Complete Care at Shrewsbury LLC

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one resident of three (Resident (R)53) of 33 sampled residents were treated with dignity in toileting. This failure had the potential to negatively impact the quality of life and self-esteem for the affected resident.

Inspectors wroteBased on observations, interviews, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) was coded accurately for five residents (Residents (R)44, R9, R133, R6, and R80 in a total sample of 33 residents. This failure placed residents at risk of unmet care needs.

Inspectors wroteBased on observations, record review, interviews, and review of facility policy, the facility failed to ensure care plans were developed and/or implemented for five residents (Residents (R) R1, R7, R14, R36, and R104) from a total sample of 33 residents. This failure had the potential that residents would not receive all necessary care and services.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure four of five residents (Resident (R)12, R82, R89, and R129) reviewed for immunizations out of a total sample of 33 residents had been offered and/or provided a pneumococcal immunization This failure increased the risk of residents contracting pneumonia.

Inspectors wroteBased on record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual the facility failed to ensure that a Significant Change Minimum Data Set (MDS) was completed for one resident (Resident (R)6) from a total sample of 33 residents. This failure had the potential for residents not to receive appropriate care in timely manner.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to revise care plans for two residents (Residents (R) 137 and R9) from a total sample of 33 residents. This failure had the potential for residents to have unmet care needs.

Inspectors wroteBased on interviews and record review, the facility failed to ensure nursing assessments of a surgical incision were provided for one resident (Resident (R)132) in a total sample of 33. This failure placed residents at risk of health complications and hospitalization.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to monitor the effectiveness of wander guards and modify interventions for two of 33 sampled residents (Resident (R)16 and R69). This failure had the potential to interfere with the residents' right to self-determination and their right to make choices about significant aspects of their life in the facility.

Inspectors wroteBased on interview, record review, and review of the Social Service Director job description, the facility failed to ensure the Comprehensive Social Services Assessment was completed upon admission for one resident (Resident (R)66) in a total sample of 33 residents. This failure placed residents at risk of unmet psychosocial needs.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure staff wore the proper Personal Protection Equipment (PPE) when caring for two of two residents (Resident (R)6 and R14) identified as requiring Enhanced Barrier Precautions (EBP) out of a total sample of 33 residents. This failure increased the risk of cross-contamination of microorganisms to other residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure four of five residents (Residents(R) 12, R82, R89, and R129) reviewed for COVID-19 immunizations out of a total sample of 33 were offered a COVID-19 immunization and/or chose to have the immunization but had not received it. Failure to offer and administer could result in the residents acquiring COVID-19.

Inspectors wroteCOMPLAINT#: NJ00176055 Based on observation, interview, and review of pertinent facility documentation on 1/16/25, it was determined that the facility failed to: a). serve hot foods at an acceptable temperature for the residents, and b). follow its Test Tray Policy. This deficient practice was identified for a test tray that was placed on the second cart that was delivered to the second floor unit during the lunch meal service. In addition to the test tray, the cart contained meals for 9 residents. This was evidenced by the following: Resident #2 was not at the facility at the time of the survey. On 1/16/25, at 10:32 A.M., during an interview with the Food Service Director (FSD), he stated, If I received a complaint about food temperatures, I would do a test tray. The FSD stated that he could not recall when the last complaint was received, nor when he last completed a test tray. [...]

Inspectors wroteCOMPLAINT #: NJ00175673 Based on interview, employee file review, and review of other pertinent documents on 7/23/24, it was determined that the facility failed to obtain and keep a record of an employee certification verification and to implement their Abuse, Neglect, Exploitation and Misappropriation Prevention Program. This deficient practice was identified for 1 of 3 sampled agency employees (Certified Nursing Assistant #1) during the employee file review. The deficient practice was evidenced by the following: Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, reviewed on 5/2023, indicated .The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. [...]

Inspectors wroteBased on observation, record review, interviews, and review of facility policy, the facility failed to ensure adequate supervision of residents by specifically failing to prevent Resident (R) #60 from wandering into other residents' rooms leading to physical altercations with other residents. Due to the vulnerable nature of the nursing home population, a potential for serious injury or serious physical or psychosocial impairment from being hit by R #60, or R #60 being hit, existed, and the likeliness of R #60 hitting another resident or being hit by another resident in the facility was high and required immediate action to prevent further events of physical abuse by or to R #60. This deficient practice was identified for one out of two residents (Resident #60) reviewed for resident to resident abuse. [...]

Inspectors wroteBased on document review and interview, the facility failed to provide copies of the facility's bed hold policy to four of five residents (Resident (R) 343, R17, R38 and R27) reviewed for hospitalization out of a sample of 21 residents. This failure created the potential for residents and/or responsible parties to not have the information needed to safeguard their return to the facility.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to ensure that seven of eight supplemental residents (R19, R51, R40, R7, R16, R49, and R58) receive adequate assistance obtaining weekly showers. During the group meeting the residents voiced concerns about not getting scheduled showers. This failure has the potential for the residents to experience a decline in their ability to perform their ADLs.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to report an injury of unknown origin in a timely manner for one (Resident (R) 13) out of one resident reviewed for injury of unknown origin out 21 sampled residents. The facility further failed to report an allegation of abuse between R60 and R24 in out of two residents reviewed for abuse in a timely manner out of 21 sampled residents. This failure had the potential to place residents at risk of not receiving appropriate care and protection.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to thoroughly investigate a resident to resident abuse incident between two (Residents (R) 60 and R24) out of two residents reviewed for abuse out of a sample size of 21. This failure has the potential for further resident-to-resident abuse occurring and not being investigated so interventions can be put in place.

Inspectors wroteBased on interview, record review, and review of the facility's transfer form, the facility failed to notify the Ombudsman program of the transfer of two of five residents (Resident (R) 17 and R38) reviewed for hospitalization out of a sample of 21 residents. This failure has the potential for residents to not be aware of their transfer rights.

Inspectors wroteBased on observation, record review, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure ''Minimum Data Set (MDS)'' assessments accurately reflected residents' status for one of three residents reviewed for elopement from 21 sampled residents (Resident (R) 29). R29's ''MDS'' did not reflect R29's wandering behaviors. This had the potential for R29 to have unmet care needs.

Inspectors wroteBased on document review, interview, and observation, the facility failed to discuss and present a copy of the baseline care plan for one of 21 sampled residents (Resident (R) 84) within 48 hours of admission; and for one of 21 sampled residents (R29) the facility failed to address the resident's use of a wander-guard. This failure had the potential for care to be provided that may not be consistent with the resident's goals for care.

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to ensure that one of two residents (Resident (R) 76) reviewed for oxygen therapy from a total sample of 21 residents had nebulizer tubing changed per physician's orders and had an order for oxygen therapy. This had the potential for R76 to develop respiratory issues.

Inspectors wroteBased on observation, documents review, and interview, the facility failed to assess and document an assessment for the use of one-quarter bed (side) rails and care plan the use of bed rails for one resident (Resident (R) R75) reviewed for bed rails out of 21 sampled residents. This failure had the potential for residents with bed rails to be uninformed of the risk of severe injury and/or death associated with bed rail use.

Inspectors wroteBased on observation, interview, review of the Food Services Director (FSD) job description, and facility policy review, the facility failed to ensure one refrigerator on the second floor in the nourishment room of three refrigerators in the facility observed had all food labeled, dated and was free of dirt and sticky shelves. The facility further failed to ensure a freezer on the third floor nourishment room out of two observed was free of ice buildup.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure personal protective equipment (PPE) was readily available and that staff donned (put on) the appropriate PPE for two of five residents (Resident (R) 9 and R140) on Enhanced Barrier Precautions (EBP) out of a total sample of 21 residents. This failure had the potential to increase the risk of the spread of infections.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous food and maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: 1 On 2/28/2002 at 12:01 PM the surveyor observed the Dietary Supervisor (DS) monitor food temperatures prior to the lunch meal in the main dining room. The DS performed hand hygiene with alcohol-based hand rub and then donned a clean pair of disposable gloves. The DS then removed a digital thermometer from a sealed plastic package. The DS sanitized the thermometer probe with an alcohol pad and then proceeded to insert the thermometer probe into the pan of Key [NAME] Vegetables on the steam table. The DS obtained a final temperature of 111.3 degrees Fahrenheit (F). [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to a.) implement infection control measures for the handling and storage or respiratory equipment and b.) have a physician order for the use of oxygen for 1 of 2 residents reviewed for respiratory care, (Resident #54). This deficient practice was evidenced by the following: During the initial tour of the 3rd floor on 2/28/22 at 10:44 AM, Resident #54 was observed with a nasal cannula in his/her nose connected to wall oxygen regulator at 2 liters per minute. The tubing had a piece of white tape dated 2/14/22. Resident #54 said he/she does wear oxygen sometimes. On 3/3/22 at 10:14 AM, Resident #54 was observed lying in bed without the oxygen. The oxygen tubing was observed to be draped over a back scratcher on the bedside table, uncovered and exposed. [...]

Inspectors wroteBased on interview, record review and review of other facility documentation, it was determined that the facility failed to address the recommendation identified by the Consultant Pharmacist. This deficient practice was identified for 1 of 5 Residents reviewed for unnecessary medications, psychotropic medications, and medication regimen review (Resident #37) and was evidenced by the following: According to the Resident Face Sheet Resident #37 was admitted to the facility with diagnoses that included hypothyroidism (a problem with the thyroid gland) and renal osteodystrophy (a bone disease). A review of the Physician Order Activity Detail Report with active orders as of 2/25/2022, revealed a physician's order dated 2/25/2022, for the resident to receive calcium acetate 667 milligrams capsule 3 times per day with meals for renal osteodystrophy. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to ensure that as-needed (PRN) psychotropic medications were administered for no more than 14 days without further evaluation with corresponding documentation. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medication use (Resident #35) and was evidenced by the following: On 2/28/2022 at 10:46 AM the surveyor observed Resident #35 lying in bed. Resident #35 was complaining of stomach pain. The certified nursing assistant alerted the assigned nurse in the presence of the surveyor of Resident #35's complaint. Resident #35 stated to the surveyor that he/she had a wound on their back that started prior to admission to facility and has been going on for weeks. [...]

Inspectors wroteBased on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to ensure that an accurate Minimum Data Set (MDS), an assessment tool, was completed. This deficient practice was identified for 1 of 21 sampled residents reviewed, (Resident #13). This deficient practice was evidenced by the following: According to the admission record, Resident #13 was admitted to the facility with diagnoses, including but not limited to; Dysphagia following Cerebral Infarction (Stroke), Aphasia following Cerebral Infarction, Hemiplegia (paralysis of one side of the body), and Gastrostomy (a surgical operation for making an opening in the stomach for food/liquids). [...]