Atlas Healthcare at Seashore Gardens

Inspectors wroteComplaint #: 2710717, 2791836 Based on interviews, medical record reviews, and review of other pertinent facility documentation it was determined that the facility failed to update the care plan (CP) with interventions for a resident (Resident #2) who's family expressed preferences related to incontinence care. This deficient practice was identified in 1 of 5 residents reviewed for care plans and was evidenced by the following:According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses including but not limited to benign prostatic hyperplasia without lower urinary tract symptoms (enlarged prostrate that is not obstructing the urethra or irritating the bladder); muscle weakness; and cognitive communication deficit (communication difficulty caused by disrupted brain function). [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to keep the kitchen's reach in refrigerator, ice machine, ice scoop holder, shelves, floor fan, rack, and the microwave ovens located in the pantry and snack rooms clean and sanitized. Additionally, the facility failed to ensure kitchen food preparation pans were dry when stored and failed to keep stored foods closed in the kitchen. This failure had the potential to create an environment for food-borne illnesses which could affect 139 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 102) reviewed for choices and food preferences were honored, Specifically, 27 out of 28 residents residing in the secure dementia unit were not offered choices of food, beverages, and condiments at meals. This failure could lead to dissatisfaction with meals, weight loss, or malnutrition.

Inspectors wroteBased on interviews, record review, document review and policy review, the facility failed to ensure concerns regarding food temperatures voiced by eight of eight residents who participated in the Resident Council meeting (R19, R34, R43, R89, R92, R105, R129, and R143) in a total sample of 36 residents were acted upon in a timely manner in an attempt to resolve the group's concerns. This failure had the potential to lead to resident dissatisfaction with the facility's Resident Council and grievance resolution processes.

Inspectors wroteBased on observation, interview, record review, document review, and facility policy review, the facility failed to serve food that was palatable and hot to three (Resident (R) 85, R158, and R159) of four residents reviewed for food palatability and eight of eight residents who participated in the Group meeting (R19, R34, R43, R89, R92, R105, R129, and R143) in a total sample of 36 residents.

Inspectors wroteBased on record review, admission agreement review and interviews, the facility failed to explicitly inform residents or their representative of their right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility; failed to explicitly state that neither the resident nor their representatives were required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility; failed to ensure that the agreement was explained to the residents and their representatives in a form and manner that they understood; failed to ensure that the residents or their representatives acknowledged that they understood the agreement; [...]

Inspectors wroteBased on record review, and interviews, the facility failed to provide for the selection of a neutral venue that is convenient to both parties in the binding arbitration agreement embedded in the facility's admission agreement signed by 131 of 139 residents currently residing in the facility. The failure had the potential for residents not to be aware of their legal right to have their disputes resolved in a court of law.

Inspectors wroteBased on document review, interview and policy review, the facility failed to develop an effective infection surveillance program in order to conduct appropriate prevention or control activities and antibiotic stewardship for two (Resident (R)80 and R45) out of four residents reviewed for antibiotic stewardship. This failure had the potential to cause avoidable spread of infection or increase antibiotic resistance throughout the facility.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure that antibiotics were used only in the presence of a diagnosed/confirmed infection for two of four residents (Resident (R) 80 and R45) reviewed for antibiotic stewardship out of a total sample of 36 residents. These failures had the potential to lead to increased antibiotic resistance or adverse side effects related to unnecessary antibiotic usage.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure timely reporting of an injury of unknown origin for one out of five residents reviewed for abuse (Resident (R) 97). This failure had the potential to contribute to further abuse or injury, which could result in mental anguish, physical harm, or fear.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to send a written notification of transfer to the hospital and a bed hold notification with the daily rate to the resident and resident representative (RR) for two (Resident (R)97 and R130 ) of two residents reviewed for hospital transfer and bed hold notification. This failed practice had the potential to affect the resident and their resident representative (RR) by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired or to make an informed decision on the bed hold.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the status of three residents (Resident (R)97, R45, and R154) out of a total sample of 36. These failures created potential for an incomplete or ineffective plan of care related to alarm use for R97 and behavioral symptoms for R45 and R154.

Inspectors wroteBased on observation, record review, interview and review of facility policy, the facility failed to maintain a medication error rate below five percent. During medication administration on one (2 South) of four wings, two errors/omissions occurred out of 25 opportunities for error for one (Resident (R)66) of six residents. The facility's medication error rate was 8%.

Inspectors wroteBased on observation, interviews, record review and review of facility documentation, it was determined that the facility failed to properly execute its food and nutrition services by not following the established portion control procedure. This deficient practice was evidenced by the following: On 01/30/24 at 11:17 AM, the surveyor interviewed the Director of Dietary (DD) who stated that the facility utilized a four week cycle menu and that they were in week three. On 02/05/24 at 12:22 PM, in the presence of the DD, the surveyor observed the cook at the steam table plating food for the lunch meal. The cook was wearing a hair covering, surgical mask and gloves. [...]

Inspectors wroteBased on observation, interviews and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination, and c.) maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 01/30/24 at 10:01 AM, the surveyor arrived in the kitchen and was informed by the [NAME] that the Director of Dietary (DD) was not on location. At 10:06 AM, in the presence of the Cook, the surveyor toured the kitchen and observed the following: 1. [...]

Inspectors wroteComplaint NJ # 165358 Based on observation, interviews, and review of facility documentation, it was determined that the facility failed to follow appropriate infection control practices and perform hand hygiene as indicated: a) during a meal tray pass observation for 1 of 4 units, (2 North unit), b) during medication administration for 1 of 3 residents observed (Resident #143), and c) during wound care for 1 of 3 residents observed (Resident #65). The deficient practice was evidenced as follows: 1. On 01/30/24 at 12:34 PM, the covered food cart arrived on The [NAME] hallway on Unit 2 North. At 12:51 PM, surveyor #1 observed a Certified Nursing Aide (CNA #1) who approached the food cart, removed a tray from the cart, entered Resident # 302's room and placed it on their bed side table (BST). [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to develop a person-centered comprehensive care plan to include residents' a.) preference for activities and b.) risk for pain. This deficient practice was identified for 1 of 1 resident (Resident #253) reviewed for activities and for 2 of 2 residents (Resident #145 and #301) reviewed for pain management and was evidenced by the following: 1. On 01/30/24 at 10:39 AM, the surveyor observed Resident #253 sitting in a wheelchair in his/her room. The resident stated that he/she would like to go to activities, but that there is no one to take him/her. According to the admission Record, Resident #253 had diagnoses which included, but were not limited to, unspecified hearing loss, muscle weakness, and altered mental status. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide a resident with meaningful activities that reflected the resident's preferences for 1 of 1 resident (Resident #253) reviewed for activities. This deficient practice was evidenced by the following: On 01/30/24 at 10:39 AM, the surveyor observed Resident #253 sitting in a wheelchair in his/her room. The resident stated that he/she would like to go to activities, but that there is no one to take him/her. On 02/01/24 at 9:45 AM, the surveyor sat in the lounge outside of Resident #253's room. There was an Activities Calendar on the table in the lounge that included a 10:00 AM sing-along activity. The calendar did not indicate where the activity was located. [...]

Inspectors wroteComplaint #NJ168566 Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) ensure a pressure reducing device was used correctly and b.) failed to provide care and services consistent with professional standards of practice to promote the prevention of pressure ulcer/injury development specifically by not providing protective boots to heels as ordered. This deficient practice was identified for two (2) of four (4) residents (Resident #3 and #104) reviewed for pressure ulcer management. This deficient practice was evidenced by the following: 1. On 1/30/24 at 11:57 AM, during the initial tour, Resident #104 was not in their room. A staff member identified Resident #104 in the dayroom, sitting in a high back wheelchair, with a chair alarm on the back of the wheelchair. [...]

Inspectors wroteComplaint #NJ168222 and NJ168566 Based on observation, interview, and record review it was determined that the facility failed to ensure an environment was free from accident hazards by failing to place assistive devices, specifically bilateral floor mats, to prevent avoidable accidents for 1 of 7 residents (Resident # 97) investigated for Accidents. The deficient practice was evidenced by the following: On 01/30/2024 at 10:55 AM, during the initial tour of the facility, the surveyor observed Resident # 97 in their room in bed. The surveyor observed two blue floor mats folded and leaning against the wall on either side of the room. At that time, Resident # 97 replied, They haven't used them. when the surveyor asked if the facility had used the floor mats while he/she was in bed. On 02/05/2024 at 09:46 AM, the surveyor observed Resident # 97 in their room in bed. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the medication error rates are not 5 percent or greater. This deficient practice was identified for 2 of 5 residents (Resident #143 and Resident #147), and 1of 2 nurses on the second-floor nursing unit during the Medication Administration task. The deficient practice was evidenced by the following: On 02/01/2024 at 08:55 AM, during the medication administration, the surveyor observed the Licensed Practical Nurse (LPN) prepare and administer medications to Resident #143 which included Metformin HCL (a medication used for managing high blood sugar levels) 500 milligrams (mg). That medication had a pharmacy label on the package which instructed to give with food. The surveyor observed Resident #143 in their room as the LPN administered the medication. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to maintain medications with appropriate dating of medications for 1 of 3 medication administration carts inspected and was evidenced by the following: On [DATE] at 10:43 AM, the surveyor inspected the medication storage cart labeled Cart A on the 2 (two) North Unit with the Licensed Practical Nurse (LPN). The surveyor identified that there was an undated opened foil package containing 17-unit dose vials of the medication Ipratropium Bromide/Albuterol (DuoNeb) used for nebulizer treatments. The surveyor interviewed the LPN at the time of the inspection who confirmed that the medication should have been dated when opened because the medication was only good for two weeks after the foil package was opened. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident's medical record contained an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress, specifically by failing to include pertinent information in the electronic medical record. The deficient practice was discovered for 1 of 1 resident (Resident # 150) reviewed for Medical Records. The deficient practice was evidenced by the following: A review of Resident #150's Electronic Medical Record (EMR) under Progress Notes revealed that he/she was discovered by staff not breathing. The note revealed that the Nurse Supervisor was notified and Resident #150 was declared deceased . [...]

Inspectors wroteComplaint NJ #: 168222 and 168566 Based on interview, record review, and review of facility documents, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 2 of 7 residents (Resident #104 and 251) reviewed for accidents. This deficient practice was evidenced by the following: 1. On 1/30/24 at 11:57 AM, during the initial tour, Resident #104 was not in his/her room. A staff member identified Resident #104 in the dayroom sitting in a high back wheelchair with a chair alarm in place. The surveyor reviewed the medical record for Resident #104. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the required members were present during the quarterly Quality Assessment and Assurance (QAA) committee meetings. This deficient practice occurred during 1 of the 4 meetings and was evidenced by the following: On 02/07/24 at 09:52 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the Quality Assurance Performance Improvement (QAPI) process in the facility. According to the data provided by the facility, there was no physician, including the Medical Director (MD) or another designated physician, in attendance at the quarterly Quality Assurance (QA) meeting that was held on 05/11/23. On 02/07/24 10:30 AM, the surveyor reviewed the quarterly QA minutes in the presence of the LNHA. [...]

Inspectors wroteBased 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 9/17/2021 from 9:58 to 10:55 AM, the surveyors, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. The FSD was observed to perform testing of the wash water temperature and the sanitizer level of the three-compartment sink. Upon completion of the temperature and sanitizer level the surveyor requested to see a copy of the temperature and chemical sanitization logs for the three-compartment sink. The FSD stated, I don't have a temperature log or sanitizer level log for the three-compartment sink. I've never had a log for that in 18 years. [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that the facility failed to A.) provide a duration of use for an order of Ativan gel (a psychotropic medication) as needed and B.) failed to follow the duration indicated on the controlled drug administration record by administering Ativan past the duration of the order for 2 of 5 residents reviewed for unnecessary medications, (Resident #19, Resident #16). The deficient practice was evidenced by the following: 1. According to a Minimum Data Set (an assessment tool), dated [DATE], Resident #19 had diagnoses including but not limited to; Non-Alzheimer's Dementia (cognitive impairment of the brain), Anxiety Disorder (disorder characterized by feelings of worry, anxiety, or fear), and Depression (condition associated with the lowering of a person's mood). [...]

Inspectors wroteBased on observation, interview, record review and review of other documentation, it was determined that the facility failed to ensure a right palm protector was applied and removed daily according to the physician's order, for 1 of 2 residents reviewed for limited range of motion, (Resident #53). This deficient practice was evidenced by the following: On 9/20/21 at 11:57 AM, the surveyor observed resident #53 in the residents' room, sitting in a wheelchair, neatly dressed and groomed. The residents' right arm was lying limp against his/her right side. Resident #53, using his/her left hand, positioned his/her right arm across his/her lap. The surveyor observed that the resident's right hand was tightly contracted; a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints. There was no palm protector in place. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to a) maintain a Foley catheter bag in manner to promote dignity, b) failed to ensure the catheter or privacy bag did not come into contact of the floor, c) change a resident leg bag daily as per facility policy for 2 of 2 Residents reviewed for Urinary Catheter (Resident #33 and Resident # 35) . This deficient practice was evidenced by the following: 1. During the initial tour of the [NAME] unit on 9/17/21 at 11:41 AM, Resident #33 was observed lying in bed. The Foley was attached to the bed and visible from the hallway and not in a privacy bag. On 09/21/21 at 11:31 AM, Resident #33 was observed in his/her room sitting in a wheelchair. The Foley was in a blue privacy bag attached under the seat of the wheelchair in contact with the floor. [...]

Inspectors wroteBased on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to ensure that an accurate Minimum Data Set (MDS), an assessment tool, was completed. This deficient practice was identified for 2 of 22 residents reviewed (Residents #2 and # 37) and was evidenced by the following: 1. Resident #37 was a resident in the facility with diagnoses which included heart failure and hypertension. During an interview on 9/20/21 at 01:05 PM, Resident #37 stated he/she said receives pain medication twice a day for pain said his/her pain is getting better every day. A review of the 7/5/2021 MDS for Resident #37, reflected that Resident #37 had a Brief Interview for Mental Status score of 12 when interviewed by staff. On the pain section of the MDS for the question should the pain assessment interview be conducted; [...]