Careone at Evesham

Inspectors wroteCOMPLAINT #2083729, 2805511 Based on interviews, review of medical records and pertinent facility documentation on 5/1/26, it was determined that the facility failed to thoroughly investigate a fall after the resident reported to staff that their injury, which the facility labeled as injury of unknown origin was sustained from a fall. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for falls and was evidenced by the following:Resident #2 was no longer at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record revealed that Resident #2 was admitted to the facility with diagnoses that included but were not limited to: discitis (an infection of the intervertebral disc space) of the lumbar region, cirrhosis of liver, and difficulty walking. [...]

Inspectors wroteBased on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for 1 of 31 residents reviewed. (Resident #63). This deficient practice was evidenced by the following:A review of Resident # 63's admission Recorded revealed the resident was admitted to the facility with the following but not limited to diagnosis, unspecified sequelae of cerebral infarction. (stroke)A review of Resident # 63's Electronical Medical Record (EMR) revealed physician's orders for escitalopram oxalate oral tablet 20 milligrams (MG) (a medication used to treat depression and anxiety). The EMR also revealed a physician's order for valproic acid 250mg/5 milliliters (a medication that can be prescribed to manage mood disorders) was to be given three times a day for mood. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure nutritional formula connected to a feeding tube (surgically placed tube into the stomach to provide nutritional formula) was accurately labeled for 1 of 1 resident (Resident #7) reviewed for tube feeding. The deficient practice was evidenced by the following: On [DATE] at 08:25 AM, the surveyor observed a bottle of nutritional formula hanging from a pole that was connected to a feeding pump attached to Resident #7's feeding tube while he/she was in bed. The feeding pump was operating. At that time, the surveyor observed that the bottle was not labeled with the residents, name, start time or the amount that was to be infused. [...]

Inspectors wroteNJ Complaint: #360874 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow the prescriber's orders and acceptable professional standards and principles by administering medications past the required time frame. The deficient practice was identified for 1 of 1 resident reviewed for being free of significant med errors. The deficient practice was evidenced by the following: A review of Resident #121's admission record reflected that this resident had diagnosis which included but not limited to: surgical aftercare following surgery on the skin and heart failure (a weakened heart muscle). A review of Resident #121's physician's orders revealed the following orders but not limited to: [...]

Inspectors wroteBased upon observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain an orderly physical environment for 2 of 2 facility units (100 & 200) reviewed under the Environmental Task. The deficient practice is evidenced by the following: On 04/11/2024 at 10:20 AM during a tour of the 100 Unit communal shower room, the surveyor observed a shelf on the wall adjacent to the shower stall. On the shelf was an unpackaged incontinence brief, a hairbrush with hair entangled in the bristles, and various hygienic bottled toiletries. The room also emanated a foul odor. On the same date at 10:27 AM during a tour of the 100 Unit common area across from the nurses station, the surveyor observed a table that had food debris and two partially consumed beverages left on top. On the floor under the table was a single, blue slipper. [...]

Inspectors wroteNJ Complaint # NJ00169132, NJ00171624 Based on observations, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) obtain a physician's order for residents to be discharged from the facility prior to discharge, b). change a central line catheter dressing as ordered by the physician (Resident #84), c.) follow physician orders to offload a residents heels while in bed (Resident #467), d.) follow physician order to check for helmet placement every two hours (Resident #468), and e.) maintain medication records that were complete with staff signatures according to professional standards of clinical practice for Resident #35, 1 of 29 residents reviewed for professional standards. [...]

Inspectors wroteBased on interview and record review it was determined the facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) level 1 assessment after a resident was newly diagnosed with a mental illness. This deficient practice was identified in 1 of 1 resident reviewed for PASRRs (Resident #54) and was evidenced by the following: On 04/15/2024 the surveyor reviewed Resident #54's electronic medical record (EMR) which included review of the PASRR level 1 completed on 06/21/2019, which was negative and marked no for any diagnosis of mental illness. A review of the admission Minimum Data Set (MDS), an assessment tool dated 07/15/2019, revealed a Brief Interview of Mental Status (BIMS) score of 7/15, indicating severe cognitive impairment and review of section I did not include any psychiatric diagnoses. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined the facility failed to develop a comprehensive person-centered care plan for a resident with pain. This deficient practice was identified for Resident #27, 1 of 24 residents reviewed for care plans and was evidenced by the following: On 04/10/24 at 10:06 AM, during the initial tour of the facility Resident #27 told the surveyor he/she had right hip pain and left foot pain. The surveyor asked if he/she received pain medication and the resident replied, Oh they are so busy. The surveyor asked the resident to rate the pain on a zero to 10 scale and the resident said it was a seven, meaning moderate pain level. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a safety device used to prevent residents from elopement was in place for 1 of 3 residents reviewed for accidents (Resident #35). This deficient practice was evidenced by: According to the admission record Resident #35 was admitted with diagnoses that included, but were not limited to, paranoid schizophrenia and major depressive disorder. The surveyor reviewed the 1/20/24 Minimum Data Set (MDS), an assessment tool, and observed that the facility had identified Resident #35 as not being cognitively intact. The MDS reflected that Resident #35 had no wandering behavior during the lookback period and he/she used an elopement alarm daily. During initial tour on 04/10/24 at 10:45 AM, the surveyor observed Resident # 35 in the activity area painting. [...]

Inspectors wroteBased on observation, interview, record review, and pertinent facility documentation, it was determined that the facility failed to provide appropriate and sufficient services based upon current standards of practice and the resident's comprehensive care plan to document urinary output in the Treatment Administration Record (TAR). The deficient practice was identified for 1 of 2 residents (Resident # 72) investigated for Urinary Catheter or UTI. The deficient practice was evidenced by the following: A review of Resident # 72's Minimum Data Set (MDS; an assessment tool) dated 03/16/2024 under section, H revealed that he/she had an indwelling urinary catheter (tube inserted into the bladder through the urethra to allow urine to drain from the bladder for collection). [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to maintain the necessary care and maintenance of respiratory equipment for 3 of 4 residents, reviewed for respiratory care. This deficient practice was evidenced by the following: On 04/10/2024 at 10:02 AM during initial tour, the surveyor observed Resident # 53 oxygen tubing not labeled, and the bag that held the tubing when not in use was dated 04/2/2024. According to the admission Record, Resident #53 was admitted to the facility with diagnoses including but not limited to; Chronic obstructive pulmonary disease (COPD). COPD is an airflow limitation caused by airway narrowing and/or obstruction, loss, or elastic recoil, or both. [...]

Inspectors wroteComplaint # NJ163924 Based on interview, review of Nursing Staffing Report sheets and facility provided documents, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 1 of 7 days reviewed for the week of 04/30/2023 through 05/06/2023 under the Sufficient and Competent Nurse Staffing Task. The deficient practice was evidenced by the following: A review of the Nurse Staffing Report completed by the facility for the week of 04/30/2023 through 05/06/2023 revealed the facility documented one Registered Nurse (RN) as having worked on 05/06/2023 during the day shift. A review of the facility provided schedule for 05/06/2023 revealed the previous Director of Nursing was scheduled. However, the Nurse Staffing Report, completed by the Facility revealed a resident census of 87. [...]

Inspectors wroteBased on observation, interview, and policy review, it was determined that the facility failed to ensure that medications were stored appropriately. This deficient practice was identified in two (2) of four (4) medication carts inspected on one (1) of two (2) units. This deficient practice was evidenced by the following: On 04/12/2024, Surveyor #1 was observing medication pass on the 100 unit. At 08:40 AM, Agency Licensed Practical Nurse #2 (Agency LPN #2) left medication cart 2 in the hallway, locked, with a grey box of individual medication envelopes on top of the cart, in the hallway on the opposite side of the hallway from room [ROOM NUMBER], while he went into room [ROOM NUMBER] to take the resident's vital signs. Surveyor #1 stayed with the medication cart. While Agency LPN #2 was in room [ROOM NUMBER], another resident wheeled past the medication cart. [...]

Inspectors wroteBased on observation, interview, and pertinent facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness in 1 of 2 Pantries, Pantry on Unit 1. This deficient practice was evidenced by the following: On 04/12/2024 at 09:42 AM during observations of the pantry on Unit 1, the surveyor observed 3 frozen meals, and a container of rice pudding not labeled in the freezer. On 04/16/2024 at 10:11 AM during a second observation of the pantry on Unit 1, the surveyor observed, a burger not labeled or dated in the refrigerator. Also observed in the refrigerator was a muffin tin covered with in foil with the edge folded back and a muffin exposed, and a cup with pink liquid without a lid not dated or labeled. [...]

Inspectors wroteDuring a meal observation on 02/10/22 at 12:03 PM, Surveyor #2 observed a four-tiered rolling beverage cart positioned in the hallway on the Subacute Rehabilitation (SAR) Unit. On the top shelf of the cart, a ceramic coffee mug was noted inside of an ice filled silver-colored metallic ice bucket. The surveyor observed a Hospitality Aide (HA) as she utilized the ceramic coffee cup to scoop the ice out of the ice bucket and into a cup with her bare hands as she prepared a beverage for a resident. When interviewed, the HA stated that she just started working at the facility on Monday. At 12:05 PM, Surveyor #2 observed CNA #2 as she utilized the coffee mug to scoop out of the ice bucket and into a cup with her bare hands. [...]

Inspectors wroteBased on observations, interviews and review of documentation provided by the facility, it was determined that the facility failed to maintain proper kitchen sanitation practices and store, label, and date potentially hazardous foods to prevent the development of food borne illness. This deficient practice was evidenced by the following: On 02/09/2022 at 09:21 am, during the initial tour of the kitchen in the presence of the Assistant Dietary Director (ADD), the surveyor observed the following: 1. The ADD was in the kitchen wearing a hair net. The hair net did not cover her hair to the hairline on the forehead and there were multiple long strands of hair that were not contained in the hair net. The ADD stated that she did not realize that all her hair was not contained in the hair net. [...]

Inspectors wroteBased on interview and review of the medical records and other facility documentation, it was determined that the facility failed to send the family representative a notification of transfer letter 1 of 2 residents reviewed for hospitalization transfers (Resident #112). This deficient practice was evidenced by the following: A review of the facility admission Record revealed Resident #112 was originally admitted to the facility on 03/2014 with diagnoses that included but were not limited to: diabetes (high blood sugar), hypertension (high blood pressure) and cerebral infarction (stroke, disruption of blood flow to the brain). A review of the Quarterly Minimum Data Set (MDS), an assessment tool dated 01/19/2022, revealed Resident #112 scored a 4/15 on the Brief Interview for Mental Status (BIMS), which indicated that the resident had severe cognitive impairment. [...]