HAMMONTON CENTER FOR REHABILITATION AND HEALTHCARE
For profit - Partnership
240 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
8/100
#322 of 344 in NJ
Photo by Hammonton Center
Photo by Hammonton Center
Photo by Hammonton Center
1 / 5 photos
Last Inspection: July 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Hammonton Center for Rehabilitation and Healthcare has received a Trust Grade of F, indicating significant concerns about the quality of care provided. They rank #322 out of 344 nursing homes in New Jersey, placing them in the bottom half of facilities statewide, and they are last in their county, ranked #10 out of 10. Unfortunately, the facility is worsening, with reported issues increasing from 15 in 2023 to 16 in 2024. Staffing is a concern, with a rating of 2 out of 5 stars and a high turnover rate of 71%, significantly above the state average. They have faced substantial fines totaling $69,167, which is higher than 77% of New Jersey facilities, indicating ongoing compliance problems. There are some serious issues highlighted in the inspector findings, including a failure to administer insulin on time to diabetic residents, which poses a serious health risk. Additionally, the facility's failure to maintain proper kitchen sanitation raises concerns about food safety, and there is a lack of qualified staff in leadership positions. While they have a decent quality measures rating of 4 out of 5 stars, these strengths are overshadowed by critical deficiencies that families should consider carefully.
- Trust Score
- F
- In New Jersey
- #322/344
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 71% turnover. Very high, 23 points above average. Constant new faces learning your loved one's needs.
- Penalties ✓ Good
- $69,167 in fines. Lower than most New Jersey facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 26 minutes of Registered Nurse (RN) attention daily — below average for New Jersey. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 34 deficiencies on record. Higher than average. Multiple issues found across inspections.
8/100
Bottom 7%
Review needed
15 → 16 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 15 issues
2024: 16 issues
The Good
-
4-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
1-Star Overall Rating
Below New Jersey average (3.2)
Significant quality concerns identified by CMS
Staff Turnover: 71%
25pts above New Jersey avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $69,167
Well above median ($33,413)
Moderate penalties - review what triggered them
Staff turnover is very high (71%)
23 points above New Jersey average of 48%
The Ugly 34 deficiencies on record
1 life-threatening
Nov 2024
2 deficiencies
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
COMPLAINT #: NJ00179283
Based on observation, interviews, medical record review, and review of other pertinent facility documents on 11/01/24, 11/04/24, and 11/06/24, it was determined that the facili...
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COMPLAINT #: NJ00179283
Based on observation, interviews, medical record review, and review of other pertinent facility documents on 11/01/24, 11/04/24, and 11/06/24, it was determined that the facility failed to develop a comprehensive person-centered care plan (CP) for a resident that included action taken by staff to educate the resident regarding alternatives and consequences. The facility also failed to follow its Care Plans - Comprehensive policy.
The deficient practice was identified for 1 of 9 residents (Resident #9) reviewed for CP and was evidenced by the following:
On 11/06/24 Surveyor #2 observed Resident #9 seated in a wheelchair dressed in a sweatshirt and pants. The resident was self-propelling the wheelchair out of the elevator onto the first floor. The resident stated recalling a recent incident that involved him/her and another resident.
Surveyor #2 reviewed Resident #9's admission Record which revealed that the resident was admitted to the facility with diagnoses that included but were not limited to: cerebral aneurysm (a bulge or ballooning in a blood vessel in the brain), cognitive communication deficit, and adjustment disorder.
Surveyor #2 reviewed Resident #9's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/07/24, which revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact.
Surveyor #2 reviewed Resident #9's progress notes which contained a social service note that revealed:
10/31/24 at 3:24 PM: IDT met on this date . Smoking was suspended for 2 days. [Resident #9] was found out back again by staff smoking a cigarette. [He/She] is now suspended for 7 days.
Surveyor #2 reviewed a Smoking Violation Notice which was provided by the facility for Resident #9, dated 10/30/24. Under the Intervention(s) section, two items were checked: Room search as needed, and Other 2 days.
Surveyor #2 reviewed Resident #9's CP which revealed that the resident had a focus that indicated that the resident was a smoker that was initiated on 02/13/24. Under the Interventions section, revealed that staff were to, Reeducate as needed to facility smoking rules/policy, which was initiated on 02/13/24. Further review of the CP showed no additional revision or updates.
On 11/06/24, at 1:45 P.M., Surveyor #2 interviewed the Director of Social Services (DSS) who stated that she recalled catching Resident #9 smoking in a non-designated smoking area. She stated that Resident #9 handed the item to her, which she destroyed. The DSS further added that the resident agreed to a room search and was suspended from smoking for two days, and that this was obtained in writing. The surveyor asked the DSS if she was responsible for updating care plans, to which she stated, I do not update care plans and I have never been instructed to do so.
On 11/06/24, at 2:47 PM, Surveyor #2 interviewed the Director of Nursing (DON) who stated that Resident #9's care plan should have been updated to reflect the incident that occurred on 10/30/24.
Review of the facility's Care Plans - Comprehensive policy, reviewed 08/02/24, revealed a Procedure section that included, 8. The comprehensive, person-centered care plan will: .f. Incorporate identified problem areas; g. Incorporate risk factors associated with identified problems .
NJAC: 8:39-11.2(i); 27.1(a)
CONCERN
(F)
📢 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
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on interviews and review of other pertinent facility documents on 11/01/24, 11/04/24, and 11/06/24, it was determined that the facility failed to ensure that the Administrator ensured that two s...
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Based on interviews and review of other pertinent facility documents on 11/01/24, 11/04/24, and 11/06/24, it was determined that the facility failed to ensure that the Administrator ensured that two staff that were currently working as Assistant Administrators were licensed as Nursing Home Administrators (NHA) per the facility's Job Description for Assistant Nursing Home Administrator.
On 11/01/24, at 10:20 AM, the surveyor completed the entrance conference with Assistant Administrator (AA) #1, who stated that he had worked at the facility for 2.5 months.
On 11/01/24, at 2:20 PM, Surveyor #1 requested a copy of Nursing Home license from AA #1 and AA #2. AA #1 stated that he was licensed in New York and not in New Jersey. AA #2 stated that he did not have a Nursing Home Administrator License. Both AA #1 and AA #2 stated that their job titles at the facility were Assistant Nursing Home Administrator.
On 11/01/24, at 2:43 PM, AA #1 verified that he is a licensed Administrator in New York, and not in New Jersey. A copy of the license was provided for review.
Surveyor #2 reviewed the undated, Hammonton Center Job Description for an Assistant Nursing Home Administrator which revealed the following under the Minimum Requirements section, This position requires the incumbent to be licensed as a Nursing Home Administrator . The license must be in good standing .
On 11/04/24 at 1:35 P.M., Surveyor #2 interviewed the Administrator who stated that he was aware that AA #1 and AA #2 were not licensed in the State of New Jersey as NHAs. In the presence of the surveyor, the Administrator reviewed the Hammonton Center Job Description for Assistant Nursing Home Administrator and stated, Oh I see it. The Administrator did not add any additional information.
N.J.A.C.: 8:39-9.3(a), (4)
Jul 2024
11 deficiencies
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 F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and review of other facility documentation, it was determined that the facility failed to issue the required beneficiary notices for 2 of 3 residents reviewed for Beneficiary Protec...
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Based on interview and review of other facility documentation, it was determined that the facility failed to issue the required beneficiary notices for 2 of 3 residents reviewed for Beneficiary Protection Notification (Resident # 140 and Resident # 162. This deficient practice was evidenced by the following:
A review of a facility policy on 07/29/2024 at 8:32 AM, titled Notice-Advanced Beneficiary Notice (ABN) with a creation date of 7/2019, revealed under the Policy section; The Advanced Beneficiary Notice of non-coverage (ABN) is issued by the facility to original Medicare (fee for service-FFS) beneficiaries in situations where Medicare payment is expected to be denied.
Medicare requires SNF's (Skilled Nursing Facilities) to issue SNFABN to Original Medicare, also called FFS beneficiaries prior to providing care that Medicare usually covers but may not pay for in this instance because the care is: not medically reasonable and necessary or considered custodial.
On 07/23/2024 at 01:45 PM, the surveyor requested 3 random residents, 1 resident who went home and 2 residents who remained in the facility beneficiary notification forms from the Assistant Administrator (AA).
On 07/24/2024 at 12:29 PM, the surveyor reviewed the SNF Beneficiary Protection Notification Review (SNFBPNR) completed by the facility as follows:
1. A review of the SNFBPNR for Resident #140 indicated that the last covered Medicare Part A Day was 04/12/2024 and the resident remained in the facility. The SNFBPNR further revealed that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage Form CMS-10055 was not given to Resident #140. There was no documentation to indicate why the form was not given to Resident #140.
2. A review of the SNFBPNR form for Resident #162 completed by the facility indicated that the last covered Medicare Part A Day was 06/24/2024. The SNFBPNR further revealed that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage Form CMS-10055 was not given to Resident #162. There was no documentation to indicate why the form was not given to Resident #162.
During an interview with the surveyor on 07/24/2024 at 12:42 PM, the Assistant Administrator said that Director of Rehab and MDS (Minimum Data Set) helped out giving notifications to residents cut from Medicare Part A.
During an interview with the surveyor on 07/24/2024 at 01:07 PM, the Director of Rehabilitation (DOR) said I give part B cut letter and Social Service is responsible for Part A notifications. In recent months the MDS coordinator has helped out.
During an interview with the surveyor on 07/24/2024 at 01:11 PM, the MDS coordinator said I have not been giving them. They took them away from me few years ago.
During a follow-up interview with the surveyor on 07/24/2024 at 01:15 PM, the surveyor reviewed that residents who remained in the facility should have received a SNFABN. The AA said I know the form and will follow up.
On 07/25/2024 at 09:21 AM, the surveyor confirmed with the AA that 100% the SNFABN was not given to the residents.
NJAC 8:39-4.1(a)(7)
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
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Complaint #: NJ00173786
Based on interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to notify in writing, the representative...
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Complaint #: NJ00173786
Based on interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to notify in writing, the representative of the New Jersey Long-Term Care Ombudsman's office (LTCO) of resident emergency transfers to the hospital/discharges, when practicable, as mandated by Federal law. This deficient practice was identified for 2 of 37 sampled residents (Resident #54 and Resident # ADD NUMBER) and was evidenced by the following:
On 07/25/2024 at 04:00 PM, a review of a facility policy titled NJ Ombudsman Mandatory Reporting with last revised date of 2/2023 under procedure section Transfer/Discharge, Copies of all facility-initiated (non-resident-driven) discharge notices shall be provided to the LTCO.
1. On 07/22/2024 at 01:29 PM, the surveyor reviewed the Electronic Medical Record (EMR) for Resident # 54 which revealed the following:
Resident # 54 was admitted to the facility with diagnoses including but not limited to: Urinary Tract Infection, Urinary Calculus (kidney stones), and Hydronephrosis (excess fluid in the kidney due to a backup of urine).
A review of the Discharge Return Anticipated Minimum Data Set (DRAMDS) revealed under the Entry/Discharge reporting section that Resident #54 was discharged with return anticipated on 2/28/2024, 3/27/2024, 4/19/2024 and on 6/20/2024.
2. On 07/24/2024 at 10:20 AM, the surveyor reviewed the EMR for Resident #516 which revealed that the resident was admitted to the facility with diagnosis that included, but not limited to: Osteoarthritis of left shoulder (degenerative joint disease), Diabetes Mellitus, Chronic Obstructive Pulmonary Disorder (long-term lung disease that makes it hard to breathe).
A review of the DRAMDS revealed under the Entry/Discharge reporting section that Resident #516 was discharged with return anticipated on 2/1/24.
During an interview with the surveyor on 07/24/2024 at 09:26 AM, the Director of Social Work (DSW) said he has been here a few months. When asked if he was responsible to send resident discharges to the hospital to the LTCO the DSW replied since he has been here, he has not sent any notifications to the LTCO of resident discharges to the hospital. He said I wasn't told I had to do that here. I am familiar with the process.
During a follow-up interview with the surveyor on 07/24/2024 at 09:28 AM, the DSW said I don't send OMB (ombudsman) notifications.
During an interview with the surveyor on 07/24/2024 at 09:31 AM the Assistant Administrator (AA) said the Social Worker (SW) is responsible to send notification to the LTCO office when residents are discharged to the hospital as well as send a monthly list.
On 07/24/2024 at 10:25 AM, the AA told the surveyor he found the binder in the SW office, and it has not been done since the new SW started.
On 07/24/2024 at 10:33 AM, a review of the binder provided by the facility contained a form titled Discharge Log by each Month. The form indicated resident name, discharge date , columns for Home, SNF (Skilled Nursing Facility), ALP (Assisted Living), AMA (Against Medical Advice), other as well as Home Care and DME company used. There was no column that indicated a discharge to the hospital. There was no documentation regarding the LTCO being notified of hospitalizations.
During a follow-up interview with the surveyor on 07/24/2024 at 11:56 AM, the AA said It doesn't look like they were sending notifications of the discharged residents to the hospital, just AMA and discharged to home. We will now be notifying the LTCO of residents discharged to the hospital.
On 07/25/2024 at 04:00 PM, a review of a facility policy titled NJ Ombudsman Mandatory Reporting with last revised date of 2/2023 under procedure section Transfer/Discharge, Copies of all facility-initiated (non-resident-driven) discharge notices shall be provided to the LTCO.
NJAC 8:39-4.1(a) 32
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 F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview, review of the medical record, and review of pertinent facility documents, it was determined that the facility failed to consistently implement and revise a care planne...
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Based on observation, interview, review of the medical record, and review of pertinent facility documents, it was determined that the facility failed to consistently implement and revise a care planned intervention (use of heel booties (prevent pressure ulcers from forming) for 1 of 2 residents (Resident #78) reviewed for position/mobility. This deficient practice was evidenced by the following:
The surveyor reviewed the facility policy titled Care Plans - Comprehensive, Last Date Revised: 10/2019. The following was revealed at POLICY: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
The following was revealed under PROCEDURE:
8. The comprehensive, person-centered care plan will:
b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
c. Describe services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights to refuse.
i. Reflect the resident's expressed wishes regarding care and treatment goals.
13. Assessments of resident's are ongoing and care plans are revised as information about the residents and the residents' conditions change.
On 07/22/2024 at 11:05 AM, during the initial tour of the facility the surveyor observed Resident #78 lying in bed. Resident #78 had their lower extremities exposed and the surveyor observed Resident #78 with bilateral lower extremity contractures. The lower left extremity was contracted against the right lower extremity, and they were in contact. The surveyor asked Resident #78 if the facility provided any intervention to help with his/her lower extremity contractures. Resident #78 stated, Sometimes they give me a pillow to put between my legs but not all the time. There was no pillow between the resident legs on this observation and Resident #78 had bare feet.
On 07/23/2024 at 12:53 PM Resident #78 was observed lying in bed. Resident #78 gave the surveyor permission to lift the bed sheet to observe the resident's feet. Upon permission, the surveyor lifted the sheet and observed Resident #78's bilateral feet/lower extremities. There were no heel protectors in place to the feet, as described in the care plan. No heel protectors were observed in the room.
On 07/24/2024 at 12:00 PM Resident #78 was observed seated in a Geri-chair in his/her room. Resident #78's feet were observed to have anti-skid socks on bilaterally while in the Geri-chair. No heel protectors were present on this observation.
On 07/25/2024 at 09:15 AM Resident #78 was observed lying in bed. Resident #78 permitted surveyor permission to observe resident's feet under the bed covers. Upon lifting the top sheet, the surveyor observed Resident #78's bilateral feet covered with blue non-skid socks. There were no heel protectors present, as indicated on Resident #78's care plan. No heel protectors were visible in the room.
On 07/30/2024 at 09:01 AM Resident #78 was observed lying in bed and watching television. Resident #78 allowed the surveyor permission to observe their feet under the bed sheet. Upon lifting the sheet, the surveyor observed Resident #78's feet had no heel protectors in place and were bare.
According to the Transfer/Discharge Report, Resident #78 was admitted to the facility with the following but not limited to diagnoses: Chronic pain syndrome, multiple sclerosis, difficulty in walking, and muscle weakness.
A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 6/24/2024, Resident #78 had a Brief Interview for Mental Status score of 12/15, which indicated moderately impaired cognition. Section E revealed that Resident #78 did not reject care. Section GG revealed that Resident #78 had functional limitation in range of motion on both sides of the lower extremity. Resident #78 also was dependent on staff for toileting, hygiene, to shower/bathe self, lower body dressing, and putting on/taking off footwear. Section GG further indicated Resident #78 required partial/moderate assist to eat, oral hygiene, and personal hygiene. Section M indicated that Resident #78 was at risk for developing pressure ulcers but had no pressure ulcers at time of assessment. Section O revealed that Resident #78 was not currently receiving occupational or physical therapy.
A review of the 7/1/2024-7/31/2024 Treatment Administration Record for Resident #78 did not include any reference to heel booties.
A review of the individualized comprehensive care plan for Resident #78 reviewed a care plan Focus of: Resident is at risk for impaired skin integrity r/t (related to) decreased ROM (range of motion) of the legs Date Initiated: 07/25/2018. The following was care planned as an intervention for the risk of skin integrity r/t decreased ROM of legs: Heel protectors to be worn when in bed/remove for hygiene and skin checks. Date Initiated: 07/25/2018.
On 07/30/2024 at 09:07 AM, the surveyor conducted an interview with the Certified Nursing Assistant (CNA #1) assigned to Resident #78 on that shift. The surveyor asked CNA #1 if f she provided Resident #78 with any special interventions, specifically heel protectors when caring for the resident. CNA #1 replied, I'm not sure if the resident is to have heel protectors or not, I'm agency. You should ask the nurse because they are more familiar with the resident. The surveyor then proceeded to interview the nurse assigned to Resident #78 on that shift. On 07/30/2024 at 09:09 AM, Registered Nurse (RN #1) stated that he regularly provided care to Resident #78. The surveyor asked RN #1 if any interventions were in place for heel protection. RN #1 said, Did he/she have a pillow under their feet? The surveyor stated that resident #78 did not have a pillow under their feet on surveyor observations. RN #1 then stated, Let me check [name of electronic medical record] and see if there is an order. RN #1 told the surveyor he did not see an order for heel protectors. He further stated, If he/she already has an air mattress they might not need them, but it would be helpful. Let me check and see if there is an air mattress. After going into Resident #78's room RN #1 told the surveyor, No, he/she does not have an air mattress.
On 07/30/2024 at 10:45 AM, the surveyor asked Registered Nurse/Unit Manager (RN/UM #1) to assess Resident #78 to see if heel protectors were in place. When the surveyor and RN/UM #1 went to Resident #78's room and observed his/her feet after gaining permission Resident #78 was observed to have a pillow under his legs on this observation. The surveyor asked the RN/UM #1 to locate the heel protectors. RN/UM #1 was able to find one heel protector in the bottom of Resident #78's closet/cabinet next to the head of the bed. RN/UM #1 could not locate a second heel protector. RN/UM #1 then told the surveyor, It's not an order it's a comfort thing. They need to be discontinued because the resident does not want to wear them. Resident #78 verbalized that he/she would prefer a pillow and did not want the heel booties. At that time Resident #78 told the surveyor that the last time he/she wore the heel protectors was approximately 3 years ago and said, I just want to wear the socks.
On 07/30/2024 at 02:02 PM, the surveyors interviewed the facility Director of Nursing (DON). The surveyor asked the DON when are care plans updated for residents. The DON responded, Care plans are reviewed quarterly, when a significant event occurs, annually, and as needed.
On 07/31/2024 at 12:34 PM, the facility Assistant Director of Nursing told the survey team that when care plans are updated all disciplines are involved in care plan development and the unit manager is ultimately responsible for resident care plans. The facility DON had provided the surveyor with a schedule of care plan updates for Resident #78 dating back to 8/10/2018. The review history provided revealed that Resident #78 last had their care plan updated on 06/27/2024.
The surveyor reviewed the facility policy titled Care Plans - Comprehensive, Last Date Revised: 10/2019. The following was revealed at POLICY: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
NJAC 8:39-11.2(3)(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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
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 follow hold parameters for administration of insulin (a diabetic medication...
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Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to follow hold parameters for administration of insulin (a diabetic medication) in accordance with the resident's physician's orders and in accordance with professional standards of practice. This deficient practice was identified for 1 of 36 residents reviewed for professional standards of practice (Resident #39).
A review of the facility's Medication Administration policy dated revised 12/2023, included medications must be administered in accordance with orders, including any required time frame .
Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
The evidence was as follows:
On 7/22/2024 at 12:32 PM, the surveyor observed Resident #39 seated at a dining room table with another resident drinking a diet ginger ale.
A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included paranoid schizophrenia, major depressive disorder, and diabetes.
A review of the most recent annual Minimum Data Set (MDS), an assessment tool dated 5/20/24, reflected the resident had a brief interview for mental status score of 15 out of 15, which indicated a fully intact cognition.
A review of the Order Summary Report, included the following medication:
Novolog solution 100 unit/milliliter (ml) (insulin aspart) inject 13 units subcutaneously before meals for DM (diabetes mellitus) HOLD for BS (blood sugar) < 100 [milligrams/ deciliter (mg/dl)]
Doses were scheduled at 8:00 AM, 12:00 PM, and 5:30 PM
A review of the July 2024 Medication Administration Record (MAR) revealed on five occasions the resident had BS >100 and the nurse documented 12 which according to the key indicated no insulin required. The dates were as follows:
7/6/24 8:00 AM, BS 129
7/11/24 8:00 AM, BS 123
7/11/24 12:00 PM, BS 124
7/11/24 5:30 PM, BS 124
7/24/24 12:00 PM, BS 121
During an interview with the surveyor on 7/30/24 at 11:45 AM, the assigned Licensed Practical Nurse (LPN #1) for Resident # 39 who stated a 12 on the MAR indicated no insulin required. At that time the surveyor and LPN #1 reviewed the July MAR. LPN #1 acknowledged the nurse recorded the resident's BS >100 on the above referenced dates and times and confirmed the nurse should have administered the Novolog according to the physician's orders.
During an ointerview with the surveyor on 7/30/2024 at 11:58 AM, the Licensed Practical Nurse Unit Manager (LPN/UM #1) who confirmed after reviewing the July 2024 MAR that on the above referenced dates the BS was documented as >100 and the nurse should have administered the Novolog as ordered according to the physician's orders.
On 7/30/2024 the Survey team met with the facility Administration. The surveyor and the Director of Nursing (DON) reviewed Resident #39's July MAR. The DON confirmed the nurse indicated on the above referenced dates and times the resident's BS >100, and the nurse should have administered the resident's Novolog in accordance with the physician's orders.
NJAC 8:39-11.2(b); 27.1(a)
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to follow physician orders specifically to change the piston ...
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Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to follow physician orders specifically to change the piston syringe (a device intended for medical purposes that consists of a calibrated hollow barrel and a movable plunger) every 24 hours for 1 of 2 residents reviewed for Tube Feeding, (Resident #37.). This deficient practice was evidenced by the following:
A review of facility policy on 07/24/2024 at 12:08 PM, titled Enteral Feedings with last revised date of 4/2023, did not include documentation of the care and changing of the piston syringe kit.
On 07/31/2024 at 10:26 AM, the DON provided the surveyor the same policy titled Enteral Feedings. The following was highlighted under the Procedure section:
4. Ensure that equipment and devices are working properly by performing any calibrations or checks as instructed by manufacturer.
12. Administration and feeding sets.
a. Feeding may be reused for next scheduled feed as long as it is free from contamination, however;
b. Replace tubing and feeding sets every 24 hours or if contamination has occurred before that time
c. store in designated, clean location until next use.
During the initial tour of the unit on 07/22/2024 at 11:06 AM, the surveyor observed the piston syringe kit in a clear plastic bag hanging from the Intravenous (IV) Pole that was dated 7/19/24.
On 07/23/2024 at 11:58 AM, the surveyor observed the piston syringe kit in a plastic bag hanging on the IV pole and it was dated 7/19/24.
A review of the Electronic Medical Record on 07/23/2024 at 11:15 AM, revealed the following:
Resident #37 was admitted with diagnoses including but not limited to; UNSPECIFIED SEVERE PROTEIN-CALORIE MALNUTRITION, Adult Failure to Thrive, and Gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food.)
A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 6/21/2024, revealed Resident #37 had severe cognitive impairment. The MDS further indicated that Resident #37 had a feeding tube, and 51% or more calories were received through tube feeding.
A review of the Order Summary Report with Active Orders as of 07/24/2024 revealed a physician order to Change Enteral feeding administration setup (tubing, Piston Syringe, Graduated cylinder) every 24 hours every night shift for tube feeding care AND as needed when compromised.
A review of the Treatment Administration Record TAR) for July 2024 had signatures in the box for the order and was timed at 11pm for 7/20, 7/21, and 7/22/2024.
On 07/23/2024 at 11:59 AM, the surveyor accompanied by Licensed Practical Nurse/Unit Manager (LPN/UM #1) went to Resident #37's room. LPN/UM #1 confirmed the date of 7/19 on the bag and 7/19/24 on the piston/syringe bottle. During an interview with the surveyor at that time, LPN/UM #1 said it should be changed daily. When asked should this have been changed, she replied yes should have been changed on the 20th, 21st, 22nd. LPN/UM #1 discarded the set dated 7/19.
During a follow up interview with the surveyor on 07/24/2024 at 10:02 AM, LPN/UM #1 was asked to review the TAR for July 2024. LPN/UM #1 confirmed the piston syringe kit was dated 7/19 and should have been changed on 7/20, 7/21 and 7/22. LPN/UM #1 said Yes there are initials there (in the blocks of the TAR) and that is the user. LPN/UM #1 explained that means they signed it out on the TAR as completed. LPN/UM #1 confirmed it (piston syringe kit) wasn't changed according to what we saw yesterday.
During an interview with the surveyor on 07/29/2024 at 08:52 AM, the surveyor questioned as to what the facility practice was regarding use of piston syringe kits for tube feeding residents? The Director of Nursing (DON) replied, We change it every 24 -48 hours and label it with pt (patient) room number/or name and date. If there is a physician order to change the piston syringe kit, then we will go by the physician order, and it will be documented on the TAR. The surveyor asked why it was important to change them (piston/syringe kits) every day? The DON said it is part of infection control to prevent infection and clogging of the tube.
NJAC 8:39-27.1(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the medical record, and review of other pertinent facility records, it was determined...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the medical record, and review of other pertinent facility records, it was determined that the facility failed to implement infection control measures for the handling and storage of respiratory equipment for 2 of 4 residents reviewed for respiratory care (Resident #22 and Resident #63). This deficient practice was identified by the following:
The surveyor reviewed the facility policy titled Nebulizer Medication/COVID 19, Last Revised Date: 1/2023. The following was revealed under the heading POLICY: Nebulization is used to deliver medications along the respiratory tract and is indicated for various respiratory problems and diseases. The therapy must be prescribed by a properly licensed physician or physician extender. The purpose of the procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Nebulizer treatments will be given by licensed nursing staff or respiratory therapists as directed, using proper technique and universal precautions.
The following was revealed under the heading PROCEDURE:
21. Rinse and disinfect the nebulizer equipment
a. Wash pieces with warm soapy water
b. Allow to air dry on a paper towel
23. When equipment is completely dry, store in a plastic bag with resident's name and date on it.
1. On 07/22/2024 at 10:36 AM, during the initial tour of the facility the surveyor observed Resident #22 lying in bed and asleep. The surveyor observed the nebulizer mask placed on the top of the over bed table. The nebulizer mask was undated, uncovered, and exposed while not in use.
On 07/24/2024 at 12:12 PM, Resident #22 was observed lying in bed with O2 (oxygen) via N/C. The nebulizer mask was observed on the over the bed table. The nebulizer mask was not currently in use and the mask was resting on top of the bed side table. The mask was uncovered and exposed. The nebulizer and tubing had no dates on observation. Resident #22 said Yes when the surveyor asked if he/she had a nebulizer treatment today. Review of Resident #22's 7/1/2024-7/31/2024 Medication Administration Record (MAR) revealed that Resident #22 received a nebulizer treatment at 0900 (9:00 AM) on 7/24/2024 and the next scheduled nebulizer treatment was 1300 (1:00 PM).
On 07/30/2024 at 08:55 AM Resident #22 was observed lying in bed with O2 at 3L/min via n/c. The nebulizer mask was observed on the over the bed table next to bed, as seen previously. A plastic T -s shaped inhaler was on top of the table. The T-shaped inhaler was not covered and was exposed while not in use. The nebulizer tubing was undated. Review of Resident #22's MAR revealed Resident #22 received a nebulizer treatment at 2100 (9:00 PM) on 7/29/2024 and received a nebulizer treatment at 0900 on 7/30/2024.
According to the facility provided Transfer/Discharge Report Resident #22 was admitted to the facility with the following but not limited to diagnoses: Chronic obstructive pulmonary disease (COPD) (a type of progressive lung disease characterized by long term respiratory symptoms and air flow limitation), acute respiratory failure with hypoxia (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level).
A review of the Minimum Data Set (MDS), an assessment tool, dated 6/21/2024, revealed Resident #22 had a Brief Interview for Mental Status score of 8/15 which indicated moderate cognitive impairment. Section O of the MDS revealed that Resident #22 received oxygen therapy while a resident at the facility.
A review of the Order Summary Report, dated 7/30/2024 revealed the following physician orders for Resident #22:
PRN (as necessary) Supplemental Oxygen via Nasal Cannula (NC) at 2L/Min (liters per minute) to maintain Oxygen SATS (saturation) greater than 90% (Hx of COPD 88%) very shift Check O2 sat every shift Start Date: 04/08/2024
Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML (milligrams/milliliter) 3ml inhale orally four times a day for COPD Start Date: 04/06/2024
A review of Resident #22's MAR (Medication Administration Record) revealed that Resident #22 had received a nebulizer treatment at 0900 on 7/25/2024 and the next treatment was scheduled for 1300.
A review of Resident #22's individualized comprehensive care plan revealed a Focus of Resident has an alteration in respiratory system r/t (related to) COPD, acute/chronic respiratory failure Date Initiated: 04/06/2020. The following intervention was included in the care plan under Interventions/Tasks: Administer treatments (nebulizer) (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs. Commonly used for the treatment of asthma, cystic fibrosis, COPD, and other respiratory diseases) & medications per MD orders. Date Initiated: 04/06/2020.
On 07/25/2024 at 09:50 AM, Resident #22 was observed on the 1D hallway speaking with the nurse at the medication cart between room [ROOM NUMBER] and 104. Resident #22 had portable O2 on via nasal cannula. After gaining permission to enter room [ROOM NUMBER]-B from Resident #22's roommate, the surveyor observed Resident #22's nebulizer mask on top of the over the bed table. The nebulizer mask was not in use and was observed to be lying on top of a sheet of paper that appeared to be a word search puzzle. The mask was not covered and was exposed while not in use. The nurse asked the resident if he/she had a nebulizer treatment this AM and the resident stated, Yes.
The surveyor then interviewed the Licensed Practical Nurse (LPN #2) previously observed speaking with Resident #22. The surveyor asked what the facility practice was for nebulizer mask maintenance between treatments. LPN #2 stated, Nebulizer masks should be covered when not in use because of germs LPN #3 further stated that both nursing and Certified Nursing Aide (CNA) staff were responsible for maintaining the protection of oxygen equipment when not in use, specifically keeping the nebulizer mask covered when not in use.
2. On 07/22/2024 at 11:20 AM, the surveyor observed Resident #63 in their room during the initial tour of the facility. Resident #63 was awake and alert. The surveyor observed a nebulizer machine and mask on top of bedside table. The nebulizer tubing was dated 7/18/24. The nebulizer mask was lying on top of the bedside table and was exposed while not in use. Resident #63 stated that he/she had received nebulizer treatments twice a day when asked by the surveyor.
On 07/23/2024 at 08:50 AM the surveyor observed that Resident #63 was out of the room at this time. The surveyor observed a nebulizer mask on top of the bedside table. The mask was resting on top of a plastic bag and was not in use. The nebulizer mask was exposed while not in use.
On 07/24/2024 at 12:28 PM Resident #63 was observed lying in bed. Resident #63 stated that they are to discharge home tomorrow. The surveyor observed a nebulizer mask on the bedside table as seen on previous observations. The nebulizer mask was not in use and was not bagged and was exposed while not in use.
A review of Resident #63's Transfer/Discharge Report revealed that Resident #63 was admitted to the facility with the following but limited diagnoses: Chronic obstructive pulmonary disease.
A review of Resident #63's comprehensive MDS, dated [DATE], revealed that Resident #63 had a BIMS score of 15/15, indicating intact cognition. Review of section J indicated Resident #63 had shortness of breath with exertion and while lying flat. Section O indicated Resident #63 was receiving oxygen therapy while a resident in the facility.
A review of Resident #63's Order Recap Report with Order Date: 07/01/2024-07/31/2024 indicated Resident #63 had the following physician orders:
Change and date nebulizer kit and storage bag once weekly on Sunday every night shift every Sun for neb (nebulizer) maintenance. Order Date: 6/13/2024
Rinse and disinfect nebulizer equipment after each use Wash pieces with warm soapy water. Allow to air dry on a paper towel. Store only when completely dry every shift for neb maintenance Order Date: 06/13/2024
Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally four times a day for COPD via nebulizer Order Date: 06/12/2024
A review of the 07/01/2024-07/31/2024 MAR revealed that Resident #63 received a nebulizer treatment on 7/22/2024 at 10:00 AM.
A review of Resident #63's individualized comprehensive care plan revealed a care plan Focus of Resident has an alteration in respiratory system r/t COPD with orthopnea (shortness of breath while laying flat) Date Initiated: 06/12/2024 The following was a care planned Intervention: Administer treatments (nebulizer) & medications per MD orders. Date Initiated: 06/12/2024
On 07/25/2024 at 09:40 AM, the surveyor observed a nebulizer mask placed on top of bedside table in Resident #63's room. The nebulizer was not in use and was not covered. The mask was exposed on the bedside table. The surveyor then conducted an interview with the nurse assigned to Resident #63 on that shift. The surveyor asked LPN #3 while in Resident #63's room if the nebulizer mask should be protected when not in use. LPN #3 stated, Well, it's not being used right now but it should be covered when it's not being used. The surveyor asked LPN #3 why the nebulizer mask should be covered when not in use. It's an infection control issue. The surveyor then asked LPN #3 who was responsible for making sure the oxygen equipment is stored properly when not in use? LPN #3 responded, It could be anybody but usually the CNA's or nurses who are responsible for maintaining the oxygen equipment.
On 07/30/2024 at 01:34 PM, the surveyor conducted an interview with facility administration, which included the Licensed Nursing Home Administrator, Assistant Administrator, Director of Nursing (DON), and Senior Resource Director. The surveyor asked what the facility expectation was for nebulizer masks when they are not in use by a resident receiving treatment. The DON told the surveyor, The expectation is that the machine is cleaned, and the tubing and mask are to be cleaned, air dried, and bagged between use once dried. It is important to bag between uses for sanitation and infection control.
N.J.A.C. 8:39- 27.1 (a)
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 review of pertinent facility documents, it was determined the facility failed to ensure an accurate ordering and receiving of narcotic medications on the required ...
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Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 3 of 3 forms provided. The evidence was as follows:
A review of the facility's provided Medication- Narcotic Management policy with a revised date of 4/2023 did not include information related to the completion of the DEA 222 forms.
On 7/30/2024 at 10:15 AM, the surveyor reviewed the facility provided DEA 222 forms which revealed on three of the three provided forms Part 5, had not been completed upon receipt of the medications from the provider pharmacy as instructed on the reverse of the ordering form. The forms were as follows:
Order form number: 221690894; 221690895; and 221690896.
On 7/30/2024 at 1:39 PM, the surveyor and Director of Nursing (DON) reviewed the provided DEA 222 forms. The DON acknowledged she should have completed the Part 5 as instructed on the reverse of the DEA 222 form as required.
A review of the Instructions for DEA Form 222, under Part 5. Controlled Substance Receipt, 1. The purchaser fills out this section on its copy of the original order form. 2. Enter the number of packages received and date received for each line item .
NJAC 8:39-29.7(c)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and review of other faciloirty documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food...
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Based on observation, interview, and review of other faciloirty 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:
A review of the facility policy titled Food Storage, Last Date Revised 7/19/2023, revealed the following under the heading POLICY:
Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination.
The following was revealed under the PROCEDURE section:
10. Food will be stored a minimum of 6 inches above the floor, 18 inches from the ceiling and 2 inches from the wall on clean racks or other clean surfaces, and is protected from splashes, overhead pipes, or other contamination (ceiling sprinklers, sewer/waste disposal pipes, vents, etc.).
12. Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within 24-72 hrs (hours). Check state regulations as state regulations may allow shorter time frames for use of leftovers.
13. Refrigerated food storage:
a. All refrigerator units will be clean and in good working condition at all times.
b. TCS (temperature control for safety) foods must be maintained at or below 41 degrees F unless otherwise specified by law. Periodically take temperatures of refrigerated foods to assure temperatures are maintained at or below 41 F. Temperatures for refrigerators should be between 35 to 39 F. Thermometers should be checked at least two times each day.
c. Every refrigerator must be equipped with an internal thermometer.
f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.
14. Frozen Foods:
c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. All frozen leftovers must be used within 30 days.
The surveyor reviewed the facility provided copy of the Daily Cleaning Schedule for the facility kitchen, undated. Review of the schedule did not include cleaning of the reach-in refrigerator daily.
The surveyor reviewed the facility policy titled Dish Washing and Storage Policy, Last Date Revised: 01/17/2024. The following was revealed under POLICY: Dishes, pot and pans will be washed and dried using procedures, chemicals and equipment that result in clean, sanitized dishes, pans, flatware, and utensils.
The policy revealed the following under the heading PROCEDURE:
Dish Machine Washing:
3. Dish machine temperatures are logged at each meal on the Dish Machine Temperature log.
4. Staff will monitor dish machine temperatures throughout the dishwashing process
b. Low Temperature Dishwasher: Spray Type Dish Machine Using Chemicals to Sanitize
Minimum Wash Temperature: 120 F
Final Rinse Temperature 120 F and sanitization 50 ppm Hypochlorite (chlorine).
Dishes, pots, pans, utensils and flatware must be air dried before being stored, Do not dry with towels.
7/ Employees are trained in proper dishwashing and drying procedures. Staff will be trained to report any problem with the dish machine to the director of food and nutrition services as soon as they occur.
The surveyor reviewed the facility policy titled FOOD FROM OUTSIDE-SAFETY, Last Date Revised: 5/2019. The following was revealed under the Monitor section:
Facility staff will be appointed to check resident refrigerators for proper temperatures, food containment and quality, and disposal of items per facility policy.
On 7/22/2024 from 9:17 to 9:50 AM, the surveyor in the presence of the facility Registered Dietitian/Nutritionist (RDN), observed the following in the kitchen:
1. On an upper shelf/rack in the walk-in freezer a package of frozen sausage was removed from its original container and had no dates. In addition, a clear garbage size bag contained what appeared to be frozen zucchini slices. The bag had no dates.
2. In the walk-in refrigerator a previously opened clear plastic bag on a middle shelf contained chopped lettuce. The bag had a manufacturer's best if used by date of 07-19-24. On the same shelf, a clear plastic bag contained chopped lettuce and carrots. The lettuce appeared slimy, and the bag had a manufacturer's best if used by date of 06/27/24. On an upper shelf a 10 pound container of cole slaw had been previously opened. The cole slaw had a manufacturer's Best If Used By date of 07/20/24.
3. The surveyor approached the designated hand washing sink to get a paper towel to perform hand hygiene. There were no paper towels in the wall mounted paper towel dispenser.
4. A white refrigerator/freezer in front of the dietary office had no internal thermometer in the freezer to monitor freezer temperatures. In addition, styrofoam take-out style container in the refrigerator that contained unknown food contents had no dates. A dietary aide (DA) threw the container in the trash.
On 07/25/2024 at 08:46 AM, on the 2nd Floor Pantry (2A hallway) the surveyor, accompanied by the facility Infection Preventionist (IP) observed the following:
1. In the bottom left drawer of the pantry refrigerator, used to store resident food and beverage, (19) 4oz containers of Thick & Easy moderately thick/honey consistency thickened waters used for residents had a Use by Jun 22, 24 manufacturer's label. In addition, four (4) more containers of the same product were observed on the lower shelf of the refrigerator door and had Use By Jun 22, 24 manufacturer's date. According to the IP on interview it (thickened beverages) was normally kept in the nutrition closet on the unit and then the nurses would stock the fridge as needed. The surveyor asked the IP who was responsible for ensuring the use by dates of products in the pantry refrigerator. The IP replied, The nurse is absolutely responsible for checking the use by date when stocking the fridge. The IP removed the expired thickened waters to the trash.
On 07/30/2024 from 09:53 to 10:23 AM the surveyor, accompanied by the Food Service Director (FSD), observed by the following in the kitchen:
1. In the three compartment sink/manual dish washing area a DA was actively washing pots and pans. Observation of the pot/pan drying rack revealed (4) quarter pans stacked on top of each other. The surveyor lifted the top pan and observed a wet/watery, clear substance on the bottom of the pan below (wet nesting, occurs when wet dishes or pots and pans are stacked, preventing them from drying, and creating conditions that are ripe for microorganisms to grow). The FSD agreed the pans were not air dried prior to stacking and instructed the DA to rewash and air dry the quarter pans before stacking.
2. At approximately 10:00 AM, kitchen staff were actively using the low temperature dish machine after the breakfast meal. When asked to see the dish machine temperature log the FSD stated, It's hanging on the wall. (opposite wall of dish machine). Observation of the temperature log revealed that no wash/rinse or sanitizer ppm levels (parts per million) had been recorded for the breakfast on 7/30/2024. The kitchen had a low temperature dish machine, according to the FSD and it had a minimum wash and final rinse temperature of 120 Fahrenheit (F). The FSD told the surveyor that they used chlorine as the sanitizing agent. At that time the facility had cleaned several racks of pellet bottoms and lids and several racks of hard plastic trays used to serve resident food. Upon observation of the sanitizer container mounted on the wall (a sanitizing agent that utilizes sodium hypochlorite to sanitize dishware) the FSD stated that it was empty. The FSD then went to the DA at the three compartment sink and asked for another bottle of sanitizer. The DA handed the FSD an approximate half bottle of sanitizer from the designated chemical closet and stated that he had more down stairs. After replacing the empty bottle of sanitizer, the FSD restarted the dish machine, and a DA assisted the surveyor in putting an empty plastic pellet lid in the plastic dish rack and the FSD then proceeded to run the rack through the wash and rinse cycle which was observed at 120 F. The rack that contained the pellet lid exited the dish machine after going through a full wash and rinse cycle. The FSD obtained a white chlorine test strip and dipped the test strip into the dishwater that had collected in the pellet lid from the wash and rinse cycle. The test strip remained white after dipping it into the collected dish machine water, indicating that no chlorine was present or 0 ppm. The surveyor then requested the FSD to attempt a second test of the sanitizer by passing the pellet lid in the dish rack through the machine a second time. The FSD dumped the previous dish water from the pellet lid. Upon placing the rack in the machine, the surveyor and FSD observed that the pump for the chlorine sanitizer was not pulling the sanitizer completely through the wall mounted pump and the chlorine sanitizer remained in the pump tubing, which was visible through the clear tubing and was unable to enter the dishwater to sanitize dishes. The FSD shut down the dishwasher at this point and told the surveyor they would contact the foodservice contract company to do necessary repairs. The surveyor told the FSD that all trays and pellet lids that had been washed would have to be rewashed and sanitized. The FSD agreed. The surveyor re-visited the kitchen at approximately 11:30 AM and the repair service had not arrived at that time. The surveyor observed the kitchen dish room, and all dish washing could be confirmed as stopped when the FSD shut down the dish machine. The FSD stated that paper products will be used for the lunch meal and until the machine is repaired. A review of the service invoice dated 2024-07-30T16:03:00, revealed the following: Final rinse sanitizer not working. Replaced a bad injector fitting and chemical line. Issue resolved. The sanitizer was test (sic) and adjusted to 50-100 ppm.
2. Observation of the floor of the reach-in refrigerator revealed an approximate 1/4 to 1/2 inch level of clear liquid fluid on the floor of the refrigerator. When asked what the fluid was the FSD stated, The line is leaking. We need to get a new refrigerator, but we have been using a shop type vacuum to remove the water. It just really started to leak. Beverages (iced tea containers) were observed to be above the level of the water on the bottom of the fridge. No active leakage was observed by the surveyor.
NJAC 18:39-17.2(g)
Feb 2024
3 deficiencies
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** Complaint # NJ00165000, NJ00163037
Based on policy review, record review, observations, and interviews, the facility failed to e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ00165000, NJ00163037
Based on policy review, record review, observations, and interviews, the facility failed to ensure effective infection control practices were maintained for one Resident (R ) R11 out of four residents observed during medication administration. Specifically, Licensed Practical Nurse (LPN 4) was observed administering a blood sugar check and sliding scale insulin and failed to ensure the glucometer was appropriately sanitized before and after use, failed to ensure a clean barrier was utilized when placing the glucometer down on a surface in the resident's room while administering the blood sugar check, and failed to ensure appropriate hand hygiene by wearing false 1.5-inch-long nails during the administration of R11's medication.
Findings include:
Review of the facility's policy titled, Cleaning/Disinfecting Resident Care Items and Equipment dated 05/18/23 indicated, .2. Shared resident care items/equipment shall be cleaned/disinfected between each resident and use according to manufacturer's instructions for use; and Disinfection refers to thermal or chemical destruction of pathogenic and other types of microorganisms.
Review of the facility's policy titled Medication Administration dated 12/2019 indicated, .14. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc. when these apply to the administration of medications.
Review of the facility's designated approved Environmental Protection Agency (EPA) registered disinfectant, MicroKill Germicidal Wipes label was reviewed and indicated a Wet/Kill Time of 60 seconds.
Review of the facility's Spectrum Advance Hand Sanitizer Wipes label indicated the product was only to be used for hand sanitization. The label indicated the active ingredient in the hand sanitizer was 70% ethyl alcohol.
Review of R11's Electronic Medical Record (EMR) titled admission Record located under the Profile tab revealed R11 was admitted to the facility on [DATE] with diagnosis Type 2 diabetes. The resident did not have a diagnosis of any bloodborne pathogen noted in the EMR.
Review of R11's admission Minimum Data Set (MDS), found in the EMR under the MDS tab and with an Assessment Reference Date (ARD) of 01/24/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated resident's cognition was intact.
Review of R11's Physician's Orders, dated 02/20/24 and found in the EMR under the Orders tab included an order for blood sugar checks to be obtained three times daily before meals with the as needed administration of Humalog insulin on a sliding scale basis.
Review of R11's Medication Administration Record (MAR), dated 02/01/24 through 02/20/24 and found in the EMR under the Orders Tab, confirmed the resident was receiving her blood sugar checks and insulin routinely as ordered.
Observation on 02/20/24 at 11:25 AM, revealed LPN 4 to be wearing false fingernail, approximately 1.5 inch long, sharply pointed at the ends fingernails, obtained R11's blood sugar check. LPN 4 obtained a glucometer from the medication cart and then obtained a Spectrum Advance Hand Sanitizer Wipe (active ingredient 70% alcohol) from the medication cart which she used to wipe the glucometer for approximately two to three seconds. LPN 4 took the glucometer and other supplies to R11's room and without placing a clean barrier on the resident's overbed table placed the glucometer directly on the overbed table. After obtaining the result of R11's blood sugar check, LPN 4 placed the glucometer on the surface of the medication cart, wiped the glucometer with another Spectrum Advance Hand Sanitizer Wipe, and then placed the blood sugar monitor back into the top drawer of the medication cart. LPN 4 was not observed to sanitize the glucometer with a facility approved cleaning agent/sanitizer. LPN 4 did not obtain any additional blood sugars for any additional residents during the noon medication administration period.
During an interview on 01/20/24 at 11:51 AM, LPN 4 stated she was aware she was supposed to use the facility's approved sanitizing agent, a MicroKill Germicidal Wipe, to clean the blood glucometer before and after each use, however she did not have any of the MicroKill Wipes in her cart at that time, and so used the Hand Sanitizer wipe to clean the glucometer instead. LPN 4 stated she checked the supply closet that morning to obtain the correct MicroKill Sanitizing Agent, however had not been able to find any (the survey team confirmed the MicroKill sanitizing wipes were available in the facility's storage area on 01/20/24 at 12:30 PM). LPN 4 stated she was aware she should have placed a clean barrier on the resident's overbed table prior to placing the blood sugar monitor on the table to ensure proper infection control, and stated she was aware false nails of any length past the end of her fingertips were not allowed to be worn while providing any type of care for residents in the facility, including medication administration.
During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 01/20/24 at 12:47 PM, the DON stated the glucometers were expected to be sanitized with MicroKill Germicidal Wipes before and Wipes) prior to using the glucometer for the next resident or placing the glucometer back into the cart. The DON stated that false nails longer than ¼ inch past the end of a staff member's fingertips were not allowed to be worn by staff members working in the facility for infection control and safety purposes. The DON stated her expectation was that a clean barrier should be placed on any resident surface prior to putting any multi-use equipment (including a blood glucose monitor) on the surface.
NJAC 8:39-19.4 (l)
CONCERN
(E)
📢 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 F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ000165571, NJ00160246, NJ00163849
Based on record review, interview and policy review, the facility failed to ens...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ000165571, NJ00160246, NJ00163849
Based on record review, interview and policy review, the facility failed to ensure the timely administration of a medication for one (Resident (R) R11) out of 15 residents reviewed in the sample. Specifically, R11's sliding scale insulin was administered late four times between 02/01/24 and 02/20/24.
Findings include:
Review of the facility's policy titled Medication Administration dated 12/2019 indicated, .3. Medications must be administered in accordance with the orders, including any required timeframe .
Review of R11's Electronic Medical Record (EMR) titled admission Record located under the Profile tab revealed R11 was admitted to the facility on [DATE] with diagnosis including Type 2 diabetes.
Review of R11's admission Minimum Data Set (MDS), found in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 01/24/24, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident's cognition was intact.
Review of R11's Physician's Orders, dated 02/20/24 and found in the EMR under the Orders tab, included an order for blood sugar checks to be obtained three times daily before meals with the as needed administration of Humalog insulin on a sliding scale basis (at 7:30 AM, 11:30 AM, and 5:30 PM).
Review of R11's Medication Administration Record (MAR), dated 02/01/24 through 02/20/24 and found in the EMR under the Orders tab, indicated the resident's insulin was administered late on the following dates/times:
02/03/24 7:30 AM dose was given at 8:59 AM (approximately one- and one-half hours late).
02/03/24 11:30 AM does was given at 2:41 PM (more than three hours late)
02/04/24 7:30 AM does was given at 8:50 AM (approximately one- and one-half hours late)
02/04/24 5:30 PM dose was given at 6:44 PM (approximately one and one quarter hour late)
02/09/24 7:30 AM dose was given at 9:02 AM (approximately one-and one-half hours late)
Review of R11's progress notes for 02/01/24 through 02/20/24 in the EMR under the Progress notes tab did not contain documentation as to the reason for the late administration and/or late documentation of the above insulin medication.
During an interview with Licensed Practical Nurse (LPN 8) on 02/21/24 at 11:41 AM, LPN 8 confirmed she was one of the nurses who administered R11's insulin medication late and stated she thought the insulin was probably given on time but documented late. She stated medications were not passed on time for this resident, sometimes, because the residents on that unit moved around a lot and had to be located. She stated she was aware she was expected to pass medications timely, especially time sensitive medications such as insulin. She stated she was expected to write a note in the resident's record to indicate the reason for late medication administration or the late documentation of any medication and was not sure why that had not been done for R11.
During an interview with LPN9 on 02/21/24 at 11:49 AM, LPN 9 confirmed she was one of the nurses who documented the above referenced late insulin administration. She stated medications were expected to be administered one hour before to one hour after the ordered administration time. She stated There are a lot of meds [medications] so I gave all my meds to all residents and documented after they (the medications) were finished (being administered).
During an interview with LPN 10 on 02/21/24 at 11:55 AM, LPN 10 confirmed she was one of the nurses who documented the above referenced late insulin administration and stated she thought R11's medication was administered on time. She stated, Normally the meds are passed on time, and I don't sign them out until later. LPN 10 acknowledged medication administration was expected to be documented immediately after the administration of each resident's medication and was unsure of what happened on the day R11's insulin was documented as given late.
During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 01/20/24 at 12:47 PM, the DON stated medication, especially time sensitive medication such as insulin, was expected to be given timely. She stated the established window for medication administration, in general, was one hour before to one hour after the indicated administration time. She confirmed, however, sliding scale insulin was expected to be given within 15 to 30 minutes prior to the resident being served and eating a meal.
During an interview with the Corporate Nurse on 02/21/24 at 12:25 PM, she confirmed her expectation was all medications were to be administered timely and then document in the record immediately.
NJAC: 8:39-29.2 (d)
NJAC: 8:39-27.1 (a)
CONCERN
(F)
📢 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
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Complaint: NJ00160690, NJ00163037, NJ00166486
Based on observation, staff interview, and facility policy review, the facility failed to ensure clean plates and pans were air dried prior to storage and...
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Complaint: NJ00160690, NJ00163037, NJ00166486
Based on observation, staff interview, and facility policy review, the facility failed to ensure clean plates and pans were air dried prior to storage and not stacked wet. This failure had the potential to increase the risk of foodborne illness and had the potential to affect 155 of 157 residents in the facility who received dietary services at the time of the survey. Two residents received tube feedings.
Findings include:
Review of the facility's policy ''Dish Washing and Storage Policy,'' dated 06/17/19, revealed, ''Policy: Dishes, pots and pans will be washed and dried using the procedures, chemicals and equipment that result in clean, sanitized dishes, pans flatware and utensils. Procedure: Dish Machine Washing: .Dishes, pots, pans, utensils, and flatware must be air dried before being stored. Do not dry with towels . 7. Employees are trained in proper dishwashing and drying procedures .
Observation and interview on 02/20/24 at 11:40 AM, the plates stacked in two different plate warmers, next to the steam table to be used for lunch service were found to still be wet from washing after being used for breakfast. The Dietary Manager (DM) confirmed, All of the plates are wet. They should be dry before being stacked. They should have been air dried before stacking.
Observation and interview on 02/20/24 at 1:08 PM, the area located next to the three-compartment sink were the pots and pans were being stored were seven pans that were 12 inches by 24 inches by 3 inches deep, were still wet when they were unstacked. The pans were found to have been stacked wet and not allowed to air dry, one pan also had food remnants on it. The DM confirmed The pans are wet, and they should be allowed to dry before being stacked.''
During an interview on 02/20/24 at 2:35 PM the Corporate Nurse (CN) stated, All plates, pots, and pans should be air dried before stacking and storage.
NJAC: 8:39-17.2 (g)
Jun 2023
1 deficiency
1 IJ (1 facility-wide)
CRITICAL
(L)
📢 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
Deficiency F0658
(Tag F0658)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ164849
Based on observation, interview, review of the medical record and review of other facility documentation, i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ164849
Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to A.) administer physician ordered insulin timely for 18 of 45 residents who receive diabetic medication. This occurred on 2 floors on 4 of 8 units. Failure to administer the prescribed Insulin and/or blood sugars (BS) put diabetic residents at risk for hyperglemic reaction, hospitalization and possible death. On 6/11/2023 at 10:38 AM, Licensed Practical Nurse (LPN) #1 who was assigned to first floor C hall, had not completed her medication pass within the acceptable timeframe parameters. LPN #1 had not administered Insulin and/sliding scale insulin to include blood sugars for 2 residents (Resident #9 and Resident #10) that were due at 7:30 AM.
On 06/11/2023 Unit Manager LPN #1 arrived to 1st floor D unit to complete the medication pass. This included 4 residents (Resident #4, Resident #6, Resident #7 and Resident #8) on insulin/sliding scale Insulin and blood sugars due at 07:30 AM.
On 06/11/2023 at 10:33 am and 11:04 am, LPN #3 was administering medications on the 2nd floor C wing. LPN #3 confirmed that medications were being given late including Resident #1 who received insulin. In addition, Resident #49, #50, #51, #66 and #70 all received their am accuchecks and/or insulin past physican ordered parameters on 6/11/23.
On 6/11/2023 at 11:01, LPN #5 (2nd fl) confirmed that she had not yet administered physician ordered insulin which was due at 07:30 AM for Resident #2. LPN #5 confirmed she had not yet completed her morning medication pass.
Interviews with Residents on 1st floor B unit revealed there was no nurse on the unit on 06/10/2023 and they had not received their scheduled Insulin dose or blood sugars due at 07:30 AM and 11:30 AM on 06/10/2023. LPN #3 who refused to take the assignment of 1st floor B unit on 6/10/2023, which included residents on prescribed Insulin, continued to work on 06/11/2023.
This resulted in an Immediate Jeopardy (IJ) situation which was identified on 06/11/2023 when the facility licensed staff failed to administer prescribed Insulin. The facility Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were notified of the IJ on 06/11/2023 at 05:37 PM. A removal plan was received on 06/12/2023 and was verified by the surveyor on 06/13/2023 at 2:16 PM.
The facility also B.) failed to administer all medications prescribed for the residents by the physician in accordance with acceptable standards of practice.
This deficient practice was evidenced by the following:
Reference: New Jersey Statutes, Annotated Title 45 Chapter 11, Nursing Board. The Nurse Practice Act for the State of New Jersey states; the practice of nursing as a Registered Professional Nurse is defined as diagnosing, and treating human response to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized Physician or dentist.
Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
On 6/11/23 at 11:08 am, Surveyor #2 asked both LPN #1 and Unit Manager LPN on the 1st floor which residents had not yet received their morning medications. The nurses provided Surveyor #2 with the names of those residents who had not yet received their morning medications to include Insulin and blood sugars that were due at 07:30 AM and 08:00 AM.
On 6/11/23 at 11:04 am and 11:01 am, both LPN #3 and LPN #5 confirmed that medication passes for 2 units on the 2nd floor had not yet been completed. LPN #3 and #5 confirmed that medication was to be given at the physican ordered time and nurses had 1 hour (hr.) prior to and 1 hr. after that time to administer medications.
1. Resident #1 (2nd floor) was admitted to the facility with diagnoses including but not limited to: Diabetes Mellitus (DM) and Chronic Obstructive Pulmonary Disease (COPD).
a. A review of the current Order Summary Report (OSR) revealed the following physician orders;
HumaLOG Subcutaneous Solution 100 UNIT/ML (milliliters) (Insulin Lispro) Inject as per sliding scale: if 150 - 200= 2 unit; 201 - 250 = 4 unit; 251 - 300 = 6 unit; 301 -350 = 8 unit; 351 - 4001 = 10 unit, subcutaneously before meals for Diabetes Mellitus (DM) NOTIFY MD if BS is above 400 and below 70, check before meals.
A review of the 6/2023 Medication Administration Record (MAR) confirmed the order for the aforementioned medication and noted it was scheduled to be administered on 6/11/23 at 7:30 am.
Review of the MAR revealed the Humalog Subcutaneous Solution (insulin)10 units was documented as administered at 7:30 am with a BS of 365. Review of the facility electronic Medication Admin Audit Report (MAAR) revealed the insulin was administered at 10:16 am (1 hr. 46 min late).
During an interview with the surveyor on 6/11/23 at 4:50 pm, Resident #1 confirmed that he/she received his/her Blood Sugar (BS) check and insulin late, at around 10:30 am. Resident #1 stated that ususally his/her medications are administered late.
2. Resident #2 (2nd floor) was admitted to the facility with diagnoses including but not limited to: Type 2 DM with Foot Ulcer and COPD.
a. A review of the current OSR revealed the following order;
Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 9 unit subcutaneously before meals for DM.
A review of the 6/2023 MAR confirmed the aforementioned order and noted it was scheduled to be administered on 6/11/23 at 7:30 am. Review of the MAAR revealed the insulin was administered at 11:21 am (2 hr. 51 min late).
During an interview with the surveyor on 6/11/23 at 4:55 pm, Resident #2 did not remember getting insulin that morning. Resident #2 stated most days medications are given late.
b. A further review of the OSR/MAR and MAAR for Resident #2 revealed:
Turmeric Oral Capsule 500 MG Give 1 capsule by mouth one time a day for supplement scheduled 7:00 am-10:00 am was given at 11:19 (19 min. late)
Farxiga Oral Tablet 10 MG scheduled 7:00 am-10:00 am was administered at 11:19 am (19 min late)
CetirizinenHCL Tablet 10 MG Give 1 tablet by mouth one time a day for Allergy symptoms, scheduled 7:00 am-10:00 am was administered at 11:18 am (18 min. late)
Cholecalciferol Tablet 1000UNIT Give 2 tablet by mouth one time a day for supplement 2 tablets=2000mg, scheduled 7:00 am-10:00 am was administered at 11:19 (19 min late)
Aspirin EC Tablet Delayed Release 81 MG Give 1 tablet by mouth one time a day, scheduled 7:00 am-10:00 am was administered at 11:17 (17 min late)
Furosemide Oral Tablet 40 MG Give 1 tablet by mouth one time a day for Hypertension (HTN) scheduled 7:00 am-10:00 am was administered at 11:18 (18 min late)
Cyanocobalamin Tablet 1000 MCG Give 1 tablet by mouth one time a day for supplement, scheduled 7:00 am-10:00 am was administered at 11:18 (18 min late)
Folic Acid Oral Tablet 1 MG Give 1 tablet by mouth one time a day for supplement, scheduled 7:00 am-10:00 am was administered at 11:18 (18 min late)
Metformin HCL Tablet 850 MG Give 1 tablet by mouth two times a day for DM. Take with breakfast and dinner, scheduled 7:30 am was administered at 11:14 (2 hr. 44 min late)
Entresto Oral Tablet 97-103 MG Give one tablet by mouth two time a day for heart failure, scheduled 9:00 am was administered at 11:17 (1 hr. 17 min. late)
Carvedilol Tablet 25 MG Give 1 tablet by mouth two times a day for HTN hold SBP (systolic blood pressure)< 110, scheduled 9:00 am was administered at 11:21 (1 hr. 21 min late)
TIZANidine HCL Tablet 2 MG Give 1 tablet by mouth three times a day for muscle relaxant/back pain, scheduled 10:00 am was administered at 11:14 (14 min late)
3. Resident #3 was admitted to the facility with diagnoses including but not limited to: Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease (ASHD), Peripheral Vascular Disease, Old Myocardial Infarction (Heart Attack), Local Infection of the Skin and Subcutaneous Tissue, Essential Hypertension (HTN), and Major Depressive Disorder.
A review of the current Order Summary Report (OSR) revealed the following physician orders:
Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro) Inject as per sliding scale: is 0-150=0 unit; 151-200 =2 unit; 201-250=4 unit, 251-300=6 unit; 301-350 =8 unit; 351-400=10 unit. If BS (blood sugar) is less than 70 or greater than 401 notify MD (medical doctor) subcutaneously before meals and at bedtime
A review of the MAR for 6/1/2023-6/30/2023 revealed the Insulin Lispro Injection Solution for sliding scale. For the date of 6/10/23 timed at 0730am and 1130am, there was no documentation that the medication had been administered as timed and prescribed. The documented blood sugar at 1730 (5:30 PM) was 400 (normal 70-100).
A review of the Medication Admin Audit Report (MAAR) revealed no documentation of the time of the 0730am and 1130am Lispro as having been administered as prescribed on 6/10/23.
b. A further review of the OSR revealed:
Aspirin Oral Capsule 81mg give 2 capsules by mouth one time a day for supplement
Bacillus Coagulans-Inulin Oral Capsule Give 2 capsule by mouth one time a day for irritable bowel syndrome
Carvedilol Tablet 3.125mg give 1 tablet by mouth two times a day for HTN
Ceftriaxone Sodium Injection Solution Reconstituted 2 GM (grams) Use 2 grams intravenously one time a day for infection for 42 days Sodium Chloride 0.9% intravenous solution 100 ml (milliliter)
Cholecalciferol Tablet 1000 units give one tablet by mouth one time a day for supplement
Docusate Sodium Capsule 100mg give 1 capsule by mouth two times day for constipation
Gabapentin Capsule 100mg give 1 capsule by mouth three times a day for nerve pain
Glycolax Powder give 17 grams by mouth one time a day for constipation 4-6 ounces of water
70 or greater than 401 notify MD (medical doctor) subcutaneously before meals and at bedtime
Lisinopril Tablet 2.5mg give one tablet by mouth one time a day for hypertension
Lovenox Solution 30mg/0.3ml Inject 30mg subcutaneously every 12 hours for blood thinner
Metformin HCL Oral Tablet Give 850mg by mouth two times a day for DM (Diabetes Mellitus)
Plavix Oral Tablet 75mg give one tablet by mouth one time a day for Coronary Artery Disease
Venlafaxine HCL ER Extended Release 24 hour 150mg Give 2 tablet by mouth one time a day for depression
A further review of the MAR revealed Metformin timed at 1000, Aspirin timed at 7-10a, Bacillus Coagulans timed 7-10a, Ceftriaxone timed 0900, Plavix timed at 0900, Carvedilol timed at 1000, Cholecalciferol timed at 1000, Docusate Sodium timed at 1400 (2:00PM), Gabapentin timed at 1000 and 1400 (2:00 PM), Glycolax Powder timed at 0900am, Lisinopril timed at 0900, Lovenox timed at 0900, Venlafaxine timed at 0900.
A further review of the MAAR revealed that Glycolax Powder, Lovenox, Venlafaxine, Cholecalciferol, Carvedilol, Gabapentin at 1000 and 1400, Metformin, and Docusate Sodium indicated no documentation that the medication had been administered as prescribed on 6/10/23. The MAAR reflected that on 6/10/23 the Bacillus Coagulans, Aspirin was documented as administered at 18:10 (6:10 PM), the CefTRIAXone was documented as administered at 16:20 (4:20 PM), Plavix and Lisinopril were documented as administered at 18:11 (6:11pm).
During an interview with the surveyor on 6/11/2023 at 4:45 PM, Resident #3 said when asked if he/she received their blood sugars and/or insulin on 6/10/2023, Resident #3 responded I did not get my blood sugars or Insulin until the second shift came on duty yesterday. We got no meds yesterday.
4. Resident #4 was admitted with diagnoses including but not limited to: Type 2 DM.
A review of the current OSR revealed the following physician orders:
Humalog Solution 100unit/ml (Insulin Lispro) Inject as per sliding scale 0-200 = 0 unit, 201-250= 2 unit, 251-300= 4 unit, 301-350 =6 unit, 351-400 = 8 unit Call if less than 70 or greater than 400 subcutaneously before meals for DM
A review of the MAR dated 6/1/2023-6/30/2023 revealed the order for Humalog Solution inject per sliding scale order. On 6/11/23 at 0730 and 1130am was documentation of 5. According to the Chart Codes 5=Hold/See Nurses Notes.
A review of the PN did not include documentation to indicate why the medication was not administered.
A review of the MAAR revealed the 0730am ordered Humalog was administered at 12:14pm and the 1130am Humalog was administered at 12:14pm (2 doses at the same time). The MAAR also showed that on 6/10/23 the 0730am and the 1130am doses were documented as having been administered at 1750 (5:50 PM) (2 doses at the same time).
5. Resident #6 was admitted with diagnoses including but not limited to: Type 2 DM.
A review of the current OSR revealed the following physician orders: Admelog Injection Solution 100unit/ml (Insulin Lispro) Inject 10 units subcutaneously before meals and at bedtime for DM.
Admelog Injection Solution 100units/ml (Insulin Lispro) Inject as per sliding scale: if 201-250 =2 units, 251-300 = 4 units, 301-350 = 6 units, 351-400 =8 units call MD if less than 70 or greater than 401, subcutaneously before meals for DM
A review of the MAR dated 6/1/2023-6/30/2023 revealed the order for Admelog Insulin Inject 10 units subcutaneously before meals and bedtime for DM. On 6/10/23 at 0730am it was documented as a 2, which according to the Chart Codes indicates refused. On 6/11/23 at 0730am and 1130am, was documentation of a 5. According to the Chart Codes 5=Hold/See Nurses Notes.
A review of the PN did not include documentation to indicate why the medication was not administered nor of the resident refusal.
A review of the [NAME] revealed the 0730am and 1130am Admelog was administered on 6/10/23 at 13:27 (1:27pm) (2 doses) along with the sliding scale and the 1130am insulin and sliding scale was administered at 1340 (1:40 PM). On 6/11/23 the 0730am insulin and sliding scale was documented as administered at 14:18 (2:18 PM) and the 1130am insulin was documented at 13:28 (1:28 PM).
6. Resident #7 was admitted to the facility with diagnoses including but not limited to: Type 1 DM.
A review of the current OSR revealed the following physician orders:
Humalog Solution 100unit/ml (Insulin Lispro) Inject as per sliding scale: if 0-150 units; 151-200=2 units, if 201-250= 4 units, 251-300= 6 units, 301-350= 8 units <70 or > 400 call MD subcutaneously before meals and at bedtime.
Insulin Glargine Subcutaneous Solution Inject 42 units subcutaneously every 12 hours for DMII.
Insulin Lispro Injection Solution 100 unit/ml Inject 10 units subcutaneously with meals for DMII Hole if NPO (nothing by mouth)
A review of the MAR dated 6/1/2023-6/30/2023 revealed the order for Humalog Solution inject per sliding scale order. On 6/11/23 at 0730 was documentation of 5.
According to the Chart Codes 5=Hold/See Nurses Notes. The MAR also indicated that the Insulin Glargine was signed as administered at 9 am by the Unit Manger/Licensed Practical Nurse (UM/LPN#1). The Insulin Lispro on 6/11/2023 was documented as a 5. According to the Chart Codes 5=Hold/See Nurses Notes.
A review of the Medication Admin Audit Report revealed the Humalog and Lispro Insulins were not administered at the prescribed times on 6/10/2023 and 6/11/2023. The audits also reflected that the 9:00 AM dose, that was signed as administered, was documented as having been given at 11:34 AM.
7. Resident #8 was admitted to the facility with diagnoses including but not limited to: Type 2 DM.
A review of the current OSR revealed the following physician order:
Novolog Injection Solution 100 unit/ml Inject as per sliding scale: 0-200 = 0 unit, 201-250= 2 unit, 251-300= 4 unit, 301-350 =6 unit, 351-400 = 8 unit subcutaneously before meals for DM Call MD if glucose level < 70 or >400.
A review of the MAR dated 6/1/2023-6/30/2023 revealed the order for NovoLog sliding scale. There was no documentation on 6/11/23 at 0730am or 1130am to indicate the blood sugar was taken and the medication administered as prescribed.
A review of the PN did not indicate why the insulin had not been administered as prescribed.
A review of the Medication Admin Audit Report revealed there was no documentation that the medication had been administered as timed and prescribed.
8. Resident #9 was admitted to the facility with diagnoses including but not limited to: Type 2 DM.
A review of the current OSR revealed the following orders:
a.Humalog Solution 100unit/ml (Insulin Lispro) Inject as per sliding scale 0-200 = 0 unit, 201-250= 2 units, 251-300= 4 units, 301-350 =6 units, 351-400 = 8 units subcutaneously before meals for DMII Notify MD for BS<70 or>400
A review of the MAR dated 6/1/2023-6/30/2023 revealed the order for HumaLog sliding scale Insulin. There was no documentation on 6/4/2023 to indicate the medication was administered at 0730am or 1130am as prescribed. On 6/11/23 at 0730am was documentation of a 5. According to the Chart Codes 5=Hold/See Nurses Notes.
A review of the Medication Admin Audit Report revealed that the 0730am blood sugar and insulin was administered at 11:01am and the 1130am blood sugar and insulin was administered at 11:02am (2 doses administered).
b. A further review of the OSR revealed:
Amlodipine 10mg tab (tablet) give 1 tablet orally one time a day for HTN hold SBP<110
Aspirin EC Relayed Release 81mg give 1 tablet by mouth one time a day for CVA (cerebral vascular accident).
Calcium Carbonate Oral Tablet 600mg give 1 tablet by mouth one time a day for supplement
Carvedilol Oral Tablet 3.125 mg give 1 tablet by mouth two times a day for HTN
Colace Oral Capsule 100mg give 1 capsule by mouth one time a day for constipation
Duloxetine HCL Oral Capsule Delayed Release Sprinkle 40mg give 1 capsule by mouth one time a day for depression
Iron Oral Tablet 325 (65Fe) mg give 1 tablet by mouth every morning and at bedtime for supplement
Magnesium Oxide 400mg tab give 1 tablet orally one time a day for supplement
Protonix Oral Tablet Delayed Release 40 mg give 1 tablet by mouth one time a day for GERD
Psyllium Oral Packet give 1 packet by mouth one time a day for constipation.
b. A further review of the MAR revealed that on 6/11/2023 the Duloxetine, Amlodipine, Magnesium, Calcium Carbonate, Iron Tablet, Protonix and Psyllium were timed at 7-10a. The Carvedilol, Colace were timed for 0900am.
A review of the PN did not indicate why the insulin had not been administered as prescribed.
The MAAR further showed the Duloxetine, Protonix, Iron Oral, Amlodipine, Magnesium, were documented as administered at 11:02am. The Carvedilol and Aspirin were documented as administered at 10:59am. The Colace was documented as administered at 11:00am.
9. Resident #10 was admitted to the facility with diagnoses including but not limited to: Type 2 Diabetes Mellitus.
A review of the current OSR revealed the following physician orders:
a. Insulin Lispro Injection Solution 100unit/ml inject 10 unit subcutaneously with meals for IDDM (Insulin Dependent Diabetes Mellitus) give prior to snack
Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro) Inject as per sliding scale: is 0-150=0 unit; 151-200 =2unit; 201-250=4 unit, 251-300=6 unit; 301-350 =8 unit; 351-400=10 unit. subcutaneously before meals and at bedtime for diabetes call MD if below 70 or above 400 give prior to snack.
Lantus Subcutaneous Solution 100unit/ml Inject 22 unit subcutaneously two times a day for DM.
a. A review of the MAR dated 6/1/2023-6/30/2023 revealed that there was no documentation on 6/3/23 at 0730am, 0800am and 1200pm the Lantus and Lispro insulin nor the blood sugar sliding scale were administered as ordered. On 6/11/23 at 0730am and 0800am was documentation of a 5. According to the Chart Codes 5=Hold/See Nurses Notes.
A review of the MAAR revealed that on 6/10/23 the 0730am the Lispro sliding scale was administered at 10:38 AM, the 0730am Lantus was administered at 10:38 AM and the Lispro 10 units was administered at 10:40 AM. On 6/11/23 the 07:30am Lispro sliding scale was documented as administered at 12:55pm, Lantus administered at 12:55pm and the Lispro 10 unit administered at 12:55pm (2doses/ same time).
During an interview with the surveyor on 06/11/2023 at 04:50 PM, Resident #10 said he/she did not receive their morning insulin before breakfast. Resident #10 said he/she left their room at 10:30am and the nurse wasn't here and I am supposed to get them before meals.
A review of the PN did not include documentation of why the insulin had not been administered.
b. A further review of the OSR revealed:
Amlodipine Besylate Oral Tablet 5 mg give one tablet by mouth one time a day for HTN hold sbp <110 or hr<60 Notify MD
Aspirin 81 Oral Tablet Chewable give 1 tablet by mouth one time a day for analgesic
Bactrim Oral Tablet 400-80mg give 1 tablet by mouth two times a day for left hip until 7/15/2023
Bumex Tablet 1 mg give 1 tablet by mouth one time a day for edema
Clonidine HCL Oral Table 0.1mg give 1 tablet by mouth every 12 hours for htn hold SBP <110 and HR<60
Coreg 25 mg give 25 mg by mouth every 12 hours for HTN Hold for SBP less than 110
Cyanocobalamin Tablet 1000mcg give 1 tablet by mouth one time a day for supplement
Duloxetine HCL Oral Capsule Delayed Release Particles 20mg give 1 capsule by mouth one time a day on odd days for neuropathy (disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness).
Ferrous Sulfate Tablet 325 (65Fe) mg give 1 tablet one time a day for supplementation/anemia
Flomax Oral Capsule 0.4mg give 1 capsule by mouth one time a day for urinary retention
Fluticasone Propionate Suspension 50Mcg/ACT 1 spray each nostril one time a day for nasal congestion.
Gabapentin Capsule 400mg give 1 capsule by mouth every 8 hours for nerve pain
Glycol Lax Powder give 17 gram by mouth one tie a day for constipation in 4-6 ounces of water
Levaquin Oral Tablet 500 mg give 1 tablet by mouth one time a day for left hip infection until 7/15/2023
Mesalamine Oral Tablet Delayed Release 1.2GM give 2 tablet by mouth one time a day for ulcerative colitis (a chronic inflammatory bowel disease) 2 tabs=2.4gm
Multivitamin Oral Tablet give 1 tablet by mouth one time a day for supplement
Pantoprazole Sodium Tablet Delayed Release 40mg give 1 tablet by mouth one time a day for GERD
Prednisolone Acetate Ophthalmic suspension 1% (percent) instill 1 drop in the left eye two times a day for inflammation administered drops until resolved
Probiotic Oral Capsule give 1 capsule by mouth three times a day for sever urinary yeast infection-pt on long term antibiotics
Sucralfate Oral Tablet 1GM (gram) give 1 tablet by mouth before meals for gastric protection 1 hour before meals
Turmeric Oral Tablet 500mg give 1 tablet two times a day for joint pains
b. A further review of the MAR showed that the Bactrim, Levaquin, Prednisolone, Probiotic were timed for 1000am. The Amlodipine, Clonidine, Coreg, Bumex, Flomax Mesalamine and Turmeric, Cyanocobalamin, Duloxetine and Fluticasone were timed at 0900am. The Multivitamin and Pantoprazole, Ferrous sulfate and Glycolax were timed at 7-10a.
A further review of the MAAR showed the Multivitamin, Pantoprazole, Ferrous Sulfate, Glycolax, Flomax, Bactrim, were documented as administered on 6/11/23 at 12:47pm.
The Sucralfate timed at 0730am was documented as administered at 12:44pm and the 11:00am dose was documented as administered at 12:47pm on 6/11/23. The Bumex, Aspirin, Amlodipine, Coreg were documented as administered at 12:45pm. The Clonidine, Duloxetine, Cyanocobalamin, Mesalamine, Turmeric, Levaquin, Prednisolone, Probiotic were documented as administered at 12:46pm on 6/11/23.
10. Resident #13 was admitted to the facility with diagnoses including but not limited to: Type 2 Diabetes Mellitus.
a. A review of the current OSR revealed the following physician orders:
Humalog Solution 100unit/ml (Insulin Lispro) Inject as per sliding scale: if 70-150 units; 151-200=2 units, if 201-250= 4 units, 251-300= 6 units, 301-350= 8 units, 351-400 = 10 unit subcutaneously in the morning for IDDM before breakfast call MD if below 70 or above 400.
A review of the MAR dated 6/1/2023-6/30/2023 revealed the order for HumaLog sliding scale Insulin timed at 0800am. On 6/10/23 at 0800am was signed as having been completed. On 6/11/23 at 0800am was documentation of a 5. According to the Chart Codes 5=Hold/See Nurses Notes.
A review of the MAAR revealed the 6/10/23 the 0800am Humalog blood sugar/dose was administered at 21:05 (9:05 PM). On 6/11/23 the 0800am blood sugar and insulin was administered at 14:15 (2:15 PM).
b. A further review of the OSR revealed:
Amlodipine Besylate Oral Tablet 10 mg give one tablet by mouth one time a day for HTN hold sbp <110 or hr<60 Notify MD
Aspirin EC Tablet Delayed Release 81mg give 1 tablet by mouth one time a day for supplement
Carvedilol Oral Tablet 25 mg give 1 tablet by mouth two times a day for hold heart rate <60 or BP <120
Clopidogrel Bisulfate Oral Tablet 75mg give 1 tablet by mouth one time a day for PPX dvt (deep vein thrombosis) monitor for s/s of bleeding
Glimepiride Tablet 2 mg give one tablet by mouth one time a day for diabetes
Isosorbide Mononitrate Oral Tablet give 30 mg by mouth in the morning for angina (chest pain)
Metformin HCI Oral Tablet 850 mg give 1 tablet by mouth two times a day for DM take with breakfast and dinner
b. A further review of the MAR revealed the that the Carvedilol, Amlodipine, and Isosorbide were timed at 0900am. The Metformin was timed for 0730am. The Clopidogrel, Aspirin, Glimepiride were timed 7-10am. The MAR documentation indicated a 2 which according to the chart codes indicated the Resident refused the medication.
A further review of the MAAR reflected that the Aspirin, Glimepiride, Clopidogrel, Metformin, Isosorbide, Amlodipine and Carvedilol were documented as having been refused on 6/11/2023 at 14:16 (2:16 PM)
11. Resident #14 was admitted to the facility with diagnoses including but not limited to: Type 2 Diabetes Mellitus, Urinary Tract Infection, Unspecified Psychosis, Peripheral Vascular Disease, Hyperlipidemia and Constipation.
a. A review of the current OSR revealed the following physician orders:
Insulin Lispro Injection Solution Inject as per sliding scale: if 70-150 units; 151-200=2 units, if 201-250= 4 units, 251-300= 6 units, 301-350= 8 units, 351-400 = 10 unit subcutaneously before meals and at bedtime for IDDM call MD if below 70 or above 400.
A review of the MAR dated 6/1/2023-6/30/2023 revealed the order for the blood sugar sliding scale Lispro insulin timed at 0730am, 1130am, 1730 (5:30 PM) and 2100 (9PM). On 6/10/23 there was no documentation to indicate the medication was administered at 0730am or 1130am as ordered.
A review of the MAAR did not include documentation that the blood sugar sliding scale was administered as prescribed on 6/10/23 at 0730am or 1130am.
b. A further review of the OSR revealed:
Abilify Tablet 10 mg give one tablet by mouth one time a day for depression.
Alogliptin Benzoate Oral Tablet 25 mg give 1 tablet by mouth one time a day for diabetes.
Aspirin EC Tablet Delayed Release 81mg give 1 tablet by mouth one time a day for ppx (prophylaxis).
Atorvastatin Calcium Tablet 40 mg give 1 tablet by mouth one time a day for hyperlipidemia
Cipro Oral Tablet 500mg give 1 tablet by mouth two times a day for UTI for 10 days
Colace Capsule 100mg give 1 capsule by mouth two times a day for constipation
Flomax Capsule 0.4mg give 2 capsule by mouth one time a day for BPH 2 caps =0.8mg
A further review of the MAR revealed the Aspirin EC, Abilify, Atorvastatin, and Alogliptin, timed at 7-10am Cipro oral tab and Colace all timed at 0900am did not include documentation that the medication had been administered as ordered.
A review of the MAAR did not include documentation that the blood sugar sliding scale was administered as prescribed on 6/10/23 at 0730am or 1130am. A further review of the MAAR revealed the Aspirin EC and Atorvastatin were administered at 19:45 (7:45 PM). The Abilify, Alogliptin, Cipro, and Colace did not include documentation of having been administered on 6/10/23.
12. Resident #15 was admitted to the facility with diagnoses including but not limited to: Type 2 Diabetes Mellitus, Cerebral Infarction (stroke) Atherosclerotic Heart Disease (ASHD) Chronic Atrial Fibrillation (abnormal heartbeat), Gastrointestinal (GI) Bleed and Cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body).
A review of the current physician orders revealed the following physician orders:
Insulin Lispro Subcutaneous Solution Cartridge 100unit/ml Inject 3 unit subcutaneously with meals for IDDM (insulin dependent diabetes mellitus)
Humalog Solution 100unit/ml (Insulin Lispro) Inject as per sliding scale 0-200 = 0 unit, 201-250= 2 unit, 251-300= 4 unit, 301-350 =6 unit, 351-400 = 8unit Call if less than 70 or greater than 400 subcutaneously before meals for DM
A review of the MAR dated 6/1/2023-6/30/2023 revealed the order for HumaLog blood sugar sliding scale insulin timed at 0730am and 1130am and 1730 (5:30 PM). An order for Lispro timed at 0800am, 1200pm and 1800 (6PM.) There was no documentation to indicate the medication had been administered as prescribed on 6/10/23.
A review of the PN did not include documentation as to why the medications were not administered.
A review of the MAAR did not include documentation that the HumaLog blood sugar and sliding scale insulin and the Lispro Insulin were administered as prescribed at the indicated times.
13. Resident #16 was admitted to the facility with diagnoses including but not limited to: Type 2 Diabetes, Bipolar Disorder, Schizophrenia, Toxic Encephalopathy, Essential Hypertension (HTN).
a. A review of the current OSR revealed the following physician orders:
Humalog Solution 100unit/ml (Insulin Lispro) Inject as per sliding scale 0-200 = 0 unit, 201-250= 2 unit, 251-300= 4 unit, 301-350 =6 unit, 351-400 = 8 unit Call if less than 70 or greater than 400 subcutaneously in the morning for DM before breakfast.
A review of the MAR dated 6/1/2023-6/30/2023 revealed the order for HumaLog blood sugar sliding scale insulin timed at 0800am. There was no documentation that the medication had been administered as prescribed on 6/10/23.
A review of the MAAR revealed there was no documentation that the Humalog sliding scale insulin and blood sugar had been administered as prescribed.
b. A further review of the OSR revealed:
Benztropine Mesylate Oral Tablet 1 mg give 1 tablet by mouth two times a day [TRUNCATED]
Jun 2023
14 deficiencies
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 observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to provide privacy and promote dignity during resident assessme...
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Based on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to provide privacy and promote dignity during resident assessment. This deficient practice was identified for 1 of 1 resident (Resident #120) reviewed for dignity.
This deficient practice was evidenced by the following:
On 05/22/23 at 10:51 AM, the surveyor entered the second floor nurse's station and observed the Nurse Practitioner as he listened to Resident #120's lung sounds with a stethoscope as the resident stood outside of the day room in the presence of other residents and staff. When interviewed at that time, the Nurse Practitioner stated that he usually assessed the resident in his/her room but the resident had a tendency to walk out of the room as he/she was a wanderer.
According to the admission Record Resident #120 was admitted to the facility with diagnosis which included but were not limited to: Dementia without behavioral disturbance, chronic obstructive pulmonary disease (COPD, condition of constriction of the airways and difficulty or discomfort in breathing) and atrial fibrillation (irregular heart beat).
Review of Resident #120's Quarterly Minimum Data Set (MDS), an assessment tool dated 04/28/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated that the resident was severely cognitively impaired.
On 05/22/23 at 11:50 AM, the surveyor interviewed the Second Floor C/D Unit Manager (UM) who stated that she observed the tail end of the Nurse Practitioner as he examined Resident #120 in front of the day room. The UM stated that resident privacy was required to be maintained at all times. The UM stated that the Nurse Practitioner should have taken the resident back to his/her room and pulled the curtain closed for privacy prior to examination. The UM stated that Resident #120 was easily redirected and pleasant.
On 05/22/23 at 1:28 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the Nurse Practitioner should have taken Resident #120 back to his/her room to listen to his/her lungs because it was both a dignity and privacy issue.
On 06/02/23 at 12:06 PM, the surveyor interviewed the Regional Director of Clinical Services (RDCS) in the presence of the Administrator. The RDCS stated that when the Nurse Practitioner performed an assessment on Resident #120 in the presence of other residents and staff it was a violation of both dignity and resident rights.
Review of the facility policy titled, Quality of Life/Dignity: (Revised 10/2021) revealed the following:
Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.
Residents shall be treated with dignity and respect at all times.
NJAC 8:39 4.1(a) 12
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to provide reasonable space to allow the resident to move abou...
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Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to provide reasonable space to allow the resident to move about the room without impairment. This deficient practice was identified for 1 of 3 residents (Resident #91) reviewed for position and mobility.
This deficient practice was identified by the following:
On 05/24/23 at 11:19 AM, the surveyor observed Resident #91 who self-propelled in the wheelchair with notable right sided weakness. The resident reportedly was unable to access his/her night stand or get out of bed on the left side as Resident #160's bed was placed horizontally against the wall and was pushed snugly up against Resident #91's night stand. CNA #3 was present and stated that she realized that Resident #160's bed was too far over and blocked the Resident #91 access to his/her night stand but she had not reported it to maintenance. CNA #3 stated that Resident #160's bed and night stand should have pushed over so that Resident #91 had more room to get in and out of bed.
On 05/25/23 at 11:32 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated that Resident #91 previously mentioned to her that Resident #160's bed was placed up against the wall and impaired his/her ability to access their night stand and left side of the bed. LPN/UM #2 further stated that she believed that she let Maintenance know, but she did not log it in the Maintenance Book. LPN/UM #2 further stated that Resident #91 liked the keep their independence.
On 05/25/24 at 9:40 AM, the surveyor interviewed the Maintenance Director (MD) who stated that if staff observed anything in need of repair they placed the request in the Log Book. The MD stated that some requests were verbal, and the work was completed and not documented. The MD did not recall receiving a request to move Resident #160's furniture to accommodate Resident #91's ability to move more freely about the room.
On 05/26/23 at 11:38 AM, the surveyor observed Resident #91 lying in bed and the resident voiced that they were pleased that Resident #160's furniture were moved over so the resident was now able to access their night stand and bed more easily.
On 06/02/23 at 10:38 AM, during an interview with Administrator, Director of Nursing (DON), and Regional Director of Clinical Services (RDCS), the DON stated that staff should write concerns in the Maintenance Log in addition to calling the MD so that requests were documented for follow-up.
NJAC 8:39 31.1(b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to provide a safe, clean and homelike environment. This defici...
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Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to provide a safe, clean and homelike environment. This deficient practice was identified for 1 of 8 nursing units (Unit 2 B) in 2 of 3 residents (Resident #45 and #160) observed for incontinence care
This deficient practice was evidenced by the following:
1. On 05/22/23 at 11:36 AM, the surveyor entered Resident #160's room and noted that there were two large holes in the wall behind the entry door of the room with exposed mesh. The area surrounding both holes had a thick, white coating around them which differed from the color the room was painted. The surveyor asked the resident how long the holes were there? The resident responded, The holes have been there forever.
On 05/24/23 at 9:44 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #3 who stated that the two holes behind Resident #160's door had been there for months. CNA #3 stated that she had not reported the holes herself, but maintenance already knew about it. CNA #3 stated that the holes were fixed once, though she was not sure when. CNA #3 further stated that they needed to put a door stopper on the door to prevent it from happening again.
On 05/24/23 at 11:05 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated that she never noticed the holes behind the entry door in Resident #160's room. LPN #1 stated that if she needed something repaired, she phoned maintenance.
On 05/24/23 at 11:45 AM, the surveyor interviewed the Maintenance Director (MD) who stated that the holes in Resident #160's room were recently repaired. The MD stated that the residents always said that it has been like that for months, but he alleged that was not the case. The MD identified the thick white substance around the holes as spackle (compound used to fill cracks). He further stated that the spackle indicated that the holes were repaired recently. The MD was unable to state when the holes were filled and spackled or when he planned to paint the area.
On 05/24/23 at 12:39 PM, the surveyor interviewed the MD who stated that he completed walking rounds of the nursing units to ensure that every room in the facility was observed within the month. The MD stated that either staff completed a request in the maintenance log or maintenance noted items that needed repair during rounds. The MD stated that the spackling was done recently, though he was unable to provide the exact date and time. He stated that normally he let the spackle dry for a couple of days, then he sanded and painted. The MD stated that he did random tackling to get the work done and did not have an itinerary in place or documented evidence of completion. The surveyor asked the MD how he ensured that projects were completed? He acknowledged that he did not systematically track work orders and stated, I am going to start doing that. The MD stated that he made notes for himself, but discarded them when finished. The MD provided the surveyor with work orders that were completed on the nursing unit for March and April 2023 which did not contain a request to repair the holes in the resident's wall.
On 05/25/23 at 11:32 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated that she was not aware that there were holes in the wall in Resident #160's room. LPN/UM #2 stated that she would have called maintenance to follow-up if she had known.
On 05/25/23 at 12:34 PM, the surveyor interviewed the Administrator who stated that there were a number of special projects that were completed throughout the building such as spackling and painting. He stated that once an area was spackled it should have been painted within a week.
2. On 05/24/23 at 10:00 AM, the surveyor accompanied Certified Nursing Assistant (CNA) #3 as she provided incontinence care to Resident #45 whose brief and linens were saturated with urine. When CNA #3 removed the sheets from the resident's bed the surveyor noted that there were holes and rips in the resident's mattress. CNA #3 proceeded to clean the mattress which glistened from moisture. When interviewed at that time CNA #3 stated, They will place another resident in this same bed when the resident leaves.
According to the admission Record (an admission summary) Resident #45 was admitted to the facility with diagnosis which included, but were not limited to: cerebral infarction (stroke), morbid obesity, osteoarthritis, difficulty walking and Hepatitis C (a form of viral hepatitis that is transmitted in infected blood, causing chronic liver disease).
On 05/24/23 at 11:26 AM, the surveyor accompanied CNA #3 to Resident #160's room to perform AM care. The resident's clothing and linens were saturated with urine. CNA #3 removed the soiled linens from the resident's bed and the surveyor noted both cracks and rips in the mattress. When the surveyor asked CNA #3 if she reported the condition of the mattresses and she stated that she had not reported it to maintenance.
According to the admission Record, Resident #160 was admitted to the facility with diagnosis that included but were not limited to: difficulty in walking, osteoarthritis, Human Immunodeficiency Virus (HIV), Parkinsonism (a disorder of the central nervous system that affects movement).
On 05/24/23 at 11:45 AM, the surveyor interviewed the MD and his assistant regarding the condition of Resident #45 and Resident #160's mattresses. The assistant stated that it was an issue if urine and feces seeped into the rips, tears, and holes in the mattress. The MD was unable to provide the surveyor with documented evidence that the mattresses were routinely inspected. Review of the Maintenance Log for the nursing unit failed to contain documented evidence that the nursing staff reported the condition of either resident's mattresses to maintenance or administration to be assessed for replacement.
On 05/25/23 at 10:59 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated that she had noted cracks and rips in the resident's mattresses and stated that if urine and feces seeped into the mattress it could cause both mold and infection.
On 05/25/23 at 11:15 AM, the surveyor and Licensed Practical Nurse/Unit Manager (LPN/UM) #2 entered Resident #45's room to assess the condition of the resident's mattress and found the room unoccupied. LPN/UM #2 stated that it did not look like the resident had received incontinence care since last night as the linens were heavily soiled with a yellow substance. LPN/UM #2 removed the resident's sheets from the bed to assess the mattress. LPN/UM #2 stated if the mattress was ripped and soaked with urine it could cause mold and bacteria and that was an infection control issue.
On 05/25/23 at 12:15 PM, the surveyor interviewed the Administrator, Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) regarding the outcome of the incontinence tour and the condition of both Resident #45 and Resident #160's mattress. The RDCS who stated that she served as a consultant to the facility for infection control related issues and was CIC (Certification in Infection Prevention and Control) certified, stated that if urine and feces seeped into the cracks, rips, or tears in the mattress it would an infection control issue.
NJAC 8:39 19.4, 31.4(a)(b)(e)(f), 4.1(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of medical records and other facility documentation, it was determined that the faci...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Annual Minimum Data Set (MDS), an assessment tool for 3 of 4 residents (Resident #169, Resident #87, and Resident #45) reviewed for smoking.
This deficient practice was evidenced by the following:
1. On 05/17/2023 at 11:01 AM, during the initial tour of the facility Resident #169 was observed ambulating in the hallway towards the room. The resident told the surveyor they were just on a smoke break.
Review of the admission Record indicated that Resident #169 was admitted to the facility on 03/2023. Medical diagnoses included, but not limited to surgical aftercare following surgery on the digestive system, abscess (collection of pus) of the abdominal wall, anxiety disorder and bipolar disease (psychiatric illness that has both depressive and manic episodes).
Review of the admission MDS, dated [DATE] showed the resident had a Brief Interview of Mental Status of 12, meaning the resident had moderate cognitive impairment.
On 05/22/2023 at 11:00 AM, the surveyor reviewed Resident #169 admission Assessment, dated 03/03/2023 which indicated the resident was a smoker and was assessed as a safe smoker, meaning a smoking apron was not needed during smoking.
On 05/22/2023 at 11:30 AM, the surveyor reviewed Resident #169 care plan, initiated 03/06/2023. The care plan had a focus stating the resident was a smoker. Goals included remaining free from injury related to smoking, and interventions included education on benefits of smoking cessation and smoking rules and policies, and that the resident would be assessed regularly for smoking safety.
On 05/22/2023 at 11:38 AM, the surveyor reviewed Resident #169 admission Minimum Data Set (MDS), an assessment tool dated 03/09/2023. Under Section J titled Health Conditions, number J1300 for Current Tobacco Use was entered as zero, meaning no current tobacco use.
On 05/25/2023 at 09:59 AM, the surveyor interviewed the Minimum Data Set Coordinator (MDSC). The surveyor asked the MDSC what sections of the MDS were completed by which facility staff and the MDSC said, I do sections A and B, the social worker does C and D, Section F is completed by the Activities Department, GG is completed by me along with the Interdisciplinary Team and K was completed by the dietician. The surveyor asked who was responsible for section J, the Health conditions section of the MDS and she responded, I do that section. The surveyor asked how she is made aware when the resident is a smoker and the MDSC said it was in the admission Assessment that was completed by the nursing Supervisor, or she asks the activities department or social services. The surveyor then asked the MDSC to look at section J of the admission MDS for Resident #169 and she responded, Oh, that resident is a smoker.
2. The surveyor reviewed the admission Record for Resident #87 which reflected that the resident was admitted on 11/2018 with diagnoses that included atrial fibrillation, depression, anxiety disorder, schizophrenia, and hypertension (high blood pressure).
On 05/24/2023 at 09:59 AM, the surveyor observed Resident #87 smoking in the designated second floor smoking area.
The surveyor reviewed Resident #87's Annual MDS dated [DATE]. The section J1300 for current tobacco use was coded as zero (0), indicating that Resident #87 does not currently use tobacco.
The MDS Coordinator was interviewed on 06/02/2023 at 11:25 AM and confirmed that Resident #87's Annual MDS dated [DATE] should have been coded as a 1 to indicate Resident #87 was a yes for tobacco use.
Further review of the Annual MDS dated [DATE] revealed that Section A1500 under Preadmission Screening and Resident Review (PASRR) was coded as zero (0) but should have been coded as a 1 to indicate Yes that Resident #87 had been evaluated by Level II PASRR and was determined to have a serious mental illness and/or mental retardation or a related condition.
The MDS Coordinator was interviewed on 06/02/2023 at 11:25 AM and confirmed that Resident #87's Annual MDS dated [DATE] should have been coded as a 1 to indicate Resident #87 was evaluated and equated it to human error.
On 06/06/23 at 11:20 AM, the surveyor reviewed the policy titled, Smoking Program, dated 06/2022. Under the procedure section, number three it indicated that a smoking evaluation will be completed in the Electronic Health Record on admission/readmission, quarterly, annually, smoking contract violation and or change in smoking status or privileges. Section 3 (e) indicated that a dated current list of residents who smoke will be maintained by Social Services and distributed to the Interdisciplinary Team.
3. On 05/25/23 at 10:00 AM, the surveyor reviewed Resident #45 smoking assessment which indicated that Resident #45 was safe to smoke at the facility. The surveyor then reviewed Resident #45 annual Minimum Data Set (MDS), dated [DATE]. Under section J, titled tobacco use was marked as zero, meaning the resident was not a smoker.
On 05/25/23 at 10:09 AM, the surveyor interviewed the MDS Coordinator. The MDS coordinator reviewed the MDS, and she stated, If I got it wrong, I know why, this was my first quarterly doing it, and I must have missed it. The MDS coordinator stated, Next quarter, I would double check with activities.
NJAC 8:39-11.2 (e)1
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
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 implement a physician's order for an orthosis (a device to correct alignment)...
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Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to implement a physician's order for an orthosis (a device to correct alignment).
The deficient practice was identified for 1 of 3 residents (Resident #67) reviewed for positioning and was evidenced by the following:
Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The nurse practice act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
According to the admission Record, Resident #67 was admitted with diagnosis that included, but were not limited to, hemiplegia (a loss of strength) affecting the left side.
A review of Resident #67's admission Minimum Data Set an assessment tool dated 11/17/22 revealed that he/she was cognitively intact and has range of motion impairment of one side of the upper and lower extremity.
On 05/17/2023 at 12:09 PM, the surveyor observed Resident #67 in bed with his/her computer. Also observed left ankle foot orthoses (LAFO) in his/her room. Resident #67 stated the staff assist him/her with putting the shoes on daily.
On 5/22/2023 at 1:43 PM, the surveyor observed Resident #67 wearing a LAFO on his/her left leg.
Upon review of Resident #67's Physician's Order (PO), the surveyor could not find a PO for the LAFO.
On 05/24/2023 at 12:17 PM, the surveyor interviewed the Director of Nursing (DON) and the Regional Director of Clinical Services. (RDCS) The DON stated there should be an order but not one that has to be signed out. The RDCS stated she cannot find a PO but further confirmed there should a physician's order.
A review of the facility policy Physician Orders with a revised date of 02/20/2020 reveals physician orders will include a correlating medical diagnosis or reason.
NJAC:8:3927.1 (a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ#00158216, NJ#00157947, NJ#00158017, and NJ#00158731
Based on interview, and record review it was determined that the facility...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ#00158216, NJ#00157947, NJ#00158017, and NJ#00158731
Based on interview, and record review it was determined that the facility failed 1.) to clarify a physician's order for wound care consistent with professional standards of practice to promote wound healing for Resident #284 and 2.) to follow an active physician's order for the daily wound care treatment for Resident #103.
This deficient practice was identified for 2 of 3 residents reviewed for pressure ulcers (Resident #284 and Resident #103), and was evidenced by the following:
1. Resident #284 was admitted to the facility and had diagnoses which included, but was not limited to fracture of the second cervical vertebra and chronic kidney disease.
A review of the order Summary Report with active orders as of 9/5/22 reflects a physician order (PO) dated 9/5/22 for Santyl Ointment (a cream used for wound care) 250unit/MG (collagenase) apply to per additional directions topically everyday shift for wound care. There is no location specified. A review of the September 2022 Medication Administration Record (MAR) reflects that the resident is receiving the wound care however there is no location specified. A review of the location of Administration Report dated 9/1/2022 thru 9/30/2022 reflects the location of administration for the Santyl ointment as other.
On 05/30/23 at 2:31 PM, the surveyor interviewed the 3 to 11 Registered Nurse Supervisor. She stated she did the admission evaluation dated 9/5/22. It reflected that Resident #284 had a pressure ulcer to his/her sacrum and scabs to elbows and left great toe. She thinks the santly was for the sacrum but can't be certain. She stated the order for santyl should have a location on it.
On 05/31/23at 02:56 PM, the surveyor reviewed the Comprehensive Care Path assessment dated [DATE] which reflected that Resident #284 was admitted with scabs to bilateral elbows and left great toe. It also reflected that Resident #284 was admitted with a sacral ulcer with santyl in progress to sacrum. At that time the surveyor interviewed the 3 to 11 Registered Nurse who stated that the santyl order should specify a location.
McCrayreid, [NAME]
2. Resident #103 was admitted to the facility and had a diagnosis that included acute osteomyelitis (bone infection) of right ankle and foot, type 2 diabetes (high blood sugar), quadriplegia (paralysis of upper and lower extremities), chronic respiratory failure, end stage renal disease (kidney failure), dependence on renal dialysis, major depressive disorder, pressure ulcer of right heel, and an unstageable, pressure ulcer of right heel
On 5/23/2023 at 11:33 AM, the surveyor reviewed the physician-signed Physician's Order Form which included a physician's order to apply treatment daily to the right heel per Medical Doctor (MD) order to aid in the prevention and/or healing of pressure sores and document progress of the wound heeling on an ongoing basis.
Review of the Minimum Data Set (MDS), an assessment tool dated 05/06/2023 showed the resident had a Brief Interview of Mental Status (BIMS) of 15, meaning the resident was cognitively intact and totally staff dependent for activities of daily living.
On 05/31/2023 at 10:15 AM, the surveyor observed Resident #103 sitting in the room listening to music. When interviewed at that time, the resident informed the surveyor that there was one staff member that consistently changed his/her wound, but there were times when that nurse was out and the other nurses did not complete the wound treatment. The resident could not recall specific dates but did refer to September and October 2022.
At that same date and time, a review of the September 2022 Treatment Administration Record (TAR) reflected that the resident received the wound care for the month of September 2022, however there were two dates on 09/21/2023 and 09/29/2023, that were blank to confirm no treatment was completed on those 2 days.
A review of the Progress notes (PN) dated 09/12/2022, revealed the Social Worker (SW) saw the resident per resident's request. Resident had filed a grievance about his/her care. SW spoke with clinical team and wrote up two grievances.
On 5/31/2023 at 02:01 PM, the surveyor interviewed the SW who stated it was not the SW who wrote the PN but was aware of Resident #103. The current SW stated they was not aware of any concerns regarding his/her care at this time and was not made aware of any outstanding grievances for Resident #103 when the SW started at the facility in January 2023, so SW could not speak to that and was unable to provide any grievances to reflect Resident's #103 concern of care during that time.
A review of the facility policy titled Physician Orders revised on 2/2020 reflects that medication orders should be followed and will include name of drug, route, dosage, frequency, diagnosis, and stop date if appropriate.
NJAC 8:39 - 27.1 (a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observations, interview, review of medical records and other facility documentation, it was determined that the facility failed to ensure that a resident with decreased range of motion (ROM) ...
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Based on observations, interview, review of medical records and other facility documentation, it was determined that the facility failed to ensure that a resident with decreased range of motion (ROM) and mobility received prescribed treatments to prevent contractures (Deformity of joints) and maintain current level of function for 1 of 3 residents reviewed for decreased ROM (Resident #91).
This deficient practice was evidenced by the following:
During the initial tour of the facility on 05/17/23 at 11:20 AM, Resident #91 was observed self-propelling in the wheelchair with notable right sided weakness. The resident motioned the surveyor into his/her room and showed the surveyor a right hand splint that was on the window sill and was reportedly not offered to the resident for assistance with application.
According to the admission Record, Resident #91 was admitted to the facility with diagnosis which included, but were not limited to: sequelae of cerebral infarction (stroke), hemiplegia (paralysis on one side of body) and Hemiparesis (weakness or inability to move one side of the body) following cerebral infarction affecting right dominant side, aphasia (impaired speech), and bipolar disorder (psychiatric condition).
Review of Resident #91's admission Minimum Data Set (MDS), an assessment tool dated 03/08/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 9 out 15 which indicated that the resident was moderately cognitively impaired. Further review of the MDS indicated that the resident required extensive assistance of one person for bed mobility, transfer, dressing, toilet use and personal hygiene and had impairment on one side of the body in upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot).
Review of the Physician's Orders that were contained within Resident #91's electronic health record (EHR) revealed an order that was placed on 04/13/23 for Patient to wear a resting hand splint on RUE (right upper extremity) 3.5-6 hrs a day. The surveyor reviewed both the Treatment Administration Record (TAR) and the Medications Administration Record (MAR) and the order was not found in either document to indicate staff accountability for RUE splint application as ordered.
Review of Resident #91's Care Plan revealed that there were no goals or interventions related to a RUE hand splint application.
On 05/22/2023 at 11:36 AM, the Resident #91's RUE hand splint was observed on the window sill.
On 05/24/2023 at 11:19 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #3 who stated that Resident #91 was independent with care and she only assisted the resdient to shower and make his/her bed.
On 05/24/2023 at 11:05 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated that the resident did not have any splints ordered, only lotion.
On 05/24/2023 at 11:14 AM, the surveyor observed Resident #91 self-propelling in the wheelchair in the hallway and the resident did not have his/her RUE hand splint on.
On 05/25/2023 at 11:32 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated that she believed that Resident #91 had a splint, but would have to clarify. LPN/UM #2 looked in the computer and stated that it looked like an order was placed by Occupational Therapy (OT) on 04/13/2023 for a hand splint to be worn three and a half to six hours a day as tolerated. LPN/UM #2 stated that the order should have been placed under scheduling details, but that was not completed so the order did not appear on the MAR/TAR for nursing to assist the resident with splint application. LPN/UM #2 stated that therapy also came to the unit and provided staff education on splint usage.
On 05/26/2023 at 10:01 AM, the surveyor interviewed the Director of Rehabilitation/Speech Language Pathologist (DOR/SLP) who stated that best practice was to make a recommendation via a triplicate form for the Unit Manager (UM). At that point, the UM wrote the order for the splint and updated the care plan to include splint usage. The DOR/SLP stated that the OT probably placed the order in the EHR incorrectly and did not enter scheduling details. She explained that either nursing or the aides could place the splint on the resident. The DOR/SLP confirmed that on 04/03/2023 a Therapy In-Service was completed with the staff who were educated on splint use and indicated that Resident #91 would tolerate hand splint on RUE for a minimum of three to five hours and maximum of six hours daily with nursing encouragement. She stated that either nursing or the aides could apply the splint and nursing did daily skin checks.
In a later interview with the DOR/SLP on 05/26/23 at 10:50 AM, she stated that the purpose of the RUE hand splint was to decrease the risk of contractures (shorteningand hardening of muscles and tendons). The Occupational Therapist (OT) who was present at that time, explained that the splint decreased contractures and maintained the resident's range of motion. The OT stated that OT placed orders in the EHR, but they did not schedule them and that was why management follow-up was needed. The OT further explained that Resident #91 needed the RUE splint solely to maintain their current level of function as the resident was not at risk for contractures.
On 05/26/23 at 11:38 AM, Resident #91 was observed lying in bed awake. The resident stated that he/she did not have their RUE splint on and stated that it was in the bottom drawer across the room. The surveyor confirmed that the splint was in the drawer and out of the resident's reach.
On 05/26/23 at 11:54 AM, the surveyor interviewed CNA #1 who stated that the resident was only assisted to shower and did not use a RUE splint on their hand.
On 05/26/23 at 12:02 PM, the surveyor interviewed LPN #1 who stated that she was not aware that Resident #91 needed a RUE splint and it was not on the MAR/TAR, only lotion was ordered. LPN #1 further stated that she was not informed by the LPN/UM #2 or nursing in report that the resident required a RUE splint.
On 05/26/2023 at 12:20 PM, the surveyor interviewed LPN/UM #1 who stated that Resident #91 used to wear a splint on the RUE but some how it fell through the cracks. LPN/UM #1 recalled that therapy provided a staff in-service and educated the staff about splint usage. LPN/UM #1 stated that she saw the resident wear the splint at times but did not question it.
On 05/26/2023 at 1:41 PM, the surveyor interviewed CNA #1 who reviewed ADLs (activities of daily living) with the surveyor in the Kiosk. CNA #1 stated that Resident #91 now had an entry for a right hand splint to wear as tolerated with directions for used provided in the link to the resident's care plan. CNA #1 stated that she was unaware of that the resident needed a splint previously.
On 05/31/2023 at 12:41 PM, the surveyor observed Resident #91 lying in bed and the resident's splint was on the window sill. The resident stated that he/she had given up on staff putting it on. The resident stated that he/she could not move to get over to the window sill and could not put it on alone.
On 05/31/2023 at 12:43 PM, the surveyor interviewed CNA #3 who stated that Resident #91 usually put the RUE splint on themselves.
On 06/02/2023 at 10:26 AM, in the presence of the LPN/UM #2, Resident #91 stated that he/she could now apply the splint themselves on their right hand. The resident stated that it was hard for them to do independently as the resident was right handed. The resident stated, If I do not do it, nothing gets done. The resident demonstrated that he/she was able to to donn (put on) the splint and did so with some difficulty.
On 06/02/2023 at 12:06 PM, in an interview with the Administrator, Director of Nursing (DON), Regional Director of Clinical Services (RDCS) the RDCS stated that the CNAs were educated on offering the splint to Resident #91 as the resident required assistance to donn the RUE splint.
Review of the facility's policy, Appliances-Sprints [sic.}, Braces and Slings (Revised 4/19) revealed the following:
In order to protect the safety and well-being of residents, and to promote quality care, this facility uses appropriate techniques and devices for appliances, splints, braces and slings. To assure all splints, braces, slings etc. are used appropriately and cared for properly and upper and lower extremities are maintained in a functional position.
Nursing:
Ensures proper schedule for donning and doffing (removal) appliance is known by CNA staff and provides appropriately sign off of task options.
Ensures the staff is aware where device is to be stored and cared for
Release devices/appliances per physician order
NJAC 8:39-27.2(m)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ#00158216
Review of the residents admission Record revealed Resident #284 was admitted to the facility with diagnosis that inc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ#00158216
Review of the residents admission Record revealed Resident #284 was admitted to the facility with diagnosis that included, but was not limited to fracture of the second cervical vertebra and chronic kidney disease.
On 06/02/23 at 10:00 AM, the surveyor reviewed the facility provided Quality Assurance (QA) report regarding Resident #284. The report indicated the resident was found on the floor on 9/10/22 at 7:25 AM. The conclusion of the report indicated that Resident #284 lowered himself to the ground and was found on the floor next to his bed. The wheelchair was locked, floor was clean and dry, bed was in the low position, call bell was within reach and not engaged. No injury was noted. There is no mention of the brakes on the bed being engaged.
On 6/02/23 at 02:02 PM, the surveyor reviewed a Registered Nurse assessment dated [DATE] at 14:07 which reflected, came into the facility approximately 8:30 AM and got a phone call from resident's sister in regards to resident saying he/she lowered himself to the floor because the bed moved and he/she lost his footing. Advised the sister that I would speak to the resident as well as the supervisor that was there. With further investigation, the supervisor advised this nurse that the resident was found on the floor when the nurse and the supervisor heard the resident yelling for help. Spoke with the resident, he/she advised that the bed wasn't locked, he lost his footing went to put his hand on the bed and realized it was moving. Resident then stated that he/she lowered himself/herself to the floor to prevent a fall. Spoke with the supervisor and the nurse gain, and they confirmed what the resident had told this nurse. This nurse spoke to residents sister and explained the situation to her, in which she was very understanding. Neuro checks started and completed, and initial even [sic.] completed. Will continue to monitor.
On 6/2/23 at 2:02 PM, the RDCS stated the breaks on the bed may not have been broken. She stated the staff may not have engaged the brakes.
A review of the facility provided In-Service Attendance Record reflects that the facility in serviced the staff on 9/10/22, regarding ensuring that resident's beds and wheelchairs were secured (locked). Staff will ensure resident's bed or wheelchair is locked before and after care.
A review of the facility policy titled Falls Management and Prevention revised 1/20/20 reflects The interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence.
NJAC 8:39-27.1 (a), 33.1 (d)
Based on observation, interviews, review of the medical record and other facility documentation, it was determined that that the facility failed to: a) properly assess and implement the facility's fall management policy for a resident after a reported, unwitnessed fall b) ensure fall prevention interventions were followed by ensuring that a resident's bed was in the locked position This deficient practice was identified for 2 of 5 residents (Resident #99, Resident #284) reviewed for falls.
This deficient practice was evidenced by the following:
1. During the initial tour of the facility on 05/17/23 at 10:52 AM, the surveyor observed Resident #99 who was seated at the foot of an unsampled resident's bed visiting with friends. The Resident reported a fall from bed a couple of nights ago and lifted their shirt and revealed a large circular purple bruise on the right side of the upper abdomen. The resident stated he/she also had a bruise and a cut on the right knee which was covered beneath the resident's clothing. The resident stated he/she informed the nurse whose name the resident did not know. The resident stated that the nurse then proceeded to place a band-aid on their knee and no other treatment was rendered. The resident stated that he/she requested to go to the hospital and the nurse stated, We do not send people out to the hospital for bruises.
According to the admission Record Resident #99 was admitted to the facility with diagnosis that included, but were not limited to: Difficulty in walking, acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty and discomfort in breathing), major depressive disorder (psychiatric condition), and Type 2 diabetes mellitus.
Review of the Quarterly Minimum Data Set (MDS), an assessment tool dated 03/05/23, revealed that the resident had a Brief Interview for Mental Status score of 12 out of 15 which indicated that the resident was moderately cognitively impaired. Further review of the MDS revealed that the resident required supervision and set up for bed mobility, ambulation and limited assistance of one staff for toilet use and personal hygiene. Further review of the MDS indicated that the resident had no documented falls or shortness of breath documented during the quarterly review.
05/22/23 10:55 AM, the surveyor attempted to meet with Resident #99 and was informed by Licensed Practical Nurse (LPN) #2 that the resident was hospitalized .
Review of the Progress Notes (PN) contained within the electronic health record of Resident #99 revealed an entry that was written by LPN #2 which indicated that the resident was sent out of the facility without incident accompanied by a Certified Nursing Assistant (CNA) to a pulmonology (lung doctor) appointment.
Further review of the PN revealed an entry written on 05/19/23 at 10:39 AM, by Licensed Practical Nurse/Unit Manager (LPN/UM) #2 which revealed that the CNA who accompanied Resident #99 to the pulmonology appointment phoned to report that the resident had a low oxygen level and was currently with the pulmonologist. The LPN/UM #2 phoned the pulmonologist's office and spoke with the Physician's Assistant who reported that the resident's pulse oximetry level was around 60% and the resident was lethargic and was sent to the hospital for further evaluation.
Further review of the PN revealed an entry written by LPN #2 on 05/19/23 at 12:42 PM, which indicated that she phoned the hospital and confirmed that Resident #99 was admitted to the hospital with SOB (shortness of breath) and CO 2 (carbon dioxide) retention.
On 05/24/23 at 9:00 AM, the Regional Director of Clinical Services (RDCS) provided the surveyor with two Full QA Reports which indicated that Resident #99 had an unwitnessed fall on 03/03/23 at 1:00 PM, after the resident tried to put a food tray on the food cart which resulted in an abrasion to the right knee. The resident reported the fall to a CNA and stated, I fell and got myself up.
Further review of a Full QA Report dated 05/10/23 at 2:18 PM, revealed that the resident had a witnessed fall in the activity room and was standing up while playing a card game and lost their balance and fell, landing on the left side. The resident did not sustain any bruises or skin tears as a result.
On 05/25/23 at 2:55 PM, the surveyor reviewed a Weekly Skin Monitoring assessment which was completed on 05/18/23 at 2:55 PM, by an agency LPN which indicated that Resident #99's skin was intact and there were no new skin alterations and the skin was warm, dry and intact.
On 05/25/23 at 11:26 AM, the surveyor interviewed LPN/UM #2 who stated that Resident #99's last reported fall occurred in the activity room when the resident fell and lost their balance on 05/10/23.
At that time, the surveyor reviewed the 24 Hour Report binder which failed to contain documented evidence that Resident #99 had an unwitnessed fall from bed and sustained abdominal bruising.
The surveyor reviewed a Physician's Progress Note contained within Resident #99's electronic health record effective 05/15/23 at 5:00 PM, which revealed:
History of Present Illness:
.Pt continues to c/o dyspnea (difficulty breathing) on exertion. Pulmonary consult is pending. Pt is ambulatory and is c/o right lower quadrant abdominal ecchymosis from recent fall. No other acute medical issue reported. Medications revived [sic.].
Plan:
Fall: recent fall from bed. Likely related to recent bed rails issue. Continue fall precaution.
Abdominal wall ecchymosis: 2/2 to trauma. Start pt on Muscle rub q 6 hr prn (as needed).
On 05/26/23 at 11:04 AM, the surveyor interviewed Resident #99's Medical Doctor (MD) who stated that on 05/15/23, he saw the resident walking in the hall with therapy and the resident informed him that they sustained a bruise recently after he/she fell from the bed. The MD explained that the facility discontinued all bed rails as they were perceived as a restraint. The MD stated that the resident used to have a bed rail to transfer and to help the resident from falling out of bed as the resident had a large body habitus and could fall out of the bed when they turned over in bed. He stated the resident's abdomen was soft, as the hematoma (a solid swelling of solid blood within the tissues) was resolving. The MD stated the resident did not tell me about any knee injury, only the belly. The MD stated that the resident's belly was soft and it was not warranted to send the resident to the hospital. The MD stated he did not know why the resident's pulse ox decreased. The MD stated that resident's pulse oximetry level was usually in the 90's and he was surprised why there was a low reading as the resident's lungs sounded okay. The MD stated he did not speak to the nurses about the abdominal bruising and fall from bed because he assumed the resident was already assessed by the nurses. The MD stated that if a resident fall was reported the nurses usually assessed the resident, documented the incident and texted him to inform him of the fall. He stated that he was not informed of the resident fall by the facility nursing staff.
On 05/26/23 at 12:07 PM, the surveyor confirmed that Resident #99's full-time CNA was not available for interview. At that time, the surveyor interviewed CNA #4 who stated that he last cared for Resident #99 a week and a half ago. He stated that the resident was set up for care and was able to wash and dress his/herself. CNA #4 stated that he had not seen the resident's skin and the resident had not reported a fall to him.
On 05/26/23 at 12:37 PM, the surveyor interviewed the Registered Nurse (RN) who stated that if a resident reported a fall she would assess the resident, and notify the unit manager, doctor and family. The RN stated that she would document the fall in a progress note, incident report and on the 24 Hour Report.
On 05/26/23 at 1:53 PM, the surveyor interviewed the agency LPN who stated that she worked at the facility for two years. She stated that on 5/18/23, she was assigned to wound rounds. She stated she performed a skin assessment on Resident #99 and did a full body scan and noted redness on the right side of the resident's abdomen. She stated, It was just a little bit red. She stated that she reviewed the resident's MD's PN and noted that he documented that he saw the bruise. She explained that if she documented the finding on her Weekly Skin Monitoring Documentation it would start a new UDA (User Defined Assessment). She stated that she did not look at the nurse's notes because it was not a new finding. She stated if it were a pressure ulcer, she would have measured it. She described the resident as independent and stated that the resident informed her of the fall. She stated that she had not noted any lacerations on the resident's legs. She stated that the resident was in bed and was a little sleepy at that time. The surveyor asked the agency LPN to describe the facility process for a resident with a reported fall with sustained bruising. She stated she would call the doctor and ask for an order to send the resident out. She further stated that she would then document the resident's complaint of pain. She further stated that she did a competency for skin assessment today or yesterday and once a year.
On 05/26/23 the surveyor was provided with a Standard Pre-Survey Review Treatment Observation Dressing: Aseptic competency dated 01/10/23. The facility was unable to provide the surveyor with documented evidence that the agency LPN received training and competency related to Weekly Skin Monitoring Documentation.
On 05/26/23 at 2:07 PM, the surveyor interviewed CNA #2 who was Resident #99's full-time CNA. CNA #2 stated that she worked on 05/18/23 and the resident had not reported a fall to her. She stated that she did not see the resident's skin as the resident dressed himself.
On 05/26/23 at 2:58 PM, the surveyor interviewed the Director of Nursing (DON) who stated that when Resident #99 reported the fall from bed and requested to go to the hospital the nurse should have informed the doctor and sent the resident out as it was their right. The DON stated that a physician's order was required to perform first-aid such as placing a band-aid on the resident's knee. The DON explained that the agency LPN who noted redness on the resident's abdomen should have reviewed the previous Weekly Skin Monitoring documentation to see if the abdominal bruising was documented, not the physician's PN. The DON stated that the agency LPN should have documented the bruise, described it and measured it to make sure that it did not spread. The DON stated that the agency LPN should have documented that the skin was intact, but there was an ongoing bruise. The DON stated that if a resident reported an unwitnessed fall a full body assessment should have been performed including neuro check,s and documented notification of administration, MD, family, complete the 24 Hour Report for a three day follow-up, and complete the event report. The DON confirmed that the resident's side rails were removed from the bed after it was determined that the resident lacked the ability to lower and raise the side rails independently in accordance with facility policy.
On 05/31/23 at 12:08 PM, the surveyor interviewed LPN #2, Resident #99's full-time nurse, who stated that she last saw the resident prior to a scheduled appointment with the Pulmonologist. LPN #2 stated that the resident had not reported a fall and was able to ambulate out of the facility to be transported to their appointment. LPN #2 stated that the resident's MD should have reported the resident's report of bruising and fall to nursing for follow-up.
On 06/05/23 at 1:30 PM, the Regional Director of Clinical Services (RDCS) provided the surveyor with the requested 24 Hour Report and Change in Condition and Nursing Unit Activities which indicated that on 05/19/23 Resident #99 was oof (out of facility) to a Pulmonary Appointment. admitted to hospital with Dx: SOB and CO 2 retention. Their was no further documentation that pertained to Resident #99 within the documentation provided.
On 06/02/23 at 12:06 PM, in the presence of the survey team, Administrator, and DON the RDCS stated that Resident #99's MD should not have assumed that the resident's fall was a reported fall and discussed it with nursing or the unit manager.
Review the facility's policy, Falls Management and Prevention (Revised 1/2020) revealed the following;
The falls may be witnessed, reported by the resident an observer or identified when a resident is found on the floor or ground.
Post Fall: In the event a resident has fallen and/or is found on the ground, a complete heard-to-toe assessment must be performed .
.Obtain vital signs, obtain neurological checks per policy for any unwitnessed fall or any fall with evidence of injury to head.
If no obvious injury move resident to a comfortable position. If injury, severe pain or abnormal assessments observed, call 9-1-1- transfer.
.Obtain finger-stick blood sugar if known diabetic.
The nurse will complete an incident report.
Contact physician and family and document in the medial record, including time and person spoken with
Resident fall will be evaluated for 72 hours' post fall , including full vital signs every shift.
The Director of Nursing will be notified immediately for falls resulting in injury an/or transfer. The DON will notify State agency per state specific requirements.
Resident will be referred to therapy for a screen-for indiction of need for therapy interventions.
Review of the facility's policy, Accidents-Incidents (Revised 8/2019) revealed the following:
It is the policy of the Facility to monitor and evaluate all occurrences of accidents or incidents or adverse events occurring on the facility's premises which is not consistent with the routine operation of the facility or care of a particular resident. These occurrences must be evaluated and investigated.
.The occurrence may be a fall, skin tear, bruise, new pressure ulcer and may involve abuse, neglect, and mistreatment or an injury of unknown origin .
Procedure:
The following forms make up the Incident and Accident packet for investigating and reporting:
Accident and Incident Report Form
Incident/Accident Statement Form RN Supervisor/UnitManager
Incident/Accident Statement Form Involved Party Statement-for all those involved
CNA Statement form-for those on duty at the time of the incident
Neuro Checklist-for unwitnessed accidents/incidents
Rehab Referral form-if applicable
Post-Accident/Incident Check List
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to provide a resident with nutritional interventions that were recommended for a resident with significant weight loss. This deficient practice was identified for 1 of 2 residents (Resident #102) reviewed for nutrition.
This deficient practice was evidenced by the following:
On 05/24/23 at 9:06 AM, the surveyor observed Resident #102 lying in bed with the head of the bed elevated eating breakfast. The Certified Nursing Assistant (CNA) #1 who assisted the resident stated that the resident always ate all of his/her food and asked for seconds.
Review of the admission Record revealed that Resident #102 was readmitted to the facility in February of 2022 with diagnoses which included but were not limited to: vascular dementia, cerebral infarction (stroke), aphasia (language disorder that affects a persons ability to communicate), dysphagia (difficulty swallowing), alcoholic cirrhosis of the liver, and generalized muscle weakness.
Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 03 out of 15 which indicated that the resident was severely cognitively impaired. Further review of the MDS revealed that the resident had a weight loss while not on a physician-prescribed weight-loss regimen and was 74 inches tall and weighed 173 lbs.
Review of Resident #102's Care Plan revealed an entry which indicated that resident had a nutritional problem or potential nutritional problem with significant weight loss/gain that was initiated on 09/16/18. Further review of the Care Plan revealed an entry which indicated that the resident had interventions which included provide diet and consistency per MD order Double Portions. On 02/05/22, an entry was initiated to offer resident a snack every HS (hours of sleep).
Review of the Order Summary Report dated 06/01/23 revealed that on 12/01/22, Resident #102 was ordered a regular diet, thin (regular) liquids, assist, set-up, and general po (per oral) supervision, upright position, small bites, small sips, slow rate, and alternate 2-3 bites/sip for diet. On 12/08/22 an order was placed for Ensure Plus three times a day for Supplement give 8 oz daily. On 02/05/22 an order was placed to weigh on admission/readmission x 1, then weekly x 4, then monthly. On 03/06/23 an order was placed for Mirtazapine (Remeron) tablet 7.5 mg give one tablet by mouth at bedtime for appetite stimulant.
On 05/26/23 at 12:47 PM, the surveyor observed Resident #102 eating lunch in the dining room. The resident ate 100% of the meal which included macaroni and cheese, cauliflower, vegetable soup, an ice cream cup, milk and iced tea. The portion size of the macaroni and cheese and cauliflower appeared small. The Registered Dietician (RD) was present and assisted other residents who dined at the same dining table.
On 05/26/23 at 2:20 PM, the surveyor interviewed the RD who stated that Resident #102 had experienced a significant weight loss and the resident weighed 193 lbs in November 2022 and on 12/04/22 the resident weighed 180.3 lbs. The RD stated that a thirteen pound weight loss of 6.7% was identified and a reweight was done on 12/7/22, and the resident weighed 178 lbs. The RD stated that the rationale for the 15 pound weight loss was not known as the resident had a documented food intake of 75% at meals. The surveyor asked the RD if weekly weights were obtained in response to the identified weight loss. The RD stated that with the reweight we assumed that the weight was accurate. The RD stated that the resident's diet was upgraded and dietary supplements were increased to three times per day. The RD stated that the scale was checked for accuracy in March 2022 and it was replaced. Review of the resident's weights within the electronic health record revealed the following: on 01/17/23 178 lbs, on 02/13/23 174 lbs, on 03/09/23 173 lbs, on 04/12/23 172 lbs, and on 05/01/23 173 lbs. The RD stated that though it was not documented, the resident looked the same and did not appear to have lost weight.
The RD further explained that in February the resident's weight was 174 lbs so we added mighty shakes in addition to the supplements. The RD stated that in March the resident weighed 173 lbs and the Medical Doctor was informed of the weight loss and Remeron (antidepressant which may stimulate appetite) was prescribed. The RD stated that the resident's current nutrition plan was continued which also consisted of double portions of protein or starch. The RD explained that the resident's tray ticket should indicate 2 X for things that should be served in double portion. The surveyor asked if the macaroni and cheese that was served at lunch to the resident looked like it was a double portion size? The RD stated that she delivered the meal tray to the resident and had not actually looked at it. The RD further stated that the Food Services Director (FSD) was informed of the recommended scoop sizes to be used when double portions were served.
On 05/31/23 at 12:48 PM, the surveyor observed Resident #102 seated in a chair eating lunch in the dining room. The resident ate 100% of the meal and only a small, single chicken drumstick bone remained on the plate. The surveyor reviewed the meal ticket which indicated the resident was served: Regular diet, thin liquids, weighted spoon and weighted fork (provide additional weight to stabilize hand and arm movements for those who experience tremors or shakes when eating), 2 X 3 oz Oven Fried Chicken, 2 X 2 fl oz Country Gravy, mashed potatoes, wax beans, mandarin oranges, 4 fl oz juice, 8 fl oz 2% milk, 4 fl oz water, 4 fl oz iced tea, and a 4 fl oz Mighty Shake. The surveyor observed that the resident had not received weighted utensils, Mighty Shake or a double portion of chicken.
On 05/31/23 at 12:54 PM, the surveyor interviewed the Dietary Aide (DA) #1 who confirmed that the Resident #102 had not received a weighted spoon or fork as indicated on the tray ticket and stated that it must have been missed. The surveyor asked DA #1 why there was only one single small chicken bone on the resident's plate if the resident were served 2 X the serving of chicken? DA #1 stated that the resident may have gotten one big piece of chicken instead of two and he was unable to make that determination based on the chicken drumstick bone that remained on the resident's plate.
On 05/31/23 at 12:56 PM, the surveyor interviewed CNA #1 who stated that Resident #102 had not received a weighted fork or spoon but did well with standard silverware. CNA #1 further stated that the resident normally received one large piece of chicken, not two as indicated on the meal ticket.
On 05/31/23 at 1:49 PM, the surveyor interviewed the FSD who stated that he worked at the facility for nearly eight years. The FSD stated that today a chicken leg/thigh of oven fried chicken was served for lunch. The FSD stated that he probably had to cut the chicken in half for the resident as he may have run a little short. The FSD stated that he had not realized that the resident was ordered double portions until one week ago when a diet requisition slip was brought down to the kitchen. The FSD stated that he was not aware that the resident required a weighted fork and spoon as there were only three residents at the facility who required them as indicated by therapy recommendation. The FSD stated that the dietary staff were required to review the meal tickets while on the tray line to ensure that both weighted silverware and double portions were provided as indicated on the meal ticket. The surveyor asked the FSD why the resident had not receive the mighty shake nutritional supplement? The FSD stated that he ran out of the mighty shakes yesterday.
On 05/31/23 at 2:31 PM, the FSD provided the surveyor with a Diet Requisition slip dated 05/17/23, for Special Request (i.e., Likes/Dislikes) Portion Adjustment Large Portion that was signed by the Assistant Director of Nursing (ADON). The FSD also provided the surveyor with a document titled, Adaptive Feeding Audit dated 04/06/23, that was provided by the Director of Rehabilitation/Speech Language Pathologist (DOR/SLP) which contained three resident names who required modified sippy cups. Resident #102 was not included on the list for weighted forks and spoons. The FSD explained that the RD informed him that the resident no longer required the weighted fork and spoon and it should not have been on the resident's meal ticket any longer. The FSD further explained that the Diet Requisition slip for large portions was provided by the ADON on 05/17/23.
On 05/31/23 at 2:45 PM, the surveyor interviewed the ADON who stated that she was informed on 05/17/23 by the 3-11 CNA that the resdient had a large appetite and was supposed to get large portions. The ADON stated that she completed a dietary requisition form and took it down to the kitchen. The ADON stated that she was not informed by the RD that the resident needed double portions prior.
On 05/31/23 at 03:02 PM, the surveyor interviewed the RD who stated that double portions should have been implemented for Resident #102 in December 2022 and the FSD should have known and ensured that the resident received double portions. The RD stated that when the request for double portions was placed in the diet system it was reflected on the diet ticket.
On 06/01/23 at 2:32 PM, the surveyor interviewed the RD who stated that she reviewed her notes and in December 2022, she documented that the Resident #102 was getting double portions in her note. The RD explained that she thought that she messed up at some point thinking that the resident had double portions and they were not really there. The RD stated that the resident absolutely should have received double portions from 05/17/23 to present as indicated on the current meal ticket. The RD further stated that an order for double portions should have been placed in the electronic health record, in the Care Plan and in the diet system. The surveyor questioned why the resident's medical record failed to contain the documentation as described by the RD? The RD stated that she learned from her mistakes and she should have placed an order into the resident's electronic health record for double portions and into the diet system. The RD stated that the ADON also should have placed an order into the electronic health record in addition to the diet requisition form that she sent to the FSD.
The RD further stated that Resident #102 weighed 173 lbs on 05/01/23 and when the resident was weighed on 06/01/23 in a wheelchair the resident weighed 191 lbs. The RD stated that she wanted to bang her head when this happened as she was unable to explain the discrepancy. The RD stated that she wanted to get another reweight.
On 06/02/23 at 10:05 AM, the surveyor accompanied the RD, Licensed Practical Nurse/Unit Manager (LPN/UM) #2 of Second Floor A/B Units, and CNA #2 to weigh Resident #102 in a wheel chair on a chair scale. The wheelchair was weighed first and weighed 36.8 lbs. The resident was then weighed and weighed 229 lbs in the wheel chair. The RD stated that the resident's weight was 192.2 lbs. The RD further stated that she did not know if there was an issue with scale accuracy. The RD stated that previously staff were not required to document whether the resident stood for their weight or if they were weighed in a wheelchair or mechanical lift but they were required to do so now.
On 06/02/23 at 10:38 AM, the surveyor interviewed LPN/UM #2 who stated that the RD was required to notify the resident's physician of weight loss or the assigned doctor monitored the resident's weights. The surveyor reviewed Resident #102's electronic health record and observed a physician's progress note dated 12/23/22 at 4:45 PM, revealed that the resident's physician noted the resident's weight loss and informed the resident's responsible party.
On 06/02/23 at 12:06 PM, the surveyor interviewed the Administrator regarding Resident #102's double portions, weighted silverware and tray accuracy. The Administrator stated, If it is on the ticket, it should go on the tray. The Administrator further explained that an order was required for the items listed on the meal ticket.
The Director of Nursing (DON) who was present at that time stated that the Unit Manager along with the RD were responsible to ensure that weekly weights were done when indicated. She stated that residents were weighed upon admission, and weekly x four, and after four weeks, they were weighed monthly thereafter. She further stated that if the resident had a weight loss or gain of five lbs then weekly weights were required to be completed x four. The DON further stated that in early February 2023, Resident #102's order for weighted silverware should have been discontinued from the meal ticket.
Review of the facility policy titled, Weight Assessment and Interventions (Reviewed 02/23) revealed the following:
Policy: The Multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents.
.Weights will be recorded in the medical record (electronic health record where available) for each resident.
a. Any weight change of 5 lb [sic.] in a month and 3 lbs in a week since their last weight assessment will be retaken within 48 hrs for confirmation and verified by nursing.
b. Re weigh should be reviewed by the Licensed Nurse.
c. Licensed Nurse will notify Dietician of identified weight change once reviewed.
d. Dietician notification should be documented within Resident's medial record
e. Dietician or diet technician will respond within 72 hours of receipt of notification
.The threshold for significant unplanned and undesired weight change will be based on the following criteria:
a. 1 month-5% weight change is significant; greater than 5% is severe.
.If the weight change is desirable, this will be documented and no change in the care plan will be necessary.
.Individual care plans shall address, to the extent possible:
a. The identified cause of weight change;
b. Goals and benchmarks for improvement; and
c. Time frames and parameters for monitoring and reassessment.
NJAC 8:39 17.1(c), 17.2(d), 27.2(e)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, facility documentation review and clinical record review, it was determined that the facility failed to provide oxygen (O2) therapy consistent with physician's order. ...
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Based on observation, interview, facility documentation review and clinical record review, it was determined that the facility failed to provide oxygen (O2) therapy consistent with physician's order.
This deficient practice was identified for 1 of 2 residents reviewed for oxygen therapy, Resident #70 and was evidenced by the following:
On 05/24/2023 at 11:00 AM, the surveyor observed Resident #70 sitting on the bed receiving oxygen per nasal cannula (NC) (device used to deliver supplemental oxygen therapy via nasil passages) by way of a concentrator (concentrates the oxygen from a gas supply by removing nitrogen to supply oxygen). The O2 concentrator was set to deliver O2 at a flow rate of 3 liters via NC and there was separate tubing on the dresser across the room that was partially inside the top drawer. The Certified Nursing Assistant (CNA) was assisting Resident #70 with getting dressed and removed the tubing and laid it down on the residents' bed. The O2 tubing was observed on the bed and was dated for 5/24/2023 with a piece of plastic tape.
During an interview with the surveyor, CNA revealed that Resident #70 cannot assist with care, exhibited behaviors, and was also receiving O2 and the nurses were responsible for the O2 setting. The CNA indicated that she did not touch the O2 concentrator and could not speak to why the setting was incorrect, why the machine was dated for 05/10/2023, or why the tubing was on the dresser. The CNA added the nurses would be responsible for that.
On 05/24/2023 at 11:05 AM, the surveyor reviewed Resident #70's current medical record which revealed that Resident #70 was admitted to the facility in January 2022 with diagnoses which included, but not limited to history of (h/o) Chronic Obstructive Pulmonary Disease (condition involving constriction of airways), h/o lung cancer, colon cancer, anxiety, dementia, right eye blindness, cataract, hospice, and claustrophobia (fear of closed spaces).
Further review of the clinical record revealed a Physician Order Sheet (POS) with a start date of 06/27/2022 that contained the following order: Supplemental oxygen via 2 at 2L (Liters)/Minute to maintain oxygen SATS greater than 91% (HX COPD 88%, Without Hx lung disease 90%) every shift Check O2 sat every shift. Every night shift every Sunday for Equipment maintenance change and date oxygen tubing and storage bags once weekly.
The most recent annual Minimum Data Set (MDS) an assessment tool with a date of 02/25/2023, indicated that Resident #70 had a Brief Interview of Mental Status (BIMS) score of 02 indicating that Resident #70 had severe cognitive impairment.
On 05/24/2023 at 11:08 AM, the surveyor interviewed the Registered Nurse (RN) assigned to Resident #70 regarding the oxygen setting, the 05/10/2023 expiration date on the oxygen machine, and the tubing on the dresser. The RN verified that the physician's order was for Resident #70 to receive O2 at a flow rate of 2 liters/min via nasal cannula. The surveyor entered Resident #70's room with the RN and both observed that the concentrator setting was for O2 to be delivered at 3 liters via NC and O2 tubing was noted to be on the dresser and partially in the top drawer. Further review of the machine revealed there was a sticker with an expiration date for 05/10/2023. The RN confirmed that the physician's order for Resident #70 was for 2 liters of O2 not 3 liters as was set on the concentrator, that the oxygen machine should have been changed out as of the 05/10/2023 date, and the tubing should not have been left on the dresser.
On 05/24/2023 at 11:10 AM, the surveyor interviewed the Unit Manager (UM) regarding the incorrect O2 setting, the outdated label on the machine, and the tubing that was left on the dresser. The UM confirmed that the O2 physician's order must be followed and acknowledged that the label on the machine meant that the machine should have been changed. The UM added that the tubing should not have been on the dresser. The UM turned off the O2 machine and removed the tubing.
During the pre-exit conference on 06/01/2023 at 1:30 PM, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Regional Director of Clinical Services (RDCS) were informed of the findings. No further information was provided. The RDCS told the survey team that the RN on shift was an agency nurse and would be educated.
A review of the facility's policy titled, Oxygen Therapy last revised September 2022, revealed the administration of supplemental oxygen is an essential element of appropriate management for a wide range of clinical conditions. However, oxygen should be regarded as a drug and therefore requires prescribing in all but emergency situations. Failure to administer oxygen therapy with appropriate monitoring is an integral component of Healthcare Professional's role. Oxygen is administered according to physician order. Tubing change-Oxygen cannula tubing, without humidification, is changed weekly and prn, filters should be changed annually.
Follow manufacturer's instructions for use to apply, adjust the flow settings, clean, and remove the device.
NJAC 8:39-11.2 (b) 27.1 (a)
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 record review, it was determined that the facility failed to A. establish a system of records for all controlled drugs in sufficient detail to enable an accurate re...
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Based on observation, interview and record review, it was determined that the facility failed to A. establish a system of records for all controlled drugs in sufficient detail to enable an accurate reconciliation for the dispensing of controlled medications and B. ensure a controlled drug was dispensed in accordance with professional standards of practice. This deficient practice was observed for 2 of 4 medication carts inspected and during the medication pass and was evidenced by the following:
A.On 5/24/23 at 10:43 AM, in the presence of the Licensed Practical Nurse (LPN), the surveyor inspected the medication cart on First Floor C Unit for storage and labeling of medications. During reconciliation of controlled medications, the surveyor observed the following:
1. 1 bottle of Methadone (a narcotic medication used to treat pain) in the narcotic box but the Controlled Drug Sheet (CDS) documented 2 bottles were left.
2. 41 Clonazepam (a narcotic medication used for anxiety) 0.5mg pills in the blister pack but the CDS documented there were 42 left.
The LPN stated that she should have signed the CDS when she administered the medications. She stated she was told to pass breakfast trays out and she was in disarray.
On 5/24/23 at 10:52 AM, in the presence of the LPN the surveyor inspected the medication cart on Second Floor D Unit for storage and labeling of medications. During reconciliation of controlled medications, the surveyor observed 16 Tramadol (a narcotic medication used to treat pain) 50mg in the blister pack but the CDS documented there were 17 left. The LPN stated that he should have signed the CDS and that he thought he had signed it out.
Review of the facility's policy titled, Control Substance Management, dated 08/2022, revealed that the medication nurse is responsible for recording any administered medications on the appropriate CDS including date, time, amount used and amount remaining signature.
On 5/25/23 at 11:56 AM, the Regional Director of Clinical Services (RDCS) stated the nurses should sign the CDS out when they give the medication.
B. On 5/22/23 at 8:45 AM, the surveyor observed the LPN preparing medication for Resident # 116. The surveyor observed 3 Lacosamide (a narcotic used to treat seizures) 150 mg in the blister pack. The declining inventory page for the Lacosamide 150mg was signed out 5/22/23 at 9am (after the current time). The surveyor observed 2 Lacosamide 50mg in the blister pack. The declining inventory sheet for Lacosamide 50mg was signed out 5/22/23 at 9am (after the current time). The surveyor observed the 2 pills in a medication cup in the top drawer of the medication cart. The LPN stated that she poured the pills early because Resident #116 asked for her medication. She stated that she signed the medications out early and placed the pills in the cart because she got sidetracked. She acknowledged that she should not have placed the medication in the top drawer. She stated she usually signs the CDS when she administers the medication. The surveyor observed the nurse administer Resident #116's scheduled medication with no concerns.
On 5/22/23 at 9:06 AM, the First Floor C/D Unit Manager stated that the LPN should not have signed the CDS before administering medication. She furthered that the LPN should not have placed any medication in the top drawer of the medication cart.
On 5/22/23 at 1:33 PM, the Director of Nursing stated the LPN should not have signed the CDS prior to administering the medication.
A review of the facility's Medication Administration-Documentation Policy with a last date revised of 1-2019 indicated, administration of medication must be documented immediately after (never before) it is given, and medication must be poured/distributed at the time of administration.
NJAC 8:39-29.2(d), 29.7(c)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ #00151692, NJ #00153388, NJ#00157947, NJ#00158216, NJ00157442, NJ00158731, NJ00158017
Based on observation, interview, and re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ #00151692, NJ #00153388, NJ#00157947, NJ#00158216, NJ00157442, NJ00158731, NJ00158017
Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to: a.) provide nursing and related services to assure the residents safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care in accordance with the facility assessment and b.) provide sufficient staffing numbers to meet minimum staffing requirements. This deficient practice was observed on 2 of 3 nursing units and for 4 of 9 residents' reviewed, (Resident #45, #72, #155 and #160) ) for care related to staffing.
This deficient practice was evidenced by the following:
Refer to F677
1. During the initial tour of the facility on 05/17/23 at 9:42 AM, the surveyors noted a strong smell of urine that permeated the air on the first floor of the facility in the hallway beyond the main entrance to the facility that led to the first floor nursing units.
On 05/24/23 at 9:02 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #3 who stated that she was assigned to 13 residents. CNA #3 stated that she had to pass breakfast trays before she performed AM care for several more residents who were all incontinent and dependent on staff for care.
At 09:44 AM, CNA #3 delivered a meal tray to the room of Resident #45 who was lying in bed and wore a brief. The resident sat up on the side of the bed to eat breakfast and the surveyor noted that the resident's sheets were saturated with urine. CNA #3 stated that the resident's sheets were always saturated when she did care in the AM. The surveyor interviewed the resident who stated that he/she was last changed at approximately 4:00 AM. The resident sat up and ate breakfast on the side of the bed in a soiled brief on top of wet sheets while CNA #3 began to collect meal trays on the nursing unit.
At 10:00 AM, CNA #3 returned to Resident #45's room to do AM care with resident permission. The resident was assisted out of the bed and into a wheelchair. The resident's bed was saturated and the room smelled of urine. The resident wore a photo identification that was attached to a lanyard around the resident's neck. CNA #3 asked the resident to remove the lanyard and informed the resident that the plastic identification holder and photo were full of urine and mildew. The surveyor observed that the resident's identification was covered with a black and brown spots and a yellow liquid substance was present beneath the plastic cover that held the identification. CNA #3 stated that the resident's skin was intact. The surveyor asked the resident how he/she felt about delayed incontinence care and the resident stated, There was nothing that they can do about it. CNA #3 proceeded to obtain disinfectant cleaner from Housekeeping and wiped down the resident's urine soaked mattress which had rips and tears.
According to the admission Record (an admission summary) Resident #45 was admitted to the facility with diagnosis which included, but were not limited to: cerebral infarction (stroke), morbid obesity, osteoarthritis, difficulty walking and Hepatitis C (a form of viral hepatitis that is transmitted in infected blood, causing chronic liver disease).
Review of Resident #45's Quarterly Minimum Data Set (MDS, an assessment tool dated 05/07/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident was fully cognitively intact and had no documented instances of rejection of care. Further review of the MDS indicated that the resident required extensive assistance of one person for both toilet use and personal hygiene and was occasionally incontinent of both urine and bowel.
At 10:51 AM, CNA #3 stated that she planned to take a 15 minute break and would resume AM care when she returned.
At 11:23 AM, CNA #3 entered the room of Resident #160 to do AM care with resident permission. The resident was assisted to sit up on the side of the bed. The resident wore a white hoody and the back of the hoody was wet and was stained with a yellow substance to the level of the resident's shoulders. The resident's bed was saturated. When interviewed at that time, Resident #160 was unable to state what time he/she was changed last. CNA #3 assisted the resident into the bathroom to get washed. CNA #3 then proceeded to strip Resident #160's bed and sprayed the mattress which had rips and tears with disinfectant cleaner.
According to the admission Record Resident #160 was admitted to the facility with diagnosis that included but were not limited to: difficult in walking, osteoarthritis, Human Immunodeficiency Virus (HIV), Parkinsonism (a disorder of the central nervous system that affects movement).
Review of Resident #160's Annual MDS dated [DATE], revealed that the resident had a BIMS score of 13 out of 15, which indicated that the resident was fully cognitively intact and had no documented instances of rejection of care. Further review of the MDS indicated that the resident required extensive assistance of one person for both toilet use and personal hygiene and was occasionally incontinent of both urine and bowel.
At 11:59 AM CNA #3 entered Resident #155's room to perform AM care with resident permission. CNA #3 stated that there were no sheets on the bed and she did not know where they were. CNA #3 stated that the resident's brief was soiled with feces since this AM, but she had other resident's to care for. CNA #3 removed the resident's brief and stated that his/her skin was intact. CNA #3 stated that she found the resident lying under a fitted sheet this AM and the resident had no blankets. CNA #3 proceeded to open the night stand and found a fitted sheet that was soiled with brown matter and was wet according to CNA #3.
According to Resident #155's admission Record the resident was admitted to the facility with diagnosis that included, but were not limited to: vascular dementia, neutropenia (presence of few neutrophils in the blood leaving the host vulnerable to infection), acute kidney failure, and adult failure to thrive.
Review of Resident #155's Quarterly MDS dated [DATE], revealed that the resident had a BIMS score of 05 out of 15, which indicated that the resident was severely cognitively impaired and had no documented instances of refusal of care. Further review of the MDS indicated that the resident required extensive assistance of one person for both toilet use and personal hygiene and was frequently incontinent of both urine and bowel.
At 12:06 PM, CNA #3 stated that when she arrived to work this AM the night shift CNA informed her that everyone was dry.
On 05/25/23 at 10:59 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated that she noted that the residents on her assignment were heavily incontinent and were not being changed as they should be. LPN #1 stated that the aides on day shift let her know that the residents were saturated about one week ago. LPN #1 stated that she informed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 of her concern that the residents on her assigned unit were overly saturated with urine.
On 05/25/23 at 11:10 AM, the surveyor interviewed LPN/UM #2 who stated that she had worked at the facility since January 2023. LPN/UM #2 stated that no one had brought it to her attention that there were concerns with incontinence care on her assigned nursing units (2 A and 2 B).
On 05/25/23 at 11:15 AM, the surveyor requested that LPN/UM #2 come to Resident #45's room. Upon entry to the room, the resident was not in the room at the time and the resident's bed sheets were noted to be soaked and covered in a yellow substance. LPN/UM #2 stated that it had not looked like the resident had not received incontinence care since last night. LPN/UM #3 then proceeded to open the resident's night stand where the resident's photo identification/lanyard was kept at the resident's request. LPN #2 stated that the plastic that covered the identification contained mold and was stained yellow from being wet with urine. LPN/UM #2 stated that the CNA #3 had 14 residents yesterday and was required to have eight on day shift according to staffing mandate. LPN/UM #2 stated that staffing was not as adequate as it should be.
On 05/25/23 at 12:04 PM, the surveyor interviewed the Administrator in the presence of another surveyor regarding the heavy smell of urine that permeated the first floor of the facility. The Administrator attributed the odor to Resident #45 who often sat in his/her wheelchair at the entrance to the facility. The surveyor observed that the resident was not present when the odor was detected. The surveyor asked why the resident smelled so heavily of urine? The DON who was present at that time stated that it meant that the resident was wet. The Regional Director of Clinical Services (RDCS) who was also present stated that if everyone was wet during the incontinence tour, there were not enough nurses and aides to help the residents in a way that was manageable. Both the Administrator and the DON stated that it was not acceptable for residents bed sheets to be permeated with urine and feces.
2. On 5/24/23 at 8:55 AM, the surveyor accompanied by the Certified Nursing Assistant (CNA) completed an incontinence tour on the First Floor C Unit. Three random residents who were identified by the CNA as being dependent on staff for care, were observed for incontinence care. Resident #72 was observed in bed with a black shirt on that was not a pajama top. Resident #72 was asked by the CNA if she could check the incontinence brief and the resident agreed. Resident #72 was wearing an incontinence brief which was completely saturated with urine. The draw sheet and fitted sheet positioned under the resident were visibly soiled and discolored. When interviewed at that time, the CNA stated that when she came into work the residents including Resident# 72 were saturated. The CNA stated that she then must give the resident full care which included changing the sheets and giving a complete shower or bed bath.
According to the admission Record, Resident #72 had diagnoses that included, but were not limited to: Cerebrovascular Accident (stroke), hemiplegia (one sided weakness), and muscle weakness.
Review of Resident #72's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/18/23, revealed 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. The MDS further revealed that Resident #72 was incontinent and required extensive assist of two people for bed mobility and toilet use.
On 5/25/23 at 12:13 PM, the surveyors interviewed the Director of Nursing (DON), the Licensed Nursing Home Administrator, and the Regional Director of Clinical Services. The DON stated it was not acceptable to have a resident's brief, clothes, and bedding urine soaked.
On 5/25/23 at 1:20 PM, the surveyor interviewed the First Floor C/D Unit Nurse Manager. When told about the incontinent rounds completed on 5/24/23, she stated that Resident # 72 must not have received care on the 11 to 7 shifts and rounds were not done. She furthered that was not acceptable for the residents to be like that.
Review of the facility's Quality of Life/Dignity Policy (revised 10/21) indicated the following:
.Demeaning practices and standards of care the compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by:
.Promptly responding to the resident's request for toileting assistance; and other needs.
1.
For the week of complaint staffing from 01/23/2022 to 01/29/2022, the facility was deficient in CNA staffing for residents on 7 of 7-day shifts, deficient in total staff for residents on 1 of 7 evening shifts, and deficient in total staff for residents on 2 of 7 overnight shifts as follows:
-01/23/22 had 16 CNAs for 194 residents on the day shift, required 24 CNAs.
-01/24/22 had 17 CNAs for 194 residents on the day shift, required 24 CNAs.
-01/25/22 had 17 CNAs for 194 residents on the day shift, required 24 CNAs.
-01/26/22 had 15 CNAs for 194 residents on the day shift, required 24 CNAs.
-01/27/22 had 20 CNAs for 196 residents on the day shift, required 24 CNAs.
-01/28/22 had 18 CNAs for 196 residents on the day shift, required 24 CNAs.
-01/28/22 had 13 total staff for 196 residents on the overnight shift, required 14 total staff.
-01/29/22 had 8 CNAs for 196 residents on the day shift, required 24 CNAs.
-01/29/22 had 16 total staff for 196 residents on the evening shift, required 20 total staff.
-01/29/22 had 11 total staff for 196 residents on the overnight shift, required 14 total staff.
2.
For the 2 weeks of complaint staffing from 03/13/2022 to 03/26/2022, the facility was deficient in CNA staffing for residents on 14 of 14-day shifts, deficient in total staff for residents on 4 of 14 evening shifts, and deficient in total staff for residents on 10 of 14 overnight shifts as follows:
-03/13/22 had 12 CNAs for 197 residents on the day shift, required 25 CNAs.
-03/13/22 had 17 total staff for 197 residents on the evening shift, required 20 total staff.
-03/13/22 had 11 total staff for 197 residents on the overnight shift, required 14 total staff.
-03/14/22 had 14 CNAs for 196 residents on the day shift, required 24 CNAs.
-03/14/22 had 13 total staff for 196 residents on the overnight shift, required 14 total staff.
-03/15/22 had 12 CNAs for 195 residents on the day shift, required 24 CNAs.
-03/16/22 had 14 CNAs for 194 residents on the day shift, required 24 CNAs.
-03/16/22 had 11 total staff for 194 residents on the overnight shift, required 14 total staff.
-03/17/22 had 14 CNAs for 193 residents on the day shift, required 24 CNAs.
-03/17/22 had 12 total staff for 193 residents on the overnight shift, required 14 total staff.
-03/18/22 had 17 CNAs for 193 residents on the day shift, required 24 CNAs.
-03/18/22 had 9 total staff for 193 residents on the overnight shift, required 14 total staff.
-03/19/22 had 12 CNAs for 193 residents on the day shift, required 24 CNAs.
-03/19/22 had 16 total staff for 193 residents on the evening shift, required 19 total staff.
-03/19/22 had 9 total staff for 193 residents on the overnight shift, required 14 total staff.
-03/20/22 had 11 CNAs for 193 residents on the day shift, required 24 CNAs.
-03/20/22 had 16 total staff for 193 residents on the evening shift, required 19 total staff.
-03/20/22 had 12 total staff for 193 residents on the overnight shift, required 14 total staff.
-03/21/22 had 16 CNAs for 192 residents on the day shift, required 24 CNAs.
-03/21/22 had 18 total staff for 192 residents on the evening shift, required 19 total staff.
-03/22/22 had 14 CNAs for 192 residents on the day shift, required 24 CNAs.
-03/22/22 had 13 total staff for 192 residents on the overnight shift, required 14 total staff.
-03/23/22 had 16 CNAs for 192 residents on the day shift, required 24 CNAs.
-03/24/22 had 17 CNAs for 192 residents on the day shift, required 24 CNAs.
-03/24/22 had 12 total staff for 192 residents on the overnight shift, required 14 total staff.
-03/25/22 had 16 CNAs for 192 residents on the day shift, required 24 CNAs.
-03/26/22 had 14 CNAs for 195 residents on the day shift, required 24 CNAs.
-03/26/22 had 11 total staff for 195 residents on the overnight shift, required 14 total staff.
3.
For the 2 weeks of complaint staffing from 07/03/2022 to 07/09/2022, the facility was deficient in CNA staffing for residents on 14 of 14-day shifts, deficient in total staff for residents on 2 of 14 evening shifts, and deficient in total staff for residents on 3 of 14 overnight shifts as follows:
-07/03/22 had 7 CNAs for 194 residents on the day shift, required 24 CNAs.
-07/03/22 had 17 total staff for 194 residents on the evening shift, required 19 total staff.
-07/04/22 had 13 CNAs for 193 residents on the day shift, required 24 CNAs.
-07/05/22 had 14 CNAs for 192 residents on the day shift, required 24 CNAs.
-07/05/22 had 18 total staff for 192 residents on the evening shift, required 19 total staff.
-07/06/22 had 12 CNAs for 192 residents on the day shift, required 24 CNAs.
-07/07/22 had 13 CNAs for 192 residents on the day shift, required 24 CNAs.
-07/08/22 had 13 CNAs for 192 residents on the day shift, required 24 CNAs.
-07/09/22 had 14 CNAs for 196 residents on the day shift, required 24 CNAs.
-07/10/22 had 14 CNAs for 196 residents on the day shift, required 24 CNAs.
-07/11/22 had 13 CNAs for 196 residents on the day shift, required 24 CNAs.
-07/12/22 had 12 CNAs for 196 residents on the day shift, required 24 CNAs.
-07/13/22 had 14 CNAs for 194 residents on the day shift, required 24 CNAs.
-07/14/22 had 15 CNAs for 195 residents on the day shift, required 24 CNAs.
-07/14/22 had 12 total staff for 195 residents on the overnight shift, required 14 total staff.
-07/15/22 had 15 CNAs for 193 residents on the day shift, required 24 CNAs.
-07/15/22 had 13 total staff for 193 residents on the overnight shift, required 14 total staff.
-07/16/22 had 11 CNAs for 193 residents on the day shift, required 24 CNAs.
-07/16/22 had 11 total staff for 193 residents on the overnight shift, required 14 total staff.
4.
For the 2 weeks of complaint staffing from 09/04/2022 to 09/17/2022, the facility was deficient in CNA staffing for residents on 14 of 14-day shifts, deficient in total staff for residents on 3 of 14 evening shifts, deficient in CNAs to total staff on 1 of 14 evening shifts, and deficient in total staff for residents on 7 of 14 overnight shifts as follows:
-09/04/22 had 14 CNAs for 191 residents on the day shift, required 24 CNAs.
-09/04/22 had 11 total staff for 191 residents on the overnight shift, required 14 total staff.
-09/05/22 had 15 CNAs for 191 residents on the day shift, required 24 CNAs.
-09/05/22 had 16 total staff for 191 residents on the evening shift, required 19 total staff.
-09/05/22 had 7 CNAs to 16 total staff on the evening shift, required 8 CNAs.
-09/05/22 had 13 total staff for 191 residents on the overnight shift, required 14 total staff.
-09/06/22 had 10 CNAs for 191 residents on the day shift, required 24 CNAs.
-09/06/22 had 12 total staff for 191 residents on the overnight shift, required 14 total staff.
-09/07/22 had 14 CNAs for 191 residents on the day shift, required 24 CNAs.
-09/08/22 had 13 CNAs for 191 residents on the day shift, required 24 CNAs.
-09/09/22 had 18 CNAs for 196 residents on the day shift, required 24 CNAs.
-09/09/22 had 13 total staff for 196 residents on the overnight shift, required 14 total staff.
-09/10/22 had 14 CNAs for 196 residents on the day shift, required 24 CNAs.
-09/10/22 had 18 total staff for 196 residents on the evening shift, required 20 total staff.
-09/11/22 had 13 CNAs for 197 residents on the day shift, required 25 CNAs.
-09/11/22 had 18 total staff for 197 residents on the evening shift, required 20 total staff.
-09/12/22 had 15 CNAs for 197 residents on the day shift, required 25 CNAs.
-09/13/22 had 14 CNAs for 197 residents on the day shift, required 25 CNAs.
-09/14/22 had 13 CNAs for 198 residents on the day shift, required 25 CNAs.
-09/15/22 had 16 CNAs for 198 residents on the day shift, required 25 CNAs.
-09/15/22 had 10 total staff for 198 residents on the overnight shift, required 14 total staff.
-09/16/22 had 15 CNAs for 198 residents on the day shift, required 25 CNAs.
-09/16/22 had 13 total staff for 198 residents on the overnight shift, required 14 total staff.
-09/17/22 had 13 CNAs for 199 residents on the day shift, required 25 CNAs.
-09/17/22 had 9 total staff for 199 residents on the overnight shift, required 14 total staff.
5.
For the 2 weeks of staffing prior to survey from 04/30/2023 to 05/13/2023, the facility was deficient in CNA staffing for residents on 14 of 14-day shifts, deficient in total staff for residents on 2 of 14 evening shifts, and deficient in total staff for residents on 14 of 14 overnight shifts as follows:
-04/30/23 had 12 CNAs for 187 residents on the day shift, required 23 CNAs.
-04/30/23 had 12 total staff for 187 residents on the overnight shift, required 13 total staff.
-05/01/23 had 15 CNAs for 187 residents on the day shift, required 23 CNAs.
-05/01/23 had 11 total staff for 187 residents on the overnight shift, required 13 total staff.
-05/02/23 had 16 CNAs for 187 residents on the day shift, required 23 CNAs.
-05/02/23 had 11 total staff for 187 residents on the overnight shift, required 13 total staff.
-05/03/23 had 14 CNAs for 187 residents on the day shift, required 23 CNAs.
-05/03/23 had 11 total staff for 187 residents on the overnight shift, required 13 total staff.
-05/04/23 had 12 CNAs for 191 residents on the day shift, required 24 CNAs.
-05/04/23 had 9 total staff for 191 residents on the overnight shift, required 14 total staff.
-05/05/23 had 16 CNAs for 183 residents on the day shift, required 23 CNAs.
-05/05/23 had 9 total staff for 183 residents on the overnight shift, required 13 total staff.
-05/06/23 had 12 CNAs for 181 residents on the day shift, required 23 CNAs.
-05/06/23 had 9 total staff for 181 residents on the overnight shift, required 13 total staff.
-05/07/23 had 12 CNAs for 181 residents on the day shift, required 23 CNAs.
-05/07/23 had 15 total staff for 181 residents on the evening shift, required 18 total staff.
-05/07/23 had 10 total staff for 181 residents on the overnight shift, required 13 total staff.
-05/08/23 had 11 CNAs for 181 residents on the day shift, required 23 CNAs.
-05/08/23 had 11 total staff for 181 residents on the overnight shift, required 13 total staff.
-05/09/23 had 16 CNAs for 181 residents on the day shift, required 23 CNAs.
-05/09/23 had 9 total staff for 181 residents on the overnight shift, required 13 total staff.
-05/10/23 had 18 CNAs for 181 residents on the day shift, required 23 CNAs.
-05/10/23 had 15 total staff for 181 residents on the evening shift, required 18 total staff.
-05/10/23 had 11 total staff for 181 residents on the overnight shift, required 13 total staff.
-05/11/23 had 12 CNAs for 184 residents on the day shift, required 23 CNAs.
-05/11/23 had 9 total staff for 185 residents on the overnight shift, required 13 total staff.
-05/12/23 had 14 CNAs for 184 residents on the day shift, required 23 CNAs.
-05/12/23 had 11 total staff for 184 residents on the overnight shift, required 13 total staff.
-05/13/23 had 13 CNAs for 184 residents on the day shift, required 23 CNAs.
-05/13/23 had 10 total staff for 184 residents on the overnight shift, required 13 total staff.
On 05/26/23 11:47 AM, the surveyor interviewed the CNA who was assigned to 2 B Unit, who stated that she was assigned to 12 residents.
05/31/23 12:27 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that often times there were only 2 aides for the whole floor and residents were saturated. She stated that residents complained that they were never changed.
On 06/02/23 at 11:44 AM, the surveyor interviewed the staffing coordinator. She stated the CNA staffing ratios for the 7 to 3 shift was 8 to 10 residents per CNA, for the 3 to 11 shift 11 to 15 residents per CNA, for the 11-7 shift up to 20 residents per CNA. She stated she tried her hardest to have enough CNA's. She further stated we could always work harder or more, but I don't think we are greatly understaffed.
On 06/02/23 at 12:29 PM, during an interview with the Licensed Nursing Home Administrator (LNHA) regarding staffing, the surveyor asked if the facility had enough Certified Nursing Assistants (CNAs) on each shift, to meet the staffing requirements set forth by the State of New Jersey Regulations. The LNHA replied, There are days when we don't meet them.
On 06/06/23 at 09:19 AM, the surveyor reviewed the policy titled, Staffing Hours, with a revised date of 04/2019. The policy stated that the facility provides adequate staffing to meet needed care and services for our resident population. Under the procedure section, number two indicated that Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan.
NJAC 8:39-5.1 (a)
CONCERN
(F)
📢 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 most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 5/24/23 at 8:55 AM, the surveyor accompanied by the Certified Nursing Assistant (CNA) completed an incontinence tour on th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 5/24/23 at 8:55 AM, the surveyor accompanied by the Certified Nursing Assistant (CNA) completed an incontinence tour on the First Floor C Unit. Three random residents who were identified by the CNA as being dependent on staff for care, were observed for incontinence care. Resident #72 was observed in bed with a black shirt on that was not a pajama top. Resident #72 was asked by the CNA if she could check the incontinence brief and the resident agreed. Resident #72 was wearing an incontinence brief which was completely saturated with urine. The draw sheet and fitted sheet positioned under the resident were visibly soiled and discolored. When interviewed at that time, the CNA stated that when she came into work the residents including Resident# 72 were saturated. The CNA stated that she then must give the resident full care which included changing the sheets and giving a complete shower or bed bath.
According to the admission Record, Resident #72 had diagnoses that included, but were not limited to: Cerebrovascular Accident (stroke), hemiplegia (one sided weakness), and muscle weakness.
Review of Resident #72's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 04/18/2023, revealed 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. The MDS further revealed that Resident #72 was incontinent and required extensive assist of two people for bed mobility and toilet use.
On 05/25/2023 at 12:13 PM, the surveyors interviewed the Director of Nursing (DON), the Licensed Nursing Home Administrator, and the Regional Director of Clinical Services. The DON stated it was not acceptable to have a resident's brief, clothes, and bedding urine soaked.
On 05/25/2023 at 1:20 PM, the surveyor interviewed the First Floor C/D Unit Nurse Manager. When told about the incontinent rounds completed on 05/24/2023, she stated that Resident # 72 must not have received care on the 11 to 7 shifts and rounds were not done. She furthered that was not acceptable for the residents to be like that.
Review of the facility's Quality of Life/Dignity Policy (revised 10/21) indicated the following:
.Demeaning practices and standards of care the compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by:
.Promptly responding to the resident's request for toileting assistance; and other needs.
Review of the facility's ADL-Personal Hygiene policy revised 10/21 indicated incontinence care for a resident will be provided as needed for each idividual per care plan and [NAME].
NJAC 8:39-27.1 (a), 27.2 (h)
Complaint #: NJ00157442, NJ00153388
Based on observation, interview, record review, and review of facility provided 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 4 of 9 residents (Resident #45, #160, #155 and #72) observed for incontinence care on 2 of 3 units (First Floor 1 C and Second Floor 2 B) observed for incontinence care.
This deficient practice was evidenced by the following:
Refer to F725
1. During the initial tour of the facility on 05/17/23 at 9:42 AM, the surveyors noted a strong smell of urine that permeated the air on the first floor of the facility in the hallway beyond the main entrance to the facility that led to the first floor nursing units.
On 05/24/23 at 9:02 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #3 who stated that she was assigned to 13 residents. CNA #3 stated that she had to pass breakfast trays before she performed AM care for several more residents who were all incontinent and dependent on staff for care.
At 09:44 AM, CNA #3 delivered a meal tray to the room of Resident #45 who was lying in bed and wore a brief. The resident sat up on the side of the bed to eat breakfast and the surveyor noted that the resident's sheets were saturated with urine. CNA #3 stated that the resident's sheets were always saturated when she did care in the AM. The surveyor interviewed the resident who stated that he/she was last changed at approximately 4:00 AM. The resident sat up and ate breakfast on the side of the bed in a soiled brief on top of wet sheets while CNA #3 began to collect meal trays on the nursing unit.
At 10:00 AM, CNA #3 returned to Resident #45's room to do AM care with resident permission. The resident was assisted out of the bed and into a wheelchair. The resident's bed was saturated and the room smelled of urine. The resident wore a photo identification that was attached to a lanyard around the resident's neck. CNA #3 asked the resident to remove the lanyard and informed the resident that the plastic identification holder and photo were full of urine and mildew. The surveyor observed that the resident's identification was covered with a black and brown spots and a yellow liquid substance was present beneath the plastic cover that held the identification. CNA #3 stated that the resident's skin was intact. The surveyor asked the resident how he/she felt about delayed incontinence care and the resident stated, There was nothing that they can do about it. CNA #3 proceeded to obtain disinfectant cleaner from Housekeeping and wiped down the resident's urine soaked mattress which had rips and tears.
According to the admission Record (an admission summary) Resident #45 was admitted to the facility with diagnosis which included, but were not limited to: cerebral infarction (stroke), morbid obesity, osteoarthritis, difficulty walking and Hepatitis C (a form of viral hepatitis that is transmitted in infected blood, causing chronic liver disease).
Review of Resident #45's Quarterly Minimum Data Set (MDS), an assessment tool dated 05/07/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident was fully cognitively intact and had no documented instances of rejection of care. Further review of the MDS indicated that the resident required extensive assistance of one person for both toilet use and personal hygiene and was occasionally incontinent of both urine and bowel.
At 10:51 AM, CNA #3 stated that she planned to take a 15 minute break and would resume AM care when she returned.
At 11:23 AM, CNA #3 entered the room of Resident #160 to do AM care with resident's permission. The resident was assisted to sit up on the side of the bed. The resident wore a white hoody and the back of the hoody was wet and was stained with a yellow substance to the level of the resident's shoulders. The resident's bed was saturated. When interviewed at that time, Resident #160 was unable to state what time he/she was changed last. CNA #3 assisted the resident into the bathroom to get washed. CNA #3 then proceeded to strip Resident #160's bed and sprayed the mattress which had rips and tears with disinfectant cleaner.
According to the admission Record Resident #160 was admitted to the facility with diagnosis that included but were not limited to: difficulty in walking, osteoarthritis, Human Immunodeficiency Virus (HIV), Parkinsonism (a disorder of the central nervous system that affects movement).
Review of Resident #160's Annual MDS dated [DATE], revealed that the resident had a BIMS score of 13 out of 15, which indicated that the resident was fully cognitively intact and had no documented instances of rejection of care. Further review of the MDS indicated that the resident required extensive assistance of one person for both toilet use and personal hygiene and was occasionally incontinent of both urine and bowel.
At 11:59 AM, CNA #3 entered Resident #155's room to perform AM care with resident's permission. CNA #3 stated that there were no sheets on the bed and she did not know where they were. CNA #3 stated that the resident's brief was soiled with feces since this AM, but she had other resident's to care for. CNA #3 removed the resident's brief and stated that his/her skin was intact. CNA #3 stated that she found the resident lying under a fitted sheet this AM and the resident had no blankets. CNA #3 proceeded to open the night stand and found a fitted sheet that was soiled with brown matter and was wet according to CNA #3.
According to Resident #155's admission Record, the resident was admitted to the facility with diagnosis that included, but were not limited to: vascular dementia, neutropenia (presence of few neutrophils in the blood leaving the host vulnerable to infection), acute kidney failure, and adult failure to thrive.
Review of Resident #155's Quarterly MDS dated [DATE], revealed that the resident had a BIMS score of 05 out of 15, which indicated that the resident was severely cognitively impaired and had no documented instances of refusal of care. Further review of the MDS indicated that the resident required extensive assistance of one person for both toilet use and personal hygiene and was frequently incontinent of both urine and bowel.
At 12:06 PM, CNA #3 stated that when she arrived to work this AM, the night shift CNA informed her that everyone was dry.
On 05/25/23 at 10:59 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated that she noted that the residents on her assignment were heavily incontinent and were not being changed as they should be. LPN #1 stated that the aides on day shift let her know that the residents were saturated about one week ago. LPN #1 stated that she informed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 of her concern that the residents on her assigned unit were overly saturated with urine.
On 05/25/23 at 11:10 AM, the surveyor interviewed LPN/UM #2 who stated that she had worked at the facility since January 2023. LPN/UM #2 stated that no one had brought it to her attention that there were concerns with incontinence care on her assigned nursing units (2 A and 2 B).
On 05/25/23 at 11:15 AM, the surveyor requested that LPN/UM #2 come to Resident #45's room. Upon entry to the room, the resident was not in the room at the time and the resident's bed sheets were noted to be soaked and covered in a yellow substance. LPN/UM #2 stated that it appeared the resident had not received incontinence care since last night. LPN/UM #3 then proceeded to open the resident's night stand where the resident's photo identification/lanyard was kept at the resident's request. LPN #2 stated that the plastic that covered the identification contained mold and was stained yellow from being wet with urine. LPN/UM #2 stated that the CNA #3 had 14 residents yesterday and was required to have eight on day shift according to staffing mandate. LPN/UM #2 stated that staffing was not as adequate as it should be.
On 05/25/23 at 12:04 PM, the surveyor interviewed the Administrator in the presence of another surveyor regarding the heavy smell of urine that permeated the first floor of the facility. The Administrator attributed the odor to Resident #45 who often sat in his/her wheelchair at the entrance to the facility. The surveyor observed that the resident was not present when the odor was detected. The surveyor asked why the resident smelled so heavily of urine? The DON who was present at that time stated that it meant that the resident was wet. The Regional Director of Clinical Services (RDCS) who was also present stated that if everyone was wet during the incontinence tour, there were not enough nurses and aides to help the residents in a way that was manageable. Both the Administrator and the DON stated that it was not acceptable for residents bed sheets to be permeated with urine and feces.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to handle potentially hazardous fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner in order to prevent food borne illness.
This deficient practice was evidenced by the following:
On 05/17/2023 at 9:33 AM, the surveyor accompanied by the Food service Director (FSD) observed the following in the kitchen:
The surveyor observed a number of unlabeled items throughout the kitchen which included three bags of sugar on the table, on a shelf there were rolls and bagels, in the meat freezer there was a bag of chicken wings and one veggie burger in a box. In the ice cream freezer there were three boxes of Dixie ice cream cups. In the dry storage there was one can of Mashed potatoes and one box of Raisin Bran cereal. Over the sink on a shelf were five bags of cake mix. In the walk in refrigerator there was one block of margarine. On the counter there was a container of [NAME] thickener that was unlabled.
The FSD observed at the time of the tour that these items were not labeled and confirmed the items should have been labeled appropriately.
The surveyor observed a crate of milk and the milk in the crate was outdated with an expiration date of 05/08/2023, there was a log of bologna with an expiration date of 05/06/2023, and a pizza box with an expiration date of 01/12/2023.
The FSD confirmed that the dates were expired, the items were removed and discarded.
On the middle shelf of the cleaned and sanitized rack, the surveyor observed four metal pans that were stacked on top of each other in an inverted position. The pans were pulled apart to separate them and the pans were wet with a clear liquid substance.
The FSD stated the staff who was normally assigned to this task was out so the FSD had to use another staff and would re-educate the alternate staff on wet nesting.
The FSD confirmed the items should have been completely dry and not wet. The FSD removed the pans from the shelf and advised the staff to rewash the four metal pans and showed the staff the appropriate way to stack the metal pans.
During that same day of the kitchen tour at 10:14 AM, the surveyor observed a Licensed Professional Nurse (LPN) walk into the middle of the kitchen area without a hair net on and requested clear juice. The FSD provided the staff with the juice. The FSD confirmed that the staff was not wearing a hair net and should have worn a hair net before entering the kitchen.
The surveyor interviewed the LPN who stated that they usually wore a hairnet and apologized for not having one on. The LPN then confirmed with the surveyor that a hairnet was important to be worn in the kitchen at all times.
The surveyor reviewed the facility policy titled Centers Health Care Food Storage, last date revised 03/09/2022. Which included that sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination.
The policy revealed the following under the Procedure heading:
7. (c.) Food should be dated as it is placed on the shelves if required by state regulation.
(d.) Date marking to indicate the date or day by which a ready-to-eat, time/temperature control for safety food, (formerly known as PHF) should be consumed, sold, or discarded will be visible on all high-risk food.
Refrigerated food storage:
f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.
Frozen Foods:
c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be checked to assure that foods will be consumed by their safe use by dates or discarded.
The surveyor reviewed the facility policy titled Cleaning Dishes, last date reviewed 01/2023. The policy revealed the following under the Procedure heading:
Sanitize
5. allow dishes to air dry. Invert dishes in a single layer to air dry. Check all dishes to be sure they are clean and dry prior to storing.
Cleaning Standards
2. Pots and Pans free of grease, edge/lips clean with no build up of debris, air dried, dry before placed on pot rack, free of pits, smooth to touch.
The surveyor reviewed the facility policy titled Centers Health Care Employee Education, last date revised 06/01/2023. Under the hair net topic, the policy revealed the following:
All staff must defer to the dietary staff when needing to order from the kitchen. If for any reason you need to enter the kitchen area you must put on a hair net and perform hand hygiene before entering.
NJAC 8:39-17.2(g)
May 2021
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on observation, interview, and review of facility menus, it was determined that the facility failed to ensure staff are following the menu for 1 of 1 residents reviewed for food complaints. This...
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Based on observation, interview, and review of facility menus, it was determined that the facility failed to ensure staff are following the menu for 1 of 1 residents reviewed for food complaints. This deficient practice was evidenced by the following:
During the initial tour on 5/4/2021 at 11:58 AM, Resident #6 stated, I only have one complaint and that is the food. It's like mustard and peanut butter. I believe I have lost weight.
A review of the admission Record revealed Resident #6 was admitted to the facility with diagnoses that included, Type 2 diabetes mellitus, dysphagia, oropharyngeal phase, major depressive disorder, essential primary hypertension, and obesity.
A review of the Minimum Data Set (MDS), a resident assessment tool, dated 4/30/2021, indicated Resident #6 had severe cognitive impairment.
On 5/5/2021 at 12:26 PM, the surveyor returned to Resident #6's room to observe the lunch meal. The lunch tray arrived at the unit and was observed to be delivered by the Certified Nursing Assistant (CNA) to Resident #6's room and set up on the over the bed table. Resident #6 received their meal on regular dishware, as appropriate for this non-People Under Investigation/COVID-19 unit. According to Resident #6's meal plan ticket, Resident #6 was to receive a CCHO (consistent carbohydrate), puree consistency and nectar/mild Thk (thick) diet on 5/5/2021 at the lunch meal. The meal ticket also specified that Resident #6 was to receive the following menu items at the lunch meal: Puree 1 ea Beef Hot Dog On Bun, 2 oz (ounce) Cheese Sauce, 1 each Mustard, Puree 4 oz Baked Beans, Puree 4 oz Buttered Carrots, Puree 4oz Peaches, 4 oz Applesauce, Nectar/Mild Thk (thick) 4 fl (fluid) oz Apple Juice, 8 Fl oz Ginger ale Diet, Nectar/Mild Thk 6 Fl oz Coffee, Nectar/Mild Thk 4 fl oz Water, 1 pc (portion control) Salt, 1 pc Pepper , 2 x 1 each Sugar Substitute Packet and 1 each Creamer. The surveyor observed the lunch tray received by Resident #6 that contained the following items on the tray: puree ground beef, mashed potatoes, pureed carrots, and nectar/mild thk coffee. Resident #6 did not receive the following items on their lunch tray: mustard packet, 4 oz pureed baked beans, puree 4 oz peaches, Puree 4 oz applesauce, nectar/mild thk 4 fl oz apple juice ,8 fl oz Ginger ale diet, and nectar/mild thk 4 fl oz water. Resident was able to feed self independently and consumed 100% of mashed potatoes, 25% of the ground beef and 25% of the puree carrots.
On 5/5/2021 at 12:36 PM the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to provide care for Resident #6 on that day. The surveyor provided the LPN with the copy of Resident #6's meal plan ticket for the lunch meal and asked her to compare the meal ticket items listed to the actual lunch tray Resident #6 received. The LPN responded with the following, We are missing cheese sauce, baked beans, water, peaches, applesauce and Ginger ale. He chokes so they downgraded his diet. The LPN stated that she had a thickened water on her medication cart and proceeded to go to the cart and brought Resident #6 a nectar thickened 4oz water. Resident #6 refused the water and stated, I don't like it.
On 5/5/2021 at 12:48 PM the surveyor interviewed the [NAME] and Food Service Director (FSD) in the kitchen. The surveyor asked the cook if they had prepared puree baked beans for the lunch meal and the cook stated, We have mashed potatoes instead of baked beans and we have pureed ground beef instead of hot dogs. We do not have cheese sauce. We don't have any puree peaches. The FSD stated, We substituted pudding for the puree peaches, the dietary aide (DA) may not have pureed any peaches. We did ground beef puree instead of hot dogs because of the skins. The DA used applesauce and pudding because she didn't think there would be enough peaches for everyone. In her mind she didn't think there would be enough after making the peach cobbler, so she substituted applesauce or pudding. No, we did not get approval from the dietitian to make these substitutions on the substitution log. I can get a copy of it for you, but I didn't fill it out. We did not make cheese sauce because we used ground beef, we used a brown gravy instead. The surveyor stated that no brown gravy was observed on the resident's tray or on the tray line. The FSD stated, there is no brown gravy, I just checked the line. We don't have any. The surveyor asked the FSD whether there was a staff member responsible for checking the lunch trays for accuracy prior to loading the meal tray on the cart to be delivered to residents on the units. The FSD stated, Yes, we had a tray line checker today at the lunch meal.
On 5/5/2021 at 12:58 PM the surveyor conducted an Interview with the FSD and DA who was designated to be the tray line checker for the lunch meal on 5/5/2021. On interview the DA stated, The peaches we substituted applesauce for the peaches. We didn't have baked beans for puree diet, we had mashed potatoes today. The nursing staff is responsible for thickening the fluids. I think we are out of the thickened water. We are supposed to put the thickened water, juices, and milks on the tray and for the coffee we have thickener packets to put on the tray. We have thickened water in the basement. We didn't bring it up for lunch today. The FSD stated to the DA We have it (thickened water and juices) but we didn't do it today at the lunch meal.
On 5/6/2021 at 8:57 AM the surveyor observed Resident #6 upon completion of the breakfast meal in their room. Resident #6's meal ticket indicated Resident #6 was to receive a CCHO, Puree with Honey/Mod Thk diet. Resident #6's meal ticket indicated Resident #6 was to receive the following menu items at the breakfast meal on 5/6/2021: 6 oz Cream of Wheat, Puree 2 oz scrambled eggs, puree 1 each assorted muffin, 2 oz margarine melted, 4 oz applesauce, Honey/mod thk 4 fl oz cranberry juice, honey/mod thk 8 fl oz Skim milk, Honey/mod thk 6 fl oz coffee, honey/mod thk 4 fl oz water, 1 pc salt, 1 pc pepper, 2x 1 each sugar sub packet and 1 each creamer. Observation of Resident #6's meal tray revealed that they received the following items for the breakfast meal: Resident #6 received scrambled egg, puree muffin, orange juice instead of cranberry juice, 8 oz thickened milk, and 4 fl oz thickened water (all honey consistency). Resident consumed 100% of all meal, except 50% of thickened milk and had no complaints. Resident #6 did not receive 4 oz applesauce and 6 oz Cream of Wheat on their breakfast tray, as well as melted butter. The surveyor asked Resident #6 whether he/she had received cream of wheat, melted butter and applesauce with their breakfast meal. Resident #6 responded, No, I would have eaten it if I got it. I like it.
On 5/6/2021 at 9:38 AM the surveyor interviewed the [NAME] in the kitchen. On interview the cook stated, Yeah, we had cream of wheat today. The surveyor requested to see the leftover cream of wheat from the breakfast line. The cook responded, we already threw it away.
On 5/6/2021 at 1:07 PM the surveyor reviewed Resident #6's monthly weights. Resident #6 's weight was stable the past 30 days and had 4% weight decline x 180 days. No significant weight decline had occurred for Resident #6.
NJAC 8:39-17.4 (a)(1)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
c. During a tour of the first floor on 05/5/21 at 12:10 PM, the surveyor observed Resident #63 in his/her room in bed with a Foley catheter (tube inserted in the bladder to drain urine) drainage bag a...
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c. During a tour of the first floor on 05/5/21 at 12:10 PM, the surveyor observed Resident #63 in his/her room in bed with a Foley catheter (tube inserted in the bladder to drain urine) drainage bag attached to the bed frame.
During another observation on 05/10/21 at 09:23 AM, Resident #63 was asleep in bed. At this time, the surveyor observed the Foley catheter drainage bag attached to the bed frame.
According to the Face Sheet, Resident #63 was admitted to the facility with a diagnoses which included but were not limited to; quadriplegia (paralysis of all four limbs), and neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord, or nerve problem).
A review of the resident's admission Minimum Data Set, an assessment tool; dated 3/8/21, revealed that the resident had an indwelling Foley catheter.
A review of the resident's Active Order Summary Report dated 5/11/21, did not include a PO for Resident #63's Foley catheter
A review of the resident's care plan dated 3/5/21 indicated Resident #63 had an indwelling catheter.
During an interview with the surveyor on 5/10/21 at 12:28 PM, the DON confirmed that there should be a physician's orders for a Foley catheter including but not limited to, daily care and Foley size.
During a follow-up interview with the surveyor on 5/11/21 at 9:42 AM, the DON confirmed Resident #63's physician's orders were updated on 5/10/21 at 1:52 PM. The DON stated she was not sure why the orders were not there before.
A review of a facility policy titled admission - Readmission with a revised date of 8/2019 revealed under Nursing Documentation Process number 4: The admitting nurse will obtain orders for any specialty care items such as: wounds, oxygen, tracheostomy, foley catheter .
NJAC 8:39-27.1(a)
b) A review of the admission Record revealed Resident #122 was admitted to the facility with diagnoses including but not limited to heart failure, diabetes, depression, and schizophrenia.
On 5/11/21 at 9:49 AM, the surveyor reviewed the January 2021 Electronic Medication Administration Record (EMAR) and the Order Summary Report for Resident # 122. When medications are ordered by the physician, the order is placed on the EMAR. When administered by the nurses, the nurse will sign their initials on the EMAR indicating that they have given the medication.
The January 2021 EMAR revealed the following:
Atorvastatin 80 mg was to be given at bedtime for high cholesterol. There were no nurses' initials on 1/23/2021 at 2100 to indicate the medication had been administered as ordered.
Losartan Potassium 25 mg to be given once a day for high blood pressure. There were no nurses' initials on 1/14/2021 at 0900 to indicate the medication had been administered as ordered.
Insulin Humalog Solution to be given according to a sliding scale before meals and at bedtime for diabetes. There were no nurse initials on 1/1/2021, 1/15/2021, 1/20/2021, 1/25/2021, 1/29/2021, 1/30/2021 at 0630; and on 1/14/2021 at 1130; and on 1/23/2021 at 2100 to indicate the medication had been administered as ordered.
Metformin tablet 500 mg to be given twice a day with breakfast and dinner for diabetes. There were no nurses' initials on 1/14/2021 at 0830 to indicate the medication had been administered as ordered .
Spironolactone tablet 25 mg to be given once a day for a diuretic (water pill). There were no nurses' initials on 1/14/2021 at 0900 to indicate the medication had been administered as ordered.
Brilinta tablet 90 mg to be given twice a day as blood thinner. There were no nurses' initials on 1/14/2021 at 0900 to indicate the medication had been administered as ordered.
Aripiprazole tablet 2 mg to be given once a day for depression. There were no nurses' initials on 1/14/2021 at 0900 to indicate the medication had been administered as ordered.
Aspirin chewable tablet 81 mg to be given once a day for analgesic. There were no nurses' initials on 1/14/2021 at 0900 to indicate the medication had been administered as ordered.
Carvedilol tablet 3.125 mg to be given twice a day for high blood pressure. There were no nurses' initials on 1/14/2021 at 0730 to indicate the medication had been administered as ordered.
Cyproheptadine 4 mg tablet to be given twice a day for an appetite stimulant. There were no nurses' initials on 1/14/2021 at 0900 to indicate the medication had been administered as ordered.
Furosemide tablet 40 mg to be given once a day for diuretic. There were no nurses' initials on 1/14/2021 at 0900 to indicate the medication had been administered as ordered.
Melatonin 3 mg to be given at bedtime for insomnia. There were no nurse initials on 1/23/2021 at 2100 to indicate the medication had been administered as ordered.
Mirtazapine tablet 15 mg give 0.5 tablet at bedtime for depression. There were no nurse initials on 1/23/2021 at 2100 to indicate the medication had been administered as ordered .
Multiple Vitamins-Minerals tablet to be given once a day for wound healing. There were no initials on 1/14/2021 at 0900 to indicate that the medication had been administered as ordered.
Protonix tablet delayed release 40 mg to be given once a day for ulcer. There were no nurse initials on 1/1/2021, 1/15/2021, 1/20/2021, 1/22/2021, 1/25/2021, 1/29/2021, and 1/30/2021 at 0600 to indicate the medication had been administered as ordered.
Repaglinide tablet 0.5 mg to be given before meals for diabetes. There were no nurses' initials on 1/14/2020 at 0730 and 1130 to indicate the medication had been administered as ordered.
Saccharomyces Boulardii capsule 250 mg to be given once a day for probiotic. There were no nurses' initials on 1/14/2021 at 0900 to indicate that the medication had been administered as ordered .
Sertraline HCL 25 mg to be given once a day for depression. There were no nurses' initials on 1/14/2021 at 0900 to indicate the medication had been administered as ordered.
Sertraline HCL 50 mg to be given once a day for depression. There were no nurses' initials on 1/14/2021 at 0900 to indicate the medication had been administered as ordered.
On 5/11/2021 at 10:00 AM the surveyor reviewed the February 2021 EMAR and Order Summary Report for Resident #122 which revealed the following:
Losartan Potassium Tablet 25 mg to be given once a day for congestive heart failure which was ordered on 10/22/2020. There were no nurses' initials on 2/15/2021 at 0900 to indicate the medication had been administered as ordered.
Insulin Humalog Solution to be given according to a sliding scale before meals and at bedtime for diabetes. There were no nurse's initials on 2/2/2021, 2/3/2021, 2/4/2021, 2/7/2021, 2/8/2021, 2/9/2021, 2/11/2021,2/12/2021,2/14/2021,2/16/2021,2/17/2021,2/18/2021, 2/21/2021, 2/23/2021, 2/26/2021, 2/27/2021 at 0630; and 2/15/2021 at 1130 to indicate the medication had been administered as ordered.
Metformin HCL tablet 850 mg to be given twice a day for diabetes. There were no nurses' initials on 2/15/2021 at 0730 to indicate the medication had been administered as ordered .
Spironolactone tablet 25 mg to be given once a day for a diuretic. There were no nurses' initials on 2/15/2021 at 0900 to indicate the medication had been administered.
Brilinta Tablet 90 mg to be given twice a day for blood thinner. There were no nurses' initials on 2/15/2021 at 0900 to indicate the medication had been administered as ordered.
Aripiprazole tablet 2 mg to be given once a day for depression. There were no nurses' initials on 2/15/2021 at 0900 to indicate the medication had been administered as ordered .
Aspirin tablet chewable 81 mg to be given once a day for analgesia. There were no nurses' initials on 2/15/2021 at 0900 to indicate the medication had been administered as ordered.
Carvedilol tablet 3.125 mg to be given twice a day for hypertension. There were no nurses' initials on 2/15/2021 at 0730 to indicate the medication had been administered as ordered.
Cyproheptadine HCL tablet 4 mg to be given twice a day for an appetite stimulant. There were no nurses' initials on 2/15/2021 at 0900 to indicate the medication had been administered as ordered.
Furosemide tablet 40 mg to be given once a day for diuretic. There were no nurses' initials on 2/15/2021 to indicate the medication had been administered as ordered.
Multiple Vitamins-Minerals tablet to be given once a day for wound healing. There were no nurses' initials on 2/15/2021 at 0900 to indicate the medication had been administered as ordered.
Protonix tablet delayed release 40 mg to be given once a day for ulcer which was ordered on 9/30/20. There were no nurses' initials on 2/2/2021, 2/3/2021, 2/4/2021, 2/7/2021, 2/8/2021,2/9/2021, 2/11/2021,2/12/2021,2/14/2021 2/16/2021 2/17/2021,2/18/2021, 2/21/2021,2/23/2021, 2/26/2021, and 2/27/21 at 0600 to indicate the medication had been administered as ordered.
Repaglinide tablet 0.5 mg to be given before meals for diabetes. There were no nurse initials on 2/15/2021 at 0730 and 1130 to indicate the medication had been administered as ordered.
Saccharomyces Boulardii capsule 250 mg to be given once a day for probiotic. There were no nurses' initials on 2/15/2021 at 0900 to indicate the medication had been administered as ordered.
Sertraline HCL 25 mg to be given once a day for depression. There were no nurses' initials on 2/15/21 at 0900 to indicate the medication had been administered as ordered .
Sertraline HCL 50 mg to be given once a day for depression. There were no nurses' initials on 2/15/2021 at 0900 to indicate the medication had been administered as ordered.
On 5/11/2021 at 10:10 AM the surveyor reviewed the MARCH 2021 EMAR and Order Summary Report for Resident # 122 which revealed the following:
Losartan Potassium Tablet 25 mg to be given once a day for congestive heart failure. There were no nurses' initials on 3/1/2021 and 3/22/2021 at 0900 to indicate the medication had been administered as ordered .
Insulin Humalog Solution to be given according to a sliding scale before meals and at bedtime for diabetes. There were no nurse initials on 3/2/2021, 3/3/2021, 3/4/2021, 3/5/2021, 3/7/2021, 3/8/2021, 3/9/2021, 3/11/2021, 3/12/2021, 3/17/2021 at 0630; and 3/1/20201,3/22/2021 at 1130 to indicate the medication had been administered as ordered.
Metformin HCL tablet 850 mg to be given twice a day for diabetes. There were no nurse initials on 3/1/2021 and 3/22/2021 at 0730 to indicate the medication had been administered as ordered.
Spironolactone tablet 25 mg to be given once a day for a diuretic. There were no nurse initials on 3/1/2021 and 3/22/2021 at 0900 to indicate the medication had been administered as ordered.
Brilinta Tablet 90 mg to be given twice a day as a blood thinner. There were no nurse initials on 3/1/2021 and 3/22/2021 at 0900 to indicate the medication had been administered as ordered.
Aripiprazole tablet 2 mg to be given once a day for depression. There were no nurses' initials on 3/1/2021 and 3/22/2021 at 0900 to indicate the medication had been administered as ordered.
Aspirin Tablet chewable 81 mg to be given once a day for analgesic There were no nurses initials on 3/1/2021 and 3/22/2021 at 0900 to indicate the medication had been administered as ordered.
Carvedilol tablet 3.125 mg to be given twice a day for hypertension. There were no nurses' initials on 3/1/2021 and 3/22/2021 at 0730 to indicate the medication had been administered as ordered.
Cyproheptadine HCL tablet 4 mg to be given twice a day for an appetite stimulant. There were no nurse initials on 3/1/2021 and 3/22/2021 at 0900 to indicate the medication had been administered as ordered .
Furosemide tablet 40 mg to be given once a day for diuretic. There were no nurse's initial on 3/1/2021 and 3/22/2021 at 0900 to indicate the medication had been administered as ordered.
Multiple Vitamins-Minerals tablet to be given once a day for wound healing. There were no nurses' initials on 3/1/2021 and 3/22/2021 at 0900 to indicate the medication had been administered as ordered .
Protonix tablet delayed release 40 mg to be given once a day for ulcer. There were no nurse's initials on 3/2/2021, 3/3/2021, 3/4/2021, 3/5/2021, 3/7/2021, 3/8/2021, 3/9/2021, 3/11/2021, 3/12/2021, and 3/17/2021 at 0600 to indicate the medication had been administered as ordered.
Repaglinide tablet 0.5 mg to be given before meals for diabetes. There were no nurse's initials on 3/1/2021 and 3/22/2021 at 0730 and 1130 to indicate the medication had been administered as ordered.
Saccharomyces Boulardii capsule 250 mg to be given once a day for probiotic. There were no nurse's initials on 3/1/2021 and 3/22/2021 at 0900 to indicate the medication had been administered as ordered.
Sertraline HCL 25 mg to be given once a day for depression. There were no nurses on 3/1/2021 and 3/22/2021 at 0900 to indicate the medication was administered as ordered .
Sertraline HCL 50 mg to be given once a day for depression. There were no nurses' initials on 3/1/2021 and 3/22/2021 at 0900 to indicate the medication had been administered as ordered.
On 5/11/2021 at 10:20 AM the surveyor reviewed the April 2021 EMAR and Order Summary Report for Resident #122 which revealed the following:
Losartan Potassium Tablet 25 mg to be given once a day for congestive heart failure. There were no nurses' initials on 4/1/2021 at 0900 to indicate the medication had been administered as ordered.
Insulin Humalog Solution to be given according to a sliding scale before meals and at bedtime for diabetes. There were no nurse's initials on 4/2/2021, 4/4/2021, 4/5/202, 4/18/2021, 4/19/2021, 4/20/2021, 4/23/2021, 4/24/2021, 4/27/2021,4/28/2021, 4/29/2021, 4/30/2021 at 0630; and 4/1/2021 at 1130 to indicate the medication had been administered as ordered.
Metformin HCL tablet 850 mg to be given twice a day for diabetes. There were no nurses' initials on 4/1/2021 at 0730 to indicate the medication had been administered as ordered.
Spironolactone tablet 25 mg to be given once a day for a diuretic. There were no nurses' initials on 4/1/2021 at 0900 to indicate the medication had been administered as ordered.
Brilinta Tablet 90 mg to be given twice a day as a blood thinner. There were no nurses' initials on 4/1/2021 at 0900 to indicate the medication was administered as ordered.
Aripiprazole tablet 2 mg to be given once a day for depression. There were no nurses' initials on 4/1/2021 at 0900 to indicate the medication had been administered as ordered.
Aspirin tablet chewable 81 mg to be given once a day for coronary artery disease. There were no nurses' initials on 4/1/2021 at 0900 to indicate the medication had been administered as ordered.
Carvedilol tablet 3.125 mg to be given twice a day for hypertension. There were no nurses' initials on 4/1/2021 at 0730 to indicate the medication had been administered as ordered.
Cyproheptadine HCL tablet 4 mg to be given twice a day for an appetite stimulant. There were no nurses' initials on 4/1/2021 at 0900 to indicate the medication had been administered as ordered.
Furosemide tablet 40 mg to be given once a day for diuretic. There were no nurses' initials on 4/1/2021 at 0900 to indicate the medication had been administered as ordered.
Multiple Vitamins-Minerals tablet to be given once a day for wound healing. There were no nurses' initials on 4/1/2021 at 0900 to indicate the medication had been administered as ordered.
Protonix tablet delayed release 40 mg to be given once a day for ulcer. There were no nurses' initials on 4/2/2021, 4/4/2021, 4/5/2021, 4/18/2021, 4/19/2021,4/20/2021, 4/23/2021, 4/24/2021, 4/27/2021, 4/28/2021, 4/29/2021, and 4/30/2021 at 0600 to indicate the medication had been administered as ordered.
Repaglinide tablet 0.5 mg to be given before meals for diabetes There were no nurses initials on 4/1/2021 at 0730 and 1130 to indicate the medication had been administered as ordered.
Saccharomyces Boulardii capsule 250 mg to be given once a day for probiotic. There were no nurses' initials on 4/1/2021 at 0900 to indicate the medication had been administered as ordered.
Sertraline HCL 25 mg to be given once a day for depression. There were no nurse's initials on 4/1/2021 at 0900 to indicate the medication had been administered as ordered.
Sertraline HCL 50 mg to be given once a day for depression. There were no nurses' initials on 4/1/2021 at 0900 to indicate the medication had been administered as ordered.
There was no documented evidence in the medical record that the resident experienced a negative reaction/harm from the possible omission of the administration of medications.
During an interview on 05/11/21 at 10:03 AM, LPN # 2 stated that when administering medications, we are to verify the correct medication, verify the correct resident, then document that you gave medications. When LPN #2 was shown the blank spaces on Resident # 122's EMARs she stated that according to the facility policy if it was not signed it was not given.
During an interview on 05/12/21 at 08:17 AM, regarding the blank spaces on Resident #122's January, February and April 2021 EMAR's the registered nurse supervisor stated, this is unacceptable. She furthered It is not the facility policy to leave blanks and it is not correct.
During an interview on 05/12/21 at 1:29 PM, the DON stated that the expectation is that the EMAR should not have blanks and if there are blank spaces then the facility policy is not being followed.
A review of the facility's Medication Pass policy with revised date of 12/2019 which included The individual administering the medication must sign the resident's MAR on the appropriate line after giving each medication and before administering the next ones and If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall sign the MAR and/or TAR at the time of administration for the indication of withhold, refused, or late administration.
Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to follow acceptable standards of clinical practice in accordance with the New Jersey Board of Nursing Statutes by; a) the facility failed to follow a physician order to obtain weekly weights from October 2020 through 5/11/21 for 1 of 2 Residents reviewed for tube feeding (Resident #70), b) the facility failed to maintain medication records that were complete with staff signatures for 1 of 5 residents reviewed for unnecessary medications (Resident #122), c) failed to obtain a physician order for the use of a Foley Catheter for 1 of 4 residents reviewed for catheter use (Resident #63). This deficiency was cited at a level E due to the length of time weekly weights were not completed and the amount of missing nurses initials on the medciation administration record. This deficient practice was evidenced by the following:
Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The nurse practice act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities with in the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
a) During the initial tour on 05/04/21 at 12:02 PM, Resident #70 was observed lying in bed with the head of bed elevated 45 degrees. Resident appeared nourished and hydrated.
A review of the admission Record revealed Resident #70 was admitted to the facility with diagnosis of Anoxic (lack of oxygen) Brain Damage and Gastrostomy (a surgical inserted tube into the stomach for liquid nutrition).
A review of the Order Summary Report dated 10/1/20-5/31/21 revealed a physician order (PO) for Weekly Weights one time per day every Monday with an order date of 10/22/20 and start date of 10/26/20.
A review of the Treatment Administration Records (TAR) dated 11/1/20 thru 5/10/21 showed the PO for the weekly weights, a signature that the order was completed but no weight was documented.
A review of the Care Plan revealed a Focus area of I am at Nutritional risk related to NPO status (nothing by mouth) with 100% dependence for nutrition and hydration via G tube (gastrostomy). The interventions section reflected to monitor weights monthly with a date initiated of 10/22/20.
A review of the Weights and Vitals Summary from 11/4/20 thru 5/10/21 did not include documentation of weekly weights.
During an interview on 5/10/21 at 10:20 AM, Nursing Assistant (NA #1) said the nurse tells us when we need to get a weight. We write it down on paper and tell the nurse the weight then put it in the computer.
During an interview on 05/10/21 at 10:27 AM, Licensed Practical Nurse (LPN #1) said facility policy on weights is we get one on admission and then monthly unless MD ordered weights more frequently due to a resident condition. She went on to say the weights go on the Medication Administration Records (MARs) and pop up when the weight is due. LPN #1 said the nurse and the aide are responsible to get the weights as ordered.
During an interview on 05/11/21 at 09:15 AM, Licensed Practical Nurse Unit Manager (LPNUM) of unit 1 C/D, confirmed that Resident #70's weight order was to be done weekly with a start date of 10/26/20. She went on to say weights would be documented under the weights and vitals tab in the Electronic Medical Record (EMR). LPNUM said No I don't see weekly weights. It should be the nurse on the cart who is responsible to make sure they are done. LPNUM confirmed that on the April 2021 TAR that the nurses are signing weekly weights as having been done. She said the Unit Manager looks at weights after they are done and are looking for a weight loss or gain of 5 pounds or more and we will have a reweight done on resident.
During an interview on 05/11/21 at 11:49 AM, the Registered Dietician (RD) said she had just started working at the facility in February. I review monthly weights and weights when residents come in. I write notes and will bring up in morning report if a resident needs a reweigh or I will e mail the nurses for a reweigh. The RD said she had no knowledge of why Resident #70 did not get weekly weights.
During an interview on 05/12/21 at 01:54 PM, the Director of Nursing (DON) said her expectation is for weights to be done and that facility policy is to do weekly weights on Monday and reweigh on Tuesday if necessary. She went on to say that Nursing management is responsible for weights being done as ordered.
A review of a facility policy titled Weight Assessment and Interventions with a revision date of 9/2020, revealed under the policy section: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents. Under the procedure section: Obtaining Weights 1. The nursing staff will measure resident weight within 24 hours of admission, weekly for four weeks then monthly thereafter. Under 4. Weights will be recorded in the medical record a. any weight change of 5 pounds in a month or 3 pounds in a week since last weight assessment will be retaken within 48 hours for confirmation and verified by nursing.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness.
This deficient practice was evidenced by the following:
On 5/4/2021 from 9:16 to 10:30 AM the surveyor, accompanied by the Cook, observed the following in the kitchen:
1. In the dry storage room on a lower shelf of a multi-tiered storage shelf, an opened box contained an opened plastic bag of plain breadcrumbs. The opened bag was wrapped with plastic wrap and had no opened or used by date. On the same shelf a stack of what appeared to be parchment paper (grease-and moisture resistant paper specially treated for oven use) was on a lower shelf. The parchment paper was removed from its original container and was exposed to dust and contamination.
2. On a middle shelf in the dry storage room two unopened boxes of medium noodles (pasta) appeared to be wet. The surveyor touched the box with their fingertips and the box was determined to be wet to the touch with an unknown substance. In addition to the two boxes of medium noodles, an opened box of Angel Hair 10 pasta had been opened and was also determined to be wet to the touch. The boxes were observed to be under a group of pipes above the shelf where food is stored. The surveyor observed a copper pipe that was actively dripping what appeared to be a watery substance. The surveyor felt the copper pipe in the vicinity of a silver hose clamp, and it was determined to be wet to the touch and actively dripping. The surveyor interviewed the cook. The cook stated, I know we have a leak from that pipe in dry storage. We told maintenance about it. I'm not sure when we told them, I know we sent an email. On 5/4/2021 at 1:58 PM the surveyor conducted an interview with the Food Service Director (FSD) about the leaking pipe in the dry storage room. The FSD stated, Yeah, I sent that to corporate a few weeks ago. Additional documentation provided by the FSD revealed that on May 1, 2021 at 11:49 AM, the Corporate Director Food & Nutrition sent an email to the facility Administrator and Regional Director of Corporate Compliance (RDCC) notifying them of the following after their visit to the facility on 4/28/2021: Leak observed in food storage room dripping on boxes etc. (sic) [NAME] moved foods around to avoid water. Area very moist and creating environment for bacteria and mold growth. Standing water also in basement. Maintenance states hole (sic) house would have to be turned off at night and it's a big job. The surveyor conducted an interview on 5/12/2021 at approximately 1:15 PM with the facility Administrator and RDCC regarding the leaking pipe in the dry storage room. The Administrator stated, I believe it's a bigger job because it's a central pipe. We have the supplies we just need to come up with a time to shut the water down. We are going to get on it next week.
3. Next to the shelf that contained the wet pasta boxes, a 6 pound can of dark red kidney beans had a significant dent in the middle of the can. This can was not in the designated dented can area. On the above shelf, a can of Deluxe Corned Beef Hash had a significant dent on the upper seam. This can was also not in the designated dented can area, which was observed on entry to the dry storage room. On interview with the cook, the cook stated, We have been a little short on help for a while.
4. Upon exiting the dry storage room, 3 boxes of laminated serving trays (Styrofoam trays) were in boxes and were stored on the floor. Adjacent to the serving trays, 2 boxes of foam hinged lid containers (used to serve resident meals on the PUI (Person Under Investigation)/COVID-19 units) were stored on the floor of the dry storage room. On interview the FSD stated, I saw the dented cans in the dry storage, and I moved them to the designated dented can area. I also saw the boxes of disposable dishware on the floor and I moved them so that they are off the floor now.
5. On 5/4/2021 at 10:00 AM upon re-entry to the kitchen, a 4 wheeled cart used to hold and warm plates during meal service was observed against a wall before the entrance to the dish room. The top of the cart was covered with unidentified food debris. On interview the cook stated, We used this for breakfast this morning, it was clean before breakfast. The top of the cart was observed to have orange unidentifiable debris near the plate holder, as well as other unidentifiable debris on the top surface of the plated holder/warmer. The surveyor questioned the cook if they had served anything orange at the breakfast meal today. The [NAME] responded, No.
6. In the walk-in refrigerator on a lower/middle rack of a multi-tiered rack, a bag of frozen spinach was removed from its original container and had no dates. On a lower shelf on the opposite side of the freezer, a frozen entree of vegetarian stuffed cabbage showed excessive ice buildup on the entree and had no dates. On the same shelf and located beneath the stuffed cabbage rolls, an aluminum pan contained frozen cheese lasagna. The aluminum covering had come loose on top of the lasagna and the frozen lasagna was exposed. On a middle shelf, an opened cardboard box contained a white plastic bag. The bag appeared to contain frozen carrots. The bag was partially opened, and the carrots were exposed. The bag had no dates. On interview the cook stated, I'm throwing all of this away. This should have been thrown in the trash already. The cook was observed to throw the cabbage rolls, lasagna, frozen carrots, and frozen spinach in the trash.
On 5/4/2021 at 1:58 PM, the surveyor conducted an interview with the FSD who had not participated in the initial brief tour of the kitchen. On interview the FSD stated, Anything removed from the original container needs to be dated.
On 5/11/2021 from 10:56 to 11:07 AM, the surveyor, accompanied by the Licensed Practical Nurse (LPN), observed the following in the First Floor Pantry. Prior to making observations the LPN stated, Housekeeping is responsible for monitoring the pantry and removing expired foods. On an upper shelf in the refrigerator a plastic bag contained what appeared to be a salad on a small Styrofoam plate. The salad was dated 5/3/2021 and 5/5/2021. A larger salad on a regular size Styrofoam plate was dated 5/4 and 5/6. The bag also contained three clear plastic containers of an unidentified substance, which appeared to be salad dressing. No dates were observed on the three containers. In addition, another small salad on a Styrofoam plate was on the same shelf. The salad was dated 5/3/21 and 5/5/21. The cucumbers on the salad appeared to be brownish and showed signs of spoilage. On interview the LPN stated, I assume those are the made and use by dates because they came from the kitchen. On a lower shelf a takeout style fast food type container with a clear plastic lid contained unidentified food. The container had no dates, name, or room number. In a bottom drawer of the refrigerator 6 containers of applesauce had no dates. The LPN threw all the food in the trash in the presence of the surveyor.
On 5/12/2021 from 9:52 to 10:23 AM the surveyor, accompanied by the FSD observed the following in the kitchen:
1. The surveyor observed the milk box just outside of the walk-in refrigerator. The FSD opened the box to check the internal thermometer for proper temperature. The FSD moved the top crate that contained individual milk cartons used for resident meals. Upon removal of the top crate of milks, the bottom of the milk refrigerator was observed to be covered with a brown, watery liquid. The surveyor questioned the FSD how often the milk box is cleaned and if it is on the regular cleaning schedule. The FSD responded, I cleaned it about six weeks ago, but I haven't had time to do it recently because I have been busy cooking.
2. On the middle pot drying wire rack, a plastic pitcher used to serve beverages was not in the inverted position and a wet watery substance was observed in the bottom of the pitcher. The FSD removed the pitcher from the drying rack and stated, I will have it rewashed.
3. The FSD removed several milk crates to find the internal thermometer for the tray line milk box. Once the milk crates had been removed and the bottom of the milk box was exposed the surveyor and FSD observed a watery, brownish/white liquid in the bottom of the milk box. The FSD stated, It's the same, we haven't had time to clean it. The FSD instructed the cook to clean the milk box after the lunch meal. Dairy product was not in contact with the watery substance as all milks and yogurts were stored on top of milk crates and not in contact with the bottom of the refrigerated box.
On 5/12/2021 from 11:27 to 11:53 AM the surveyor, accompanied by the FSD observed the following in the kitchen:
1. Upon entry to the kitchen the surveyor observed the baseboard tile that is outside of the FSD office. The tiles were observed to be cracked and missing in some spots, exposing the sheetrock. The surveyor also observed several cracked and broken tiles on the opposite wall of the FSD office that lead to the entry of the dish room. When interviewed, the FSD stated, Maintenance fixed a couple of them one time but they have pretty much been like that since I've been here.
2. The surveyor observed the plate warmer cart that contained cleaned and sanitized plates to be used for the residents' lunch meal. The top plate on the warmer had a significant chip out of the outside edge of the plate. The surveyor made the FSD aware of the plate and the FSD removed the plate from the plate warmer cart and discarded the plate in the trash. The FSD stated, Thanks.
The surveyor reviewed the facility policy titled Centers Health Care Food From Outside-Safety, last date revised 5/2019. Under the Procedure heading, the policy revealed the following:
Educate and Inform:
Education on safe food handling will be provided to all staff, family, residents, resident council, visitors and community groups who may provide foods or fluids to residents of the facility. This education will include at a minimum:
Proper labeling and dating of each item.
Leftover foods will be used within 3 days or discarded.
In addition, the policy further revealed under the Monitoring heading the following:
Facility staff will be appointed to check resident refrigerators for proper temperatures, food containment and quality, and disposal of items per facility policy.
Foods requiring refrigeration will be received by the facility designee (activity department, food and nutrition department, charge nurse, etc.) for proper and immediate storage including labeling and dating.
Staff will examine food for quality (smell, packaging, appearance) to identify potential concerns. If concerns are identified, staff will notify the resident or resident representative of findings and necessary actions per proper food and beverage safe handling.
The surveyor reviewed the facility policy titled Centers Health Care Food Storage Policy, last date revised 2/25/2021. The policy revealed the following under the Procedure heading:
1. Dry storage rooms must be well ventilated. All storage areas should have adequate illumination with temperature and humidity controls to prevent condensation of moisture and growth of mold.
3. Food items will be stored on shelves, with heavier and bulkier items stored on the lower shelves.
7. (c.) Food should be dated as it is placed on the shelves if required by state regulation.
(d.) Date marking to indicate the date or day by which a ready-to-eat, time/temperature control for safety food, (formerly known as PHF) should be consumed, sold, or discarded will be visible on all high-risk food.
(g.) Dented cans will be stored in separate designated area.
10. Food will be stored a minimum of 6 inches above the floor, 18 inches from the ceiling and 2 inches from the wall on clean racks or other clean surfaces, and is protected from splashes, overhead pipes, or other contamination (ceiling sprinklers, sewer/waste disposal pipes, vents, etc.).
13. Refrigerated food storage:
a. All refrigerator units will be kept clean and in good working condition at all times. Walls, ceilings and fans will be cleaned regularly.
f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.
14. Frozen Foods:
c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be checked to assure that foods will be consumed by their safe use by dates or discarded.
The surveyor reviewed the facility policy titled Centers Health Care Equipment Failure and Repair, last date revised 3/2021. The policy stated, Food and Nutrition equipment shall be maintained in a good state of repair. The policy revealed the following under the Procedure heading:
1. Staff is trained to report equipment that does not work or is not functioning properly.
2. Supervisor or staff member reports problem to Maintenance Department according to facility procedure giving as much detail as needed to describe problem.
3. Outside repair services is called if problem cannot be corrected in a reasonable time frame by facility maintenance staff.
The surveyor reviewed the facility provided Cleaning Schedule for the kitchen, undated. The schedule revealed the following
MONDAY-REFRIDGERATORS (sic) Clean out all refrigerators. Throw out all expired food. Clean inside and outside of refrigerator with soap and hot water.
The surveyor reviewed the facility policy titled Centers Healthcare Policy and Procedure Cracked and chipped glassware, revised on 10/2019. The following was observed under Policy:
China and glassware that is chipped, cracked or is in otherwise unusable condition is removed from service.
The following was revealed under the Procedure heading:
1. Any employee who notices china or glassware that is cracked, chipped, permanently stained or otherwise unsuitable for service removes it from service and notifies supervisor.
NJAC 8:39-17.2(g)
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?"
- "Why is there high staff turnover? How do you retain staff?"
- "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), $69,167 in fines. Review inspection reports carefully.
- • 34 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $69,167 in fines. Extremely high, among the most fined facilities in New Jersey. Major compliance failures.
- • Grade F (8/100). Below average facility with significant concerns.
Bottom line: Trust Score of 8/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Hammonton Center For Rehabilitation And Healthcare's CMS Rating?
CMS assigns HAMMONTON CENTER FOR REHABILITATION AND HEALTHCARE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within New Jersey, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Hammonton Center For Rehabilitation And Healthcare Staffed?
CMS rates HAMMONTON CENTER FOR REHABILITATION AND HEALTHCARE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 71%, which is 25 percentage points above the New Jersey average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 59%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Hammonton Center For Rehabilitation And Healthcare?
State health inspectors documented 34 deficiencies at HAMMONTON CENTER FOR REHABILITATION AND HEALTHCARE during 2021 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 33 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 Hammonton Center For Rehabilitation And Healthcare?
HAMMONTON CENTER FOR REHABILITATION AND HEALTHCARE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 240 certified beds and approximately 203 residents (about 85% occupancy), it is a large facility located in HAMMONTON, New Jersey.
How Does Hammonton Center For Rehabilitation And Healthcare Compare to Other New Jersey Nursing Homes?
Compared to the 100 nursing homes in New Jersey, HAMMONTON CENTER FOR REHABILITATION AND HEALTHCARE's overall rating (1 stars) is below the state average of 3.2, staff turnover (71%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Hammonton Center For Rehabilitation And Healthcare?
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?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Hammonton Center For Rehabilitation And Healthcare Safe?
Based on CMS inspection data, HAMMONTON CENTER FOR REHABILITATION AND HEALTHCARE 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 1-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 Hammonton Center For Rehabilitation And Healthcare Stick Around?
Staff turnover at HAMMONTON CENTER FOR REHABILITATION AND HEALTHCARE is high. At 71%, the facility is 25 percentage points above the New Jersey average of 46%. Registered Nurse turnover is particularly concerning at 59%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Hammonton Center For Rehabilitation And Healthcare Ever Fined?
HAMMONTON CENTER FOR REHABILITATION AND HEALTHCARE has been fined $69,167 across 1 penalty action. This is above the New Jersey average of $33,771. 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 Hammonton Center For Rehabilitation And Healthcare on Any Federal Watch List?
HAMMONTON CENTER FOR REHABILITATION AND HEALTHCARE 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.