Avant Rehabilitation and Care Center

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure kitchen staff thoroughly cleaned and air-dried pots and pans prior to storage. This failure had the potential to increase the risk of foodborne illness and had the potential to affect 143 of 145 residents who received dietary services.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure a residents who self-administered medication was assessed for self-administration, had a physician's order for self-administration, and ensure the interdisciplinary care planning team was involved in the decision for the resident to self-administer for one of one residents (Resident (R) 40) reviewed in the sample of 33 residents. As a result of this deficient practice the residents had the potential for harm by self-medicating without the knowledge of the physician or nursing staff.

Inspectors wroteBased on document review, interview, and facility policy review, the facility failed to provide written quarterly statements within 30 days of the end of the quarter to residents and/or resident representatives to inform them of the residents' balance in their personal funds accounts. This failure had the potential to affect 10 residents (R)64, R153, R104, R83, R85, R96, R93, R29, R94, and R61) of 55 residents who had a personal funds account in the second quarter (April - June 2025) to be uninformed of the balance in their account.

Inspectors wroteBased on observation, interview, record review, and policy review the facility failed to ensure the code status was in easy access for one of one resident (Resident (R)15) reviewed for Advanced Directive information prominently displayed in the medical record in the sample of 33 residents. As a result of this deficient practice the residents had the potential for receiving cardiopulmonary resuscitation (CPR) when potentially against the wishes of the residents.

Inspectors wroteBased on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment related to medications for one of 33 sampled residents (Resident (R)4), and a urinary catheter for one of one resident (R138) This deficient practice increased the potential for missed opportunities of care or services.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure a resident assessed as a smoker had a care plan for smoking for one of six residents (Resident (R)7) evaluated for safety when smoking. As a result of this deficient practice the residents had the potential for harm while smoking.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to clean respiratory equipment for one of one resident (Resident (R)56) reviewed for respiratory care in the sample of 33 residents. The failure to maintain a clean oxygen concentrator filter had the potential to increase the risk of infections for the resident.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure the care of a dialysis resident with a fistula was checked for the patency daily, and document in the medical record for one of five residents (Resident (R)15) reviewed for dialysis care. As a result of this deficient practice the residents had the potential for clotting of the access point for dialysis treatments.

Inspectors wroteBased on observation, interviews, and review of facility policy, the facility failed to ensure the daily nurse staffing information was posted in a manner that residents and visitors had access to the information. This deficient practice has the potential to affect all residents and visitors.

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) notify a physician of a resident's multiple refusals for a sliding scale coverage insulin (Resident #68) and b.) maintain and monitor the functionality and the effectiveness of a pacemaker since admission to the facility for a resident with a pacemaker (Resident #32) in accordance with professional standards of practice. This deficient practice was identified for 2 of 5 residents reviewed for unnecessary medications (Resident #32 and Resident #68). 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 observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) consistently complete the dialysis communication form and b.) maintain a resident's dialysis communication record. This deficient practice was identified for 1 of 2 residents reviewed for dialysis (Resident # 60), and was evidenced by the following: On 3/13/24 at 9:46 AM, the surveyor observed Resident #60 in bed in their room, who stated he/she went to dialysis on Mondays, Wednesdays, and Fridays. The surveyor reviewed the medical record for Resident #60. A review of the Resident Face Sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses which included end stage renal disease, diabetes mellitus with diabetic neuropathy (nerve damage), anemia( a low number of red blood cells), and chronic kidney disease. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of the resident. This deficient practice was identified for 1 of 26 residents reviewed for accommodation of needs (Resident #37), and was evidenced by the following: On 3/13/24 at 10:58 AM, the surveyor observed Resident #37 in bed with their eyes open; the resident did not speak but responded to the surveyor's greeting with a smile and waved both arms. The surveyor observed the resident's call bell (a bell used to summon staff for assistance) was on the floor, not within his/her reach. On 3/15/24 at 11:43 AM, the surveyor observed Resident #37 in bed with the call bell tied to the lower aspect of the right side rail (bar positioned on the side of a bed to assist residents with mobility) not within his/her reach. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the accuracy of a re-admission nutrition assessment for a resident with significant weight loss. This deficient practice was identified for 1 of 4 residents reviewed for nutrition (Resident #60), and was evidenced by the following: On 3/13/24 at 9:46 AM, the surveyor observed Resident #60 in bed who stated he/she just finished breakfast and was still hungry. At this time, the surveyor observed the Licensed Practical Nurse (LPN) deliver the resident a sandwich. The surveyor reviewed the medical record for Resident #60. [...]

Inspectors wroteBased on interview, review of Nurse Staffing Report sheets, and other pertinent facility documents, it was determined that the facility failed to ensure a Registered Nurse worked seven days a week for at least eight consecutive hours a day for 4 of 21 days reviewed. This deficient practice was evidenced by the following: During entrance conference on 3/13/24 at 10:45 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) how the facility's staff was, and the LNHA stated that staffing was good; that the facility primarily utilized agency staff for certified nursing aides (CNA). At this time, the surveyor requested the Nurse Staffing Report to be completed for the following weeks: 6/25/23 through 7/1/23; 7/2/23 through 7/8/23; 3/3/24 through 3/9/24. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures during a wound care treatment. This deficient practice was identified for 1 of 2 wound observations observed for 1 of 2 residents reviewed for pressure ulcer and injury (Resident #56), and was evidenced by the following: On 3/13/24 at 10:25 AM, the surveyor observed Resident #56 in bed with a pressure-relieving device who stated he/she had a wound on his/her bottom. The surveyor reviewed the medical record for Resident #56. [...]

Inspectors wrotePart B The facility's failure to have a system in place to ensure: a.) that staff immediately reported an allegation of verbal abuse that occurred on 09/23/22 between staff , a Temporary Nurse Aide (TNA #4), and a resident (Resident #56), b.) prevent further abuse from occurring (TNA #4 continued to work, and on 09/24/22 had an allegation of abuse), and c.) conducted an investigation, and implemented interventions to prevent further abuse posed a serious and immediate treat to the health and welfare of all residents who resided in the facility and was evidenced by the following: An adverse outcome had occurred, and was likely to occur as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that began on 09/23/22 at 7:20 AM, when TNA #4 was yelling and pointing a finger in Resident #56's face. [...]

Inspectors wroteBased on interview, record review and document review it was determined that the Licensed Nursing Home Administrator (LNHA) failed to ensure policies, procedures and systems were developed and implemented to ensure immediate action was taken to make certain that the facility operated in a manner to ensure residents' attained or maintained the highest practicable physical, mental and psychosocial well-being of each resident by ensuring that a resident was free of sexual abuse, and the facility maintained an effective infection control program that limited the spread of COVID-19 an infectious deadly virus as was identified during an on-site survey that began on 09/21/22 and was evidenced by the following: Refer to 600L, 880L, 886L This IJ situation began on 9/28/22 and the facility administration was notified of the IJ on 9/28/22 at 2:55 PM. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent documentation, it was determined that the facility failed to ensure that Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) guidance was implemented to limit the spread of infectious disease by failing to ensure: 1.) a process was in place to conduct comprehensive contact tracing upon the identification of a single new case of COVID-19 for 3 of 3 resident care units, and 2.) a process was in place to ensure all required staff were appropriately fit tested for an N-95 respirator and documentation was completed for 3 of 3 resident care units. This deficient practice placed all residents and staff at risk for contracting a contagious infectious and potentially deadly virus and was evidenced by the following: Reference: [...]

Inspectors wroteBased on interview, record review and document review it was determined that the facility failed to: 1.) conduct immediate resident and staff testing upon the identification of a single COVID-19 positive staff or resident result, and 2.) ensure a system was in place, and the facility Infection Preventionist followed the facility policy to ensure that all staff who required weekly or bi-weekly COVID-19 testing was completed and documented during a COVID-19 outbreak. The facility's failure to take immediate action, follow Centers for Disease Control and Prevention (CDC) , Centers for Medicare and Medicaid Services (CMS) guidance, and facility policies to limit exposure risks placed all residents and staff at risk for contracting COVID-19, a contagious deadly virus. Reference: [...]

Inspectors wroteBased on interview, record review and document review, it was determined that the facility failed to: a.) ensure the facility policy, Centers for Disease Control and Prevention (CDC), and Centers for Medicare and Medicaid Services (CMS) for COVID-19 vaccinations was implemented to ensure that all staff were up to date with COVID-19 vaccinations, or have been granted a qualifying exemption during a COVID-19 outbreak that began on 06/24/22; and, b.) ensure all staff that were not up to date with vaccinations, or had been granted a qualifying exemption were not permitted to work in the facility. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, the facility failed to implement their abuse policy to report a.) an allegation of sexual abuse between two residents, b.) verbal abuse between a staff member and a resident, c.) physical abuse by a resident against two other residents, and d.) an injury of unknown origin for two residents. This deficient practice was identified for 5 of 6 residents reviewed for abuse (Resident #10, #56, #63, #65, and #72) and 1 of 1 resident reviewed for hospitalization (#193), and was evidenced by the following: Refer to F600 and F684 a.) On 08/10/22, multiple staff members observed on the locked nursing unit, Resident #63, a registered sex offender, exit Resident #10's room. Resident #10 had intellectual disabilities and was dependent completely on staff for Activities of Daily Living (ADLs). [...]

Inspectors wroteBased on observation, interview, record review, and document review, it was determined that the facility failed to provide sufficient nursing staff to ensure resident's highest practical wellbeing by failing to: a.) provide incontinence care on 1 of 3 units (unsampled resident), b.) provide psychiatric consultation per physician order for a resident who expressed suicidal ideation and feelings of loneliness for 1 of 3 residents reviewed for mood and behavior (Resident #63), c.) schedule a resident's appointment with their preferred cardiologist after a hospital visit for 1 of 5 residents who attended a Resident Council Meeting (unsampled resident), and d.) maintain the required minimum direct care staff-to-shift ratios as mandated by New Jersey State requirement, CHAPTER 112 (An Act related to staffing requirements for nursing homes and supplementing Title 30 of the Revised Statutes). [...]

Inspectors wroteBased on interviews and review of pertinent facility provided documentation, the facility failed to ensure that staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety, and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This deficient practice was evidenced by the following: On 10/07/22 at 11:48 AM, the surveyor interviewed the Interim Infection Preventionist (IIP) who had been the facility Educator prior to becoming the IIP regarding staff competencies. The IIP stated that she was only the Educator for a month and that she had been implementing the new computer system during that time. She added that the Director of Nursing (DON) and the Assistant DON (ADON) were the facility's educators and that the competency book would possibly be located in the DON's office. [...]

Inspectors wroteBased on observation, interview, and review of documentation, it was determined that the facility failed to store, label, and date potentially hazardous food, and maintain kitchen sanitation in a manner intended to limit the spread of food-borne illnesses. The deficient practice was evidenced by the following: On 09/21/22 at 9:38 AM to 10:09 AM, the surveyor entered the facility kitchen and toured with the Food Service Director (FSD). On 09/21/22 at 9:41 AM, the surveyor observed the facility ice machine. The baffle area (the interior back of the basin in direct contact with the ice) located in the bucket with ice, contained black streaked debris, and accumulated debris above it. The FSD confirmed the ice machine was not clean. The FSD stated maintenance would come monthly to clean filters and the cover of the ice machine. [...]

Inspectors wroteBased on interview and review of pertinent facility provided documents, it was determined that the facility failed to ensure the facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies was reviewed and updated, as necessary, and at least annually. This deficient practice was evidenced by the following: On 09/21/22 at 01:09 PM, during the entrance conference held with the facility administration, another surveyor requested a copy of the Facility Assessment (FA). On 9/22/22 at 2:28 PM, the Licensed Nursing Home Administrator (LNHA) provided the other surveyor with the FA. The FA was not signed or dated to indicate when the FA was conducted or reviewed. On 10/07/22 at 10:49 AM, the surveyor interviewed the LNHA regarding the FA. The LNHA stated that the FA should have been dated and signed. [...]

Inspectors wroteBased on interview and document review it was determined that the facility failed to ensure the Medical Director (MD) duties per the MD Job Description were implemented to ensure resident care policies and services were provided to all residents that were consistent with current professional standards of practice on 3 of 3 resident units. The deficient practice was evidenced by the following: Refer to: F600K, F609F, F610F, F684H, F835L, 838F, 850F, F865F, F867F, F880L, F886L, F888L During a recertification survey conducted on 10/12/22, the survey team identified multiple findings of Immediate Jeopardy which included, but were not limited to: The facility failed to ensure residents were free from sexual abuse after an allegation of sexual abuse involving (Resident #10), and b.) protect vulnerable residents from being verbally abused by staff (Resident #56). [...]

Inspectors wroteBased on interview and review of facility provided documentation, it was determined that the facility failed to have a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs. The deficient practice was evidenced by the following: On 10/11/22 at 01:00 PM, the surveyor asked the Regional Licensed Nursing Home Administrator (RLNHA) to view the written transfer agreement that the facility had with one or more hospitals. The RLNHA was unable to provide the surveyor a written transfer agreement. On 10/12/22 at 10:53 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) to view the written transfer agreement that the facility had with one or more hospitals. The LNHA stated that the agreement would be in the Emergency Preparedness (EP) manual. [...]

Inspectors wroteBased on interview and review of documentation, it was determined that the facility failed to employ a Social Worker (SW) with the required experience per facility policy and Centers for Medicare and Medicaid Services (CMS). This was identified for 1 of 1 SW employed and was evidenced by the following: On 09/27/22 at 12:31 PM, during an interview with a surveyor, the SW stated she had been in the position of Social Services Director (SSD) since March 2022. The SW stated some of her responsibilities included initial social services assessments, communication with residents and families, handling concerns such as any investigations, and interviewing anyone involved. The SW reiterated that she had started in March 2022 and added that this was her first job out of school, she had not been educated on this (her job), and had not been provided with clear direction to handle grievances. [...]

Inspectors wroteBased on concerns identified during this survey that ended 10/12/2022, interviews and review of pertinent facility provided documentation, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to put forth a good faith attempt to identify and correct their own concerns related to infection prevention and control during an ongoing COVID-19 virus (an acute disease in humans caused by a Coronavirus) outbreak that began on 06/24/22. This deficient practice was identified during the standard survey and was evidenced by the following: Refer to F880L, F886L, F888L On 09/21/22 at 01:09 PM, during the entrance conference held with the facility administration, another surveyor requested information regarding the QAA (Quality assessment and assurance) committee and QAPI plan. [...]

Inspectors wroteBased on concerns identified during the survey through interviews, and review of pertinent facility provided documents, it was determined that the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. This deficient practice was identified during the standard survey and was evidenced by the following: On 09/21/22 at 01:09 PM, during the entrance conference held with the facility administration, another surveyor requested information regarding the QAA (Quality assessment and assurance) committee and QAPI plan. On 10/07/22 at 10:00 AM, the surveyor reviewed facility provided Quality Assurance Meeting minutes for the last three meetings. [...]

Inspectors wroteBased on interview and pertinent documentation, it was determined that the facility failed to employ an Infection Preventionist (IP) who had completed specialized training in infection prevention and control per Centers for Medicare & Medicaid Services (CMS) guidance. This deficient practice was identified for 1 of 1 employees reviewed for IP and was evidenced by the following: On 09/21/22 at 1:08 PM, entrance conference was conducted with the facility Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). At that time, the surveyor was informed that the current position of IP was held by a Registered Nurse (RN) who had not completed the Center for Disease Control and Prevention (CDC) specialized training for infection prevention and control. [...]

Inspectors wroteBased on interview, record review, and other pertinent facility documentation, it was determined that the facility failed to a.) notify in writing of residents' room changes for cognitively impaired residents and b.) develop facility policy for room changes in accordance with federal and state regulations. This deficient practice was identified for 2 of 3 residents reviewed for room changes (Resident #10 and #47) and was evidenced by the following: On 09/26/22 at 2:52 PM, the surveyor interviewed the Director of Social Services (DSS) who stated the process for a resident room change was the nurse or nurse's aide would inform her the resident's room needed to be changed. The DSS stated if a room was available, she talked to the resident directly as well as the roommate and then let the Director of Nursing (DON) or Assistant Director of Nursing (ADON) know a room would be changed. [...]

Inspectors wroteBased on observation, interview, and document review, it was determined that the facility failed to maintain a clean and sanitary environment in the shower room on 1 of 3 units (second floor unit) and was evidenced by the following: On 09/21/22 at 11:55 AM, the surveyor in the presence of two other surveyors were touring the second floor of the facility. The surveyors entered the resident shower room and observed the following: Shower labeled C1 had a visibly stained blanket being used as a shower curtain and tied in a knot on the shower rod. The blanket was wet and lying on the base of the shower. The grout on the floor was blackened. There was an area below the shower handrail which was blackened and chipped. Shower labeled C2 had visibly darkened grout below the shower chair. There was an area below the shower handrail which was blackened and chipped. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete a quarterly Minimum Data Set Assessment (MDS), an assessment tool, as required for 6 of 20 residents (Resident #8, #12, #13, #14, #26 and #34) system selected for MDS over 120 days and was evidenced by the following: On 9/27/22 at 11:52 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the MDS coordinator resigned about three weeks ago and that the Regional MDS coordinator was now responsible for completing the MDS. The DON further stated that the Regional MDS coordinator was only in the facility, once in a while but usually communicated via email. The surveyor asked the DON how often the MDS should be completed. The DON replied, quarterly, annually, and for changes in the resident's condition. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to develop and revise a person-centered comprehensive care plan to: a.) address a resident's aggressive and inappropriate behavior (Resident #63); b.) specify supervision required for residents at risk for falls (Resident #24 and #13); and c.) update the care plan, identify steps to be implemented to manage the behavior of residents with history of sexual assault and prevent them from attempting to engage in inappropriate sexual behavior (Resident #63 and #8), for 4 of 35 residents reviewed for person-centered care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed follow the facility policy for fall prevention, and to ensure: a.) interventions in place to prevent accidents were consistently implemented, and b.) residents at risk for falls received adequate supervision to prevent falls. This deficient practice was identified for 2 of 5 of five residents (Resident #13 and #24) reviewed for accidents and was evidenced by the following: On 09/21/22 at 10:15 AM, the surveyor observed Resident #13 in a low bed and his/her face was discolored. Resident #13 had bruises on the facial area. Resident #13 was alert and was calling out mommy continuously. On 09/21/22 at 11:30 AM, the surveyor returned to the room and observed that Resident #13 remained in bed. Resident #13 was able to hold a conversation for a brief period of time and denied being in pain. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to document the amount of fluid administered by nursing for 1 of 2 residents (Resident #69) reviewed for fluid restriction while on hemodialysis (HD -the process of purifying the blood of a person whose kidneys are not working normally). This deficient practice was evidenced by the following: On 09/21/22 at 10:41 AM, the surveyor observed Resident #69 sitting in a chair by the window in his/her room. Resident #69 stated he/she was on HD and there was an access in their right arm. On 09/26/22 at 11:03 AM, the surveyor observed Resident #69 in their room eating ice chips out of a pink water pitcher. Resident #69 stated that he/she had HD that day and would be picked up at 1 PM. The resident further stated he/she was not on any fluid restrictions. [...]

Inspectors wroteBased on observations, interviews, and review of other pertinent facility documentation, it was determined that the facility failed to provide psychiatric consultation for a resident who expressed suicidal ideation and feelings of loneliness as ordered by the physician in April of 2022. This deficient practice was identified for 1 of 3 residents reviewed for mood and behavior (Resident #63) and was evidenced by the following: On 09/27/22 at 09:57 AM, the surveyor interviewed Temporary Nursing Aide (TNA) #1, who stated the facility's locked unit was for residents who had a tendency to wander off of a unit, had dementia, and more aggressive behaviors. TNA #1 continued Resident #63 was a resident on the unit who usually stayed in their room or in the hallway and went outside to smoke cigarettes. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure: a.) a medication was removed from active inventory after being discontinued in July 2022 for one (1) of three (3) medication carts inspected; and b.) expired medications were removed from emergency (back-up) supply box for 1 of 1 back up supply box. This deficient practice was evidenced by the following: 1.) On 09/26/22 at 11:58 AM, the surveyor inspected the Low side medication cart on the third floor in the presence of the Licensed Practical Nurse (LPN #1). The surveyor found one bingo card (a multidose card containing individually packaged medication) of Divalproex sodium (Depakote) extended release (ER; [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to properly label, date and discard expired biologicals in 2 of 3 medication carts, and 1 of 2 medication rooms inspected on the second floor unit. This deficient practice was evidenced by the following: On 09/26/22 at 10:10 AM, the surveyor, in the presence of the second floor Registered Nurse/Unit Manager (RN/UM), observed the following items in the High side unit medication cart (second floor): -one unlabeled inhaler [no Resident's name and unmarked with open date] of Ventolin HFA (albuterol oral inhaler; a medication used to help in breathing) 90 micrograms (mcg) per actuation. -one unlabeled bottle [no Resident's name] of Linzess (linaclotide; a medication used to treat chronic constipation or chronic irritable bowel syndrome) 145 milligrams (mg). [...]

Inspectors wroteBased on observation, interview, record review and review of documentation, it was determined that the facility failed to promote dignity by failing to ensure: a.) a resident who required assistance at meals and foods in bowls was provided , and b.) a resident was provided with priviacy during dressing. This deficient practice occurred for 2 of 19 residents reviewed (Resident #7) and (Resident #54) and was evidenced by the following: a. ) During observation of the lunch meal on 09/23/22 at 12:30 PM, the surveyor observed Resident #7 seated at a table eating lunch. Resident #7 spilled all the food on his/her shirt and was observed picking up the food with his/her hands from the shirt to eat. Two staff members (TNA #1 and CNA #2) were observed in the dayroom assisting the residents. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete a comprehensive Minimum Data Set Assessment (MDS), an assessment tool, as required for 2 of 20 residents (Resident #10 and #248), system selected for MDS over 120 days and was evidenced by the following: On 9/27/22 at 11:52 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the MDS coordinator resigned about three weeks ago and that the Regional MDS coordinator was now responsible for completing the MDS assessments. The DON further stated that the Regional MDS coordinator was only in the facility, once in a while but usually communicated via email. The surveyor asked the DON how often the MDS assessments should be completed. The DON replied, quarterly, annually and for changes in the resident's condition. [...]

Inspectors wroteBased on interview, record review and document review it was determined that the facility failed to implement revised interventions to prevent recurrent falls for a resident who had a history of falls and sustained a fall without injury on 01/11/23. The deficient practice occurred for 1 of 4 Residents reviewed for incidents (Resident #9) during a re-visit survey conducted on 01/26/23 and was evidenced by the following: On 01/26/23 at 8:43 AM, the Director of Nursing (DON) informed the surveyor team that there had been four investigations/ Reportable Events since 12/05/22. The surveyor reviewed the medical record for Resident #9 which revealed: A Resident Face Sheet which indicated the resident had diagnoses which include, but were not limited to, vascular dementia, unspecified severity, with behavioral disturbance, essential hypertension and chronic ischemic heart disease. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide residents with the care needed to meet the resident's assessed needs. This deficient practice was identified for 2 of 19 residents reviewed for care, (Resident #48 and #54) was evidenced by the following: On 09/21/22 at 10:20 AM, during the initial tour of the locked 300's unit, the surveyor observed Resident #48 in their room, the room had a strong odor of urine. Flies were noted in the room, the mattress was yellow stained. On 09/21/22 at 11:00 AM, an interview with LPN # 6 assigned to the 300's unit low side, revealed that all residents on the low side were confused, they defecated and urinated on the floor and wandered from room to room. The LPN could not comment if Resident #48 was on a toileting program or what had been done to address the behavior. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide appropriate services for a resident with contractures by failing to ensure: a.) appropriate interventions were in place for a resident with contractures, and b.) a resident with limited range of motion received appropriate services in accordance with person centered care plan to prevent further contractures, and c.) interventions were appropriately documented as administered for resident with limited range of motion for 1 of 4 residents (Resident #20) reviewed for position/mobility. This deficient practice was evidenced by the following: On 09/22/22 at 12:43 PM, the surveyor observed Resident #20 seated in a chair. [...]

Inspectors wroteComplaint #NJ00155999 Based on observation, interview, and other facility documentation, it was determined that the facility failed to maintain complete, accurate, and readily accessible medical records. This deficient practice was identified for (a) 1 of 4 residents closed medical records reviewed (Resident #194), and (b) 1 of 35 Sampled residents reviewed (Resident #8). The deficient practice was evidenced by the following: a) On 09/27/22 at 11:47 AM, the surveyor requested Resident #194's closed records from the Medical Records department. On 09/28/22 at 12:02 PM, the surveyor interviewed the Unit Clerk/ Medical Records (UC/MR) who explained her process. She stated she thinned the paper charts, closed charts, and sent data to other physicians when needed. She informed the surveyor that the electronic Medical Record (eMR) started in May 2022. [...]

Inspectors wroteBased on interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer a resident a Pneumococcal Vaccine. This deficient practice was identified for 1 of 5 residents reviewed for immunization status (Resident #11). The deficient practice was evidenced by the following: On 09/26/22 at 9:18 AM, the surveyor reviewed Resident #11's medical record which revealed the following information: Review of the Resident Face Sheet Record (an admission summary) revealed that Resident # 11 had been admitted to the facility with diagnoses which included but were not limited to dementia, acute embolism, thrombosis of lower extremities and an International Classification of Diseases, 10th Revision (ICD-10; [...]

Inspectors wroteBased on interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer a resident a COVID-19 Immunization. This deficient practice was identified for 1 of 5 residents reviewed for immunization (Resident #11). The deficient practice was evidenced by the following: On 09/26/22 09:18 AM, the surveyor reviewed Resident #11's medical record which revealed the following information: Review of the Resident Face Sheet Record (an admission summary) revealed that Resident # 11 had been admitted to the facility with diagnoses which included but were not limited to dementia, acute embolism, thrombosis of lower extremities and an International Classification of Diseases, 10th Revision (ICD-10; [...]

Inspectors wroteBased on observation, interview, and document review, it was determined that the facility failed to ensure corridors were equipped with firmly secured handrails on 1 of 3 floors (second floor) and was evidenced by the following: On 09/21/22 at 12:21 PM, the surveyor in the presence of a second surveyor was touring the second floor and observed the handrails from the elevator door located in front of the second floor conference room to be unsecure. The surveyors observed the handrail from the elevator to the corner of the low side corridor was visibly leaning outward. The surveyor was able to touch the handrail and it was observed to have almost completely separated from where it was screwed into the wall. [...]

Inspectors wroteBased on interview, record review and review of other pertinent facility documents, it was determined that the facility failed to provide the resident and or the resident's representative written notification of the reason for transfer to the hospital and also send a copy to a representative of the Office of the State Long-Term Care Ombudsman for 2 of 2 resident's (Residents #86 and #193) reviewed for hospitalization. This deficient practice was evidenced by the following: On 09/22/22 at 09:49 AM, the surveyor reviewed Resident #86's medical record which revealed a Progress Note (PN), dated 8/4/22, that indicated that the resident was transferred to the hospital. A PN, dated 8/10/22, indicated that Resident #86 returned to the facility from the hospital on that date. [...]

Inspectors wroteBased on interview, review of the medical record and review of other pertinent facility documentation, it was determined that the facility failed to provide the resident or resident representative written notification of the facility's bed hold policy prior to transfer to the hospital for 2 of 2 resident's (Resident #86 and #193) reviewed for hospitalizations. This deficient practice was evidenced by the following: On 9/22/22 at 09:49 AM, the surveyor reviewed Resident #86's medical record which revealed a Progress Note (PN), dated 8/4/22, that indicated that the resident was transferred to the hospital. A PN, dated 8/10/22, indicated that Resident #86 returned to the facility from the hospital on that date. There was no documented evidence of written notification to the resident or resident's representative of the facility's bed hold policy prior to transfer to the hospital. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the posted 24-hour staffing report was completed in its entirety and provided accurate information. This deficient practice was evidenced by the following: On 09/30/22 at 11:24 AM, the surveyor observed the facility's version of the Nursing Home Resident Care Staffing Report, dated 09/30/22, posted near the receptionist desk, which included the following: On 09/30/22 Day Shift, the Staffing Report omitted the Current Resident Census, the number of Staff for each staff category and the Staff to Resident Ratios for each staff category. The Total Hours Worked for Registered Nurse (RN) was 3; for Licensed Practical Nurse (LPN) was 4; and Certified Nurses Aide (CNA) was 10. [...]