Altercare Newark North Inc.

Inspectors wroteBased on medical record review, interview, and facility policy review, the facility failed to follow correct orders for wound care for a resident with a pressure ulcer. This affected one resident (Resident #03) of three residents reviewed for wound care. The facility census was 64.

Inspectors wroteBased on medical record review, hospital record review, staff interview, and facility policy review, this facility failed to ensure medication was transcribed in a resident's medication administration record as ordered by the physician. This affected one (Resident #66) of the four residents reviewed for medication administration. The facility census was 63. Review of the medical record for Resident #66 revealed and admission date of 02/24/2025 and a discharge date of 02/27/2025. Diagnosis included influenza, chronic pain, acute and chronic respiratory failure with hypoxia, and heart failure. Review of Resident #66 hospital discharge records dated 02/24/2025 revealed all ordered medication was transcribed into this resident's medication administration record correctly other than the order for Ipratropium-Albuterol 0.5-2.5 milligrams (mg)/3 milliliter (ml). [...]

Inspectors wroteBased on observation, interviews, and review of facility policy the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 68 residents of 68 who consumed food from the kitchen. The facility identified no residents who consumed nothing by mouth. The facility census was 68.

Inspectors wroteBased on review of employee files, the facility tuberculosis risk assessment, and staff interview, the facility failed to ensure two new employees were tested for tuberculosis. This had the potential to affect all 68 residents. Facility census was 68.

Inspectors wroteBased on record review and interview the facility failed to monitor and document on Residents #14, #21, #37, and #53's nutrition status, to implement nutrition interventions as ordered for Resident #37, and to address significant weight changes for Resident's #14, #21, and #53. This affected four residents (#14, #21, #37, and #53) of five residents reviewed for nutrition. The facility census was 68.

Inspectors wroteBased on medical record review, and interview the facility failed to notify the physician of significant weight changes for Residents #14, #21, and #53. This affected three residents (#14, #21, and #53) of five residents reviewed for nutrition. The facility census was 68.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure dependent residents were able to take baths/showers per preference and the facility did not develop a plan/mechanism to address constant bathing refusals. This affected one (Resident #19) of three residents reviewed for activities of daily living (ADLs). The census was 68. Findings Include: Resident #19 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to assess all residents after falls to determine if they remained in the safest environment as possible. This affected one (Resident #21) of five residents reviewed for accidents. The census was 68. Findings Include: Resident #21 was admitted to the facility on [DATE]. His diagnoses were end stage renal disease, repeated falls, anemia, hypokalemia, muscle weakness, difficulty walking, type II diabetes, hyperlipidemia, obesity, obstructive sleep apnea, insomnia, anxiety disorder, benign prostatic hyperplasia, hypertension, venous insufficiency, acute respiratory failure, dysuria, chronic kidney disease. Review of his Minimum Data Set (MDS) assessment, dated 11/25/24, revealed he was cognitively intact. [...]

Inspectors wroteBased on interview, and medical record review the facility failed to ensure proper justification for the use of psychotropic medications. This affected one person (#5) of five residents reviewed for unnecessary medications. The facility census was 68.

Inspectors wroteBased on observation, interviews, medical record review, and review of facility policy the facility failed to ensure Resident #223's medication was secured appropriately and not left in his room. This affected one resident (#223) of one resident reviewed for accident hazards. The facility census was 68.

Inspectors wroteBased on medical record review, observation, and interview the facility failed to ensure Resident #53 was given the diet texture as ordered. This affected one resident (#53) of five residents reviewed for nutrition. The facility census was 68.

Inspectors wroteBased on medical record review, staff interview, review of facility contracts, and review of the facility policy, the facility failed to obtain laboratory tests as ordered by the physician. This affected one (Resident #24) of three residents reviewed for laboratory services. The facility census was 66 residents.

Inspectors wroteBased on medical record review, facility Self-Reported Incident (SRI) review, video recording review, interviews, and facility policy review, this facility failed to ensure residents were not recorded without their consent or knowledge. This affected one (Resident #300) of the four residents reviewed for respect and dignity. The facility census was 66.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure physicians orders were transcribed and blood sugars were obtained as ordered. This affected one (Resident #64) of five medical records reviewed. The census was 62.

Inspectors wroteBased on review of the medical record and staff interview, the facility failed to provide treatment as ordered for Resident #62. This affected one resident (#62) out of three residents reviewed for wound care. The facility census was 60.

Inspectors wroteBased on review of resident council minutes, observations, staff interviews, and resident and family interviews, the facility failed to ensure residents had adequate fluids available per the resident's preferences. This affected seven residents (#14, #18, #22, #26, #28, #35, and #50). The facility census was 60.

Inspectors wroteBased on record review and resident and staff interview, the facility failed to administer medications to the residents as physician ordered. This affected two (Residents #34 and #61) of three residents reviewed for medication administration. The facility census was 60.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure pressure ulcer prevention interventions were implemented for residents with known pressure ulcers as per their physician's orders and plan of care. This affected two residents (#3 and #52) of three residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, facility staff interview, and policy review the facility failed to store food in a sanitary manner. This had the potential to affect all residents as the facility identified all residents receive food from the kitchen. The facility also failed to store food items correctly in the secured unit which had the potential to affect all residents who lived on the secured unit. The total facility census was 47. Findings Include: 1. Observation of the reach in refrigerator in the main kitchen on 12/04/22 at 8:55 A.M. revealed there was a large plastic container labeled vegetable soup dated 11/26, one 112 ounce open can of vanilla pudding covered with plastic wrap dated 11/17/22 -11/21/11. In the refrigerator were also two pitchers of milk, one pitcher of sweet tea, and one pitcher of orange cool aid that were undated and unlabeled. [...]

Inspectors wroteBased on observation, interview and facility policy review the facility failed to implement appropriate infection and control practices. This had the potential to affect one (Unit One) of three units. Unit One housed 21 of 47 residents residing in the facility.

Inspectors wroteBased on record review, resident, and facility staff interview and policy review the facility failed to have quarterly care conference meetings for two (#17 and #32) of two residents reviewed for care planning. The total facility census was 47. Findings Include: 1. Record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses that include but are not limited to cerebral palsy, dementia, and anxiety disorder. Review of the most recent annual minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident had cognitive impairment, had hallucinations and delusions during the review period. Resident #17 had trouble falling asleep or staying asleep two to six days of the review period. [...]

Inspectors wroteBased on observation, interview, and facility document review the facility failed to ensure resident privacy curtains were clean. This affected two Residents (#37 and #41) of 47 residents reviewed for environment. The facility census was 47.

Inspectors wroteBased on record review and facility staff interview the facility failed to accurately code minimum data set (MDS) 3.0 assessments for one (#2) of one resident reviewed for insulin. The total facility census was 47.

Inspectors wroteBased on interview, record review and facility policy review the facility failed to develop care plans completely and timely upon admission. This affected two residents (#39 and #42) of three residents reviewed for urinary catheter/urinary tract infection and two residents reviewed for behavior and emotional needs. The facility census was 47.

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to update care plans timely. This affected one resident (#37) of one resident reviewed for anticoagulant use. The facility census was 47.

Inspectors wroteBased on observation, interview, record review and facility policy review the facility failed to ensure a care planned nutritional intervention for weight loss was followed. This affected one resident (#39) of four residents reviewed for nutrition. The facility census was 47.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Resident #13's oxygen was in place and being administered as ordered. This affected one (Resident #13) of two residents reviewed for respiratory care. The facility census was 47.

Inspectors wroteBased on observation, interview, record review and facility policy review the facility failed to proper assess residents for trauma-informed care. This affected one resident (#42) of two residents reviewed for behavioral/emotional services. The facility census was 47.

Inspectors wroteBased on observation, interview and facility policy review the facility failed to ensure a resident room and bathroom was free of pests. This affected two residents (#9 and #32) of 47 residents residing in the facility.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure residents who were dependent on staff for personal care received the assistance they needed for nail care, the removal of unwanted facial hair and/or the application of glasses. This affected two residents (#36 and #48) of two residents reviewed for communication-sensory and two residents (#15 and #38) of four residents reviewed for activities of daily living (ADL) care.

Inspectors wroteBased on observation, record review, activity calendar review and interview the facility failed to ensure cognitively impaired residents on the secured unit were being offered preferred activities and offering scheduled activities after 6:00 P.M This affected two resident (#36 and #365) of two residents reviewed for activities and had the potential to affect all residents on the secured unit (Resident #2, #4, #8, #11, #13, #14, #16, #18, #19, #21, #22, #26, #27, #28, #29, #30, #31, #32, #34, #37, #39, #40, #41, #48, #50, #51, #53, #54, #55, #56, #58, #59, #60 and #366) on the evening shift.

Inspectors wroteBased on record review and interview the facility failed to ensure pneumococcal immunizations were offered and/or provided to residents. The facility also failed to ensure written procedures were in place to identify who and when pneumococcal vaccines would be offered (in accordance with Centers for Disease Control (CDC) guidelines). This affected five residents (#11, #20, #23, #34 and #60) of five residents reviewed for pneumococcal immunizations.

Inspectors wroteBased on observation and interview the facility failed to ensure the environment was maintained in a safe, clean and sanitary manner. This affected nine residents (#12, #15, #20, #23, #35, #38, #45, #60, and #62) of 24 residents whose rooms were observed.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #35 was treated in a dignified manner when a notice was posted in the resident's room in plain view that provided information regarding her care. This affected one resident (#35) of two residents reviewed for dignity.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #12's call light was within reach and accessible for the resident to use. This affected one resident (#12) of 20 residents whose care plans were reviewed.

Inspectors wrote2. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, schizoaffective disorder and major depressive disorder. Review of the electronic physician progress note, dated 01/30/19 revealed a new delusional disorder diagnosis for Resident #56. Review of Resident #56's PAS/RR dated 02/16/19 revealed diagnoses including mood disorder and schizoaffective disorder. There was no evidence delusional disorder was captured on the PAS/RR. On 01/09/20 at 11:25 A.M., interview with Administrator #24 verified Resident #56's PAS/RR dated 02/16/19 was inaccurate as it did not include the resident's diagnosis of delusional disorder. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #48's care plan was revised to reflect the use of eyeglasses. This affected one resident (#48) of two residents reviewed for communication-sensory.

Inspectors wroteBased on record review and staff interview the facility failed to implement a comprehensive and individualized bowel protocol for Resident #418 when the resident did not have a bowel movement recorded for eight days. This affected one resident (#418) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #12's fall prevention interventions, including the use of a call light was in place as per the resident's plan of care. This affected one resident (#12) of three residents reviewed for accidents.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #58's admission bladder assessment was accurate. This affected one residents (#58) of 20 residents whose assessments and care plans were reviewed.

Inspectors wroteBased on observation, required state/local information posting review and interview the facility failed to ensure required postings included all required contact information including local and state agency information. This affected three resident (#9, #17 and #25) of three residents who participated in resident council and had the potential to affect all 68 residents residing in the facility.