Hammonton Center for Rehabilitation and Healthcare

Inspectors wroteBased on interview, review of the facility's policy, and other pertinent facility documents, it was determined that the facility failed to implement their abuse policy to complete a.) reference checks on employees before their start date for 38 of 77 employee files reviewed; b.) a check of the appropriate licensing boards and registries for 8 of 77 employee files; and c.) a criminal background checks for 6 of 77 employee files. The deficient practice was evidenced by the following: From 1/7/26 through 1/12/26, the survey team reviewed the facilities' new employee files and identified the following: a.) Employee #1 was hired as a Certified Nursing Assistant (CNA) on 2/10/25; there was no evidence of a reference check prior to the start of employment. Employee # 4 was hired as a Certified Nursing Assistant (CNA) on 8/26/24; [...]

Inspectors wroteBased on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 1/5/2026 at 9:30 AM the surveyor, accompanied by the Assistant Director (AD) and the Assistant Licensed Nursing Home Administrator (ALNHA), observed the following in the kitchen:Upon entry to the kitchen the surveyor observed that the baseboard tile molding was missing from the diet office doorway and extending into the kitchen area towards the service line. Observation of the juice box temperature log revealed that temperatures had been recorded daily, up to and including the AM temperature on 1/5/2026. [...]

Inspectors wroteBased on interviews and review of other pertinent facility documentation, it was determined that the facility failed to ensure the implementation of the antibiotic stewardship program, including ongoing monitoring and surveillance for 12 of 12 months and utilization of the infection assessment tool for 3 of 5 residents (Resident #106, #144, #175) reviewed for antibiotics This deficient practice was evidenced by the following:On 1/7/2026 at 1:15 PM, the surveyor interviewed the Infection Preventionist (IP), during the interview, a request was made for evidence of the antibiotic tracking log for January 2025 through January 2026. At that time, the IP provided the surveyor with the Infection Control Binder, which did not include any evidence that the antibiotics were being tracked for all twelve months of 2025 to present. She then confirmed that she did not have the tracking logs for 2025. [...]

Inspectors wroteBased on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to a.) provide services consistent with professional standards of practice by failing to document weekly skin assessments for a resident with a history of pressure ulcers; b.) consistently implement pressure relieving interventions in accordance with the facility policy and professional standards of nursing practice. This deficient practice was identified for 2 (two) of three (3) residents reviewed for pressure ulcers (Resident #8 and #199) and was evidenced by the following:a.) A review of the admission Record (admission summary) reflected that Resident #199 was admitted to the facility with diagnoses which included, but were not limited to: unspecified dementia, anxiety and major depressive disorder. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide the correct menu items in accordance with their weekly cycle menu for 5 residents observed during the lunch meal on 1/6/2026 as indicated on a meal ticket. This deficient practice was identified for 5 (five) of 12 residents (Resident #22, #46, #92, #179, #214) reviewed during the dining observation and was evidenced by the following:A review of Resident #22's admission Record (AR-an admission summary) indicated that the resident was admitted to the facility with diagnoses which included but were not limited to, Parkinson's disease and cerebral palsy. A review of the quarterly Minimum Data Set (MDS), an assessment that facilitates a resident's care, dated 11/1/25, indicated that the resident was on a mechanically altered diet. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a clean, sanitary, and home-like environment for 1 of 4 nursing units (1C), reviewed for environment. This deficient practice was evidenced by the following:On 1/12/2026 at 9:02 AM, the surveyor went to Resident #180's room to conduct an interview with them. When the resident sat upright, a large brown embedded stain was noted on the resident's fitted sheet. At that time, the resident stated that the stain was there when they received the fitted sheet. They further stated that on occasions, they received linens with holes. On 1/12/2026 at 9:19 AM, the surveyor, accompanied by the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 observed the first floor, C-hall clean linen cart. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to accurately complete a Minimum Data Set (MDS), an assessment tool, for 1 of 56 residents (Resident #184) reviewed. This deficient practice was evidenced by the following:On 1/5/2026 at 10:26 AM, the surveyor observed Resident #184 in the bed with a C-PAP (Continuous Positive Airway Pressure machine that helps treat sleep apnea (a sleeping disorder in which temporary cessation of breathing occurs) on their nightstand next to them. The C-PAP mask was uncovered and touched the surface of the nightstand. At that time, Resident #184 stated that they last used their C-PAP machine one day last week, and they also used it a couple of times per week. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a resident received proper foot care that included treatment to prevent complications, including but not limited to, following up with podiatry (foot doctor) recommendations. This deficient practice was identified for 2 of 2 residents (Resident #8 and Resident #164) reviewed for Activities of Daily Living (ADLs) and was evidenced by the following:1. On 1/5/26 at 12:40 PM, the surveyor observed Resident #8 who was fully dressed and was seated in a wheelchair at the bedside. The resident stated that they had a wound on their left foot that may have resulted from their boot. On 1/7/26 at 12:50 PM, the surveyor interviewed Certified Nursing Assistant (CNA) #1 who stated that she was assigned to Resident #8. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) ensure necessary services and assistance, specifically incontinent care, was provided to a dependent resident (Resident #199) for 1 of 5 residents reviewed for bladder incontinence and b.) ensure that a resident's urinary catheter bag was covered with a privacy bag to maintain the resident's dignity. This deficient practice was identified for 1 of 1 resident, (Resident # 14) reviewed for urinary catheter. This deficient practice was evidenced by the following:a.) On 1/9/2026 at 9:44 AM, the surveyor completed a facility wide incontinence rounds. The surveyor requested Certified Nursing Assistant (CNA) #4 and another staff member to announce and request permission to see Resident #199's brief. [...]

Inspectors wroteBased on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) obtain weekly weights according to a physician's order, and b.) obtain re-weights according to the facility's policy for 1 of 3 residents (Resident #7) reviewed for nutrition. This deficient practice was evidenced by the following: On 1/5/2026 at 11:26 AM, the surveyor observed Resident #7 in their room seated in a wheelchair beside their bed, dressed and groomed. Resident #7 stated they were vegetarian and wanted better food, like fresh fruits and vegetables. Resident #7 also stated they had lost a lot of weight since admission to the facility. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure: a.) respiratory equipment was stored in an appropriate way to prevent the spread of infection, and b) a physician's order (PO) was obtained for necessary treatment for 2 of 3 residents (Resident #110 and #184) reviewed for respiratory care. This deficient practice was evidenced by the following:On 1/5/2026 at 10:26 AM, the surveyor observed Resident #184 in the bed with a C-PAP (Continuous Positive Airway Pressure) machine (a common treatment for sleep apnea that uses pressurized air delivered through a mask to keep your airway open during sleep, improving breathing, and overall health by preventing pauses in breathing which consisted of a motor, a hose, and a mask (nasal or full-face) that delivers a steady stream of air) on the nightstand next to them. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined the facility failed to ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 5 of 5 forms reviewed. This deficient practice was evidenced by the following: On 1/9/25 at 2:09 PM, the surveyor reviewed the facility provided DEA 222 forms which revealed on five of the five provided forms Part 5, had not been completed upon receipt of the medications from the provider pharmacy as instructed on the reverse of the ordering form. The forms were as follows: [...]

Inspectors wroteBased on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to: follow appropriate infection control practices by having necessary personal protection equipment (PPE) readily available for a resident who required enhanced barrier precautions (EBP). This deficient practice was identified for 1 of 10 residents (Resident #55) reviewed for infection control and was evidenced by the following: This deficient practice was evidenced by the following: 1. On 1/9/26 at 11:18 AM, the surveyor knocked on Resident #55's closed door, at that time the surveyor observed a sign posted outside of Resident #55's door that revealed Enhanced Barrier Precautions, once inside the room, the surveyor observed the resident seated in a wheelchair, hair disheveled and the resident smelled of smoke. [...]

Inspectors wroteBased on record review, interview, and review of facility documents, it was determined that the facility failed to a.) document the administration of the influenza vaccine after signed consent was obtained for one (Resident #41) of five sampled residents; b) ensure the provision of the influenza and pneumococcal vaccines were properly offered to a resident with impaired cognition for one (Resident #6) of five residents reviewed for influenza and pneumococcal immunizations. This deficient practice was evidenced by the following:On 1/6/2025 at 12:42 PM, the surveyor observed Resident #6 walking in the hallway and yelling. A review of the admission Record, an admission summary, revealed Resident #6 had diagnoses which included, but were not limited to: Schizophrenia, Major Depressive Disorder, and Anxiety Disorder. [...]

Inspectors wroteBased on interviews and review of other pertinent facility documents on 11/01/24, 11/04/24, and 11/06/24, it was determined that the facility failed to ensure that the Administrator ensured that two staff that were currently working as Assistant Administrators were licensed as Nursing Home Administrators (NHA) per the facility's Job Description for Assistant Nursing Home Administrator. On 11/01/24, at 10:20 AM, the surveyor completed the entrance conference with Assistant Administrator (AA) #1, who stated that he had worked at the facility for 2.5 months. On 11/01/24, at 2:20 PM, Surveyor #1 requested a copy of Nursing Home license from AA #1 and AA #2. AA #1 stated that he was licensed in New York and not in New Jersey. AA #2 stated that he did not have a Nursing Home Administrator License. [...]

Inspectors wroteCOMPLAINT #: NJ00179283 Based on observation, interviews, medical record review, and review of other pertinent facility documents on 11/01/24, 11/04/24, and 11/06/24, it was determined that the facility failed to develop a comprehensive person-centered care plan (CP) for a resident that included action taken by staff to educate the resident regarding alternatives and consequences. The facility also failed to follow its Care Plans - Comprehensive policy. The deficient practice was identified for 1 of 9 residents (Resident #9) reviewed for CP and was evidenced by the following: On 11/06/24 Surveyor #2 observed Resident #9 seated in a wheelchair dressed in a sweatshirt and pants. The resident was self-propelling the wheelchair out of the elevator onto the first floor. The resident stated recalling a recent incident that involved him/her and another resident. [...]

Inspectors wroteBased on observation, interview, and review of other faciloirty documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: A review of the facility policy titled Food Storage, Last Date Revised 7/19/2023, revealed the following under the heading POLICY: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. The following was revealed under the PROCEDURE section: 10. [...]

Inspectors wroteBased on interview and review of other facility documentation, it was determined that the facility failed to issue the required beneficiary notices for 2 of 3 residents reviewed for Beneficiary Protection Notification (Resident # 140 and Resident # 162. This deficient practice was evidenced by the following: A review of a facility policy on 07/29/2024 at 8:32 AM, titled Notice-Advanced Beneficiary Notice (ABN) with a creation date of 7/2019, revealed under the Policy section; The Advanced Beneficiary Notice of non-coverage (ABN) is issued by the facility to original Medicare (fee for service-FFS) beneficiaries in situations where Medicare payment is expected to be denied. [...]

Inspectors wroteComplaint #: NJ00173786 Based on interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to notify in writing, the representative of the New Jersey Long-Term Care Ombudsman's office (LTCO) of resident emergency transfers to the hospital/discharges, when practicable, as mandated by Federal law. This deficient practice was identified for 2 of 37 sampled residents (Resident #54 and Resident # ADD NUMBER) and was evidenced by the following: On 07/25/2024 at 04:00 PM, a review of a facility policy titled NJ Ombudsman Mandatory Reporting with last revised date of 2/2023 under procedure section Transfer/Discharge, Copies of all facility-initiated (non-resident-driven) discharge notices shall be provided to the LTCO. 1. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and review of pertinent facility documents, it was determined that the facility failed to consistently implement and revise a care planned intervention (use of heel booties (prevent pressure ulcers from forming) for 1 of 2 residents (Resident #78) reviewed for position/mobility. This deficient practice was evidenced by the following: The surveyor reviewed the facility policy titled Care Plans - Comprehensive, Last Date Revised: 10/2019. The following was revealed at POLICY: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The following was revealed under PROCEDURE: 8. The comprehensive, person-centered care plan will: b. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to follow hold parameters for administration of insulin (a diabetic medication) in accordance with the resident's physician's orders and in accordance with professional standards of practice. This deficient practice was identified for 1 of 36 residents reviewed for professional standards of practice (Resident #39). A review of the facility's Medication Administration policy dated revised 12/2023, included medications must be administered in accordance with orders, including any required time frame . 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, review of the medical record and other facility documentation, it was determined that the facility failed to follow physician orders specifically to change the piston syringe (a device intended for medical purposes that consists of a calibrated hollow barrel and a movable plunger) every 24 hours for 1 of 2 residents reviewed for Tube Feeding, (Resident #37.). This deficient practice was evidenced by the following: A review of facility policy on 07/24/2024 at 12:08 PM, titled Enteral Feedings with last revised date of 4/2023, did not include documentation of the care and changing of the piston syringe kit. On 07/31/2024 at 10:26 AM, the DON provided the surveyor the same policy titled Enteral Feedings. The following was highlighted under the Procedure section: 4. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and review of other pertinent facility records, it was determined that the facility failed to implement infection control measures for the handling and storage of respiratory equipment for 2 of 4 residents reviewed for respiratory care (Resident #22 and Resident #63). This deficient practice was identified by the following: The surveyor reviewed the facility policy titled Nebulizer Medication/COVID 19, Last Revised Date: 1/2023. The following was revealed under the heading POLICY: Nebulization is used to deliver medications along the respiratory tract and is indicated for various respiratory problems and diseases. The therapy must be prescribed by a properly licensed physician or physician extender. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined the facility failed to ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 3 of 3 forms provided. The evidence was as follows: A review of the facility's provided Medication- Narcotic Management policy with a revised date of 4/2023 did not include information related to the completion of the DEA 222 forms. On 7/30/2024 at 10:15 AM, the surveyor reviewed the facility provided DEA 222 forms which revealed on three of the three provided forms Part 5, had not been completed upon receipt of the medications from the provider pharmacy as instructed on the reverse of the ordering form. The forms were as follows: Order form number: 221690894; [...]

Inspectors wroteNJ COMPLAINT #: 169607 Based on interview and review of pertinent facility documents, it was determined that the facility failed to complete a significant change in status assessment using the Resident Assessment Instrument (RAI) process for a resident who elected hospice services. This deficient practice was identified for 1 of 6 residents reviewed for accidents (Resident #565), and was evidenced by the following: [...]

Inspectors wroteComplaint #: NJ00172065 and NJ00169138 Based on interview and review of pertinent facility documents, it was determined that the facility failed to revise comprehensive care plans in a timely manner following an allegation of abuse. This deficient practice was identified for 2 of 36 residents (Resident #515 and #265) reviewed for care plans. A review of the facility's Care Plan policy, last revised 10/2019, included .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. A review of the facility's undated Job Description Licensed Practical Nurse document included .Participate in the development of a plan of care for each resident. A review of the facility's undated Job Description Registered Nurse document included .Reviews and regularly evaluates resident care plans to meet nursing goals. [...]

Inspectors wroteNJ Complaint #:163266 Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure a resident who smoked cigarettes was assessed for safety; educated on facility rules and safety for smoking; and care planned for smoking to ensure resident safety. The deficient practice was identified for 1 of 7 residents reviewed for accidents (Resident #266), and was evidenced by the following: A review of the facility's Smoking Program dated revised October 2022, included a Smoking Assessment will be completed by the nurse for all new admissions who are identified as patients who smoke. [...]

Inspectors wroteComplaint: NJ00160690, NJ00163037, NJ00166486 Based on observation, staff interview, and facility policy review, the facility failed to ensure clean plates and pans were air dried prior to storage and not stacked wet. This failure had the potential to increase the risk of foodborne illness and had the potential to affect 155 of 157 residents in the facility who received dietary services at the time of the survey. Two residents received tube feedings.

Inspectors wroteComplaint #: NJ000165571, NJ00160246, NJ00163849 Based on record review, interview and policy review, the facility failed to ensure the timely administration of a medication for one (Resident (R) R11) out of 15 residents reviewed in the sample. Specifically, R11's sliding scale insulin was administered late four times between 02/01/24 and 02/20/24.

Inspectors wroteComplaint # NJ00165000, NJ00163037 Based on policy review, record review, observations, and interviews, the facility failed to ensure effective infection control practices were maintained for one Resident (R ) R11 out of four residents observed during medication administration. Specifically, Licensed Practical Nurse (LPN 4) was observed administering a blood sugar check and sliding scale insulin and failed to ensure the glucometer was appropriately sanitized before and after use, failed to ensure a clean barrier was utilized when placing the glucometer down on a surface in the resident's room while administering the blood sugar check, and failed to ensure appropriate hand hygiene by wearing false 1.5-inch-long nails during the administration of R11's medication.

Inspectors wroteComplaint #: NJ00157442, NJ00153388 Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner. This deficient practice was identified for 4 of 9 residents (Resident #45, #160, #155 and #72) observed for incontinence care on 2 of 3 units (First Floor 1 C and Second Floor 2 B) observed for incontinence care. This deficient practice was evidenced by the following: Refer to F725 1. During the initial tour of the facility on 05/17/23 at 9:42 AM, the surveyors noted a strong smell of urine that permeated the air on the first floor of the facility in the hallway beyond the main entrance to the facility that led to the first floor nursing units. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner in order to prevent food borne illness. This deficient practice was evidenced by the following: On 05/17/2023 at 9:33 AM, the surveyor accompanied by the Food service Director (FSD) observed the following in the kitchen: The surveyor observed a number of unlabeled items throughout the kitchen which included three bags of sugar on the table, on a shelf there were rolls and bagels, in the meat freezer there was a bag of chicken wings and one veggie burger in a box. In the ice cream freezer there were three boxes of Dixie ice cream cups. In the dry storage there was one can of Mashed potatoes and one box of Raisin Bran cereal. Over the sink on a shelf were five bags of cake mix. [...]

Inspectors wroteNJ #00151692, NJ #00153388, NJ#00157947, NJ#00158216, NJ00157442, NJ00158731, NJ00158017 Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to: a.) provide nursing and related services to assure the residents safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care in accordance with the facility assessment and b.) provide sufficient staffing numbers to meet minimum staffing requirements. This deficient practice was observed on 2 of 3 nursing units and for 4 of 9 residents' reviewed, (Resident #45, #72, #155 and #160) ) for care related to staffing. This deficient practice was evidenced by the following: Refer to F677 1. [...]

Inspectors wroteBased on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to provide privacy and promote dignity during resident assessment. This deficient practice was identified for 1 of 1 resident (Resident #120) reviewed for dignity. This deficient practice was evidenced by the following: On 05/22/23 at 10:51 AM, the surveyor entered the second floor nurse's station and observed the Nurse Practitioner as he listened to Resident #120's lung sounds with a stethoscope as the resident stood outside of the day room in the presence of other residents and staff. When interviewed at that time, the Nurse Practitioner stated that he usually assessed the resident in his/her room but the resident had a tendency to walk out of the room as he/she was a wanderer. [...]

Inspectors wroteBased on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to provide reasonable space to allow the resident to move about the room without impairment. This deficient practice was identified for 1 of 3 residents (Resident #91) reviewed for position and mobility. This deficient practice was identified by the following: On 05/24/23 at 11:19 AM, the surveyor observed Resident #91 who self-propelled in the wheelchair with notable right sided weakness. The resident reportedly was unable to access his/her night stand or get out of bed on the left side as Resident #160's bed was placed horizontally against the wall and was pushed snugly up against Resident #91's night stand. [...]

Inspectors wroteBased on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to provide a safe, clean and homelike environment. This deficient practice was identified for 1 of 8 nursing units (Unit 2 B) in 2 of 3 residents (Resident #45 and #160) observed for incontinence care This deficient practice was evidenced by the following: 1. On 05/22/23 at 11:36 AM, the surveyor entered Resident #160's room and noted that there were two large holes in the wall behind the entry door of the room with exposed mesh. The area surrounding both holes had a thick, white coating around them which differed from the color the room was painted. The surveyor asked the resident how long the holes were there? The resident responded, The holes have been there forever. [...]

Inspectors wroteBased on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Annual Minimum Data Set (MDS), an assessment tool for 3 of 4 residents (Resident #169, Resident #87, and Resident #45) reviewed for smoking. This deficient practice was evidenced by the following: 1. On 05/17/2023 at 11:01 AM, during the initial tour of the facility Resident #169 was observed ambulating in the hallway towards the room. The resident told the surveyor they were just on a smoke break. Review of the admission Record indicated that Resident #169 was admitted to the facility on 03/2023. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to implement a physician's order for an orthosis (a device to correct alignment). The deficient practice was identified for 1 of 3 residents (Resident #67) reviewed for positioning and 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 wroteNJ#00158216, NJ#00157947, NJ#00158017, and NJ#00158731 Based on interview, and record review it was determined that the facility failed 1.) to clarify a physician's order for wound care consistent with professional standards of practice to promote wound healing for Resident #284 and 2.) to follow an active physician's order for the daily wound care treatment for Resident #103. This deficient practice was identified for 2 of 3 residents reviewed for pressure ulcers (Resident #284 and Resident #103), and was evidenced by the following: 1. Resident #284 was admitted to the facility and had diagnoses which included, but was not limited to fracture of the second cervical vertebra and chronic kidney disease. [...]

Inspectors wroteBased on observations, interview, review of medical records and other facility documentation, it was determined that the facility failed to ensure that a resident with decreased range of motion (ROM) and mobility received prescribed treatments to prevent contractures (Deformity of joints) and maintain current level of function for 1 of 3 residents reviewed for decreased ROM (Resident #91). This deficient practice was evidenced by the following: During the initial tour of the facility on 05/17/23 at 11:20 AM, Resident #91 was observed self-propelling in the wheelchair with notable right sided weakness. The resident motioned the surveyor into his/her room and showed the surveyor a right hand splint that was on the window sill and was reportedly not offered to the resident for assistance with application. [...]

Inspectors wroteBased on observation, interviews, review of the medical record and other facility documentation, it was determined that that the facility failed to: a) properly assess and implement the facility's fall management policy for a resident after a reported, unwitnessed fall b) ensure fall prevention interventions were followed by ensuring that a resident's bed was in the locked position This deficient practice was identified for 2 of 5 residents (Resident #99, Resident #284) reviewed for falls. This deficient practice was evidenced by the following: 1. During the initial tour of the facility on 05/17/23 at 10:52 AM, the surveyor observed Resident #99 who was seated at the foot of an unsampled resident's bed visiting with friends. [...]

Inspectors wroteBased on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to provide a resident with nutritional interventions that were recommended for a resident with significant weight loss. This deficient practice was identified for 1 of 2 residents (Resident #102) reviewed for nutrition. This deficient practice was evidenced by the following: On 05/24/23 at 9:06 AM, the surveyor observed Resident #102 lying in bed with the head of the bed elevated eating breakfast. The Certified Nursing Assistant (CNA) #1 who assisted the resident stated that the resident always ate all of his/her food and asked for seconds. Review of the admission Record revealed that Resident #102 was readmitted to the facility in February of 2022 with diagnoses which included but were not limited to: [...]

Inspectors wroteBased on observation, interview, facility documentation review and clinical record review, it was determined that the facility failed to provide oxygen (O2) therapy consistent with physician's order. This deficient practice was identified for 1 of 2 residents reviewed for oxygen therapy, Resident #70 and was evidenced by the following: On 05/24/2023 at 11:00 AM, the surveyor observed Resident #70 sitting on the bed receiving oxygen per nasal cannula (NC) (device used to deliver supplemental oxygen therapy via nasil passages) by way of a concentrator (concentrates the oxygen from a gas supply by removing nitrogen to supply oxygen). The O2 concentrator was set to deliver O2 at a flow rate of 3 liters via NC and there was separate tubing on the dresser across the room that was partially inside the top drawer. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to A. establish a system of records for all controlled drugs in sufficient detail to enable an accurate reconciliation for the dispensing of controlled medications and B. ensure a controlled drug was dispensed in accordance with professional standards of practice. This deficient practice was observed for 2 of 4 medication carts inspected and during the medication pass and was evidenced by the following: A.On 5/24/23 at 10:43 AM, in the presence of the Licensed Practical Nurse (LPN), the surveyor inspected the medication cart on First Floor C Unit for storage and labeling of medications. During reconciliation of controlled medications, the surveyor observed the following: 1. [...]