Atrium Post Acute Care of Wayne

Inspectors wroteBased on observation, interview, record review, facility policy, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure five residents (Resident (R) 89, 138, 293, 295, and R299) out of 37 sampled residents had an accurate Minimum Data Set (MDS) assessment. This had the potential to cause the residents to have unmet care needs.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to complete a discharge Minimum Data Set (MDS) tracking form within 14 days of a resident's discharge and submit it to the Centers for Medicare and Medicaid Services (CMS) system for one resident out of 37 sampled residents (Resident (R) 7) reviewed for MDS completion. This failure prevented the transmission and compilation of resident-specific information for payment and quality measure purposes.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy reviews, the facility failed to ensure one out of two resident (Resident (R)4) had an accurate Pre-admission Screening and Resident Review (PASRR) done out of the 37 sampled residents. This failure put R4 at risk of not receiving the services needed.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure comprehensive care plans were initiated for two out of three residents (Resident (R) 63 and R128) of the 37 sampled residents. Specifically, R63 was on Intravenous (IV) medication and fluids, and R128 had religious and cultural preferences that were not addressed in the care plan.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure comprehensive care plans were revised for one out of three residents (Resident (R91) of the 37 sampled residents. Specifically, R91 had a contracture to the left hand and it was not addressed in the care plan.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure one out of the 37 sampled residents (Resident (R)91) who had a contracture to the left hand was provided restorative services. This failure put R91 at risk for worsened contracture.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure infection control procedures were followed while lunch trays were being passed on one of the three floors. This failure puts residents at risk for infections.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure the facility received licensure and certification approval prior to changing the name of the facility on the facility sign located outside the facility. Failure to get approval prior to changing the name of the facility on the sign had the potential to result in confusion among visitors, employees, and residents. This had the potential to affect 144 of 144 residents in the facility.

Inspectors wroteNJ00172016 Based on observation, interview, and record review, it was determined that the facility failed to assure that the Physician responsible for supervising the care of residents signed and dated monthly physician's orders. This deficient practice was observed for 4 of 4 residents (Resident #1, 2, 3, and 4) reviewed and was evidenced by the following: 1. According to the admission RECORD (AR), Resident #1 has diagnoses of including but not limited to Toxic Encephalopathy, Megaloblastic Anemia, Urinary Tract Infection, and Malignant Neoplasm of Breast and Ovary. A review of the Minimum Data Set (MDS), an assessment tool dated 01/05/24, showed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating that Resident #1 had intact cognition and was independent with Activity of Daily Living (ADLs). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to assure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders. This deficient practice was observed for 18 of 32 residents (Resident # 81, 98, 86, 11, 5, 135, 136, 133, 120, 28, 73, 84, 9, 112, 59, 95, 12, and 66) reviewed and was evidenced by the following: 1. The surveyor reviewed the 9/2022, 10/2022, and 11/2022 Order Summary Reports for Resident #81 which revealed that the physician did not sign and date the monthly orders for these months. 2. The surveyor reviewed the 9/2022, 10/2022, and 11/2022 Order Summary Reports for Resident #98 which revealed that the physician did not sign and date the monthly orders for these months. 3. [...]

Inspectors wroteBased on record review and interview it was determined that the facility did not provide written notification of an emergency transfer to the resident, resident representative, and/or the Office of the Long-Term Care Ombudsman (LTCO) for 5 of 7 residents reviewed for hospitalization, Residents #98, 86, 76, 69, 135.

Inspectors wroteBased on interview, and record review, it was determined that the facility failed to provide residents and/or their representatives with the facility's notice of bed hold policy. This was found with for 5 of 7 residents reviewed for hospitalization, Residents #98, 86, 76, 69, and 135. The deficient practice was evidenced by the following: 1. The surveyor reviewed the medical record of Resident # 135 which revealed that the resident was transferred to the hospital on [DATE] with a high fever, high blood pressure and low blood oxygen level. On 12/02/22 at 11:55 AM, the surveyor interviewed the Administrator. The Administrator confirmed written notification of the bed hold policy is not provided to residents or their representatives when transferred. 2. The surveyor reviewed Resident #98's medical record. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to obtain a physician's order and maintain accountability for the use of a bed alarm to ensure it's use for Resident # 120. This was found with 1 of 31 residents reviewed for professional standards of practice. 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. The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to assess a resident returning from the dialysis center for any complications. The deficient practice was observed for 1 of 3 residents (Resident # 141), reviewed for dialysis care. The deficient practice was evidenced by the following: 1. On 11/30/22 at 12:11 pm, the surveyor observed Resident #141 lying in bed and the resident had a tracheostomy collar. The tracheostomy collar delivered the oxygen to the resident via the tracheostomy (a surgical opening in the windpipe). The resident had unclear speech related to their tracheostomy, but the resident was able to communicate with simple gestures. On 11/30/22 at 1:26 pm, the surveyor reviewed the electronic health record (EHR) of Resident #141 which revealed: [...]

Inspectors wroteBased on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, b.) failed to sanitize and air-dry steam table pans and sheets pans in a manner to prevent microbial growth and c.) failed to maintain the kitchen equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 11/30/22 at 10:02 AM, in the presence of the Food Service Director the surveyor observed the following: 1. In the dry storage area, the surveyor observed a random sampling of dented cans which were in rotation for use. The surveyor observed the following: [...]

Inspectors wroteBased on observation, interview, and facility documentation review, it was determined that the facility failed to ensure the resident's right to be treated with dignity and respect. This deficient practice was identified for 2 of 25 residents observed; Resident #49 and #58. This deficient practice was evidenced by the following: 1. On 10/5/20 at 10:40 AM, the surveyor, observed Resident #49 in bed with their head and neck leaning to the left side. The alert resident greeted the surveyor, speaking in a low voice with slurred speech, and informed the surveyor that they had Parkinson's disease and had no neck muscle control. The surveyor reviewed the admission Record indicating that Resident # 49 was admitted to the facility with diagnoses, including Parkinson's Disease, Muscle Weakness, Depression, and Dysphagia (difficulty swallowing). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accommodate the needs of a resident (dependent on staff) to utilize their call bell system for assistance. This deficient practice was identified for 1 of 25 residents reviewed; Resident #49, and was evidenced by the following: On 10/5/20 at 10:40 AM, the surveyor observed Resident #49 in bed with their head and neck leaning to the left side. The alert resident greeted the surveyor, stated that they had Parkinson's disease, and had no neck muscle control. Resident #49 stated that they wanted to get out of bed, but the Certified Nursing Assistant (CNA) had not yet come to assist. The surveyor asked the resident if they were able to use the call bell to obtain assistance. The resident replied that they were unable to reach it and gestured toward the call system. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to respect the resident's right to mail delivery privacy. This deficient practice was identified for 1 of 25 residents reviewed; Resident #58, and was evidenced by the following. On 10/5/20 at 11:47 AM, the surveyor observed Resident #58 lying in bed. Resident #58 greeted the surveyor, and after obtaining the resident's permission, agreed to be interviewed. At that time, Resident #58 told the surveyor that the facility Social Worker (SW) delivered a letter that was opened on 10/2/20. The resident explained that it was a letter from a law firm suing for monies owed to the facility. Resident #58 further stated that it was upsetting that someone would have the nerve to open mail addressed to the resident. The resident showed the surveyor the letter that was clearly addressed to Resident #58. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of nursing practice by not following a physician's order for 2 of 28 residents reviewed; Resident #6 and #49. This deficient practice was evidenced by the following: 1. On 10/9/20 at 10:20 AM, the surveyor observed Resident #6 seated on the bed in the resident's room. The resident smiled and responded to the surveyor's greeting in Spanish. On 10/9/20 at 11:00 AM, the surveyor reviewed the records for Resident #6 who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included but were no limited to End-Stage Renal Disease, Respiratory Failure Diastolic (Congestive) Heart Disease, Acute Respiratory Failure and Dependence on Renal Dialysis. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide the necessary services to maintain adequate grooming for a resident who was dependent on the staff for activities of daily living. This deficient practice was observed for 1 of 25 residents reviewed; Resident #32, and was evidenced by the following: On 10/01/20 at 1:07 PM, the surveyor observed Resident #32 lying in bed. Resident #32's was observed having long hair and a thick, long beard. The resident told the surveyor that they had asked the Unit Manager (UM) for a shave over a week ago. Resident #32 stated that the UM informed the resident that he had someone who would do it, but the UM never followed through. The surveyor reviewed the admission Record that indicated Resident #32 was admitted to the facility with diagnoses which included: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a) ensure that contracting agents who provided services to residents were familiar and adhered to infection practice guidelines according to the facility's policy, Contracting Agents Policy and Center for Disease Control (CDC) identified for 2 of 25 residents, (Resident's #227, #226) observed during lab procedures rendered by a Certified Phlebotomy Technician (trained professional that draws blood for medical testing) (CPT); and, b.) ensure that staff perform hand washing as per the facility's policy to prevent the spread of infection while rendering care for resident for 1 of 25 residents (Resident #49). This deficient practice was evidenced by the following: 1. On 10/5/20 at 9:13 AM, the surveyor observed the CPT, wearing gloves and facemask, completing the blood draw for Resident #227. [...]