Jersey Shore Post Acute Rehabilitation and Nursing

Inspectors wroteBased on observation, interviews, review of the clinical records and pertinent facility documentation, it was determined that the facility to a.) ensure the documentation for the administration of wound treatments for 1 of 2 residents (Resident #46) reviewed for wounds, b.) properly secure medications during medication administration observation, and c.) ensure the medication cart was locked when not in use for 1 of 4 medication carts (east high side) in accordance with professional standards of practice. Reference: New Jersey Statutes, 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 a individualized comprehensive care plan (ICCP) that included interventions that were specific to a resident identified as having a diabetic ulcer. This deficient practice was identified for 1 of 18 residents reviewed (Residents #46), and was evidenced by the following: A review of the admission Record face sheet (admission summary) indicated that Resident #46 was admitted to the facility with diagnoses which included but was not limited to; diabetes mellitus (DM), chronic osteomyelitis (bone infection), and peripheral vascular disease (PVD). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 1/7/25, reflected that Resident #46 was cognitively intact and required supervision with activities of daily living (ADLs). [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to activate their emergency response system by calling 911 and immediately initiating Cardiopulmonary Resuscitation (CPR) for 1 of 3 residents reviewed who were full-code and were found unresponsive and without respirations and a heart rate (Resident #82), in accordance with the American Heart Association and the Basic Life Support (BLS) for Healthcare Providers. Resident #82 was a full-code status and had requested aggressive life-saving treatment despite medical decline. The resident was last seen on [DATE] at 7:58 AM, by the nurse who took vital signs, administered blood pressure medications, and left the resident in stable condition. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an allegation of staff to resident neglect that occurred on [DATE] when the Licensed Practical Nurse (LPN) failed to call 911 and initiate cardiopulmonary resuscitation (CPR) for a resident (Resident #82) with a full-code status. This deficient practice was identified for 1 of 2 investigations reviewed, and was evidenced by the following: On [DATE] at 9:17 AM, the surveyor reviewed the closed medical record for Resident #82 who had expired in the facility. The surveyor reviewed the medical record for Resident #82. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) assess and educate a resident on self-administration of oxygen and respiratory inhalers; b.) obtain a physician's order for the self-administration of oxygen and respiratory inhalers; c.) care plan for the self-administration of oxygen and respiratory inhalers; d.) accurately sign in the Treatment Administration Record for the administration of oxygen; and e.) accurately sign the Medication Administration Record for the administration of a respiratory inhaler in accordance with standards of practice. The deficient practice was identified for 1 of 2 residents reviewed for respiratory care (Resident #51), and was evidenced by the following: On 1/27/23 at 10:59 AM, the surveyor observed Resident #51 sitting in their wheelchair at their tray table in their room. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least every thirty days. This deficient practice was identified for 4 of 4 residents (Resident #3, #29, #51, and #55) reviewed for physician visits and was evidenced by the following: 1. On 1/27/23 at 10:59 AM, the surveyor observed Resident #51 sitting in their wheelchair at their tray table in their room. The resident was being administered oxygen via nasal cannula (tubing used to deliver oxygen through the nose) at a rate of five liters per minute (5 lpm). [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to a.) communicate a hospice recommendation for a toe treatment to the physician and b.) to follow hold parameters for the administration of a blood pressure medication in accordance with professional standards of practice. This deficient practice was identified for 2 of 24 residents (Resident #66 and #82) reviewed for standards of practice 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 review of pertinent facility documents, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation performed on 1/30/23, the surveyors observed two nurses administer medication to five ( 5) residents. There were 28 opportunities, and two (2) errors were observed, which calculated to a medication administration error rate of 7.14%. This deficient practice was identified for 1 of 5 residents (Resident # 36) that were administered medications by 1 of 2 nurses. The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain proper infection control practices identified for 1 of 2 nurses observed during medication administration and for 1 of 4 nurses interviewed during medication storage and b.) perform hand hygiene after 1 of 6 observed kitchen staff pull their surgical mask down and then back up. This deficient practice was evidenced by the following: 1. On 1/30/23 at 9:05 AM, the surveyor observed the Licensed Practical Nurse (LPN #1) prepare to administer medication to Resident #59. LPN #1 entered the resident's room with an infra-red thermometer scan and obtained a temperature of 97.3 degrees Fahrenheit (F). LPN #1 went to the medication cart and placed the thermometer on top of the cart without disinfecting the thermometer. [...]