Complete Care at Shorrock

Inspectors wroteBased on record review and interview, the facility failed to protect the resident's right to be free from physical abuse by another resident for three of five residents (Resident (R) R64, R129 and R106) reviewed for abuse out of 44 sampled residents. This had the potential for continued abuse to the residents.

Inspectors wroteBased on interview, record review, and policy review, the facility staff failed to report an allegation of physical abuse for one resident (Resident (R)105 against R177) of five residents reviewed for abuse immediately to the State Agency (SA). This had the potential to delay an investigation to determine whether abuse occurred or not.

Inspectors wroteBased on record review, interview and policy review, the facility failed to thoroughly investigate resident to resident abuse for four of five residents (Resident (R)129, R64, R106 and R177) reviewed for abuse out of 44 sampled residents. This had the potential for continued abuse to the residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure three of three residents and their resident representatives (Resident (R)18, R20 and R158) reviewed for emergent hospital transfer out of a total sample of 44 residents were provided with a written bed hold policy and transfer notice. This failure had the potential to affect the resident and their resident representative (RR) by not having the knowledge of how to appeal the transfer, if desired, and had the potential to contribute to the possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. This had the potential to affect all residents who resided at the facility in the event they were transferred out of the facility.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to develop a comprehensive care plan that addressed the use of an indwelling urinary catheter for one of three residents (R)166) reviewed for urinary catheter in the sample of 44 residents. This failure had the potential to result in improper catheter care or maintenance.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to administer oxygen therapy as ordered for one Resident (R) 169 of 44 sampled residents. The facility failed to provide oxygen therapy according to physician orders, has the potential to contribute to the risk of respiratory failure.

Inspectors wroteComplaint NJ#: 160630; 169902; 170619; 172027 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure that incontinence care was provided to dependent residents for 5 of 8 residents observed during incontinence rounds (Residents #94, #16, #8, #109 and #137) on 1 of 2 nursing units (Applewood), and b.) provide activities of daily living (ADL) care for 4 of 7 residents reviewed for ADL care (# 95, #94, #109 and #16). This deficient practice was evidenced by the following: 1. On 5/20/24 at 11:41 AM, the surveyor observed Resident #94 in bed. The Resident's Representative (RR #1) informed the surveyor that Resident #94 had not received care that morning, which included incontinence care, and was still wearing the same jeans from last night. At that time, Resident #94 nodded in agreement. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure a residents who received hemodialysis were being assessed in accordance to their hemodialysis access site and professional standards of practice every shift and b.) ensure a resident who received hemodialysis services was care planned for. This deficient practice was identified for 2 of 2 residents reviewed for hemodialysis (Resident #62 and #84), and was evidenced by the following: 1. On 5/21/24 at 11:39 AM, the surveyor observed Resident #62 in their room watching television. The resident informed the surveyor that he/she received dialysis treatments (removes waste products and excess fluid from the blood when the kidneys no longer function properly). The surveyor reviewed the medical record for Resident #62. [...]

Inspectors wroteComplaint NJ #: 157735; 160630; 164199; 170619; 172027 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure sufficient and competent staff were available to a.) provide appropriate incontinence care to dependent residents for 5 of 8 residents (Resident # 94, #16, #8, #109, and #137) and b.) ensure residents received showers as scheduled for 2 of 2 residents (Resident #95 and #94) reviewed for sufficient staffing, and was evidenced by the following: Refer to F677 1. On 5/20/24 at 11:41 AM, the surveyor observed Resident #94 in bed with their eyes open, very soft-spoken. The Resident's Representative (RR #1) informed the surveyor that Resident #94 had not received care that morning which included incontinence care, and that they were still wearing the same jeans from last night. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to a.) store potentially hazardous foods to prevent food-borne illness; b.) maintain multiuse food-contact surface cutting board in a manner to prevent microbial growth; c.) ensure washed cookware was dried in a manner to prevent microbial growth; d.) maintain storage areas in a sanitary manner. This deficient practice was evidenced by the following: On 5/21/24 at 8:40 AM, the surveyor toured the kitchen with the Dining Service Director (DSD) and observed the following: 1. In front on the walk-in freezer unit, stored directly on the floor, five stacks of twenty-four cases in total of ice cream cups, and a stack of frozen vegetables with a box of oriental blend vegetables directly on the floor. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to properly dispose and maintain cardboard waste in dumpster areas. This deficient practice was identified for 1 of 3 garbage dumpsters, and was evidenced by the following: During a tour of the kitchen on 5/21/24 at 8:40 AM, the surveyor accompanied by the Dining Service Director (DSD) observed the facility's garbage compactor and cardboard dumpster. The surveyor observed the cardboard dumpster to be overfilled with intact cardboard boxes that prevented the lid from closing. The area surrounding the dumpster had piles of intact cardboxes surrounding the side walk of the dumpster area approximately four to five feet in height, as well as intact cardboard boxes in the fire zone of the facility parking lot. The DSD stated the cardboard dumpster was disposed of twice a week, and today was a delivery day. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control standards of practice and procedures to a.) ensure appropriate hand hygiene was performed during lunch meal in 2 of 5 dining areas; b.) ensure appropriate infection control practices were maintained for 1 of 1 Resident (Resident #16) observed during wound treatments and c.) follow appropriate hand hygiene practices during resident care for 1 of 7 residents (Resident #8) reviewed for Activities of Daily Living (ADLs). The evidence was as follows: 1. On 5/20/24 from 11:35 AM to 11:48 AM, the surveyor observed dining in the Meadows Unit. Prior to handing out lunch trays, the Unit Manager/Licensed Practical Nurse (UM/LPN #1) was observed placing alcohol based hand rub (ABHR) on top of the food truck that contained resident lunch trays. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to notify the New Jersey Department of Health (NJDOH) an allegation of neglect for a Certified Nursing Aide who was discovered sleeping during a shift in a resident's room who reported they were under the influence of a substance. This deficient practice was identified for 1 of 6 terminated employee files reviewed, and was evidenced by the following: During entrance conference on 5/20/24 at 9:54 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to provide the survey team with a list of all employees hired since last standard survey who were still employed by the facility or terminated. The surveyor requested the facility provide the reason for termination. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to investigate an allegation of neglect when a Certified Nursing Aide was discovered sleeping during shift in a resident's room who reported they were under the influence of a substance. This deficient practice was identified for 1 of 6 terminated employee files reviewed, and was evidenced by the following: During entrance conference on 5/20/24 at 9:54 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to provide the survey team with a list of all employees hired since last standard survey who were still employed by the facility or terminated. The surveyor requested the facility provide the reason for termination. [...]

Inspectors wroteComplaint NJ #: 161027 Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the resident's primary physician wrote and signed their Physician's Progress Notes at the time of each visit. This deficient practice was identified for 1 of 3 residents reviewed for closed records (Resident #147) , and evidenced by the following: The surveyor reviewed the closed medical record for Resident #147. A review of the admission Record face sheet (an admission summary) reflected that Resident #147 was admitted to the facility with diagnosis that included, but not limited to, aftercare following joint replacement surgery, and infection/inflammation reaction due to internal right knee prosthesis. [...]

Inspectors wroteComplaint NJ #: 161027 Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least every 30 days. This deficient practice was identified for 1 of 3 residents reviewed for closed records (Resident #151) and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #151. A review of the admission Record face sheet (an admission summary) reflected that Resident #151 was admitted to the facility with diagnosis that included, but not limited to dementia and polyosteoarthritis (inflammation of one or more joints). According to the admission Record, Resident #151 was in the facility for a total of 66 days. [...]

Inspectors wroteBased on interviews and document review, it was determined that the facility failed to ensure: 1.) a symptomatic unvaccinated Certified Nurse Aide (CNA #1) notified the supervisor, prior to the start of her shift on 04/08/22 that she was ill, 2.) immediate action was taken to initiate COVID-19 testing upon the identification of a staff member (CNA #1) who provided resident care to 9 of 27 residents who resided on a Dementia unit, and tested COVID-19 positive at the end of shift on 04/08/22 and resident testing for COVID-19 was initiated on 04/11/22 (three days later), 3.) the facility followed the relevant Centers for Disease Control and Prevention (CDC), Federal, State guidance for infection control, and 4.) the facility's Outbreak Plan was followed to prevent exposure and mitigate the spread of COVID-19, a deadly highly transmissible infectious disease. [...]

Inspectors wroteBased on interview, and review of facility documentation, it was determined that the facility failed to: 1.) immediately conduct contact tracing to identify residents and staff who had close contact with a COVID-19 positive staff member, 2.) conduct contact tracing to identify residents and staff who had close contact with a symptomatic COVID-19 positive resident, 3.) ensure an unvaccinated symptomatic Certified Nurses Aide (CNA) #1 notified a supervisor of symptoms prior to her shift on 04/08/22, when she proceeded to deliver direct care for nine of 27 residents on the Dementia unit, and assisted with care for other residents, 4.) ensure that unvaccinated staff, CNA #1 was tested prior to the start of their shift per facility policy, and 5.) follow the Centers for Disease Control and Prevention (CDC), Federal, State, and County guidance to prevent exposure and mitigate the spread of [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to respond to a resident call light in a timely manner to provide assistance to a resident who required toileting assistance. This deficient practice was identified for 1 of 25 residents reviewed (Resident #34) and was evidenced by the following: On 04/25/22 at 9:35 AM, two surveyors were at the nursing station on the Long Term Care Unit (LTC) when we heard screaming in the hallway. The call light for Resident #34's room was activated and sounded at the nursing station. The surveyors proceeded down the hallway and observed Resident #34 was sitting on the bed and appeared visibly upset. At that time, Resident #34 summoned the surveyors to come into the room. The surveyors entered the room and asked Resident #34 if he/she needed something. [...]

Inspectors wroteBased on observation, interviews, record reviews, and review of facility documentation, it was determined the facility failed to ensure a comprehensive person-centered care plan was developed with measurable objectives and individualized interventions for 2 of 25 sampled residents (Residents #34, #62) and was evidenced by the following: 1. On 04/21/22 at 9:30 AM, the surveyor observed Resident #34 sitting in a wheelchair in the room watching television. On 04/25/22 at 9:35 AM, two surveyors were at the nursing station and heard screaming from the hallway. The surveyors proceeded to the hallway and we both observed Resident #34 sitting on the bed and was upset. Resident #34 asked the surveyors to come to to the room. The surveyors entered the room and asked Resident #34 if he/she needed something. [...]