Heath Village

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 2 of the 21 residents (Resident #9 and Resident #14) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following:1. On 3/18/26 at 10:11 AM, the surveyor observed Resident #14 in bed. The resident's call device hung down to the floor, out of reach of the resident. On 3/18/26 at 10:13 AM, the surveyor interviewed Resident #14 and asked where their call bell was located. The resident replied that they did not see where it was. The resident stated further, What am I going to do if I need to call someone? On 3/18/26 at 1:22 PM, the surveyor made a second observation of Resident #14 lying in bed. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to revise the care plan (CP) report for 1 (one) of 21 residents (Resident #49) reviewed for a comprehensive CP.This deficient practice was evidenced by the following:On 3/18/26 at 10:13 AM, the surveyor observed Resident #49 in bed, awake, watching TV, and was able to answer the surveyor's inquiry. Resident #49 stated that they do not have any concerns with the facility. On 3/19/26 at 12:48 PM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #49, which revealed the following:A review of the admission Record (AR, an admission summary) reflected that Resident #49 was admitted with diagnoses that included but were not limited to depression, anxiety, mood disorder, and dementia (loss of memory). [...]

Inspectors wroteBased on observations, interviews, review of the medical records, as well as review of other pertinent facility documentation, it was determined that the facility failed to a.) report and immediately investigate a fall which occurred for 1 of 4 sampled Residents, (Resident #15), who were investigated for falls and, b.)consistently implement identified safety interventions as per the residents physician's orders and care plan to prevent falls for 1 of 4 sampled Residents, (Resident #16), who were investigated for falls. This deficient practice was evidenced by the following: 1. On 3/18/26 at 11:45 AM, the surveyor interviewed Resident # 15, who was in their room, and the resident stated that the resident did fall in the facility two different times, with no injuries and that the staff educated the resident to call for assistance. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide ordered respiratory care consistent with professional standards of practice for 1 of 2 residents (Resident #9) reviewed for respiratory care. This deficient practice was evidenced by the following:On 3/18/26 at 10:27 AM, the surveyor observed Resident #9 lying in bed, receiving oxygen via a nasal cannula (NC, a plastic prong attached to a tube, inserted into the nostrils through which oxygen flows). The surveyor observed that the oxygen flow meter was set at 1.5 liters per minute (L/min). On 3/18/26 at 1:26 PM, the surveyor made a second observation of Resident #9 lying in bed, receiving oxygen via NC. The surveyor observed that the oxygen flow meter was set at 1.5 L/min. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policies, it was determined that the physician's progress notes (PPN) are not legible. This deficient practice was identified for 1 of 22 residents (Resident #35). This deficient practice was evidenced by the following:On 3/18/26 at 10:20 AM, the surveyor observed Resident#35 sitting in the activity room. On 3/18/26 at 1:23 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #35, which revealed the following:A review of the admission Record (AR, an admission summary) reflected that Resident #35 was admitted with diagnoses that included, but were not limited to, an unspecified dementia (loss of memory) and mood disturbance. [...]

Inspectors wroteBased on observation and interview on 3/24/26 in the presence of the Life Safety Director (LSD) Assistant Plant Operations Director (APOD) and Plant Operations Director (POD), it was determined that the facility failed to ensure that wooden handrails were installed, maintained, secured and splinter free in all required locations. This deficient practice was identified for 1 of 8 areas observed, had the potential to affect all residents, and was evidenced by the following by the following: An observation at 11:40 PM revealed that the Juniper Way wing handrails by the exit/egress doors to the public way were blocked from access due to a long 2-shelf furniture unit approximately 5' wide. In an interview during the above findings, the LSD, APOD and POD all confirmed the observation. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the proper administration of Fluticasone (Flonase; nasal spray used to relieve allergies and nasal congestion) in accordance with manufacturer's specifications and professional standards of practice during the medication pass observation on 12/13/24. The deficient practice was identified for 1 of 4 nurses who administered medications to 1 of 4 residents (Resident #11) 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 wroteBased on observation, interview, and record review it was determined that the facility failed to maintain infection control standards and procedures during wound care treatment for 1 of 2 residents (Resident #89), reviewed for care and services for pressure ulcers. 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: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and 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 maintain proper care of indwelling urinary catheters to prevent Urinary Tract Infections (UTIs) for 4 of 4 residents (Resident #41, #23, #20 and #14) reviewed for urinary catheter care use. This deficient practice was evidenced by the following: 1. On 9/27/23 at 10:33 AM, Resident #41 was observed lying in bed with both eyes closed. The surveyor reviewed the medical record for Resident #41. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in October 2020 with diagnoses that included urinary retention (difficulty urinating), a history of malignant neoplasm of the bladder (bladder cancer), and Alzheimer's disease(a brain disease that causes memory loss). [...]

Inspectors wroteBased on observation, interviews, and record review it was determined that the facility failed to ensure a fall intervention, specifically a bathroom door alarm, was in place and functioning for a resident with a history of falls. This deficient practice was identified for 1 of 2 residents reviewed for falls, Resident #49, and was evidenced by the following: According to the admission Record, Resident #49 had diagnoses that included but were not limited to Alzheimer's disease and fracture of the left radius (forearm). A review of the Quarterly Minimum Data Set (MDS), an assessment tool, dated 9/10/2023, revealed that the resident had a Brief Interview for Mental Status (BIMS) of 3 which indicated that the resident's cognition was severely impaired. An additional review of the MDS revealed the resident had falls with injuries. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined the facility failed to accurately document the administration of controlled medication for 1 sampled resident (Resident #7) identified upon inspection of 1 of 4 medication carts (Willow unit). The evidence was as follows: On 9/28/23 at 10:44 AM, the surveyor in the presence of the Registered Nurse (RN) inspected the [NAME] unit medication cart. The surveyor and the RN reviewed the controlled medications located in a secured and locked controlled medications box. When the controlled medication inventory was compared to the corresponding declining inventory sheet, the surveyor identified the following concerns. [...]