Careone at Holmdel

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to promote the dignity of one (Resident (R) 63) of 13 residents reviewed with indwelling catheters from a sample of 24 residents when R63 was observed with urinary drainage bag without a privacy covering. This had the potential for the residents to have a diminished quality of life.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the monitoring of target behaviors for the use of Seroquel (an antipsychotic medication) for one of five sampled residents (Resident (R) 28) reviewed for unnecessary medications out of a total sample of 24. This had the potential for the resident to be administered unnecessary or the incorrect does medication due to not knowing if the medication was effective.

Inspectors wroteBased on record review, observation, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one of 24 sample residents (Resident (R) 3) had an accurate Minimum Data Set (MDS) reviewed for accuracy of assessments. Failure to code the MDS correctly could potentially lead to inaccurate assessment and care planning of the residents.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to develop a care plan with interventions for one of one resident (Resident (R) 9) with a diagnosis of post-traumatic stress disorder (PTSD) from a sample of 24 residents. This failure has the potential for R9 not to receive adequate services for their diagnosis.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure residents received alternative measures prior to the installation of bedrails and that assessments were completed for the risk of entrapment for two of two residents (Resident (R) 57 and R8) reviewed for side rails out of 24 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment.

Inspectors wroteBased on observation, record review, interview, review of Center for Disease Control (CDC) recommendations and guidelines, the facility failed to ensure staff followed enhanced barrier precautions (EBP) for wearing personal protective equipment (PPE) for residents on EBP for two of 18 residents (Residents (R) 73 and R63) reviewed for EBP of 24 sample residents. This failure has the potential to promote the spread of infections.

Inspectors wroteBased on observations, interviews, and pertinent facilty documents it was determined that the facility failed to maintain the designated emergency supply of water needed for residents in the event of a loss of normal water supply. This deficient practice was evidenced by the following: On 3/04/24 at 10:22 AM, the surveyor conducted an entrance conference with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The facility was licensed for 120 beds and the facility census was 86 (the number of residents who currently resided at the facility). On 3/04/24 at 9:30 AM, the surveyor conducted a kitchen tour with the Food Service Director (FSD), in the presence of a second surveyor. The FSD showed the emergency water supply located in the salon separate from the kitchen. [...]

Inspectors wroteComplaint NJ# 164959 Based on observation, interviews, record review and review of pertinent facility documentation, it was determined that the facility failed to (a) document the measurement of a pressure ulcer (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin), and (b) obtain a physician's order for wound care for a resident admitted with a community-acquired pressure ulcer in accordance with professional standards of practice. This deficient practice was identified for 1 of 3 resident's (Resident #70) reviewed for pressure ulcers. This deficient practice was evidenced by the following: On 3/4/24 at 11:33 AM, the surveyor observed Resident #70 lying in bed. The resident was awake and alert and stated that he/she had a pressure ulcer on their feet, but it did not occur at the facility. [...]

Inspectors wroteBased on observation, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to obtain, record and monitor weights on admission, readmission and weekly in accordance with professional standards of practice. This deficient practice was identified for 1 of 6 residents (Resident #82) reviewed for nutrition. The deficient practice was evidenced as follows: On 03/11/24 at 12:30 PM, the surveyor observed Resident #82 in bed, awake, and alert. The resident was observed independently feeding themselves and had eaten 75% of lunch. A review of the electronic medical record (EMR) revealed that the resident was admitted to the facility on [DATE], discharged on 2/2/24, and re-admitted back to the facility on 2/7/24. [...]

Inspectors wroteComplaint # NJ 169012 Based on observation, interviews, review of medical records (MR) and other pertinent facility documentation, it was determined that the facility failed to report an injury of unknown origin which resulted in serious bodily injury to the New Jersey Department of Health (NJ DOH) within 2 hours for 1 of 3 sampled residents, (Resident #20). This deficient practice was evidenced by the following: On 3/04/24 at 11:49 AM, the surveyor observed the resident in their room sitting in chair. The resident was wearing a short sleeve shirt, long sweatpants and skid proof socks. Resident #20 was pleasant and offered no concerns. Review of the residents admission Record (an admission summary) reflected that the resident had diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observation, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to (a) obtain a physician order to maintain peripheral intravenous (IV) access and, (b) discontinue peripheral IV access after completion of an IV antibiotic in accordance with professional standards of practice. This deficient practice was identified for 1 of 1 resident (Resident #70) reviewed for antibiotic use. The deficient practice was evidenced by the following: On 03/04/24 at 11:26 AM, Resident #70 was observed lying in bed with a heparin lock (IV peripheral line) in the left antecubital space (region of the arm in front of the elbow). A transparent dressing was covering the peripheral site. On 03/05/24 at 10:28 AM, Resident #70 was observed in bed awake and alert, after having received morning care from the certified nursing assistant (CNA). [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to follow a Physician Orders (PO) for the administration of blood pressure medication for 1 of 1 residents (Resident #25) reviewed for blood pressure medication management. This deficient practice was evidenced by the following: 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, interviews, and review of facility documentation, it was determined that the facility failed to ensure staff wear the appropriate personal protective equipment (PPE) to prevent the potential spread of COVID-19 (a contagious disease caused by the virus SARS-CoV-2) observed on 1 of 2 units observed, (North unit). This deficient practice was evidenced as follows: On 03/05/24 at 10:30 AM, the surveyor observed a Certified Nursing Assistant (CNA) exiting Resident #342's room. The CNA was not wearing goggles, or a face shield. She was wearing glasses that did not have protective shields to protect her eyes from exposure to splashes, sprays, splatter, and respiratory secretions. The surveyor observed a STOP: ISOLATION DROPLET/CONTACT PRECAUTIONS sign on the outside of the resident's door. The sign read Everyone Must: including visitors, doctors, and staff; Clean hands: [...]

Inspectors wroteBased on facility staff interviews and review of pertinent facility documentation, it was determined that the facility failed to provide a designated qualified Infection Prevention and Control Nurse from 12/1/23 until 2/18/24. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health Executive Directive No 20-026-1 dated October 20, 2020, revealed the following: ii. Required Core Practices for Infection Prevention and Control: Facilities are required to have one or more individuals with training in infection prevention and control employed or contracted on a full-time basis or part-time basis to provide on-site management of the Infection Prevention and Control (IPC) program. The requirements of this Directive may be fulfilled by: a. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent documents obtained from the facility, it was determined that the facility failed to thoroughly investigate an allegation of abuse for 1 of 20 sampled residents (Resident #39). This deficient practice was evidenced by the following: On 11/23/21 at 10:23 AM, Surveyor #1 observed Resident #39 lying in a, low to the ground bed, with his/her eyes closed. There was a floor mat located to the right side of the bed. A review of Resident #39's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to, hypertension, malignant neoplasm (cancer) of skin and major depressive disorder. On 12/01/21 at 8:47 AM, Surveyor #2 reviewed two facility provided fall incident reports for Resident #39. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that preventive measures to prevent/ promote healing of pressure sores were in place and staff were consistently following the order. This deficient practice was identified for (Resident #71), 1 of 4 residents reviewed for pressure sores and was evidenced by the following: During the initial tour on 11/23/21 the surveyor observed Resident #71 lying in bed. Resident #71 told the surveyor that he/she needed staff assistance to get out of bed. The surveyor reviewed Resident #71's clinical record on 11/23/21 at 12:55 PM. [...]

Inspectors wroteBased on observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to apply a positioning device as ordered by the physician for 1 of 1 residents (resident # 453) reviewed for positioning. This deficient practice was evidence of the following: On 11/23/21 at 9:15 am during tour, the surveyor observed Resident #453 lying in bed wearing an abductor pillow (A hip abduction pillow is a device used to prevent your hip from moving out of the joint after hip replacement surgery. The pillow is placed between your thighs and attached to your legs with straps). The resident was observed with garbled speech and was unable to be interviewed. The surveyor reviewed Resident #453 electronic medical record (EMR) revealed the following: [...]

Inspectors wroteBased on observations, interviews, record review, and review of pertinent facility documents, the facility failed to ensure that the Foley urinary catheter drainage bag was stored in a manner to prevent Urinary Tract Infection (UTI) for 1 of 3 residents reviewed for urinary catheter care (Resident #18). The deficient practice was evidenced by the following: Resident #18 was readmitted to the facility with diagnoses which included Urinary Tract Infection, muscle weakness, adult failure to thrive and urinary retention. A care area assessment (CAA) associated with an admission Minimum Data Set (MDS), an assessment tool, dated 03/15/21, specified Resident #18 had a diagnosis of urinary retention and Resident #18 used a urinary catheter (tube inserted into the urethra to facilitate urinary drainage). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation on 11/24/21, the surveyor observed three (3) nurses administer medications to five (5) residents. There were 32 opportunities, and three (3) errors were observed which calculated to a medication administration error rate of 9.38 %. This deficient practice was identified for two (2) of five (5) residents, (Resident #87 and #454), that were administered medications by two (2) of three (3) nurses. The deficient practice was evidenced as follows: 1. On 11/24/21 at 8:57 AM, the surveyor observed the Licensed Practical Nurse (LPN) preparing to administer medications to Resident #87. [...]