Hope Creek Nursing & Rehab

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen ceilings are free of dirt and debris. This failure has the potential to affect all residents residing in the facility with a current census of 162 residents. The Facility Resident Census Roster and Facility Matrix/802, dated 7/24/26, were reviewed. The Census Roster documented 162 Residents resided in the Facility. The facility policy, entitled Sanitation/Infection Control, document: the dietary manager is responsible for supervising all sanitation, and housekeeping procedures within the dietary department; monthly or more often as needed walls, ceilings, and shelves are clean thoroughly. Vents lights, cupboards, windows and screens are cleaned. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the resident call light system in working order for 4 of 5 residents (R1, R2, R8, R13) reviewed for call lights in the sample of 13.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a clean, comfortable, homelike environment for 1 of 5 residents (R1) reviewed for physical environment in the sample of 13.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents that were dependent on staff with toileting were provided Activities of Daily Living (ADL) for 2 of 8 residents (R7 and R6) reviewed for ADL care in the sample of 13.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Physician Progress Notes and orders were maintained with a resident's record and followed promptly. The facility failed to ensure accurate and complete monitoring of a surgical site was being completed. This applies to 1 of 3 residents (R1) reviewed for quality of care in the sample of 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fall interventions were implemented for a resident who is at a high risk for falls. This failure resulted in R1 being found in her room, laying on the floor, sustaining a comminuted right humerus fracture requiring surgical interventions. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 8.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify a pressure wound prior to becoming a stage 3 for a resident at risk for pressure ulcers (R1) and failed to ensure pressure relieving interventions were implemented for 2 of 3 residents (R1, R4) reviewed for pressure ulcers in the sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe environment, provide adequate supervision, and implement necessary assistive interventions for three (R1, R2, and R3) of three residents reviewed for falls. These failures resulted in repeat falls or injury events, some with head trauma, lacerations, and hospitalizations.

Inspectors wroteBased on interview and observation, the facility failed to ensure 1 of 4 residents (R1) in the sample of 7 reviewed for visitation rights were allowed to receive their chosen visitors.

Inspectors wroteBased on observation, interview and record review the facility to ensure a resident's therapeutic diet was provided. This applies to 1 of 3 residents (R3) reviewed for diets in the sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for one of 29 residents (R76) in a sample of 67.

Inspectors wroteBased on interview and record review, the facility failed to correctly assess fall risks, develop a comprehensive care plan and implement intervention to prevent a fall with injury. This resulted in the resident sustaining a wrist fracture due to a fall because appropriate fall prevention interventions were not implemented timely for one of 29 residents (R76) in a sample of 67.

Inspectors wroteBased on interviews and record review the facility failed to prevent and protect cognitively impaired residents from physical abuse for 2 of 4 residents (R1, R4) reviewed for abuse in a sample of 7. This failure resulted in R1 wandering into R2's room, was then physically removed and led to R1 falling on the floor and sustaining head trauma and also resulted in R5 forcefully grabbing her roommate R4 by the hair and wrists that caused R4 to feel angry and scared of R5.

Inspectors wroteBased on interview and record review the facility failed to provide timely incontinence care for one of one resident(R1), reviewed for incontinence care, in a sample of 3. The facility policy, Guidelines for Incontinence Care, dated 9/21/23 documents, It is the policy of the facility to ensure that residents receive as much assistance as needed for cleansing the perineum and buttocks after an incontinent episode or with daily care. Frequency depends on bladder diary results and/or routine minimal every two-hour checks as well as care planning. R1's facility Face Sheet documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Polyneuropathy, Arthritis, Morbid Obesity, Major Depressive Disorder, Lymphedema and Dementia. R1's most recent Minimum Data Set Assessment, dated 10/11/24 documents that R1 is, always incontinent of bowel and bladder. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide immediate post-fall care to one resident (R1) receiving anticoagulant therapy of three residents reviewed for falls with injury. This failure resulted in delayed treatment of a subdural hematoma. The facility also failed to safely turn and position one resident (R4) of three residents reviewed for accidents with injury. This failure resulted in R4 sustaining a nasal fracture.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from physical and verbal abuse and identify and investigate a potential allegation of abuse and protect resident from further abuse from R500, with a known history of verbal and physical aggression. These failures resulted in R500 verbally yelling and physically hitting R134 and shoving both R84 and R103 to the ground. R84 sustained a bleeding laceration to posterior head, facial bruising, and hospitalization requiring three staples to R84's posterior head. R103 experienced hip and knee pain, bruising, and hospital evaluation. R134 was hit in the face. These failures have the potential to affect all 35 residents residing in the facility's Dementia unit. These failures resulted in an Immediate Jeopardy. [...]

Inspectors wroteBased on record review and interview the facility failed to effectively resolve grievances voiced in resident council meetings. This failure has the potential to affect all 160 residents who reside in the facility. Findings Include: Resident Council Meeting Minutes dated 10/25/23 documents concerns from residents stating the kitchen needs to be more organized to be able to serve meals on time, and there needs to be more staff in the dining room to help serve meals on time as well. The General Feedback/Grievance Form dated 10/25/23 documents Resident Council topic of concern Dietary. Detailed Description of Occurrence: kitchen to be more organized, need service to be faster, would like alternatives to spicy food. The Steps taken to investigate concern and corrective action taken areas were blank. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store dry foods in a clean manner and failed to ensure all kitchen staff had their hair covered. These failures have the potential to affect all 160 residents who currently reside in the facility. Findings Include: The facility's Employee Health and Personal Hygiene policy dated 4/2017 documents Food service employees shall maintain good personal hygiene and free from communicable illnesses and infections while working in the facility. Hair restrains will be worn at all times. Beards should be well trimmed and covered with an appropriate hair restraint. The facility's Storage of dry foods/supplies policy dated 4/2017 documents dry foods stored in bins such as flour and sugar will be removed from the original packaging. Storage bins used will be kept clean, labeled and dated. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to don PPE (Personal Protective Equipment) properly during a COVID-19 outbreak, ensure Personal Protective Equipment (PPE) was utilized throughout wound care, residents were placed in contact isolation with active wound infections and Enhanced Barrier Precautions per order, assess residents for signs and symptoms of COVID-19, initiate isolation precautions and ensure a resident's environment was kept free from cross contamination of MRSA (Methicillin- Resistant Staphylococcus Aureus) pathogen during wound care for eight of 32 residents (R55, R37, R57, R71, R101, R114, R122, R127) reviewed for Infection Control in the sample of 124 residents. These failures have the potential to affect all 160 residents who currently reside in the facility. Findings Include: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing program of activities daily to meet the resident's physical, mental, and psychosocial well-being. These failures have the potential to affect all 35 residents residing in building four on the second floor.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff treated the resident with dignity and respect for one resident (R101) reviewed for resident's rights in a sample of 124.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their abuse prevention program to protect residents from abuse for three (R84, R103, and R500) of four residents reviewed for abuse in the sample of 124.

Inspectors wroteBased on interview and record review the facility failed to identify and investigate a potential allegation of verbal and physical abuse for two (R84 and R500) of four residents reviewed for abuse in the sample of 124.

Inspectors wroteBased on interview and record review the facility failed to do a Level 2 PASARR (Pre- admission Screening and Resident Review) screen for one of two residents (R73) reviewed for PASARRs in total sample of 124. Findings Include: The facility policy, named, Resident Assessment Policy and Procedure, dated 2019, documents the following: The facility shall coordinate assessments with the preadmission screening and resident review (PASARR) program. Referring all Level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. [...]

Inspectors wroteBased on record review and interview the facility failed to update the care plan to reflect the removal of the tracheostomy for one of one resident (R127) reviewed for careplans in a sample of 124.

Inspectors wroteBased on interview and record review the facility failed to provide range of motion programming to residents with limitations in range of motion for two of seven residents (R57, R78) reviewed for limited range of motion in a sample of 124 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a residents indwelling urinary catheter drainage bag was secured in a dignity enclosure bag for one of four residents (R55) reviewed for urinary catheters in the total sample of 124.

Inspectors wroteBased on observation, interview and record review the facility failed to store medications in a safe manner for three residents (R7, R5, and R124) observed during a routine medication pass in a total sample of 124. Findings Include: The facility's Storage of Medications policy dated 5/8/19 documents the purpose of the policy is to ensure that medications are stored in a safe, secure and orderly manner. Medications are stored in the containers in which they are received. On 8/27/24 at 8:10 AM V22 (Registered Nurse) opened her medication cart and pulled out a clear medicine cup full of pills with writing on the side and administered the medications to R124. V22 stated that the medicine cup was full of R124's morning medications to include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure coordinated care was implemented by failing to ensure documented hospice services rendered was included in the resident's medical record and available and accessible to the interdisciplinary team (IDT) for one of 11 residents (R71) reviewed for Hospice care Management in a total sample of 124.

Inspectors wroteBased on interview and record review the facility failed to immediately provide CPR (Cardiopulmonary Resuscitation) to one resident (R1) identified as having no Advance Directives and failed to follow their policy which documents that Direct and non-direct care staff upon finding a resident non-responsive shall remain with that resident as is possible while signaling for assistance. The facility also failed to ensure all staff received training on the facility CPR Policy. On [DATE] at approximately 9:25am R1 was found unresponsive and without a pulse or respirations in his room by V7 (RN - Registered Nurse). V7 then left R1's room to make telephone calls to another nurse regarding R1's condition and to V2, (DON - Director of Nursing). [...]

Inspectors wroteBased on interview and record review the facility failed to develop a system to assess and evaluate residents for capacity to consent to sexual activity, failed to ensure two cognitively impaired residents (R1, R2) who engaged in a sexual act had the capacity to consent, and failed to prevent two cognitively impaired residents (R1, R2) who didn't have the capacity to consent, from engaging in a sexual act resulting in (R1) experiencing psychosocial harm as any reasonable person would be affected in a total sample of four resident reviewed for abuse. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 4/4/24, the facility remains out of compliance at a Severity Level Two as additional time is needed to evaluate the implementation and effectiveness of the removal plan including their Inservice Training and Quality Assessment oversite.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent resident to resident physical abuse for one resident (R2) of three residents reviewed for abuse in the sample of four.

Inspectors wroteBased on interview and record review, the facility failed to perform pressure ulcer treatments per order for one (R1) of three residents reviewed for pressure ulcers in a sample of five. This failure resulted in (R1) acquiring a Stage 4 pressure ulcer.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered within the one hour before/one hour after the designated 8:00 a.m. and 9:00 a.m., medication pass for two residents (R4 and R6) of four residents (R2, R3, R4, and R6) reviewed for medications being administered on time, in a total sample of four.

Inspectors wroteBased on observation, interview and record review, the facility failed to store food off the floor in the dry food storage area, refrigerator, and freezer. This failure has the potential to affect 123 of the 125 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to answer resident call lights in a timely manner for six residents (R15, R36, R38, R42, R49, R62) of 32 residents reviewed for call lights in a sample of 32.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident Council Members complaints and concerns were addressed and residents received responses and/or rationales for their recommendations for five (R15, R36, R38, R49, and R62) of five residents reviewed for Resident Council Concerns in the sample of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to provide an appropriate indication for use of antipsychotic medications, failed to identify target behaviors on the psychotropic medication consent, failed to document justification for administration of antipsychotic injections and failed to justify duplicate antipsychotic medications for six residents (R61, R63, R71, R73, R115, R233) of seven residents reviewed for unnecessary medications in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Residents were offered snacks in the evening for five (R15, R36, R38, R49, and R62) of five residents reviewed for Resident Council Meetings in the sample of 32.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a plan of care for a resident who is a current smoker in the facility for one of one resident (R49) reviewed for smoking in the sample of 32.

Inspectors wroteBased on observation, interview and record review, the facility failed to address a residents need for incontinence care for one resident (R42) and failed to provide daily grooming needs for one resident (R90) out of three residents reviewed for activities of daily living in a sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to follow a physician's order to obtain daily weights for one of 26 residents (R111) reviewed for physicians' orders in the sample of 32.

Inspectors wroteBased on observation, interview and record review the facility to ensure a resident (R49) was not in possession of their own smoking materials (cigarettes and lighter) and failed to identify the root cause of falls (R71) for two of eight residents reviewed for accidents and supervision in the sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to investigate and determine a root cause analysis of a fall, failed to implement fall interventions, and failed to provide supervision during toileting to prevent a fall for one of five residents (R120) and failed to monitor a personal safety monitoring device for a resident identified as high risk for elopement for one of two residents (R341) reviewed for accidents/incidents in the sample of 64. As a result of this failure R120 fell in the bathroom after being left unattended on the toilet on 05/03/22, and was subsequently transferred to a local hospital and diagnosed with a left femoral neck fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide required staff to care for dependent residents. This failure has the potential to affect all 136 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to conduct the required 12 hours of CNA (Certified Nursing Assistant) in-services including Dementia training. This failure has the potential to affect all 136 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to employ the services of a Certified Dietary Manager. This failure has the potential to affect all 136 residents currently residing in the facility. Findings Include: The facility's Classification Description for Director of Food Services job description (undated) documents the following: Duties: Develops nutrition care plans on each resident; Attends multi-disciplinary care plans as scheduled; Assumes in-service training for dietary employees. The training should encompass regular and therapeutic diets, interpretation of classification description and work procedures, use of equipment, safety and sanitation standards, and personal grooming; Follow up on nutrition goals set for residents, including supplements, diet changes, weight recommendations, etc. Evaluate progress being made towards goals with Dietician; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were served warm, palatable meals. This failure has the potential to affect all 136 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide substitutes of equal nutritional value during meals. This had the potential to affect all 136 residents residing in the facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure items in the kitchen were clean and dry, food items were dated upon opening, scoops were stored out of direct contact with food, beverages and nutritional supplements were not expired, and pipelines in the freezer were undamaged and functioning without signs of water damage. This failure has to potential to affect all 136 residents currently residing in the facility.

Inspectors wroteBased on interview and record review, the facility's Quality Assurance Committee failed to meet quarterly to identify, review and correct identified issues. This failure has the potential to affect all 136 residents residing in the facility. Findings Include: On 6/30/2022, V1/Administrator provided the following: (The facility) Quarterly QAA (Quality Assurance Attendance) meeting dated May 27, 2022. On 06/30/2022 at 9:15 A.M., V1/Administrator, was unable to provide attendance sign-in sheets for any Quality Assurance Meetings held with documentation of who attends, or issues that have been identified and are being discussed for performance improvement, prior to 5/27/2022. At that time, V1 stated he has only conducted one QA Meeting and has no idea what happened prior to him beginning employment at the facility. [...]

Inspectors wroteNoncompliance resulted in two deficient practices. A. Based on observation, interview and record review, the facility failed to complete required COVID-19 testing, failed to ensure staff donned and doffed PPE (personal protective equipment) prior to entering/exiting a COVID-19 isolation/quarantine room and failed to ensure appropriate signage was posted to identify residents in COVID-19 isolation. These failures have the potential to affect all 136 residents in the facility. B. Based observation, interview and record review, the facility failed to place a urinary catheter collection bag in a clean area for one of three residents (R67) reviewed for urinary catheters in the sample of 64. 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a functioning call system to 20 residents (R11, R29, R32, R42, R46, R65, R67, R82, R85, R86, R92, R108, R109, R110, R117, R241, R243, R244, R245, R246) of 136 residents reviewed for call light response.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure electronic monitoring was not tampered with for one of two residents (R34) whose rooms are electronically monitored by family in a sample of 64. Findings Include: The Facility's undated Policy and Procedure: Photographing, Video Recording, Audio Recording, and Other Imaging of Residents, Visitors and Employees policy documents, 2. Photographing/Audio Recording of Residents by Residents, Family Members and/or by Visitors: The facility is not required to obtain consent from the resident, but must be notified in advance, when the resident is the subject of the photography/audio recording and such recording is performed by the resident or the resident's family members or the resident's visitors. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to allow visitation for one resident (R82) of 13 residents reviewed for visitation during a COVID-19 outbreak in the sample of 64.

Inspectors wroteBased on interview and record review, the facility failed to obtain Advanced Directives for two of five residents (R108 and R241) reviewed for Code Status in the sample of 64.

Inspectors wroteBased on record review and interview, the facility failed to recognize potential abuse for two of eleven residents (R51 and R127) reviewed for abuse in a total sample of 64. Findings Include: The Facility's Abuse Prevention Program dated 3/1/21 documents It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. The Facility's Abuse Prevention Program defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that two allegations of abuse were immediately reported to the Administrator for three of 11 residents (R34, R51 and R127) reviewed for abuse in the sample of 64.

Inspectors wroteBased on record review and interview, the facility failed to investigate two instances of potential abuse for two of 11 residents (R34 and R51) reviewed for abuse in a sample of 64. Findings Include: The Facility's Abuse Prevention Program dated 3/1/21 documents It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. The Facility's Abuse Prevention Program defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. [...]

Inspectors wroteBased on record review and interview, the facility failed to obtain orders for routine water flushes with gastric feedings and failed to have one resident (R34) assessed by a Registered Dietician. R34 was one of three residents reviewed for nutrition in a sample of 64. Findings Include: The Facility's undated Dietitian Consultant Policy and Procedure documents, A qualified, licensed Dietitian will be contracted for consulting purposes. The Dietitian Consultant Policy and Procedures documents, The dietitian will work with the facility per contract which may include but not limited to a) assess special nutritional needs of the residents. R34's admission Record documents R34 was admitted on [DATE] with a gastric tube in place and was being fed through the gastric tube three times daily. R34's Medical History and admission Orders form dated 2/7/2022 documents Diet: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the feeding port cap was secure to prevent the unintended leakage of formula, and failed to position a resident to prevent aspiration for one of two residents (R132), reviewed for tube feedings, in a sample of 64.

Inspectors wroteBased on interview and record review, the facility failed to obtain a physician's order for the implementation of dialysis, failed to follow physician ordered dietary restrictions, and failed to communicate the resident's condition regularly with the dialysis center, for two of two residents (R84 and R113), reviewed for dialysis, in a sample of 64. The (undated) facility policy, Communication Hemodialysis directs staff, To ensure coordination of care for residents requiring Hemodialysis in the community. All residents that are admitted to the facility with needs for Hemodialysis will have coordination of services between the facility and the Hemodialysis unit. Special consideration will be given to residents going to dialysis to coordinate therapy, medication administration and meals. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's menu met a resident's nutritional preferences for one of six resident (R113), reviewed for food preferences, in a sample of 64. The (undated) facility policy, Resident Likes and Dislikes/Food Preferences, directs staff, Resident's food preferences will be recorded and consistently utilized. Data including resident likes, dislikes, allergies, food preferences will be entered into the computerized tray card system. The (undated) facility policy, Dining Experience documents, Meals will be nourishing, attractive, palatable and will haven taken into account religious, cultural and ethnic needs. All residents will be visited by the Dining Services Manager within 48-72 hours to introduce them to the dining program and inquire about food preferences and eating habits. [...]