated 07/25/23, revealed the following: Wound 1: Right buttock MASD, Wound Type: dermatitis improving, measured 1 x 1 x 0.1 (measurements length x width x depth, unit of measurement not specified), pain level 3 out of 10, with low serous (clear) exudate, Tissue exposed: partial thickness. (Note: On 07/11/23, area measured 5 x 2 x 0.1). Wound 2: Left buttock MASD, Wound Type: dermatitis, unchanged, pain level 2 out of 10, 1 x 0.5 x 0.1, low exudate, serous, Tissue exposed: partial thickness. (Note: On 07/11/23, area measured 4 x 2 x 0.1). Wound 3: Right Dorsal Hand, Skin Tear, Pain level 3 out of 10, 1.4 x 0.6 x 0.1, wound status unknown, minimum exudate sanguinous (sic.) (bloody), partial thickness. Wound 4: Left Lateral Heel, Pressure Ulcer, wound status unknown, Pain level 2 out of 10, 1 x 1, Stage or grade if applicable: NPIAP (National Pressure Injury Advisory Panel) Stage DTI (deep tissue injury), No exudate, Intact Skin. Wound 5: Right Lateral Ankle. Pressure Ulcer. Wound status unknown, Pain level 2 out of 10, 0.9 x 2 x 0.2 Area 1.8 Volume cm 3 0.36 cm, NPIAP Stage Unstageable, moderate serous exudate, 100% necrotic (death of most or all the cells in an organ or tissue due to injury, disease, or failure of blood supply) material, Tissue exposed, Subcutaneous, Debridement (removal of damaged tissue from a wound): Sharp. Debridement Treatment Response: The patient tolerated the procedure well. Pain assessment status post procedure is one on the 0-10 pain scale. On 12/04/23 at 10:46 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) #3 who stated that she worked at the facility for two years. CNA #3 stated that when she was assigned to a resident who had any type of hip or leg surgery, she would make sure that the resident's heels were maintained off the bed, apply heel boots if ordered and turn the resident every two hours. CNA #3 stated that if she noted a skin abnormality, she would report the finding to the nurse and document it. CNA stated that if TEDS stockings or ACE wraps were ordered they were removed at bedtime and the CNAs applied the TEDS in the am, but nursing was responsible to apply the ACE wrap in the morning as ordered. CNA #3 then proceeded to demonstrate the computer system she utilized to document care rendered. On 12/04/23 at 11:17 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that she did weekly wound rounds every Tuesday with the Unit Managers, Director of Nursing and Nurse Practitioner from the Wound Consultant group. LPN/UM #1 stated that for a hip fracture it was automatic that the resident's heels should immediately be offloaded with either pillows or heel boots. LPN/UM #1 explained that an order was required for both heel boots and waffle boots to off load the heels from the mattress to alleviate pressure. LPN/UM #1 further explained that pillows could also be used to elevate the heels off of the bed. On 12/05/23 at 12:53 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that residents received a skin assessment upon admission and then weekly skin checks. She stated that for a resident who had sustained a femur fracture she would have expected that the resident required frequent turning and skin checks which were documented by the CNA's. The ADON stated that heel boots were ordered upon admission if the resident was bedbound. The ADON stated that if a resident liked to stay up in their wheelchair, they were required to have footrests on their wheelchairs and she would have implemented heel boots as, it was better to be safe than sorry. On 12/05/23 at 2:28 PM, the surveyor interviewed the Registered Nurse, who identified herself as the overnight supervisor via telephone. The surveyor asked if she noted Resident #172 wearing TEDS stockings as she had described in both the Incident Report and Progress Notes? The RN responded, She would have had to have seen the resident wearing TEDS stockings if that was what she documented. The RN stated that a Physician's Order was required for TEDS and they were available in house if ordered. The RN further stated, We have a doctor's note for anything going on a patient because they are for compression, the doctor may not want them. On 12/06/23 at 10:58 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with the, Documentation Survey Report for June and July 2023, that pertained to CNA care provided which included: Turning and repositioning, bladder continence, bowel continence, and preventative skin care with moisture barrier after each incontinence episode. The surveyor observed that there was no documented evidence that the tasks were completed by the assigned staff member who failed to sign that they completed the tasks below on the following dates as indicated: June 2023: 1. Turning and positioning: On day shift blanks were noted in the signature column on: 06/20/23, 06/22/23, 06/23/23, 06/24/23, 06/25/23, 06/27/23, 06/28/23 and 06/29/23. On evening shift blanks were noted in the signature column on: 06/24/23, 06/25/23, and 06/26/23. On night shift blanks were noted in the signature column on: 06/21/23, 06/23/23, 06/25/23, 06/27/23 and 06/28/23. 2. Bladder continence: On day shift blanks were noted in the signature column on: 06/20/23, 06/23/23, 06/25/23, 06/27/23, 06/28/23, and 06/29/23. On evening shift blanks were noted in the signature column on: 06/24/23, 06/25/23 and 06/26/23. On night shift blanks were noted in the signature column on: 06/21/23, 06/23/23, 06/25/23, 06/27/23, and 06/28/23. 3. Bowel continence: On day shift blanks were noted in the signature column on: 06/20/23, 06/23/23, 06/24/23, 06/25/23, 06/27/23, 06/28/23 and 06/29/23. On evening shift blanks were noted in the signature column on: 06/24/23, 06/25/23, and 06/26/23. On night shift blanks were noted in the signature column on: 06/21/23, 06/23/23, 06/25/23, 06/27/23 and 06/28/23. 4. CNA Skin Checks: On day shift blanks were noted in the signature column on: 06/20/23, 06/22/23, 06/23/23, 06/24/23, 06/25/23, 06/27/23, 06/28/23 and 06/29/23. On evening shift blanks were noted in the signature column on: 06/24/23, 06/25/23, and 06/26/23. On night shift blanks were noted in the signature column on: 06/21/23, 06/23/23, 06/25/23, 06/27/23, and 06/28/23. 5. Personal Hygiene including mouth/denture care: On day shift blanks were noted in the signature column on: 06/20/23, 06/22/23, 06/23, 06/25/23, 06/27/23, 06/28/23, and 06/29/23. On evening shift blanks were noted in the signature column on: 06/24/23, 06/25/23, and 06/26/23. On night shift blanks were noted in the signature column on: 06/21/23, 06/23/23, 06/25/23, 06/27/23, and 06/28/23. 6. Preventative Skin Care with Moisture Barrier after each incontinence episode: On day shift blanks were noted in the signature column on: 06/20/23, 06/22/23, 06/23/23, 06/25/23, 06/27/23, 06/28/23 and 06/29/23. On evening shift blanks were noted in the signature column on: 06/24/23, 06/25/23 and 06/26/23. On night shift blanks were noted in the signature column on: 06/21/23, 06/23/23, 06/25/23, 06/27/23 and 06/28/23. July 2023: 1. Turning and positioning: On day shift blanks were noted in the signature column on: 07/01/23, 07/02/23, 07/04/23, 07/05/23, 07/06/23, 07/07/23, 07/08/23, 07/09/23, 7/11/23, 07/12/23, 07/13/23, 07/14/23, 07/21/23, 07/22/23, 07/23/23, 07/24/23, 07/25/23, 07/26/23, 07/27/23 and 07/28/23. On evening shift blanks were noted in the signature column on: 07/01/23, 07/10/23, 07/14/23, 07/22/23, and 07/23/23. On night shift blanks were noted in the signature column on: 07/02/23, 07/15/23, and 07/24/23. 2. Bladder continence: On day shift blanks were noted in the signature column on: 07/01/23, 07/02/23, 07/04/23, 07/05/23, 07/06/23, 07/07/23, 07/08/23, 07/09/23, 07/11/23, 07/12/23, 07/13/23, 07/14/23, 07/21/23, 07/22/23, 07/23/23, 07/24/23, 07/25/23, 07/26/23, 07/27/23, and 07/28/23. On evening shift blanks were noted in the signature column on: 07/01/23, 07/10/23, 07/14/23, 07/22/23 and 07/23/23. On night shift blanks were noted in the signature column on: 07/02/23, 07/15/23 and 07/24/23. 3. Bowel continence: On day shift blanks were noted in the signature column on: 07/01/23, 07/02/23, 07/04/23, 07/05/23, 07/06/23, 07/07/23, 07/09/23, 07/11/23, 07/12/23, 07/13/23, 07/14/23, 07/21/23, 07/22/23, 07/23/23, 07/24/23, 07/25/23, 07/26/23, 07/27/23 and 07/28/23. On evening shift blanks were noted in the signature column on: 07/01/23, 07/10/23, 07/14/23, 07/22/23, and 07/23/23. On night shift blanks were noted in the signature column on: 07/02/23, 07/15/23, and 07/24/23. On night shift blanks were noted in the signature column on: 07/01/23, 07/15/23, and 07/24/23. 4. CNA Skin Checks: On day shift blanks were noted on the signature column on: 07/01/23, 07/02/23, 07/04/23, 07/05/23, 07/06/23, 07/07/23, 07/09/23, 07/11/23, 07/12/23, 07/13/23, 07/14/23, 07/21/23, 07/22/23, 07/23/23, 07/24/23, 07/25/23, 07/26/23, 07/27/23 and 07/28/23. On evening shift blanks were noted on the signature column on: 07/01/23, 07/10/23, 07/14/23, 07/22/23, and 07/23/23, On night shift blanks were noted on the signature column on: 07/02/23, 07/15/23, and 07/24/23. 5. Personal Hygiene including mouth and denture care: On day shift blanks were noted on the signature column on: 07/01/23, 07/02/23, 07/04/23, 07/05/23, 07/06/23, 07/07/23, 07/08/23, 07/09/23, 07/11/23, 07/12/23, 07/13/23, 07/14/23, 07/21/23, 07/22/23, 07/23/23, 07/24/23, 07/25/23, 07/26/23, 07/27/23 and 07/28/23. On evening shift
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain dignity during mealtime for residents during dining observation. T...

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Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain dignity during mealtime for residents during dining observation. This deficient practice of not serving all residents seated at a table at the same time was observed for 2 of 3 meals in 1 of 2 dining rooms. The deficient practice was evidenced by the following: On 11/28/23 at 12:30 PM, in the second floor Hickory unit dining room, the surveyor observed residents preparing for meal service. Once meal trays arrived, at one table, staff served one resident who began eating and failed to serve the remaining residents at that table. At another table staff served two residents who began eating and failed to serve the remaining residents at that table. At 12:48 PM, the residents who were not served, received their meal trays from a second meal cart as the residents at their tables who were served first were nearly finished with their meals. On 12/05/23 at 11:57 AM, the surveyor observed residents preparing for meal service in the second floor Hickory unit dining room. When the first meal cart arrived on the unit, at one table staff served one resident who began eating and failed to serve the remaining residents at that table. At another table staff served two residents who began eating and failed to serve the remaining residents at that table. At 12:13 PM, the second meal cart arrived on the unit and the staff began serving the remaining residents who had not been served yet, as the residents at their tables were nearly finished with their meals. On 12/05/23 at 12:11 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #2, who stated that residents are encouraged to come to the dining room. She further stated that they try to have all residents at a table eat at the same time but sometimes it's hard to do. On 12/06/23 at 10:32 AM, the surveyor interviewed the Assistant Director of Nursing, who stated that in the dining rooms, the staff should serve one table at a time and all residents sitting at each table should be served at the same time. Review of the undated facility policy Assistance with Meals which was provided by the administrator, did not address this deficient practice. N.J.A.C. 8:39-4.1(a)12
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

MDS Data Transmission (Tag F0640)

Could have caused harm · This affected 1 resident

Based on interview and record review, it was determined that the facility failed to electronically transmit the discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management o...

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Based on interview and record review, it was determined that the facility failed to electronically transmit the discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, for 1 of 25 residents, (Resident #106) reviewed for resident assessments. The deficient practice was evidenced by the following: Review of Resident #106's discharge MDS assessment with initiation date 7/24/23 and completion date 8/2/23, indicated it was not transmitted. On 11/29/23 at 01:02 PM, the surveyor interviewed the MDS Coordinator who stated that the MDS assessment should have been transmitted within 14 days of completion. She further stated that they had remote MDS help at that time, and the transmission was missed. A review of the policy Electronic Transmission of the MDS revised on November 2019, indicated that MDS assessments are completed and transmitted to CMS in accordance with current OBRA regulations governing the transmission of MDS data. According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated October 2019) revealed on page 2-17, Discharge Assessment-return not anticipated must be transmitted no later than MDS Completion Date + 14 calendar days . NJAC 8:39-11.2 (e) 3
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

NJ00166442 Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure that incontinence care was provided to de...

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NJ00166442 Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner. This deficient practice was identified for 3 of 10 residents (Residents #175, # 104, #173) on 1 of 3 units (Cherry Unit) observed for incontinence care. This deficient practice was evidenced by the following: Refer to F725 and F686 On 12/05/23 at 9:10 AM, the surveyor interviewed Certified Nursing Assistant (CNA #5) who stated that she was assigned to 13 residents. CNA #5 stated that five of the residents on her assignment were dependent on staff for incontinence care. CNA #5 stated that one of the resident's who she had already changed had removed their brief and it was messy. CNA #5 stated that she still had two additional residents to provide incontinence care for. On 12/05/23 at 9:23 AM, CNA #5 entered the room of Resident #175 and checked the resident's brief for incontinence with the resident's permission, in the presence of the surveyor. CNA #5 stated that resident's brief was a little wet. CNA #5 stated that the blue line on the brief got real faint in color if it were saturated. Though the blue line remained visible as described by CNA #5, the frontal portion of the brief was mildly distended with urine. Review of Resident #175's admission Record revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: Benign prostatic hyperplasia without lower urinary tract symptoms (age associated prostate gland (a gland surrounding the neck of the bladder in male mammals) enlargement that can cause urination difficulty), syncope and collapse (temporary loss of consciousness caused by a fall in blood pressure), rhabdomyolysis (breakdown of muscle tissue that results in release of a protein into the blood that can damage the kidneys). Review of Resident #175's admission Minimum Data Set (MDS), an assessment tool, revealed that it was not yet completed or available for review. Review of the Resident #175's Care Plan revealed an entry dated 12/03/23, which revealed: I have urinary incontinence related to impaired mobility. The Goal indicated: I will not have skin breakdown due to incontinence through the review date. Interventions included: .Check resident approximately every two hours and provide incontinence care as needed . Further review of the Care Plan revealed, I have bowel incontinence r/t (related to) impaired mobility. Goal: I will not have skin breakdown due to incontinence through the review date (Target Date: 02/25/24). Interventions included .Check resident approximately every two hours and provide incontinence care as needed . Review of a Health Status Note dated 12/03/23 at 3:49 PM, indicated that Resident #175 was awake, alert and oriented x 3 (person, place and time). Further review of the Progress Notes (PN) revealed an eMar (electronic Medication Administration Record) Medication Administration Note with an effective date of 12/04/23 at 11:21 AM, which revealed the following: Solifenacin Succinate (helps to reduce urine leakage and the need to urinate right away) Oral Tablet 5 mg (milligrams) Give one tablet by mouth one time a day for over active bladder daughter will bring it from home. Spoke with patient's daughter, she will bring in med this afternoon .Doctor . made aware. Review of Resident #175's Medication Administration Record (MAR) revealed that the medication was administered on 12/04/23 and 12/05/23 at 9:00 AM. Further review of the MAR revealed that Flomax 0.4 mg (urinary retention medication, used to treat an enlarged prostate) give one capsule by mouth in the evening for benign prostatic hyperplasia, was administered on 12/04/23 at 6:00 PM. Review of Resident #175's Documentation Survey Report (DSR, documentation of care tasks completed by nursing assistants) revealed that on 12/04/23, the 11 PM to 7 AM CNA assigned to the resident documented that bladder incontinence care was completed at 4:41 AM. Further review of the DSR revealed that on 12/05/23 on the 7 AM to 3 PM shift, there was no documented evidence that the following tasks were documented to indicate completion: bladder continence care, bowel continence, bowel movement, CNA Skin Check, Bed mobility-Turn and Positioning, Personal Hygiene, Toileting Hygiene and Transfers, Preventative Skin Care with Moisture Barrier. On 12/05/23 at 9:39 AM, the surveyor interviewed CNA #2 who stated that he was assigned to 14 residents. CNA #2 stated that seven of the residents that he was assigned to required incontinence care. On 12/05/23 at 09:41 AM, CNA #2 entered the room of Resident #104 and checked the resident's brief with the resident's permission, in the presence of the surveyor. The surveyor observed that the resident's brief was completely saturated with urine and there was no blue indicator line observed on the brief. The surveyor asked CNA #2 to turn the resident in order to view the sheet beneath the resident. When the resident was turned to their right side, the surveyor observed a large, dark yellow, wet area on the resident's sheet where the resident's brief was previously positioned. When interviewed at that time, CNA #2 stated, The resident was changed during the night per report and was a heavy wetter who was on Lasix (furosemide, a diuretic or water pill used to treat fluid retention and edema (swelling). The surveyor then asked CNA #2 if the resident's brief should be that saturated if the resident were changed every two hours in accordance with resident's Care Plan? CNA #2 then stated, That is a lot of saturation. Review of Resident #104's admission Record revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: Heart failure (heart does not pump blood as well as it should) (unspecified), acute kidney failure (condition in which the kidneys suddenly can not filter waste from the blood), Pressure Ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral (triangular bone in the lower back) region, unspecified stage), difficulty in walking, malignant neoplasm of the prostate, and cognitive, communication deficit. Review of the resident's admission Minimum Data Set (MDS), an assessment tool, dated 11/04/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated that the resident was moderately, cognitively impaired. Further review of Section H of the MDS, Bladder and Bowel, indicated that the resident was frequently incontinent (seven or more episodes of urinary incontinence, but at least one episode of continent voiding) and was frequently incontinent of bowel (two or more episodes of bowel incontinence, but at least one continent bowel movement). Review of Resident #104's Care Plan revealed an entry dated 10/30/23, which indicated, I have urinary incontinence. Goal: I will not have skin breakdown due to incontinence through the review date (Target Date: 02/14/23). Interventions included: .Check resident approximately every two hours and provide incontinence care as needed . Provide incontinence care and apply moisture barrier as needed. Further review of the Care Plan further revealed an entry dated 10/30/23, I am on diuretic therapy r/t (related to) Edema Goal: I will be free from discomfort or adverse side effects of diuretic therapy through the review date (Target Date: 02/14/23). Interventions included: .I am on diuretic therapy and may need to void frequently and quickly. Routinely check and offer/provide me toileting assistance . Review of Resident #104's Order Summary Report revealed that on 10/29/23, the resident was ordered Furosemide oral tablet 40 mg Give one tablet by mouth in the morning for Diuretic at 8:00 AM. Hold for SBP (systolic blood pressure, top number of blood pressure value) less than 110. Review of the Resident #104's MAR revealed that on 12/04/23 at 8:00 AM, Furosemide was documented on the MAR with a code of 5, which indicated hold medication. According to the legend that pertained to the entry, the resident's blood pressure was documented to have been 100/60, the medication was held in accordance with the physician's order to hold the medication for a SBP less than 110. Further review of the MAR revealed that on 12/05/23 and 12/06/23 at 8:00 AM, the resident's Furosemide dosage was charted as administered. Review of Resident #104's, Documentation Survey Report revealed that on 12/04/23, the 11 PM to 7 AM CNA assigned to the resident documented that bladder incontinence care was completed at 3:36 AM. Further review of the DSR revealed that on 12/05/23 on the 7 AM to 3 PM shift, there was no documented evidence that the following tasks were documented by CNA #2, who was assigned to the resident to indicate task completion: bladder continence care, bowel continence, bowel movement, CNA Skin Check, Bed mobility-Turn and Positioning, Personal Hygiene, Toileting Hygiene and Transfers and Preventative Skin Care with Moisture Barrier. Instead, another employee documented completion of all previously mentioned tasks on 12/05/23 at 2:59 PM. On 12/05/23 at 9:46 AM, CNA #2 entered the room of Resident #173 and checked the resident's brief with the resident's permission, in the presence of the surveyor. CNA #2 viewed the resident's brief and stated that the resident's brief still had a blue line on it which indicated that the resident was wet, but not saturated. Review of Resident #173's admission Record revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: Acute kidney failure unspecified, malignant neoplasm of pancreas, unspecified (cancer that begins in the organ lying behind the lower part of the stomach (pancreas), and Type 2 diabetes mellitus (chronic condition which affects the way the body processes blood sugar (glucose) without complications. Review of the Resident #173's admission Minimum Data Set (MDS), an assessment tool, was not yet completed or available for review. Review of Resident #173's Care Plan revealed an entry dated 11/27/23, which indicated, I have urinary incontinence r/t (related to) CA (cancer), DM (diabetes mellitus), CKD (chronic kidney disease). Goal: I will not have skin breakdown due to incontinence through the review date (Target Date: 02/27/24) Interventions included: .Check resident approximately every two hours and provide incontinence care as needed .Provide incontinence care and apply moisture barrier as needed . Further review of the Care Plan revealed I have bowel incontinence r/t (related to) CA, DM, CKD. Goal: I will not have skin breakdown due to incontinence through the review date (Target Date: 02/27/24). Interventions included: .Check resdient approximately every two hours and provide incontinence care as needed .Provide incontinence care and apply moisture barrier as needed. Review of Resident #173's, Documentation Survey Report revealed that on 12/04/23, the 11 PM to 7 AM CNA assigned to the resident documented that bladder incontinence care was completed at 4:15 AM. Further review of the DSR revealed that on 12/05/23 on the 7 AM to 3 PM shift, there was no documented evidence that the following tasks were documented by CNA #2, who was assigned to the resident to indicate completion: bladder continence care, bowel continence, bowel movement, CNA Skin Check, Bed mobility-Turn and Positioning, Personal Hygiene, Toileting Hygiene and Transfers and Preventative Skin Care with Moisture Barrier. On 12/06/23 at 10:20 AM, the surveyor accompanied CNA #2 into Resdient #104's room to observe the resident's brief with resident permission. CNA #2 stated that the resident's brief was wet, but the blue line was visible. CNA #2 then assisted the resident to turn to their right side. CNA #2 stated, The sheets were not wet. The surveyor observed an opened area on the resident's left buttock that had a white, thick substance on it. CNA #2 stated, the nurse's put cream on it. On 12/06/23 at 10:24 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #6. When asked if the residents on her assignment were very wet when she reported to work in the morning LPN #6 stated, It depends on the day. LPN #6 stated, A couple of times last week, one of the aides complained that Resident #104 wet through their diaper. LPN #6 stated that there had been an aide who had to leave in the middle of their shift which may have contributed to short staffing. LPN #6 further stated, Resident #104 was on Lasix and voided heavily whether the medication was held or not. Review of Resident #104's MAR revealed that on 12/06/23 at 8:00 AM, the resident was medicated with Furosemide Oral Tablet 40 Mg. Review of Resident #104's Documentation Survey Report revealed that on 12/05/23, the 11-7 CNA documented that bladder continence care was documented as completed at at 6:31 AM. On 12/06/23 at 10:33 AM, the surveyor attempted to interview the Registered Nurse/Unit Manager (RN/UM #1) who was assigned to the medication cart and stated that she would not be available for an interview for another hour or two. On 12/06/23 at 10:37 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated, It is my expectation that residents should be found dry during morning incontinence rounds as the night shift should have done rounds before they left and residents should not be saturated. ADON stated, Residents should have minor wetting if they received Lasix prior to AM care. ADON stated, If the resident was saturated the aide may have missed them and they should not be that wet. ADON further stated that nursing was expected to help out if the aides were short-staffed. On 12/06/23 at 10:48 AM, the surveyor interviewed the Staffing Coordinator (SC) who stated, On 12/04/23 on the 11-7 shift, she had call outs and a no call no show on the Cherry Unit on 12/04/23 into 12/05/23. SC stated that RN/UM #1 was assigned to the medication cart because there were two nurse call outs today which was unusual. On 12/06/23 at 1:10 PM, the surveyor informed the LNHA and the ADON of the concerns that were identified during the incontinence tour that was conducted on 12/05/23 and 12/06/23. On 12/07/23 at 9:33 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with an Employee Performance Improvement Notification (EPIN) forms for both CNA #5 and CNA #2 which indicated that both CNAs failed to complete their POC's (documentation found in Documentation Survey Report) on 12/05/23. Further review of the EPIN revealed that CNA #2 also failed to completed POC documentation on 12/06/23. The EPIN revealed that CNA #2 Failed to document in kiosk resident's care. Supervisor asked to do prior to leaving . Review of the facility policy, Urinary Incontinence-Clinical Protocol (Revised April 2018) revealed the following: As appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting prompted voiding (urination), or other interventions to try to improve the individual's continence status. Review of the facility policy, Activities of Daily Living (ADLs), Supporting (Revised March 2018) revealed the following: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. NJAC 8:39-27.1(a), 27.2 (h)
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

NJ Complaint # NJ 1560250 Based on interview, record review, and review of pertinent facility documentation it was determined that the facility failed to consistently provide effective pain relief all...

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NJ Complaint # NJ 1560250 Based on interview, record review, and review of pertinent facility documentation it was determined that the facility failed to consistently provide effective pain relief allowing the resident to achieve optimal results during physical therapy sessions. This deficient practice was identified in 1 of 1 resident (Resident #222) reviewed for pain management and was evidenced by the following: On 12/04/23 at 11:11, AM, the surveyor reviewed the admission Record for Resident #222 which revealed the resident was admitted to the facility following hip replacement surgery for physical therapy and wound care. On 12/04/23 at 11:13 AM, the surveyor reviewed the physician orders which showed Resident #222 was prescribed the following medications for pain. Oxycodone HCL (narcotic pain reliever) 15 mg one tablet every four hours as needed for severe pain (pain level of 7 to 10 on numeric scale) and Acetaminophen (analgesic for treating minor pains) 325 mg two tablets every six hours as needed for general discomfort. There was an order for the staff to monitor the resident for pain every shift and document pain scale (0 to 10) every shift. On 12/04/23 at 11:19 AM, the surveyor reviewed the care plan which included a focus of pain and goals to not have an interruption in normal activities due to pain. Another goal was for staff to administer analgesics as ordered. On 12/04/23 at 11:32 AM, the surveyor reviewed the five-day Minimum Data Set (MDS), an assessment tool dated 12/13/22. The MDS revealed the resident had a Brief Interview of Mental Status of 15, meaning the resident was cognitively intact. Review of section J, titled Health conditions showed the resident was on a pain medication regime. The assessment revealed the resident had pain which was at a moderate level (4-6) on the numeric pain scale. On 12/04/23 at 11:36 AM, the surveyor reviewed the residents pain assessments which showed that the staff were assessing the residents pain level every shift with highest pain levels being nine, meaning severe pain and lowest a zero meaning no pain. On 12/04/23 at 01:08 PM, the surveyor reviewed Resident #222 physical therapy (PT) notes which showed that the resident had a PT evaluation on 12/11/22. Following the evaluation, the PT plan was that the resident would receive therapy five times per week. The next day of therapy the resident received was on 12/13/22, 12/14/22, 12/17/22, 12/18/22, 12/20/22, 12/21/22, and 12/22/22. Therapy was discontinued on 12/23/22 as the resident was being transferred to another sub-acute facility. On 12/04/23 at 01:26 PM, the surveyor reviewed Resident #222 Medication Administration Record (MAR). On 12/14/22 at 01:00 AM the resident received Oxycodone 15 mg one tablet for severe pain as ordered. At the time the resident received the pain medication the resident had pain of seven on the one to 10 pain scale, meaning the resident had severe pain. Further review of the MAR revealed the resident did not receive any pain medications for the rest of the day on 12/14/22. The surveyor then reviewed the section of the MAR for monitoring of pain every shift. On 12/14/22 for evening shift (three to eleven shift), the resident complained of pain as a seven, meaning the resident had severe pain. The resident did not receive any pain medication for the pain at that time. On 12/05/23 at 12:10 PM, the surveyor reviewed the residents Physical Therapy notes. Review of the notes showed that on 12/17/22 it was documented that the resident activities during therapy were limited secondary to his/her pain. Review of the MAR revealed that on 12/17/22 the resident did not receive any pain medication until 03:44 PM. Further review of the physical therapy notes showed that on 12/18/22 it was documented that the residents' activities were limited secondary to his/her pain level. On 12/05/23 at 12:43 PM, the surveyor interviewed a facility physical therapist regarding what actions would be taken if a resident had complaints of pain when a therapist was going to pick them up for therapy or during therapy. The therapist told the surveyor, I would ask the resident if they had any pain and if they do, I will ask the nurse if they can be medicated. If a resident needs pain meds i will come back half hour later to let the pain medications work and then begin therapy. On 12/06/23 at 01:45 PM the surveyor reviewed the policy titled, Pain Assessment and Management. The policy had a revision date of 10/2022. The purpose of the policy was to help staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs that address the underlying causes of pain. NJAC 8:39-27.1 (a)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected 1 resident

NJ Complaint # NJ00163433 Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to a.) provide nursing related services to assure r...

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NJ Complaint # NJ00163433 Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to a.) provide nursing related services to assure residents maintain the highest practicable physical, mental, and psychosocial wellbeing as determined by resident assessments and individual plans of care in accordance with the facility assessment and b.) maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficient practice was evidenced by the following: Refer to F677 Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio (s) were effective on 02/01/2021: One (1) Certified Nurse Aide (CNA) to every eight (8) residents for the day shift. One (1) direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and One (1) direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties. a.) On 11/27/23 at 12:15 PM, the surveyor reviewed the Payroll Based Journal (PBJ) staffing report submitted by the facility for the third quarter of 2023, April 1st through June 30th, 2023. The report triggered excessively low weekend staffing for the third quarter. On 11/28/23 at 10:10 AM, the surveyor interviewed the Unit Manager/Registered Nurse on the Cherry Unit regarding staffing. The UM/RN told the surveyor the unit had 48 residents and five Certified Nursing Assistants, so the ratio was one CNA to nine and 10 residents. On 11/28/23 at 11:00 AM, during the initial tour of the unit the surveyor interviewed an unsampled resident who was in the room in bed. The resident had a urinal that was full of urine and another urinal that was half full of urine. The resident told the surveyor that the staff hadn't emptied the urinal since the night shift. The resident told the surveyor, There isn't enough help. On 12/04/23 at 10:49 AM, a surveyor interviewed CNA#1 who said she was assigned 11 residents and stated that sometimes it's 13 residents. CNA#1 stated some mornings when she came into the facility (for day shift) the residents were saturated. CNA#1 stated that it could be staffing related. b.) 1. The facility was deficient in CNA staffing for residents on 13 of 14 day shifts for the two weeks prior to survey: -11/12/23 had 13 CNAs for 124 residents on the day shift, required at least 15 CNAs. -11/13/23 had 13 CNAs for 124 residents on the day shift, required at least 15 CNAs. -11/14/23 had 14 CNAs for 124 residents on the day shift, required at least 15 CNAs. -11/15/23 had 12 CNAs for 123 residents on the day shift, required at least 15 CNAs. -11/16/23 had 12 CNAs for 123 residents on the day shift, required at least 15 CNAs. -11/17/23 had 11 CNAs for 123 residents on the day shift, required at least 15 CNAs. -11/18/23 had 12 CNAs for 123 residents on the day shift, required at least 15 CNAs. -11/19/23 had 13 CNAs for 123 residents on the day shift, required at least 15 CNAs. -11/20/23 had 12 CNAs for 123 residents on the day shift, required at least 15 CNAs. -11/21/23 had 13 CNAs for 123 residents on the day shift, required a t least 15 CNAs. -11/22/23 had 12 CNAs for 123 residents on the day shift, required at least 15 CNAs. -11/24/23 had 13 CNAs for 120 residents on the day shift, required at least 15 CNAs. -11/25/23 had 12 CNAs for 119 residents on the day shift, required at least 15 CNAs. 2.For the week of Complaint staffing from11/06/2022 to 11/12/2022, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -11/06/22 had 13 CNAs for 124 residents on the day shift, required at least 15 CNAs. -11/07/22 had 14 CNAs for 123 residents on the day shift, required at least 15 CNAs. -11/08/22 had 13 CNAs for 123 residents on the day shift, required at least 15 CNAs. -11/09/22 had 12 CNAs for 123 residents on the day shift, required at least 15 CNAs. -11/10/22 had 13 CNAs for 123 residents on the day shift, required at least 15 CNAs. -11/11/22 had 13 CNAs for 123 residents on the day shift, required at least 15 CNAs. -11/12/22 had 11 CNAs for 123 residents on the day shift, required at least 15 CNAs. 3. For the week of Complaint staffing from 01/08/2023 to 01/14/2023, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -01/08/23 had 9 CNAs for 120 residents on the day shift, required at least 15 CNAs. -01/09/23 had 11 CNAs for 120 residents on the day shift, required at least 15 CNAs. -01/10/23 had 9 CNAs for 119 residents on the day shift, required at least 15 CNAs. -01/11/23 had 11 CNAs for 119 residents on the day shift, required at least 15 CNAs. -01/12/23 had 10 CNAs for 119 residents on the day shift, required at least 15 CNAs. -01/13/23 had 11 CNAs for 119 residents on the day shift, required at least 15 CNAs. -01/14/23 had 10 CNAs for 121 residents on the day shift, required at least 15 CNAs. 4. For the week of Complaint staffing from 04/09/2023 to 04/15/2023, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts and deficient in total staff for residents on 1 of 14 evening shifts as follows: -04/09/23 had 10 CNAs for 127 residents on the day shift, required at least 16 CNAs. -04/10/23 had 12 CNAs for 125 residents on the day shift, required at least 16 CNAs. -04/11/23 had 11 CNAs for 125 residents on the day shift, required at least 16 CNAs. -04/12/23 had 12 CNAs for 125 residents on the day shift, required at least 16 CNAs. -04/13/23 had 12 CNAs for 125 residents on the day shift, required at least 16 CNAs. -04/14/23 had 11 CNAs for 126 residents on the day shift, required at least 16 CNAs. -04/15/23 had 8 CNAs for 125 residents on the day shift, required at least 16 CNAs. -04/15/23 had 11 total staff for 125 residents on the evening shift, required at least 10 total staff. 5. For the 2 weeks of Complaint staffing from 07/02/2023 to 07/15/2023, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts as follows: -07/02/23 had 9 CNAs for 121 residents on the day shift, required at least 15 CNAs. -07/03/23 had 9 CNAs for 121 residents on the day shift, required at least 15 CNAs. -07/04/23 had 10 CNAs for 121 residents on the day shift, required at least 15 CNAs. -07/05/23 had 12 CNAs for 121 residents on the day shift, required at least 15 CNAs. -07/06/23 had 12 CNAs for 121 residents on the day shift, required at least 15 CNAs. -07/07/23 had 13 CNAs for 117 residents on the day shift, required at least 15 CNAs. -07/08/23 had 14 CNAs for 117 residents on the day shift, required at least 15 CNAs. -07/09/23 had 9 CNAs for 116 residents on the day shift, required at least 14 CNAs. -07/10/23 had 11 CNAs for 112 residents on the day shift, required at least 14 CNAs. -07/11/23 had 10 CNAs for 112 residents on the day shift, required at least 14 CNAs. -07/12/23 had 10 CNAs for 110 residents on the day shift, required at least 14 CNAs. -07/13/23 had 10 CNAs for 110 residents on the day shift, required at least 14 CNAs. -07/14/23 had 10 CNAs for 110 residents on the day shift, required at least 14 CNAs. -07/15/23 had 8 CNAs for 110 residents on the day shift, required at least 14 CNAs. On 12/06/23 at 10:48 AM, the surveyor interviewed the Staffing Coordinator (SC). The surveyor asked the SC if she was familiar with the regulations regarding staffing, and she replied, Every time I ask it changes and is something different. The surveyor asked how scheduling for the Certified Nursing Assistants (CNA) was completed and she said, Every six weeks. The surveyor then asked how you know there are enough CNA on each day, and she responded, I call at 0:430 AM to see if anyone called out for that day. If staffing is less, I get on the computer and begin calling people. I keep list of people of people available to work for call outs. The surveyor then asked the SC that if she was not aware of the ratios how would you know you have enough staff and she said, The numbers are on our schedule. She then told the surveyor that June and July of 2023 were tough. On 12/06/23 at 11:20 AM, the surveyor requested a staffing policy from the Licensed Nursing Home Administrator (LNHA). The LNHA could only provide a policy for Assisted Living Facilities, not Long-Term Care Facilities. On 12/06/23 at 12:50 PM, the surveyor made the LNHA aware of the staffing concerns. No additional information was provided. NJAC 8:39-25.2 (a), (b)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on observation, interview, and pertinent record review, it was determined that the facility failed to ensure the accountability of the Narcotic Shift Count logs were completed in accordance with...

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Based on observation, interview, and pertinent record review, it was determined that the facility failed to ensure the accountability of the Narcotic Shift Count logs were completed in accordance with facility policy and accurately account for and document the administration of controlled medications. This deficient practice was identified on 1 of 3 medication carts and was evidenced by the following: On 11/29/23 at 12:56 PM, the surveyor, in the presence of the Registered Nurse Supervisor (RNS), reviewed the narcotic logbook for the Cherry nursing unit's middle hall's medication cart. The logbook contained narcotic shift logs which revealed the following incomplete or blank sections: Going off Duty Nurse's Signatures missing for: 7/26/23 3 PM, 7/29 7 AM, 8/2 7AM, 8/14 7 AM, 8/5 7 AM, 8/8 7 AM, 8/12 11:15 AM, 8/13 7 AM, 8/16 7 AM, 8/17 7 AM, 8/18 7 AM, 8/18 11 PM, 8/19 3 PM, 8/22 7 AM, 8/23 7 AM, 8/24 7 AM and 3 PM, 8/25 7 AM, 8/26 7 AM, 8/28 7 AM, 8/29 7 AM and 11 PM, 8/30 7 AM, 8/31 7 AM, 9/1 3 PM, 9/2 7 AM, 9/4 3 PM, 9/5 7 AM, 9//6 7 AM and 11 PM, 9/7 7 AM, 9/8 7 AM, 9/9 7 AM and 3 PM, 9/11 7 AM, 9/12 7 AM, 9/13 7 AM, 9/14 7 AM, 9/15 7 AM, 9/16 7 AM, 9/17 7 AM, 9/18 7 AM and 3 PM, 9/19 7 AM and 3 PM, 9/20 7 AM, 9/22 7 AM, 9/26 7 AM, 9/29 7 AM, 9/30 11 PM, 10/2 7 AM, 10/3 7 AM and 11 PM, 10/4 7 AM, 10/8 7 AM, 10/13 7 AM, 10/14 7 AM, 10/15 7 AM, 10/16 7 AM, 10/17 7 AM, 10/18 7 AM, 10/19 11 PM, 10/20 11 PM, 10/23 7 AM, 10/24 7 AM and 11 PM, 10/25 7 AM, 10/26 7 AM, 10/27 7 AM and 3 PM, 10/29 7 AM, 10/30 7 AM and 3 PM, 10/31 7 AM, 11/1 7 AM, 11/2 7 AM, 11/3 7 AM, 11/5 7 AM and 3 PM, 11/6 7 AM, 11/7 7 AM, 11/8 7 AM, 11/9 7 AM, 11/11 7 AM, 11/12 7 AM and 11 PM, 11/13 7 AM and 3 PM, 11/15 7 AM, 11/16 7 AM, 11/17 7 AM, 11/18 7 AM, 11/19 7 AM 3 and 11 PM, 11/20 7 AM and 11 PM, 11/21 7 AM, 11/22 7 AM, 11/23 7 AM and 11 PM, 11/24 7 AM, 11/25 7 AM and 11 PM, 11/26 7 AM, 11/27 7 AM, 11/28 7 AM and 3 PM. Coming on Duty Nurse's Signature missing for: 8/1 11 PM, 8/2 11 PM, 8/19 7 AM, 8/22 11 PM, 8/23 11 PM, 8/24 7 AM, 8/25 11 PM, 8/26 11 PM, 8/29 3 and 11 PM, 8/31 11 PM, 9/1 11 PM, 9/4 11 PM, 9/5 11 PM, 9/6 3 and 11 PM, 9/7 11 PM, 9/8 11 PM, 9/9 3 and 11 PM, 9/10 11 PM, 9/11 11 PM, 9/12 11 PM, 9/13 11 PM,9/14 11 PM, 9/16 11 PM, 9/17 3 and 11 PM, 9/18 7 AM and 11 PM, 9/19 7 AM, 9/22 7 AM and 11 PM, 9/30 11 PM, 10/2 11 PM, 10/3 3 and 11 PM, 10/4 11 PM, 10/6 11 PM, 10/7 4 PM, 10/12 11 PM, 10/13 11 PM, 10/14 11 PM, 10/16 7 AM, 10/19 11 PM, 10//20 11 PM, 10/22 3 PM, 10/24 3 and 11 PM, 10/25 11 PM, 10/26 11 PM, 10/27 7 AM, 10/28 11 PM, 10/30 7 AM and 11 PM, 10/31 11 PM, 11/1 11 PM, 11/2 11 PM, 11/4 11 PM, 11/5 7 AM and 11 PM, 11/7 11 PM, 11/8 11 PM, 11/9 11 PM, 11/10 11 PM, 11/11 11 PM, 11/12 11 PM, 11/13 7 AM, 11/14 11 PM, 11/15 11 PM, 11/16 11 PM, 11/17 11 PM, 11/18 7 AM and 11 PM, 11/19 7 AM 3 and 11 PM, 11/20 3 and 11 PM, 11/21 11 PM, 11/22 11 PM, 11/23 3 and 11 PM, 11/24 11 PM, 11/25 3 and 11 PM, 11/26 11 PM, 11/28 7 AM. Time of Day section for: 10/5 and 10/6 7 AM, 3 PM, and 11 PM. At this time, the surveyor interviewed the RNS, who acknowledged the missing documentation and confirmed that there should be no missing documentation or signatures, and that the incoming and outgoing nurses should be counting the narcotics at shift change and signing the log together to confirm the count. The surveyor along with the RNS continued review of the logbook and the individual narcotic declining inventory logs. At this time the RNS indicated to the surveyor that she had administered hydrocodone 5-325 milligrams (mg) (a narcotic used to treat pain) to Unsampled Resident #2 at 10:30 AM that day (11/29/23) and failed to sign the narcotic out on the declining inventory sheet. The RNS was able to show that she signed the medication out in the resident's electronic medication administration record (MAR) but did not sign it out in the narcotic log. On 11/30/23 at 11:53 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the shift change narcotic count log should be completed at the change of shift by two nurses and they should both sign for completion and verifying the narcotic count is correct and that there should be no missing signatures. The DON confirmed that if signatures are not documented, the facility cannot confirm if this was completed or not and could result in inaccuracies with narcotics. The DON further confirmed that nurses should be completing the declining inventory log for narcotics at the time the medication is dispensed from the pharmacy packaging and should not wait and complete later on. The DON acknowledged these missing signatures should not have been missed. Review of the facility's Controlled Substances policy with revision date of 11/2022 included under the section labeled Dispensing and Reconciling Controlled Substances, included: 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: records of personnel access and usage, medication administration records, declining inventory records, and destruction, waste and return to pharmacy records. 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory. 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. NJAC 8:39-29.7(c)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) properly store medications and properly label opened multidose medica...

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Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) properly store medications and properly label opened multidose medications. This deficient practice was observed in 1 of 2 medication storage rooms and 3 of 3 medication carts reviewed for medication storage and labeling and was evidenced by the following: On 11/29/23 at 10:42 AM, the surveyor, in the presence of the Licensed Practical Nurse Unit Manager #2 (LPN/UM #2) reviewed the Hickory nursing unit's medication storage room. The surveyor observed an opened tuberculin purified protein (a medication used to test for tuberculosis) multidose vial with no opened date on the vial. The LPN/UM #2 acknowledged the vial and confirmed it should have been dated and initialed once opened. The surveyor further observed a small plastic storage bin with three drawers, a clear plastic bag containing 16 individually packaged, partially used/opened prescription medications which included eye drops, multidose insulin vials, and medicated nasal sprays. These medications were labeled and dated with opened date between 11/2022 and 1/2023. At this point the LPN/UM #2 informed the surveyor that she was not aware that these medications where still stored in the medication storage room, stating I've been through this med room many times and never seen this bag before, and that these medications were no longer being given to their prescribed residents and should have been returned to the pharmacy once discontinued. On 11/29/23 at 11:10 AM, the surveyor in the presence of Licensed Practical Nurse #3 (LPN #3), observed the front cart for the Hickory nursing unit. The following was observed: One opened and undated foil envelope of ipratropium bromide 0.5 milligrams (mg) and albuterol sulfate 3 mg inhalation solution (a medication used to treat respiratory disease) containing four of five single use vials with manufacturer instructions to use within one week of opening. One opened and undated 414 milliliter (ml) bottle of sucralfate oral suspension 1 gram (g)/10 ml (medication used to treat ulcers). One opened and undated bottle of fluticasone propionate 50 microgram (mcg) (allergy nasal spray). Three opened and undated bottles of artificial tears One opened and undated bottle of ciprofloxacin ophthalmic solution 0.3% (antibiotic eye drops) One opened and undated bottle of bromide tartrate ophthalmic solution (eye drop medication used to treat glaucoma) One opened and undated bottle of latanoprost ophthalmic solution (eye drop medication used to treat glaucoma) One opened and undated bottle of dorzolamide HCL ophthalmic solution (eye drop medication used to treat glaucoma) One opened and undated bottle of timolol maleate 0.5% (eye drop medication used to treat glaucoma) One opened and undated bottle of Lumigan ophthalmic solution .01% (eye drop medication used to treat glaucoma) 10 loose pills of varying colors and sizes. At 11:59 AM, LPN #3 acknowledged there should not be any loose pills in the medication cart drawer, and stated, I didn't know the bottle should be dated and labeled too, since the box was. On 11/29/23 at 12:14 PM, the surveyor in the presence of LPN #4, observed the Evergreen nursing unit's medication cart. The following was observed: One opened and undated vial of timolol maleate 0.25% eye drops. One opened and undated bottle of dextromethorphan polistirex extended-release oral suspension (medication used to treat cough). Two opened and undated Anoro 62.5 mcg / 25 mcg inhalers (medications used to treat lung disease) One opened and undated fluticasone propionate and salmeterol inhalation powder inhaler (medications used to treat lung disease). One opened and undated Trelegy 200 mcg / 62.5 / 25 mg inhaler (medications used to treat lung disease). At this point, LPN #4 informed the surveyor that she had opened these inhalers earlier that morning and did not get a chance to label them yet. On 11/29/23 at 12:56 PM, in the presence of the Registered Nurse Supervisor (RNS), the surveyor observed the middle cart on the Cherry nursing unit. The following was observed: One opened and undated vial of latanoprost ophthalmic solution .005% (medication used to treat glaucoma). One opened and undated vial of dorzolamide HCL and timolol maleate ophthalmic solution 22.3 mg/6.8 mg per ml One opened and undated bottle of fluticasone propionate 50 mcg nasal spray One opened and undated Incurse Ellipta 62.5 mcg inhaler (medication used to treat lung disease). Eight loose pills of varying colors and sizes. At this point the RNS acknowledged that these multidose medications should have been labeled and dated with the date opened. She further informed the surveyor that the facility recently had an in-service for med labeling. On 11/30/23 at 11:53 AM, the surveyor interviewed the Director of Nursing (DON), who stated that medications no longer in use should be placed in a return to pharmacy bag and returned to the pharmacy, within a reasonable timeframe of 24 hours to be sent back. The DON included the 16 medications observed in the Hickory unit medication room should have been returned and not around still. The DON also stated that medications that are opened should be labeled and dated on the actual vial, bottle, or inhaler and not just the box it came in. Review of the facility's Administering Medications policy with revised date of 4/2019 included, the expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Review of the facility's Medication Labeling and Storage policy with revised date of 2/2023 included, the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. N.J.A.C. 8:39-29.4
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food b...

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Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 11/28/23 from 09:46 AM to 10:29 AM, the surveyor, accompanied by the facility Food Service Director (FSD), observed the following in the kitchen: Upon surveyor entrance into kitchen and during tour, the FSD was not wearing a beard guard. In the walk-in freezer, one box of riblets and one box of chicken tenders were open and the plastic bags inside the boxes were open, leaving the meat products open to air. On the shelves by the pot sink, a stack of stainless-steel pans (for use in the steam table) were noted with wet nesting. On 12/05/23 at 01:14 PM, the surveyor interviewed the FSD in the presence of the Regional FSD, who stated that all staff should wear hair nets and beard guards while in the kitchen, plastic bags inside boxes in the freezer should be sealed to prevent freezer burn, and pots and pans should be air dried before being stored. A review of the policy Food Receiving and Storage revised November 2022, under the section Refrigerated/Frozen Storage included: #8. Frozen foods are maintained at a temperature to keep the frozen food solid. Wrappers of frozen foods must stay intact until thawing. A review of the policy Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised November 2022, under the section Hair Nets: #15. Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. A review of the policy Sanitation revised November 2022, #7. Food preparation equipment and utensils that are manually washed are allowed to air dry whenever practical. N.J.A.C. 8:39-17.2(g)
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 11/30/2023 at 12:32 PM during lunch time on the Cherry unit, Surveyor #2 observed a Certified Nurse Assistant (CNA #1) del...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 11/30/2023 at 12:32 PM during lunch time on the Cherry unit, Surveyor #2 observed a Certified Nurse Assistant (CNA #1) delivering food tray to a resident in room [ROOM NUMBER] A. CNA #1 did not perform hand hygiene upon entering the room. CNA #1 placed the tray on the overbed table, assisted the resident to a sitting position, and exited the room. CNA #1 did not perform hand hygiene upon leaving the room. CNA #1 proceeded to a food truck parked in the hallway, removed another food tray, and delivered it to the resident in room [ROOM NUMBER] B. No hand hygiene was observed. On 11/30/2023 at 12:34 PM, a Certified Nurse Assistant (CNA #2) entered room [ROOM NUMBER] to deliver a food tray. CNA #2 did not perform hand hygiene upon entering and leaving the room. On 11/30/2023 at 12:35 PM while still in room [ROOM NUMBER] B, CNA #1 asked CNA #2 to help him/her reposition resident in 122 B. CNA #2 entered the room, and together with CNA #1 lifted the resident up in bed and assisted him/her to a sitting position. CNA #1 and CNA #2 were observed in contact with resident's bed, bedsheets, and overbed table. On 11/30/2023 at 12:36 PM, CNA #2 exited room [ROOM NUMBER] B. No hand hygiene was observed at that time. CNA #2 proceeded to push the food truck down the hallway, removed a food tray and delivered it to another room. No hand hygiene was observed upon entering the room. On 11/30/2023 at 12:37 PM after repositioning the resident and assembling food tray in room [ROOM NUMBER] B, CNA #1 left the room without performing hand hygiene. On 11/30/2023 at 12:48 PM during an interview with Surveyor #2, CNA #2 stated, Every time after we go in, or leave the room when asked about hand hygiene expectations. During the same interview, CNA #2 replied, Yes when asked if hand hygiene should be performed during food tray delivery and when assisting residents. On 11/30/2023 at 12:41 PM during interview with Surveyor #2, a Licensed Practical Nurse (LPN #1) stated, We wash hands frequently. It depends on what we do. If we provide care like changing patient, we wash our hands with soap and water. If we're just readjusting things, we should use sanitizer when asked about hand hygiene expectations. On 12/05/2023 at 12:17 PM during an interview with Surveyor #2, a Registered Nurse/Unit Manager (RN/UM #1) stated, I wash for 25 seconds during any interaction with patient. I wash before I go to do care, after touching patients or surfaces near patients when asked about hand hygiene protocol. During the same interview, RN/UM #1 replied, Yes, before and after when Surveyor #2 asked if a CNA should perform hand hygiene when delivering food to residents' rooms. Furthermore, RN/UM #1 stated, Infection control. To prevent spread of infections when asked by the Surveyor #2 about importance of hand hygiene. On 12/05/2023 at 11:41 AM during an interview with Surveyor #2, Registered Nurse/Infection Preventionist (RN/IP) stated, Before we go to any patient room, we want to wash hands. Any time you enter patient's room, before and during wound care, peri care, medication administration depending on medication for example liquids. Of course, when they have to give eye drops or when they carry anything soiled. I expect them to wash their hands before leaving the room. I tell them to wash in and wash out when asked about staff hand hygiene expectations. During the same interview, the RN/IP stated, Absolutely. They [employees] should wash their hands or use sanitizer when they deliver food trays when Surveyor #2 asked if hand hygiene should be exercised during meal delivery. Furthermore, the RN/IP replied, To prevent the spread of infections from resident to resident, and employee to employee when asked by Surveyor #2 about importance of hand hygiene. 3. On 11/29/23 at 12:13 PM, the surveyor observed a Certified Nursing Assistant #4 (CNA#4) handing out trays on the low side of the Cherry Unit. CNA#4 entered room [ROOM NUMBER]-B, rearranged items on the residents' overbed table, and placed the resident's tray down. CNA#4 then exited the room, went to the enclosed lunch tray cart, and proceeded to get the tray for room [ROOM NUMBER]-A. CNA#4 then entered room [ROOM NUMBER]-A, set up the tray for the resident, exited the room, and proceeded to the cart with the lunch trays to get the tray for room [ROOM NUMBER]-B. CNA#4 then set up the lunch tray for the resident in room [ROOM NUMBER]-B and exited room. CNA#4 then entered room [ROOM NUMBER]-A, pulled back the privacy curtain and proceeded to set up the lunch tray for the resident. CNA#4 did not wash hands or use hand sanitizer between the rooms. On 11/30/23 at 12:06 PM, the surveyor observed lunch being handed out on the Cherry Unit. The surveyor observed CNA#4 place a tray in room [ROOM NUMBER]-A, open utensils, and remove a drink lid. CNA#4 proceeded to go back to cart and get a tray for 101-B and set up the tray for the resident. CNA#4 then moved the tray cart to the next room, set up room [ROOM NUMBER]-A and get the tray for 102-B The surveyor did not observe any handwashing between residents. On 11/30/23 at 12:24 PM, the surveyor observed CNA#5 passing a lunch tray to room [ROOM NUMBER]. The resident in room [ROOM NUMBER] was on contact isolation. CNA#5 applied a gown and gloves prior to entering the room to give the resident the tray. The CNA#5 exited the room, prior to exiting the CNA #5 removed the gown and gloves. The surveyor did not observe any handwashing or use of hand sanitizer. The CNA then walked to room [ROOM NUMBER], which was across the hall. The resident was also on contact isolation. CNA #5 applied a gown and gloves prior to entering the room with the tray. CNA#5 set the tray down, offered to put up the resident to get more comfortable to have lunch. She then offered to elevate the residents' legs and proceeded to touch the residents bed rails, and then the food ticket on the tray. After exiting the room CNA #5 used hand sanitizer and went to another room with a tray. A review of the facility provided policy adopted in August 2021 and titled Handwashing/Hand Hygiene revealed that 2. All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. Furthermore, the same policy revealed, 6. Use of an alcohol-based hand rub containing at least 60% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . l) after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m) after removing gloves . o) before and after eating or handling food; p) before and after assisting a resident with meals. A review of the facility provided policy, Handwashing/Hand Hygiene (Revised August 2019) revealed the following: This facility considers hand hygiene the primary means to prevent the spread of infections. .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after coming on duty; Before and after direct contact with residents; Before preparing and handling medications; .Before moving from a contaminated body site to a clean body site during resident care; After contact with a resident's intact skin; After contact with blood or bodily fluids; .After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; After removing gloves; Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Single-use disposable gloves should be used: before aseptic procedures; when anticipating contact with blood or body fluids; A review of the facility provided policy, Administering Medications (Revised April 2019) revealed the following: Medications are administered in a safe and timely manner, and as prescribed. .Staff follows established facility infection control procedures (e.g., handwashing, aseptic technique, gloves, .etc.) for the administration of medications, as applicable. A review of the facility provided policy, Blood Glucose Meter Cleaning, Disinfecting, and Storage (Revised October 2019) revealed the following: Blood Glucose Meters must be appropriately cleaned and disinfected between uses. .Each medication cart will have a container of appropriate wipes for cleaning and disinfecting. After use, the blood glucose meter must be cleaned and disinfected per manufacturer guidelines. While one blood glucose meter is drying, the other can be in use. Appropriate wipes are indicated in the manufacturer guidelines. N.J.A.C. 3:39-19.4(n) Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to maintain proper infection control practices during the a) Medication administration observation and b) Dining observation. This deficient practice was identified on 1 of 3 nursing units (Cherry Unit) and for 1 of 3 nurses (LPN #5) observed during the medication pass. This deficient practice was evidenced by the following: 1. On 12/01/23 at 8:16 AM, the surveyor observed Licensed Practical Nurse (LPN #5) as he prepared and administered medications on the Cherry Unit. LPN #5 first obtained a treatment cart from the other end of the hall and placed it beside the medication cart and stated that he intended to use it for additional work space. LPN #5 then opened the locked medication cart with keys, donned (put on) a pair of gloves, and obtained a container of alcohol based disinfectant wipes which he used to clean the top of the treatment cart. LPN #5 then doffed (removed) his gloves and failed to perform hand hygiene with the Alcohol Based Hand Rub (ABHR) that was present on the top of the medication cart before he entered Resident #99's room to assess the resident's pain level. LPN #5 then returned to the medication cart and opened the top drawer of the medication cart and obtained a glucometer (device for measuring the concentration of glucose in the blood), a lancet (used to prick the finger to obtain a blood sample) and a diabetes test strip (inserted in the glucose meter and a drop of blood is placed on the strip to yield a result). LPN #5 stated that the glucometer was not dedicated to Resident #99 and was used to obtain blood glucose levels for multiple residents on the unit. LPN #5 then doffed his gloves and failed to perform hand hygiene after. LPN #5 placed the glucometer, test strip and lancet in a plastic cup and carried it into Resident #99's room. LPN #5 then donned gloves, cleaned the resident's right index finger with an alcohol prep pad and pricked the resident's finger with the lancet and squeezed a drop of blood onto the test strip that was inserted in the glucometer. When finished, he placed the glucometer with the test strip still inserted into the plastic cup where he had previously discarded the used lancet. LPN #5 then proceed to reach into his pocket and obtained a pulse oximeter (instrument placed on resident's finger to obtain the oxygen saturation level in the blood) and placed it on the resident's left index finger. LPN #5 then proceeded to place a blood pressure cuff on the resident's right arm and obtained a reading. LPN #5 removed the blood pressure cuff and pulse oximeter from the resident and documented the results on a piece of paper. LPN #5 then picked up the plastic cup that contained the blood glucose meter with test strip still inserted, and lancet and returned to the medication cart where he discarded the lancet and test strip into the sharps container that was on the side of the medication cart. LPN #5 then doffed his gloves, and failed to perform hand hygiene, and donned gloves before he obtained the keys to the medication cart and accessed the medication cart to obtain alcohol based disinfectant wipes and proceeded to wipe the blood pressure cuff, pulse oximeter and glucometer with disinfectant wipes and left the items on top of the treatment cart to dry after. LPN #5 stated that the dry time was one minute to ensure that the glucometer was disinfected. LPN #5 then proceeded to doff his gloves and washed his hands for 20 seconds. At 8:31 AM, LPN #5 returned to the medication cart and began to prepare medications for Resident #99 which included a Lidocaine (topical pain patch used to relieve pain) 4% patch. LPN #5 obtained a black marker to sign and date the time of administration of the Lidocaine 4% patch. He dropped the marker on the floor. LPN #5 then proceeded to donn gloves and picked the marker up off of the floor and cleaned it with a disinfectant wipe. LPN #5 then doffed his gloves and failed to perform hand hygiene afterward before he picked up the medication cup filled with oral medications, Dorizol/Timolol 2/.05% (eye drops used to treat dry eye) and Flonase 50 mcg (used to relieve symptoms of rhinitis such as sneezing, stuffy, or itchy nose and eyes caused by allergies) one spray in both nostrils nasal spray and entered Resident #99's room. At 8:45 AM, LPN #5 administered oral medications to Resident #99. LPN #5 then proceeded to administer nasal spray, one puff in each of the resident's nares (nostrils) without first donning gloves. When finished, LPN #5 donned gloves and administered eye drops to the resident and instilled one drop in each eye as ordered. LPN #5 provided the resident with a tissue to wipe away any tears that resulted from eye drop administration. LPN #5 then dated the lidocaine patch, pulled up the resident's shirt and placed it on the resident's back as ordered. LPN #5 then placed non-medicated heat wraps in a belt that the resident wore around his waist. LPN #5 doffed his gloves after and failed to perform hand hygiene. LPN #5 picked up the eye drops and nasal spray and returned to the medication cart, unlocked the medication cart with keys and returned the eye drops and nasal spray to the top drawer of the medication cart. LPN #5 then used the computer keyboard and mouse to chart the medications as administered without first performing hand hygiene. LPN #5 then proceeded to return the glucometer that had dried to the medication cart. At 8:56 AM, LPN #5 moved both the medication and treatment carts to the outside of Unsampled Resident #1's room. LPN #5 entered the resident's room and assessed the resident's pain level. LPN #5 then proceeded to obtain the resident's temperature, pulse oximetry level and blood pressure without first performing hand hygiene. When finished, he donned gloves and cleaned the blood pressure cuff, pulse oximeter and thermometer with a disinfectant wipe. LPN #5 then doffed his gloves and washed his hands for 21 seconds before he began to prepare the resident's medications. During medication preparation, LPN #5 stated that he needed to phone the doctor to clarify a medication order. He then proceeded to use his cell phone and attempted to both text and call the doctor. LPN #5 then continued to prepare the resident's medications without first performing hand hygiene after using his cell phone. LPN #5 then entered Unsampled Resident #1's room where he administered oral medications and an inhaler to the resident. LPN #5 returned the inhaler to the box that it was stored in. LPN #5 then proceeded to move the resident's blanket at the resident's request and placed both gloved hands on the resident's bed. LPN #5 then doffed his gloves and used ABHR afterward before he returned to the medication cart to document the medications as administered. ON 12/01/23 at 10:53 AM, in a later interview with LPN #5, he stated that he was not required to perform hand hygiene if he only intended to pop medications from their bingo cards (blister packs) into the medication cup. LPN #5 stated that he did not really need to donn gloves when he administered nasal spray as he did not feel their was a risk for spread of infection as there was no contact with the spray or the resident's nostrils. LPN #5 stated that he was required to wash his hands after he doffed his gloves and after cleaning the blood pressure cuff because he intended to pop someone's medications from the bingo cards for infection control purposes. LPN #5 further stated that hand hygiene should have been done both before he donned gloves and after he doffed gloves. LPN #5 further stated that he should have washed his hands, but thought that he was okay because he washed his hands after he left Resident #99's room. On 12/01/23 at 11:11 AM, the surveyor interviewed Registered Nurse/Unit Manager (RN/UM #1) who stated that nursing was required to wipe the glucometer until saturated and allow to dry for one minute between residents to disinfect. RN/UM #1 stated that any time that nursing doffed their gloves hand hygiene should be performed for infection control purposes. RN/UM #1 stated that gloves were required to be worn for nasal spray administration for infection control. RN/UM #1 stated that nursing should wash their hands after nasal spray was administered prior to eye drop administration for infection control. RN/UM #1 stated that if LPN #5 failed to wash his hands before he prepared medications he could have potentially contaminated the medications. RN/UM #1 stated that hand hygiene was required to be performed after a blood sugar was obtained for infection control reasons. On 12/01/23 at 11:26 AM, the surveyor interviewed the Infection Preventionist/Registered Nurse (IP/RN) who stated that she expected that nursing should wash their hands after they cleaned equipment and before they entered a resident's room because there was always bacteria on the surfaces that could be transmitted. IP/RN stated that you could spread germs if hands were not cleaned after gloves were doffed. IP/RN stated that a full minute of contact time was required to kill germs when the glucometer machines were cleaned and two minutes of dry time was required. IP/RN stated that if the proper cleaning time and dry time were not performed we may not kill germs on the surface. IP/RN stated that in order to protect yourself and the patient when nasal spray was administered gloves should be worn. IP/RN further stated that nursing was required to wash their hands after nasal spray was administered prior to donning gloves and administering eye drops to prevent the possibility of cross-contamination. IP/RN stated that hand hygiene should be performed after you touched dirty equipment and supplies and gloves were required to be donned prior to resident contact. IP/RN stated that you were required to wash your hands after gloves were doffed when in contact with the resident's covers or bed because there could be bacteria on those items. IP/RN further stated that if hand hygiene were not performed after resident contact prior to documenting medication administration in the computer you could contaminate the computer keyboard and spread things to someone else. The surveyor requested the name of the disinfectant wipes that were required to be used to disinfect the glucometer. On 12/01/23 at 1:19 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the disinfectant wipes that were on the middle cart that was observed during the medication pass that was used to clean the glucometer was not the correct wipe to disinfect the glucometer machine. LNHA stated that an in-service was completed previously, with the correct wipes to be used that were identified as appropriate for use in the glucometer procedural manual. LNHA stated that she was not a clinician and was unable to state what possible harm could result if the incorrect wipes were used to clean the glucometer and deferred to nursing for further clarification. On 12/01/23 at 1:27 PM, in a later interview with the IP/RN, she stated that she identified that bleach wipes were supposed to be used to clean the glucometer in accordance with the glucometer procedural manual. IP/RN stated that if the alcohol based wipes were used to clean the glucometer they may not kill germs effectively. On 12/01/23 at 1:45 PM, the LNHA provided the surveyor with documentation which indicated that educational in-services were conducted with staff on how to clean the glucometer with bleach wipes on 1/05/23, 1/06/23, 03/25/23, and 05/18/23. Review of the in-service records revealed that LPN #5 attended the aforementioned in-services on 12/01/23, and 05/18/23, On 12/05/23 at 1:08 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that staff should wash their hands after gloves were doffed because they were touching things and spreading germs from place to place. ADON stated that gloves should be worn when nasal spray was administered. ADON further stated that hands should be washed before gloves were donned and eye drops were administered because you do not know what you have touched. ADON stated that if something were dropped on the floor, clean it, doff your gloves and wash your hands. ADON stated that glucometers were required to be cleaned with bleach wipes and not alcohol wipes because they would not clean it and germs could be spread. ADON stated that hand hygiene should have been performed after the medication cart was handled and before entering a resident's room to obtain vital signs because the medication cart was not clean.
Sept 2021 1 deficiency
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to ensure the narcotic medication compartment locked securely. This deficient pr...

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Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to ensure the narcotic medication compartment locked securely. This deficient practice was identified for 1 of 2 medication carts (low cart 1 on the Hickory unit) that was reviewed as part of the Medication Storage Task and was evidenced by the following: On 9/1/21 at 11:20 AM, the surveyor and Licensed Practical Nurse (LPN #1) were at the low cart 1 and LPN #1 unlocked the medication cart using a key. At that time, LPN #1 opened the bottom drawer of the cart revealing a fixed, metal compartment with a keyhole lock on the lid. LPN #1 utilized the key to unlock the compartment and then pulled on the lid and the compartment opened. LPN #1 closed the lid, inserted, and turned the key again. At that time the surveyor completed the medication cart review in the presence of LPN #1. On the same date at 11:26 AM, the surveyor asked LPN #1 to pull on the lid of the locked compartment. LPN #1 pulled on the lid and the lid opened without using a key. At that time, LPN #1 said the lid latches when the spacing is good (how the medication cards are placed in the compartment). LPN #1 also said she believes it wasn't latching yesterday and today. At 11:34 AM, the surveyor and LPN #1 counted the narcotic medications, and no discrepancies were discovered. LPN #1 then placed the medication packages back into the compartment. She then closed the lid, inserted, and turned the key. At that time, she pulled on the lid and it opened again. LPN #1 stated she will call the maintenance man. A review of the policy titled, Controlled Substances Administration, Control, and Wastage with an effective date of 7/2020, revealed under Procedure, All narcotics are to be stored under double locks. NJAC 8:39-29.7(c)
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "What changes have you made since the serious inspection findings?"
  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • Licensed and certified facility. Meets minimum state requirements.
Concerns
  • • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s), $57,944 in fines. Review inspection reports carefully.
  • • 14 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
  • • $57,944 in fines. Extremely high, among the most fined facilities in New Jersey. Major compliance failures.
  • • Grade F (38/100). Below average facility with significant concerns.
Bottom line: Trust Score of 38/100 indicates significant concerns. Thoroughly evaluate alternatives.

About This Facility

What is Berlin Rehabilitation And Healthcare Center's CMS Rating?

CMS assigns BERLIN REHABILITATION AND HEALTHCARE CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within New Jersey, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Berlin Rehabilitation And Healthcare Center Staffed?

CMS rates BERLIN REHABILITATION AND HEALTHCARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 47%, compared to the New Jersey average of 46%.

What Have Inspectors Found at Berlin Rehabilitation And Healthcare Center?

State health inspectors documented 14 deficiencies at BERLIN REHABILITATION AND HEALTHCARE CENTER during 2021 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 12 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Berlin Rehabilitation And Healthcare Center?

BERLIN REHABILITATION AND HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by MARQUIS HEALTH SERVICES, a chain that manages multiple nursing homes. With 128 certified beds and approximately 123 residents (about 96% occupancy), it is a mid-sized facility located in BERLIN, New Jersey.

How Does Berlin Rehabilitation And Healthcare Center Compare to Other New Jersey Nursing Homes?

Compared to the 100 nursing homes in New Jersey, BERLIN REHABILITATION AND HEALTHCARE CENTER's overall rating (3 stars) is below the state average of 3.3, staff turnover (47%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Berlin Rehabilitation And Healthcare Center?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.

Is Berlin Rehabilitation And Healthcare Center Safe?

Based on CMS inspection data, BERLIN REHABILITATION AND HEALTHCARE CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in New Jersey. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Berlin Rehabilitation And Healthcare Center Stick Around?

BERLIN REHABILITATION AND HEALTHCARE CENTER has a staff turnover rate of 47%, which is about average for New Jersey nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Berlin Rehabilitation And Healthcare Center Ever Fined?

BERLIN REHABILITATION AND HEALTHCARE CENTER has been fined $57,944 across 1 penalty action. This is above the New Jersey average of $33,658. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.

Is Berlin Rehabilitation And Healthcare Center on Any Federal Watch List?

BERLIN REHABILITATION AND HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

BERLIN REHABILITATION AND HEALTHCARE CENTER

100 LONG-A-COMING LANE, BERLIN, NJ 08009 | (856) 322-3600

F
Trust Grade (38/100)
3.0
CMS Rating
14
Deficiencies

Strengths

  • 5-star quality

Concerns

  • 1 Immediate Jeopardy citation

Ask about: Inspection Response, Rn Coverage

nursinghomedata.org | Data: CMS November 2025