Allaire Rehab & Nursing

Inspectors wroteBased on observation, interview, and policy review, 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 05/21/2026 from 09:47 AM until 11:00 AM, the surveyor observed the following in the kitchen in the presence of the Food Service Director (FSD):1. In the walk-in refrigerator three opened containers of chicken base were observed to have no opened or use-by date. The FSD indicated that the date observed on the item was the received date and further stated they should have an opened-on date as well.2. In the walk-in refrigerator a metal container with a plastic cling wrap cover with ketchup written on the plastic. On the plastic wrap was a sticker label with a use-by date of 4/25/26. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the facility designated garbage area free of trash and debris and failed to have a closed cover over the opening of 1 of 2 garbage containers. This deficient practice was evidenced by:On 05/21/2026 at 10:53 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the facility's outdoor trash disposal area. The surveyor observed two garbage containers (GC) situated side by side outside of the facility. The surveyor observed one GC with an open lid which contained cardboard boxes exposed to the elements. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete the Quarterly Minimum Data Set assessment in a timely manner for 6 residents. This deficient practice was identified for 6 of 8 Residents (Residents #45,81,139,141,142 and #148) reviewed for Resident Assessment and was evidenced by the following:Resident #45 was admitted with diagnoses that included but were not limited to nontraumatic subarachnoid hemorrhage. On 05/28/2026, the surveyor reviewed the electronic medical record (EMR) for resident #45. The Quarterly Minimum Data Set (QMDS), an assessment tool completed every 3 months, revealed an Assessment Reference Date (ARD), a date used as the last day of a look-back period, of 04/3/2026. The EMR revealed that the QMDS for Resident #45 had been completed on 04/25/2026, 8 days late. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to administer medication with an error rate of less than 5%. The surveyor observed 3 nurses administer medications for 5 residents, errors were observed for 2 of 5 residents (Resident #37 and Resident #109). There were 25 opportunities for error with 11 errors observed resulting in an error rate of 44% as evidenced by the following: During the medication pass observation on 5/22/26 from 10:01 AM until 10:24 AM, the surveyor observed the following:At 10:01 AM, the surveyor observed Licensed Practical Nurse #1 (LPN #1) prepare 10 medications for Resident #109, they were as follows:Vascepa 1GM (gram) capsule, give two capsules by mouth two times a day; scheduled for 8:00 AM and 5:00 PM.Keppra 1000 mg (milligram) tablet, give one tablet by mouth two times a day; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provided a safe, clean, and homelike environment for 1 of 4 floors and 1 of 1 resident (Resident # 119) reviewed under the Environmental Task. The deficient practice was evidenced by the following: On 05/21/2026 at 10:28 AM during the initial tour, the surveyor observed Resident # 119 in bed in his/her room. At that time, the surveyor observed an emptied, needleless, saline syringe left on top of his/her blanket. On 05/21/2026 at 10:38 AM during the initial tour, the surveyor observed a plastic drawer outside of room [ROOM NUMBER]. At that time, the surveyor observed a soiled paper towel inside the top drawer that contained personal protective gowns. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents it was determined that the facility did not ensure a residents medication regimen was free from unnecessary psychotropic medications. Specifically, a psychotropic medication ordered for an extended duration lacked a documented clinical rationale in the resident's record. The deficient practice was identified for 1 of 5 residents (Resident #1) reviewed for unnecessary medications. This deficient practice was evidenced by the following:05/21/2026 at 9:50 AM, the surveyor observed Resident #1 speaking loudly and appearing upset regarding his/her breakfast tray. Staff intervened immediately. The surveyor reviewed Resident #1's medical record which reflected that the resident had diagnoses which included anxiety and depression. [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation it was determined that the facility failed to notify the Long-Term Care Ombudsman when a resident was transferred to an acute care hospital. The deficient practice was identified for 1 of 1 (resident # 161) resident reviewed for hospitalization. The deficient practice was evidenced by the following: A review of Resident # 161's diagnoses located in the medical record revealed diagnosis of but not limited to neurofibromatosis (a group of genetic disorders that cause benign (non-cancerous) tumors to grow on nerves throughout the body) and moderate protein calorie malnutrition. A review of the progress notes located in the medical record revealed that on 04/02/2026 Resident # 161 complained of abdominal pain. He/She refused all vitals and all as-needed medications. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete the Annual Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 1 of 8 residents (Residents #91) reviewed for timing of assessments and was evidenced by the following: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual indicates that at a minimum, facilities are required to complete a comprehensive assessment for each resident not less than once every 12 months while a resident, where 12 months refers to a period within 366 days. This deficient practice was evidenced by the following:Resident #91 was admitted with diagnoses that included but were not limited to injury to the thoracic spinal cord. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive care plan to address an anticoagulant (a blood thinner) medication for 1 of 32 residents (Resident #1) reviewed. The deficient practice was evidenced by the following: On 05/21/2026 at 9:50 AM, the surveyor observed Resident #1 speaking loudly and appearing upset regarding his/her breakfast tray. Staff intervened immediately. The surveyor reviewed Resident #1's medical record which reflected that the resident had a diagnosis which included atrial fibrillation. A review of the physician orders for Resident #1 reflected an order dated 12/01/2025 for the resident to receive Eliquis (an anticoagulant). The admission Minimum Data Set, an assessment tool, dated 12/19/2025 reflected that Resident #1 received an anticoagulant daily. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan to include indwelling urinary catheter. This deficient practice was identified for 1 of 29 residents reviewed for resident-centered care plans (Resident #124), and was evidenced by the following: On 05/21/2026 at 11:35 AM, during initial tour, Resident #124 was observed lying in his/her bed while family visited. At this time Resident #124's family stated that the resident recently had an indwelling catheter placed. On 05/26/2026 at 9:38 AM, during follow up with Resident #124 the surveyor was informed by the Assistant Director of Nursing (ADON) that the resident had been admitted to the hospital with diagnoses that included urinary tract infection (UTI). [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to follow the recommendation identified by the Consultant Pharmacist. This deficient practice was identified for 1 of 5 Residents (Resident #1) reviewed for unnecessary medications, psychotropic medications, and medication regimen review and was evidenced by the following: 05/21/2026 9:50 AM, the surveyor observed Resident #1 speaking loudly and appearing upset regarding his/her breakfast tray. Staff intervened immediately. The surveyor reviewed Resident #1's medical record which reflected that the resident had diagnoses which included anxiety and depression. [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to a.) ensure residents were free from unnecessary medications and b.) medications were administered in accordance with a physician's orders. This deficient practice was identified for 1 of 5 residents (Resident #7) reviewed for unnecessary medication use. On 5/21/2026 at 11:51 AM, the surveyor observed Resident #7 in their room, with the lights off and resting. The surveyor reviewed the medical record for Resident #7. A review of the admission Record face sheet reflected the resident was admitted to the facility in April of 2025 with diagnoses which included paraplegia (the partial or complete paralysis of the lower half of the body), major depressive disorder, and hypotension (low blood pressure). [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to ensure medication carts were kept clean, orderly, and free of loose medications. The deficient practice was identified for 2 of 4 medication carts reviewed under the Medication Storage task. The deficient practice was evidenced by the following: On 05/21/2026 at 11:54 AM, while inspecting the 1 South medication cart, the surveyor found 13 loose, unidentified tablets and pills located in the drawers. The surveyor also observed a card containing medication located behind the drawers out of reach. On 05/27/2026 at 10:24 AM while inspecting the Annex medication cart, the surveyor observed that the bottom drawer contained prescription inhalants, pain-relief patches, and cartons of nutritional formula amongst one another and not organized and separated by administration route. [...]

Inspectors wroteBased on observations, interviews, record review and other pertinent facility documents, it was determined that the facility failed to use appropriate infection control a.) respiratory device tubing, masks, and mouthpiece were stored in protective coverings between uses identified for 1 of 2 residents (Resident #108) reviewed for respiratory care, b.) perform central line dressing changes, identified for 1 of 1 residents (Resident #119) reviewed for antibiotic use. This deficient practice was evidenced by the following:On 5/21/2026 at 12:27 PM, during initial tour, the surveyor observed Resident #108's nebulizer on the bedside table. At that time the surveyor observed the tubing to the nebulizer leading behind the bedside table. A review of Resident #108's Electronic Medical Record (EMR) revealed diagnosis of but not limited to; [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain the physical environment in a safe condition by failing to ensure that a corridor handrail was firmly secured to the wall. The deficient practice was identified for 1 of 4 floors. The deficient practice was evidenced by the following: On 05/21/2026 at 10:43 AM, during the initial tour while on the first floor, the surveyor observed a portion of the wall adjacent to the elevator missing a handrail. The surveyor observed dry-wall exposed where a previous handrail may have been secured. On 05/27/2026 at 1:09 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) of the finding. The LNHA said that the handrail became dislodged and maintenance was working to install it. A review of the facility provided policy titled, Maintenance Services Policy revealed that, a. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:On 10/30/25 at 11:30 AM, during a tour of the first floor, with the Unit Manager (UM), the nourishment room was noted to be in disrepair. The cabinet doors were askew. The UM stated this had not been reported to Maintenance. [NAME] stains were noted on the grates of the ice maker, the UM stated that it was not always like this. The paper towel dispenser was empty, and the roll of paper towels were sitting on top of the refrigerator. The microwave had brown debris on the bottom. The UM stated she was not sure how often the microwave was cleaned, and the CNA or nurse cleans it if there was a mess. [...]

Inspectors wroteComplaint # 2582137 Refer to F610 and F835Based on observations, interviews, and review of pertinent facility documentation on 08/05/2025, 08/06/2025, and 08/07/2025, it was determined that the facility failed to implement their abuse policy to ensure a.) residents were protected from abuse after an allegation of abuse was made on 08/05/2025, by the local police regarding Resident #8 and their caregiver, Resident Representative (RR #1). This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #8). During an interview with the Licensed Nursing Home Administrator (LNHA) on 08/06/2025, revealed that on 08/05/2025, he observed the local police at the facility, and overheard the police officer tell the facility's Receptionist that Resident #8 was being mistreated by RR #1, who was caring for the resident. [...]

Inspectors wroteComplaint # 2582137Based on interviews and review of other pertinent facility documentation on 08/05/2025, 08/06/2025, and 08/07/2025, it was determined that the facility failed to implement their abuse policy by thoroughly investigating an allegation of abuse to a resident (Resident #8) that the police officer reported the allegation on 08/05/2025. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #8). During an interview with the Licensed Nursing Home Administrator (LNHA) on 08/06/2025, revealed that on 08/05/2025, he observed the local police at the facility, and heard the police officer tell the facility's Receptionist that Resident #8 was being mistreated by the Resident Representative (RR #1), who was caring for the resident. [...]

Inspectors wroteComplaint # 2582137Based on interviews and review of other pertinent facility documentation on 08/05/2025, 08/06/2025, and 08/07/2025, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure himself, as well as staff, implemented the facility's abuse policies and procedures to ensure resident safety and well-being by a.) protecting a resident from an alleged perpetrator pending a thorough investigation and b.) thoroughly investigating an allegation of abuse. The Licensed Nursing Home Administrator (LNHA) was interviewed by the surveyor on 08/06/2025. The LNHA stated that on 08/05/2025 he observed the local police at the facility and overheard the police officer tell the facility's Receptionist that Resident #8 was being mistreated by the Resident Representative (RR #1), who was caring for the resident. [...]

Inspectors wroteComplaint # 2582137Census: 137Sample:12Based on observations, interviews, medical record review and review of other pertinent facility documentation on 08/05/2025, 08/06/2025 and 08/07/2025 it was determined that the facility failed to administer medications according to the acceptable practice for 1 of 4 residents (Resident #8). The facility failed to follow their policy titled Administering Medications. The deficient practice was evidenced by the following:Reference: New Jersey Statues Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. [...]

Inspectors wroteComplaint #: NJ185442 and NJ187702 Based on interview and review of pertinent facility documents on 6/30/25, 7/1/25, and 7/2/25, it was determined that the facility failed to ensure residents' New Jersey Universal Transfer Forms (UTF) for discharge to the hospital were completed fully and accurately. This deficient practice was identified for 3 of 3 residents reviewed (Resident #2, Resident #3, Resident #6), and was evidenced by the following: Reference: NJ.gov: https://www.nj.gov/health/forms/hfel-7instr_1.pdf:INSTRUCTIONS FOR COMPLETING THE NEW JERSEY UNIVERSAL TRANSFER FORM dated [DATE], The purpose of the New Jersey Universal Transfer Form: A form that communicates pertinent, accurate clinical patient care information at the time of a transfer between health care facilities/programs. [...]

Inspectors wroteComplaint #: NJ185442 Based on interviews, medical records review, and review of other pertinent facility documentation 6/30/25, 7/1/25, and 7/2/25, it was determined that the facility failed to obtain and administer narcotic pain medication according to physician's order (PO) in a timely manner. This deficient practice was identified 1 of 3 residents reviewed for pain management (Resident #6), and was evidenced by the following: Resident #6 was not at the facility at the time of the survey. A closed record review was conductedA review of Resident #6's Resident admission Record (AR; admission summary) revealed that the resident was admitted to the facility with diagnoses which included but were not limited to; anoxic brain damage (occurs when the brain is completely deprived of oxygen, leading to cell death and potential brain damage); [...]

Inspectors wroteComplaint #: NJ185442 Based on interviews, review of the medical record, and other pertinent facility documents on 6/30/25, 7/1/25, and 7/2/25, it was determined that the facility failed to ensure controlled medications were appropriately destroyed in accordance with state and federal regulations. This deficient practice was identified for 1 of 3 residents reviewed for pain management (Resident #6), and was evidenced by the following:Resident #6 was not at the facility at the time of the survey. A closed record review was conducted. A review of Resident #6 admission Record (AR; an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to; [...]

Inspectors wroteBased on interview, record review, and review of facility policy, it was determined that the facility failed to protect the residents' rights to be treated with respect and dignity when the facility searched all 136 residents' rooms for drugs, including marijuana without properly obtaining informed consent for 2 of 31 residents reviewed for resident rights (Resident #65 and Resident #105) . Review of documentation provided by the Licensed Nursing Home Administrator (LNHA) revealed that on 10/07/24, all the resident rooms in the facility were searched. On 10/14/24, four resident rooms were searched, and on 10/21/24, an additional four resident rooms were searched. On 10/29/24 at 1:21 PM, the surveyor interviewed Resident #105 who stated that the facility had drug dogs come and search the facility every week. Resident #105 stated that they felt harassed by being searched. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure four (4) of four (4) medication storage carts, and three of three treatment supply carts were free of dust, debris, and residue. This failure had the potential to contaminate all resident medications and treatment supplies stored in the carts.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a performance review was completed every 12 months for five (5) of seven (7) employees' personnel records reviewed.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to promote the residents' right to have immediate access to visitors of immediate family members for one (1) of 31 sampled residents (Resident#126). This had the potential to cause psychosocial harm to R#126.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure the SNF ABN (skilled nursing facility advanced beneficiary notice) was complete and accurate prior to discharge from Medicare part A skilled services for two (2) of three (3) residents (Resident#12 and Resident#57) reviewed for SNF Beneficiary Protection. This failure placed the residents and/or representatives at risk of not being fully informed.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure residents were provided with clean and unstained privacy curtains in their room for one (1) of 31 sampled residents (Resident#20). This failure placed the resident at risk of not being provided with a clean and homelike environment.

Inspectors wroteBased on observation, interview, record review, facility policy review, and review email correspondence, the facility failed to make prompt efforts to resolve a grievance related to gastrostomy (g-tube) care for one of one (1) of 31 residents (Resident#126) reviewed for grievances. This failure caused Resident#126 to have an unresolved grievance, placed Resident#126 at continued risk of infection of the gastrostomy site, and placed the resident at risk for a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident safety for one (1) of 31 residents (Resident#125) reviewed for overdose when they did not assess the risk of substance abuse while in the facility, develop a comprehensive care plan with interventions to help prevent overdose, and increase monitoring and supervision after Resident#125 experienced an overdose while at the facility.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide appropriate gastrostomy (g-tube) care for one (1) of two (2) residents (Resident#126) reviewed for tube feeding. This failure increased Resident#126's risks of g-tube complications.

Inspectors wroteComplaint # NJ00176157 Based on observation, interview, record review, and review of pertinent facility documents on 8/15/24, it was determined that the facility failed to ensure that 1 of 1 Justice Involved Individual (JII) Resident #6 was afforded the autonomy to participate in group activities, community dining, serving meals in a dignified manner, freely communicate with visitors, leave rooms at will and be free from physical restraints. The failure to treat Resident #6 respectfully and in a dignified manner had the likelihood to cause serious injury and psychological harm. This was cited as an isolated incident that immediately jeopardizes the health and safety of the JII that resided in the facility which resulted in an immediate jeopardy(IJ) situation.

Inspectors wroteComplaint # NJ00176157 Based on observation, interview, record review, and review of pertinent facility documents on 8/15/2024, it was determined that the facility failed to ensure that 1 of 1 Justice Involved Individual (JII) Resident #6 was afforded the right to retain personal possessions and to have a homelike environment. This failure to treat Resident #6 respectfully and in a dignified manner had the likelihood to cause serious injury and psychological harm. This was cited as an isolated incident that immediately jeopardizes the health and safety of the JII which resulted in an immediate jeopardy ( IJ) situation.

Inspectors wroteComplaint # NJ00176157 Based on observation, interview, record review, and review of pertinent facility documents on 8/15/24, it was determined that the facility failed to ensure that 1 of 1 Justice Involved Individual (JII) Resident #6 was afforded the right to make own choices regarding aspects of life and care; participate in activities and interact with other residents inside of the facility. The failure to treat Resident #6 respectfully and in a dignified manner had the likelihood to cause psychological harm. This was cited as an isolated incident that immediately jeopardizes the health and safety of the JII that resided in the facility which resulted in an IJ situation.

Inspectors wroteComplaint # NJ00176157 Based on observation, interview, review of resident medical records and other pertinent facility documentation it was determined that the facility failed to ensure that 1 of 1 Justice Involved Individual (JII) (Resident #6) was free from involuntary seclusion. The JII was secluded from having autonomy and to make choices to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. The failure to allow JII autonomy posed the likelihood to cause psychological harm which resulted in an Immediate Jeopardy (IJ) situation.

Inspectors wroteComplaint # NJ00176157 Based on observation, interview, review of resident medical records and other pertinent facility documentation it was determined the facility failed to ensure that 1 of 1 Justice Involved Individual (JII) (Resident #6) was free from physical restraints. The failure to treat residents respectfully and in a dignified manner had the likelihood to cause psychological harm, that resulted in an immediate jeopardy (IJ) situation.

Inspectors wroteComplaint # NJ 176157 Based on observation, interviews, and review of pertinent facility documents on 8/15/2024, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to a.) ensure the facility implemented policies and procedures for Resident Rights and Self Determination as well as policies and procedures to prevent physical restraints and seclusion; b.) ensure residents signed an admission Agreements upon admission to the facility; c.) were afforded the autonomy to participate in group activities, community dining, serving meals in a dignified manner, freely communicate with visitors, and to leave rooms at will; and d.) ensure facility policies for Justice Involved Individual (JII) were in compliance with State and Federal regulations. This deficient practice was identified for 1 of 1 JII reviewed (Resident #6).

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to a.) clarify a duplicate oxygen order for one resident, b.) consistently document in the Medication Administration Record (MAR) for 2 residents, and c.) consistently document a prn (as needed) controlled substance medication in the MAR for one resident, in accordance with professional standards. This deficient practice was identified for one resident (Resident #6) reviewed for oxygen, 3 of 5 residents reviewed for unnecessary medications (Resident #10, Resident #67, and Resident #136) 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: [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to consistently monitor urine output in accordance with the physician's order and professional standards of care for 3 of 3 residents (Residents #16, #22 and #137) reviewed for urinary catheters. 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: [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure recommendations made by the Consultant Pharmacist were acted upon in a timely manner and documented for 5 of 5 residents (Residents #10, #44, #50, #67, and #139) reviewed for unnecessary medications. This deficient practice was evidenced by: 1.) According to the admission Record, Resident #10 was admitted with diagnoses that included, but were not limited to, unspecified psychosis not due to a substance or known physiological condition, anxiety disorder, major depressive disorder, personality change due to known physiological condition, mood disorder due to known physiological condition and Diabetes Mellitus. Review of the Consultant Pharmacist's (CP) Comments Report (CPCR) form included the following recommendations dated 02/04/22: [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to maintain a urinary catheter bag in a manner to promote dignity as per facility policy for 1 of 4 Residents (Resident # 16) reviewed for Urinary Catheter. This deficient practice was evidenced by the following: During the initial tour of the facility on 11/15/22 at 11:11 AM, the surveyor observed Resident #16's urinary catheter bag that was attached to the bed frame. The drainage bag contained urine and was not covered to maintain privacy. The surveyor made the same observations on 11/18/22 at 12:17 AM, 11/21/22 at 10:31 AM and 11/22/22 at 11:37 AM. During an interview with the surveyor on 11/22/22 at 12:17 AM, Resident #16 stated they don't use a cover on my urinary catheter bag, but they are supposed to. Resident #16 further stated I don't like it; [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to implement care plan interventions for 1 of 4 residents (Resident #22) reviewed for urinary catheter. This deficient practice was evidenced by the following: According to the admission Record, Resident #22 had diagnoses that included, but were not limited to, multiple sclerosis (immune system disorder), retention of urine and neuromuscular dysfunction of bladder (bladder dysfunction caused by nervous system conditions). Review of Resident #22's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/02/2022, included the resident had a Brief Interview for Mental Status of 15, which indicated that the resident was cognitively intact. [...]

Inspectors wroteBased on observation, interview, record review, and review other facility documentation, it was determined that the facility failed to maintain a medication error rate of less than 5%. This deficient practice was identified for 1 of 2 nurses on 1 of 2 units (3rd Floor) administering medications to 2 of 4 residents (Resident #30 and #79) making 2 errors out of 25 medication opportunities which resulted in a medication error rate of 8%. This deficient practice was evidenced by the following: 1. On 11/22/22 at 8:21 AM, the surveyor observed Licensed Practical Nurse (LPN) #1 administer medications to Resident #79. LPN #1 dispensed six medications including Ventolin HFA Aerosol Solution (a medication used to treat or prevent bronchospasm) (inhaler). [...]