Dwellside Care and Rehab

Inspectors wroteCOMPLAINT #259311 Based on interview, review of medical records and other pertinent facility documentation on 1/6/26, it was determined that the facility failed to maintain an accurate and complete medical record in accordance with acceptable professional standards of practice. This deficient practice was identified for 1 of 4 residents reviewed (Resident #1) and was evidenced by the following:During an interview on 1/6/26, at 12:24 PM, Resident #1 stated that there was a time in August when they ran out of morphine and that the facility did not refill the medication timely. The resident further stated that they received Oxycodone and Percocet as substitute during the period when the morphine was not available. A review of the admission Record revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: [...]

Inspectors wroteCOMPLAINT #: 2599447Based on observation, interviews, review of medical records, and review of other pertinent facility documents on 9/10/2025, 9/11/2025, 9/18/2025, and 9/23/2025, it was determined that the facility failed to provide adequate supervision of a severely cognitively impaired resident (Resident #2) with a known history of exit seeking behaviors and documented history of previous attempts to elope from their unit; who eloped form the facility on 8/23/2025. The deficient practice was identified for 1 of 3 residents reviewed (Resident #2). A review of facility record revealed that on 8/23/2025 at approximately 8:15 AM, Resident #2 eloped from the facility while wearing a Wander Guard (WG; alarmed security bracelet) through an alarmed second floor elevator, down to the first floor, and exited the building through the employee entrance door on the first floor. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to: a.) maintain one resident bathroom in good condition, b.) ensure that bath towels and wash cloths were readily available in sufficient quantities for resident care needs, and c.) maintain the resident's environment, equipment and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified for 1 unsampled resident's bathroom (Resident room [ROOM NUMBER]), 1 of 1 resident (Resident #47) observed for pressure ulcer/injury, and 2 of 3 residents (Residents #26 and #78) observed for tube feeding, and was evidenced by the following: 1.) On 5/14/25 at approximately 9:26 AM, Surveyor #1 observed inside Resident room [ROOM NUMBER]'s bathroom that the wallpaper was loose and lifting apart form the wallboard. [...]

Inspectors wrote2.) On 5/14/25 at 1:33 PM, the surveyor observed Resident #2 awake and alert in his/her room. The resident was not displaying any behaviors. The surveyor reviewed the medical record for Resident #2. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: dementia, major depressive disorder, and post-traumatic stress disorder (PTSD). A review of the resident's quarterly MDS, an assessment tool used to facilitate the management of care, dated 4/22/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident received an antidepressant and antianxiety medication within the last seven days of the assessment. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to notify the physician of a resident's elevated blood pressure for 1 of 28 sampled residents (Resident #13). This deficient practice was evidenced by the following: The surveyor reviewed the medical record for Resident #13. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, essential hypertension (high blood pressure), and unspecified dementia. A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/23/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated the resident's cognition was severely impaired. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to notify the physician of a physician's order that was pending a physician's signature which resulted in five missed doses of an anti-hypertensive medication for 1 of 4 residents (Resident #13) observed during the medication administration pass. This deficient practice was evidenced by the following: On 5/15/25 at 8:12 AM, the surveyor observed Licensed Practical Nurse (LPN) #4 prepare medications for Resident #13. As the LPN was reviewing the physician's orders (PO) to dispense the resident's medications, the surveyor observed a PO for Metoprolol Succinate (an anti-hypertensive medication which is used to lower blood pressure) which had an alert of Pending Order Signature and the PO would not allow the LPN to administer the medication. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to properly secure medication within the medication cart for 1 of 2 nurses observed during the medication administration pass. This deficient practice was evidenced by the following: On 5/15/25 at 8:12 AM, the surveyor observed Licensed Practical Nurse (LPN) #4 prepare medications for Resident #13, which included two medicated eye drops: Cosopt and Brimonidine Tartrate. The LPN then locked the medication cart and took the PO (by mouth) medications into the resident's room, but left the medicated eye drops on top of the medication cart while the cart was left unattended. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On 5/13/25 from 9:41 AM until 10:52 AM, the surveyor observed the following in the presence of the Food Service Director (FSD): 1.) In the walk-in refrigerator, on the second shelf from the top of a four-tiered wired rack, there was an opened and undated container of cranberry juice. The FSD stated that it should not have been in there and discarded the cranberry juice 2.) In the galley of the kitchen, the bottom aspect of the oven was heavily soiled with a thick, black substance. The FSD stated that it was cleaned recently and regularly. [...]

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to employ a full time Social Worker (SW) from 3/24/25 to 5/19/25. This deficient practice was evidenced by the following: On 5/14/25 at 12:41 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated the full time Social Worker (SW) was on a leave of absence. When asked who was filling in for the full time SW, he stated they had a part time SW. On 5/16/25 at 9:33 AM, the surveyor interviewed the Receptionist who stated the full time SW was out on leave, and they had a part time SW who handled all of the social service related concerns. On 5/16/25 at 12:07 PM, the surveyor interviewed the part time SW who stated her role was very limited and she was just the assistant. [...]

Inspectors wroteBased on interviews and review of other pertinent facility documentation, it was determined that the facility failed to implement the antibiotic stewardship program, including ongoing monitoring and use of surveillance criteria when antibiotics were being prescribed. This deficient practice was identified for 10 of the 10 months reviewed and evidenced by the following: On 5/16/25 at 10:47 AM, the surveyor interviewed the Infection Preventionist (IP) and reviewed the the facility's Antibiotic Stewardship Program (efforts to ensure that antibiotics are used only when necessary and appropriate). The IP stated that she completed the facility's Infection Tracking Worksheet (clinical and laboratory findings used to define and track infections) for each resident when an antibiotic was prescribed to ensure that the resident met the criteria for antibiotic usage. [...]

Inspectors wroteBased on interview and review of facility documents, it was determined that the facility failed to ensure that residents who maintained a Personal Needs Account (PNA) received a written notification that their account approached the limit that could jeopardize a resident's eligibility for Medicaid or Supplemental Security Income (SSI). This deficient practice was identified for 2 of 94 residents (Resident #28 and #51) who maintained a Personal Needs Accounts at the facility and was evidenced by: On 5/13/25 at 1:10 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with the PNA balances. A review of the Funds Balance Report, dated 5/6/25, included a list of 94 active resident names with a total balance of $45,057.40. There were two (2) residents (Residents #28 and #51) listed with PNA funds that ranged from $1,835.38 to $1,868.83. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to report an allegation of staff-to-resident verbal abuse to the New Jersey Department of Health (NJDOH) within two hours of the allegation being made for 1 of 2 residents (Resident #4) reviewed for abuse. This deficient practice was evidenced by the following: On 5/14/25 at 9:01 AM, the surveyor observed Resident #4 seated in the wheelchair at the nurse's station. The resident stated that he/she wanted to leave the facility. The resident further stated that a nurse called him/her a bitch yesterday. When the surveyor asked the resident who said that, the resident pointed to a nurse who walked past the nursing station in blue scrubs. The resident was unable to state the nurse's name or to give any further details. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documents it was determined that the facility failed to code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care for all residents, accurately. This deficient practice was identified for 1 of 28 residents reviewed for MDS (Resident #69), and was evidenced by the following: On 5/13/25 at 9:52 AM, during entrance conference with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor requested a list of residents who smoke. On 5/13/25 at 10:33 AM, during the initial tour, Licensed Practical Nurse/Unit Manager (LPN/UM) #3 identified Resident #69 as a smoker. On 5/13/25 at 10:51 AM, during the initial tour, the surveyor observed Resident #69 sitting in a wheelchair in their room resting with their eyes closed. [...]

Inspectors wroteBased on interview, record review, and review of pertinent documents, it was determined that the facility failed to develop and implement a baseline care plan within 48 hours of admission to include a resident's code status for 1 of 1 resident (Resident #142) reviewed for death. This deficient practice was evidenced by the following: On 5/13/25 at 12:49 PM, the surveyor reviewed the medical record for Resident #142. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, dementia, chronic kidney disease, and adult failure to thrive. A review of the Baseline Care Plan, dated 2/28/25, revealed the Code Status was left blank. A review of the Universal Transfer Form, dated 2/28/25, include a Code Status of Do Not Resuscitate (DNR). [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to develop an individual comprehensive care plan to include a resident's fall risk for 1 of 4 residents (Resident # 12) reviewed for accidents. This deficient practice was evidenced by the following: On 5/14/25 at 12:46 PM, the surveyor observed Resident #12 being fed by staff in the day room. The surveyor reviewed the medical record for Resident #12. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, dementia, muscle weakness, and difficulty in walking. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to obtain a physician's order for a resident's code status (medical instructions regarding resuscitation and other lifesaving measures in the event of a medical emergency) for 1 of 1 resident reviewed (Resident #142) for death. This deficient practice was evidenced by the following: On [DATE] at 12:49 PM, the surveyor reviewed the medical record for Resident #142. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but was not limited to, dementia, chronic kidney disease, and adult failure to thrive. A review of the Order Summary Report (OSR) as of [DATE], did not include a physician's order (PO) for the resident's code status. [...]

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 2 of 3 residents (Resident #20 and Resident #48) reviewed for nutrition and was evidenced by the following: 1.) On 5/13/25 at 10:01 AM, the surveyor observed Resident #20 awake and alert sitting in a wheelchair in the lounge. On 5/14/25 at 9:18 AM, the surveyor observed Resident #20 during breakfast, but the resident refused to eat. The resident had a split plate, built-up angled utensils, nectar thickened liquids, and a fortified frozen supplemental dessert on his/her tray. On 5/14/25 at 1:15 PM, the surveyor observed Resident #20 during lunch. [...]

Inspectors wrote3.) On 5/13/25 at 10:27 AM, during the initial tour of the B Unit, the surveyor observed Resident #79 awake, alert, and lying in bed. Resident #79 stated that his/her medications were always late, usually about an hour and a half late. Resident #79 further stated I did not get my morning medications yet. On 5/13/25 at 1:06 PM, the surveyor reviewed the medical record for Resident #79. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: metabolic encephalopathy (a change in how your brain works due to an underlying condition), depression, Type 2 Diabetes, Non -Hodgkin's Lymphoma (a type of blood cancer), anxiety, and chronic pain. [...]

Inspectors wroteComplaint #: NJ184692 Based on observation, interview, record review, and other facility documents, it was determined that the facility failed to ensure that resident's preferences were accurately identified and implemented for 2 of 5 residents (Resident #111 and Resident #128) reviewed for food and dining services. This deficient practice was evidenced by the following: 1.) On 5/14/25 at 9:12 AM, the surveyor observed Resident #128 lying in bed with their meal tray in front of them. The resident's meal ticket indicated that the resident was on a liberalized diabetic diet with no pork, beef, or fish, and included that the resident received regular skim milk six (6) ounces (oz). The surveyor observed the meal tray and noted that the resident had received whole milk instead of skim milk. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to properly dispose of waste in and around the trash compactor in order to maintain a safe, and sanitary environment. This deficient practice was evidenced by the following: On 5/13/25 at 10:46 AM, in the presence of the Food Service Director (FSD) the surveyor observed that there were three cigar tips and an empty pack of cigars outside of the trash compactor on the loading dock. The FSD stated that staff cleaned the area around the trash compactor three times daily. When the surveyor asked if staff were permitted to smoke on the loading dock, the FSD stated that smoking was not permitted. The FSD stated the cigar packaging and cigar tips may have blown from trash onto the ground. [...]

Inspectors wroteBased on observation, interview, record review, and review other facility documentation, it was determined that the facility failed to ensure residents' records were kept confidential for 1 of 4 residents (Resident #13) observed during the medication administration pass. This deficient practice was evidenced by the following: On 5/15/25 at 8:12 AM, the surveyor observed Licensed Practical Nurse (LPN) #4 prepare medications for Resident #13. When the LPN left the medication cart to administer the resident's medications, she did not put up a privacy screen to cover the resident's information displayed on the laptop. On 5/15/25 at 8:49 AM, the surveyor interviewed LPN #4 who stated that she should have put the privacy screen up on her laptop when leaving the medication cart to protect the resident's private information. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to adhere to proper infection control practices during the provision of a wound treatment. This deficient practice was identified for 1 of 2 residents (Resident #47) reviewed for Pressure Ulcer/Injury and was evidenced by the following: Refer to F584 On 5/14/25 at 9:44 AM, the surveyor observed Resident #47 lying in bed awake. The resident stated that he/she had a Stage 3 (three) pressure ulcer (a deep wound with full-thickness skin loss with no exposed bone, tendon, or muscle) that developed in the hospital on 4/6/25. The resident stated that Licensed Practical Nurse (LPN) #1 changed the dressing the day prior. The resident agreed to allow the surveyor to observe his/her next scheduled wound treatment. The surveyor reviewed the medical record for Resident #47. [...]

Inspectors wroteNJ00176090, NJ00175919, NJ00171909, NJ00169026, NJ00165303, NJ00181236, NJ00179553, NJ00179421, NJ00175629, NJ00177976, NJ00183043, NJ00167029, NJ00165390, NJ00165211, NJ00164234, NJ00181173, NJ00183473, N00183733. Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure three residents (Resident (R)21, R22, and R24) were free from physical abuse by R20 out of a total sample of 32 residents. Due to the vulnerable nature of the nursing home population, the potential for serious injury or serious physical or psychosocial impairment from being physically abused by R20 existed, and the likeliness of R20 hitting another resident in the facility was high and required immediate action to prevent further events of physical abuse by R20. [...]

Inspectors wroteBased on record review and interview, the facility failed to monitor and assess a resident's skin around a cast and notify the physician timely when necrotic skin was found around the cast for one of one (Resident (R)14) reviewed for timely monitoring and assessments of 32 sampled residents. This failure resulted in harm when R14 was sent to the hospital, surgery was required, and a maggot infestation was found under the cast.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure the environment was clean, sanitary, and homelike for four out of 11 sampled residents (Resident (R)4, R17, R18, R27) who resided on the second floor ([NAME] unit). Specifically, the only shower room on the second floor ([NAME] unit) and common area floors on the second floor were unclean. Additionally, food carts with partially eaten meals from the previous day were observed in the hallway on the first floor.

Inspectors wroteBased on observations, interviews, record review, review of Resident Council Meeting Minutes, and policy review, the facility failed to provide palatable food to eight out of 32 sampled residents (Residents (R)4, R17, R18, R26, R1, R28, R6, and R30). Additionally, there were complaints from Resident Council Meetings without responses. The food was not at an appetizing temperature when residents received their meals, the food was bland, food was not prepared appropriately, and condiments were not available or served. This created the potential for weight loss and resident dissatisfaction.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure abuse investigations were thoroughly investigated for three out of five investigations reviewed affecting four out of 32 sampled residents (R20, R21, R22, and R24) Specifically, the facility failed to interview the alleged victims, perpetrators, witnesses, and failed to determine whether abuse occurred, the extent, the cause, and failed to ensure complete and thorough documentation was maintained. This created the potential for abuse to occur unchecked.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure that one of two medication carts on A Hall was secure when staff were not present. This had the potential to affect all residents on that hall who could have accessed the cart.

Inspectors wroteCOMPLAINT #: NJ00167155 Based on interviews, medical record review, and review of other pertinent facility documents on 1/26/24 and 1/30/24, it was determined that the facility failed to initiate a comprehensive person center care plan for a resident with a vaginal infection. The facility also failed to follow its undated policy titled Nursing Documentation. This deficient practice was identified for 1 of 2 residents (Resident #4) reviewed for comprehesive Care Plan (CP) and was evidenced by the following: Review of the Medical Record was as follows: According to the Face Sheet, Resident #4 was admitted to the facility with diagnoses that included but were not limited to: [...]

Inspectors wroteCOMPLAINT #: NJ00170403 Based on interviews, medical record review, and review of other pertinent facility documents on 1/26/24 and 1/30/24, it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the resident according to facility policy and protocol for 2 of 2 residents (Resident #4 and Resident #5) reviewed for documentation. This deficient practice was evidenced by the following: 1.) According to the admission Record (AR), Resident #4 was admitted to the facility with diagnoses that included but were not limited to: Multiple Sclerosis (a condition that happens when the immune system attacks the brain and spinal cord), muscle weakness, and epileptic seizures. [...]

Inspectors wroteCOMPLAINT #: NJ00166293 Based on observation, interview, record review, and other facility documentation on 1/26/24 and 1/30/24, it was determined that the facility failed to submit a specimen to the laboratory in a timely manner. This deficient practice was identified for 1 of 1 resident (Resident #4)reviewed for laboratory services and was evidenced by the following: The surveyor reviewed the medical record for Resident #4. According to the admission Record, Resident #4 was admitted to the facility with diagnoses that included but were not limited to Multiple Sclerosis (is a condition that happens when the immune system attacks the brain and spinal cord), muscle weakness, and epileptic seizures. [...]

Inspectors wroteComplaint #: NJ00165770 Based on observation, interview, record review, and review of other pertinent facility documentation on 01/26/24 and 01/30/24, it was determined that the facility failed to provide shower care to a resident that was dependent on staff for activities of daily living (ADLs). This deficient practice was identified for 1 of 2 residents (Resident #4) reviewed for showers, and was evidenced by the following: The surveyor reviewed the medical record for Resident #4. According to the admission Record, Resident #4 was admitted to the facility with diagnoses that included but were not limited to Multiple Sclerosis (is a condition that happens when the immune system attacks the brain and spinal cord), muscle weakness, and epileptic seizures. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to administer a physician ordered scheduled pain medication to a resident who was verbalizing pain at a level of ten (10) out of ten. This deficient practice was identified for one (1) of one residents, (Resident #35) reviewed for pain management and was evidenced by the following: Refer to F684E On 04/06/23 at 12:35 PM, Surveyor #1 observed Surveyor #2 talking to Resident #35 at the end of the hallway on the [NAME] unit. Surveyor #1 overheard the resident tell Surveyor #2 that he/she had not received any of his/her medications that day and their shoulders were in pain. [...]

Inspectors wroteBased on interview, record review and review of pertinent facility documentation it was determined the facility failed to follow resident rights for the distribution of funds from a resident's personal needs allowance (PNA). This deficient practice was identified for five (5) of five (5) residents (Resident #30, #47, #56, #72 and #87) who attended a Resident Council (RC) group meeting and was evidenced by the following: On 04/14/23 at 11:04 AM, the surveyor conducted RC with five (5) residents (Resident #30, #47, #56, #72 and #87), who were alert and oriented and regularly attended the RC group meeting. During the RC meeting, five (5) out of five (5) residents had complaints regarding their PNA. They stated that they should not be told several times during the day that there was not enough money for withdrawal. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation it was determined the facility failed to: a.) ensure staff consistently document the urine output from the indwelling urinary catheter drainage bag for, (Resident #41), b.) ensure staff consistently follow a Physician Order (PO) to apply heel booties and offload heels for, (Resident #100), and c.) notify a resident's representative of an injury that occurred at the facility for, (Resident #24). This deficient practice was identified for three (3) of 38 residents reviewed for professional standards of practice related to nursing care. 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, interview, record review and review of pertinent facility documentation it was determined the facility failed to ensure discharge summaries were documented which included a recapitulation (recap) of the resident's stay and a final summary of the resident's status for five (5) of five (5) residents (Resident #29, #123, #325, #326, and #327) reviewed for discharge. This deficient practice was evidence by the following: 1.) On 04/06/23 at 10:02 AM, during the initial tour, the surveyor observed Resident #29 sitting in his/her wheelchair watching television in their room. Resident #29 stated that he/she might be discharged on Saturday 04/08/23, due to insurance issues but was not completely sure. The surveyor reviewed the electronic medical record (EMR) for Resident #29. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a.) ensure a resident who had multiple clinical diagnoses received their medications to treat their clinical diagnoses in accordance with physician prescribed orders consistently over a two month time frame, b.) ensure a resident received their medications in accordance with manufacturer specifications and c.) follow their medication administration policy and procedure. This deficient practice was identified for one (1) of 38 residents, (Resident #35), reviewed for quality of care and was evidenced by the following: Refer to F697H On 04/06/23 at 12:35 PM, Surveyor #1 observed Surveyor #2 talking to Resident #35 at the end of the hallway on the [NAME] unit. [...]

Inspectors wroteBased on interview, medical record review and review of other pertinent facility documentation it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents documented physician visit progress notes at the time of each visit. This deficient practice was identified for seven (7) of sixteen (16) residents reviewed (Resident #6, #13, #29, #31, #57, #72, #225) and one (1) of two (2) physicians reviewed for physician visits and was evidenced by the following: On 04/18/23 at 12:23 PM, the surveyor reviewed physician visits in the electronic medical records for the following residents which revealed the following information: [...]

Inspectors wroteBased on observation, interview and review of facility documentation it was determined that the facility failed to: a.) properly store potentially hazardous foods in a manner intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was evidenced by the following: On 04/06/23 from 09:34 AM until 10:42 AM, the surveyor toured the kitchen in the presence of the Food Services Director (FSD) and observed the following: 1.) The blue base of the can opener mounted on the counter was observed with brown debris. The FSD acknowledged that it was dirty and stated it should not have been like that. The FSD stated that the can opener got cleaned nightly and that it was missed last night. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a.) ensure that an urinary catheter drainage bag was stored in a manner to prevent the spread of infection for a resident, (Resident #63) one (1) of two (2) residents reviewed for urinary catheter care, b.) provide appropriate infection control practices to prevent the spread of infection during one of one wound treatment observation for, (Resident #6) one of two residents reviewed for pressure ulcers, and c.) provide appropriate hand hygiene while passing out food to three unsampled residents during the lunch meal pass observation, observed on one of three (3) resident dining rooms, the [NAME] unit. This deficient practice was evidenced by the following: 1.) On 04/14/23 at 11:29 AM, the surveyor observed Resident #63 lying in bed in his/her room. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to: a.) store respiratory equipment in a manner to prevent infection, b.) create a Care Plan for the use of respiratory equipment for the resident and c.) provide physician orders for the care of the respiratory equipment. This deficient practice was identified for one (1) of one (1) resident, (Resident #57) reviewed for respiratory care and was evidenced by the following: On 04/06/23 at 11:12 AM, the surveyor observed Resident #57 in bed in his/her room. At that time, the surveyor observed that the resident had a Continuous Positive Airway Pressure (CPAP) machine (a treatment option for sleep apnea which provides air pressure just high enough to prevent collapse of the airway) and a CPAP mask on the nightstand next to the resident's bed. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation it was determined, that the facility failed to: a.) ensure that medication records were in order and b.) an account of all controlled medications were maintained and reconciled for one (1) resident's, (Resident #43's) controlled medications which was identified during the inspection of medication carts. This deficient practice was observed in 1 of three (3) medication carts inspected and was evidenced by the following: The admission Record indicated that Resident #43 was admitted to the facility with diagnoses which included but was not limited to epilepsy (seizures disorder). The quarterly Minimum Data Set (MDS), an assessment used to facilitate the management of a resident's care) dated 02/18/2023, indicated that the resident had short- and long-term memory deficits and was nonverbal. [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documentation it was determined that the facility failed to serve hot and cold foods at an acceptable temperature for the residents. This deficient practice was identified for five (5) of five (5) residents who attended a Resident Council (RC) group meeting, and on one (1) of three (3) nursing units, the [NAME] unit, during the lunch meal service on 04/19/23. The deficient practice was evidenced by the following: 1.) On 04/14/23 at 11:04 AM, the surveyor conducted RC with five (5) residents (Resident #30, #47, #56, #72 and #87), who were alert, oriented and regularly attended the RC group meeting. During the RC meeting, 5 out of 5 residents had complaints regarding the temperature of the food. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation it was determined that the facility failed to properly handle and store hazardous foods in a manner that is intended to prevent the spread of food borne illnesses. This deficient practice was observed in the facility kitchen and was evidenced by the following: On 03/02/21 at 09:20 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the following: 1. The surveyor went to the handwashing station to wash her hands and observed there was not a trash can for the discarded paper towels. The surveyor asked the FSD where to discard the paper towels and he pointed to a trash bin approximately 10 feet across the kitchen. 2. In the main cooking area the surveyor noted large food particles, paper particles and crumbs on the floor under two ovens and under the gas range. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to remove and discard expired medication and medical supplies from medication storage rooms. This deficient practice was observed for 2 of 3 medication storage areas and was evidenced by the following: On [DATE] 10:57 AM, in the presence of staff Licensed Practical Nurse (LPN) the surveyor inspected the medication room on A wing and identified the following expired items: 1. 15 - BD Vacutainers with expiration dates of [DATE] 2. 2 - sterile white top specimen containers with expiration dates of [DATE] 3. 6 - sterile orange top specimen containers with expiration dates of [DATE] 4. 2 - Bactiswab collection and transport system with expiration dates of [DATE] 5. 5 - Vacutainer blood transfer device expiration date [DATE] 6. [...]