Complete Care at St. Vincents LLC

Inspectors wroteComplaint #: 3054815Based on interviews, record reviews, and review of pertinent facility documents, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) and failed to notify law enforcement agencies of an allegation of resident sexual abuse against a hospice Certified Nursing Assistant (CNA #1) working in the facility. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #4). This deficient practice is evidenced by the following:A facility reportable event (FRE), a form used by facilities to communicate reportable events to the New Jersey Department of Health (NJDOH), dated [DATE], was reviewed. The FRE revealed Yes under Was this a Significant Event? and Yes under Was Significant Event Called in?. The FRE further revealed the event was called in on [DATE] at 4:00 PM. [...]

Inspectors wroteComplaint #s: 3031703, 3054815 Based on interviews, medical record review, and review of pertinent facility documents it was determined that the facility failed to a) develop a wound care Care Plan (CP) for a resident who had a heel wound on admission and received wound care in the facility (Resident #3) and b) update the CP of a resident who alleged that they were sexually assaulted in the facility (Resident #4). This deficient practice was identified for 2 of 3 residents reviewed for care plans. This deficient practice was evidenced by the following:Resident #3 was no longer at the facility, a closed record review was conducted. According to the admission Record (AR), Resident #3 was admitted to the facility with diagnoses including but not limited to: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a.) ensure that there was an order for the administration of oxygen being provided to Resident # 189 and b.) failed to accurately document a medication being administered per Physicians order for Resident # 35. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that medications were stored and labeled appropriately. This deficient practice was identified in three (3) of four (4) medication carts inspected on four (4) of four (4) units. This deficient practice was evidenced by the following: On 1/18/23 at 11:37 AM, the surveyor inspected 1st floor South Cart High in the presence of LPN#1 and an additional surveyor and observed one (1) foil package of Budesonide (Pulmicort) nebulizer solution (a steroid inhalant liquid used with a mechanical nebulizer to treat asthma) with no date documented on the foil package when opened. The surveyor also observed one (1) box of Ipratropium/Albuterol (DuoNeb) nebulizer solution (an inhalant liquid used with a mechanical nebulizer to treat asthma), which contained one (1) open foil packet. [...]

Inspectors wroteReference: The American Heart Association (AHA) 2010 . guidelines every five years for CPR and Emergency Cardiovascular Care (ECC). These guidelines reflect global resuscitation science and treatment recommendations . In the guidelines, AHA has established evidenced-based decision-making guidelines for initiating CPR when cardiac or respiratory arrest occurs in or out of the hospital. AHA urges all potential rescuers to initiate CPR unless: 1) a valid Do Not Resuscitate (DNR) order is in place; 2) obvious clinical signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or 3) initiating CPR could cause injury or peril to the rescuer. AHA guidelines for CPR provide the standard for the American Red Cross, state EMS agencies, healthcare providers, and the general public. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to accurately develop and implement a person-centered comprehensive care plan for care and service needs. This deficient practice was observed for 6 of 27 residents reviewed, Residents # 7, # 25, # 38, # 94, # 98, and # 112, as evidenced by the following: 1. On 9/15/21 at 1:04 PM, the surveyor observed Resident #94 in the resident's room. Resident # 94 informed the surveyor that he/she was receiving an anticoagulant medication. The surveyor reviewed Resident #94's Electronic Medical Records. Resident #94's face sheet revealed that the resident was admitted to the facility with diagnoses that included Paroxysmal Atrial Fibrillation. [...]

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to provide full visual privacy for 2 of 24 residents reviewed, Resident #96 and Resident #85. The deficient practice was evidenced by the following: 1. On 9/15/2021 at 10:15 AM, Resident #85 was observed lying in bed with eyes open. The resident was pleasant when spoken to. The surveyor reviewed Resident #85's Electronic Medical Records (EMR) that revealed the following: The 7/30/21 Quarterly Minimum Data Set (MDS) an assessment tool indicated the resident had short term and long term memory problems and moderate cognitive impairment, had diagnoses of Non-Alzheimer's Dementia and Parkinson's Disease, and had one stage three pressure ulcer (an injury to the skin and underlying tissue primarily caused by prolonged pressure on the skin). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to reassess and provide care for pressure ulcers in accordance with professional standards of practice for 1 of 3 residents reviewed for pressure ulcer care, Resident #85. The deficient practice is evidenced by the following: On [DATE] at 10:15 AM, Resident #85 was observed lying in bed with eyes open. On [DATE] at 9:35 AM, the surveyor observed the pressure ulcer (an injury to the skin and underlying tissue primarily caused by prolonged pressure on the skin) in the presence of the Registered Nurse Unit Manager (RNUM) and the hospice home health aide (HHA) during the resident's morning care. The surveyor observed an open wound on the sacrum with redness around the outside of the wound and yellowness inside of the wound bed. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide care and services for a nephrostomy in a manner that would decrease the possibility of infection. This was found with Resident #96, who was 1 of 1 resident reviewed for nephrostomy care. The deficient practice was evidenced by the following: On 9/15/21 at 10:51 AM, the surveyor observed Resident #96 in bed awake. The resident was alert and oriented and watching television. The surveyor asked Registered Nurse #1 (RN) who was assigned to the resident if the resident had a urinary catheter. RN #1 said the resident had a nephrostomy (a tube surgically inserted through the skin and into the kidney to divert urine into a drainage bag). The surveyor asked RN #1 if she could assist the surveyor to see the nephrostomy, the tube, and the drainage bag. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility nurse failed to consistently assess the dialysis vascular access site before transport to the hemodialysis clinic for 1 of 1 resident (Resident #118) reviewed for hemodialysis. The deficient practice was evidenced by the following: The surveyor observed the resident on 9/15/21 at 10:46 AM. The resident was seen lying in bed in a hospital gown. A review of the resident's Electronic Medical Records (EMR) which revealed the following: The 8/18/21 admission Minimum Data Set (MDS) an assessment tool, indicated the resident had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 of a possible 15. Additionally, the resident was assessed to have dependence on Renal Dialysis and a diagnosis of End Stage Renal Disease (ESRD). [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete a Comprehensive admission 14-day Minimum Data Set (MDS) assessment according to the Resident Assessment Instrument (RAI) for 1 of 27 residents (Resident #323) reviewed. Reference: The Centers For Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. [...]