Lakeland Nursing & Rehab

Inspectors wroteCOMPLAINT #NJ162233 Based on observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to thoroughly investigate an injury of unknown origin. This deficient practice was identified for 1 of 1 resident reviewed, Resident #70. This deficient practice was evidenced by the following: On 7/22/24 at 11:02 AM, during initial tour, the surveyor observed Resident #70 resting in their bed with their eyes closed. The surveyor also observed the Registered Nurse (RN) in the room who stated that she assessed the resident's vital signs. On 7/22/24 at 11:32 AM, the surveyor reviewed the form that was provided by the facility titled, Reportable Event Record/Report for a Facility Reported Event (FRE) dated 3/9/23 which included the following: Today's date: 3/9/23 Date of Event: 3/7/23 Was This a Significant Event: [...]

Inspectors wroteCOMPLAINT #NJ162233 Based on observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to thoroughly investigate an injury of unknown origin. This deficient practice was identified for 1 of 1 resident reviewed, Resident #70. This deficient practice was evidenced by the following: On 7/22/24 at 11:02 AM, during initial tour, the surveyor observed Resident #70 resting in their bed with their eyes closed. The surveyor also observed the Registered Nurse (RN) in the room who stated that she assessed the resident's vital signs. On 7/22/24 at 11:32 AM, the surveyor reviewed the form that was provided by the facility titled, Reportable Event Record/Report for a Facility Reported Event (FRE) dated 3/9/23 which included the following: Today's date: 3/9/23 Date of Event: 3/7/23 Was This a Significant Event: [...]

Inspectors wroteComplaint #: NJ00165369 Based on interviews, and record review, as well as review of pertinent facility documents on 9/13/23, 9/14/23, and 9/19/23, it was determined that the facility failed to report an allegation of a resident-to-resident physical and verbal abuse to the New Jersey Department of Health (NJDOH) and to follow the facility policy Abuse Neglect Exploitation Mistreatment and missappropriatin of Property Prevention for 1 of 3 residents (Resident #7) reviewed for grievance. This deficient practice is evidenced by the following: According to the admission Record (AR), Resident #7 was admitted to the facility on [DATE] with diagnoses which included but were not limited to; Dementia, Post Traumatic Stress Disorder, and Obsessive Compulsive Disorder. [...]

Inspectors wroteComplaint #: NJ00165369 Based on interviews and review of medical records (MRs) and other facility documentation on 9/13/23, 9/14/23, and 9/19/23, it was determined that facility failed to thoroughly investigate an alleged staff-to-resident verbal abuse allegation and to follow facility policy titled Abuse Neglect Exploitation Mistreatment and Misappropriation of Property Prevention for 1 of 3 residents (Resident #2). This deficient practice is evidenced by the following: A review of the statement written by the Certified Nursing Assistant (CNA #1) to the Facility's Regional Human Resources (RHR) via email, dated 9/11/23 at 12:51 a.m., revealed that CNA #1 heard and seen [CNA #2] abuse, scream, and disrespect patients and their Families on XX unit. The statement further revealed that CNA #1 reported the aforementioned incident to the Licensed Practical Nurse (LPN #1). [...]

Inspectors wroteC #: NJ00160399 and NJ00167145 Based on interviews, medical record review, and review of other pertinent facility documents on 9/13/23, 9/14/23, and 9/19/23, 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 the facility protocol for 3 of 4 residents (Resident #2, Resident #3, and Resident #4) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the facility admission Record (AR), Resident #2 was admitted on [DATE], with diagnosis that included but were not limited to: Hemiplegia and Hemiparesis, and Alzheimer's Disease. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure resident's nutrition needs were met for one of nine residents (Resident (R)103) reviewed for nutrition. The facility failed to reconcile discrepancies between facility weights, reflecting stable weight, and hospital weights, reflecting significant weight loss. R103 was weighed during the survey and weighed 126 pounds; the most recent facility weight two weeks earlier was 170.6 pounds. Due in part to the failure to obtain accurate weights, review the hospitalization documentation in the resident's record, and physically/clinically assess the resident, R103's tube feeding regimen was not increased to address weight loss, severe protein malnutrition, and a worsening sacral pressure ulcer.

Inspectors wroteBased on observation, record review, and staff and resident interviews, the facility failed to develop a comprehensive plan of care directing measurable goals and interventions for five residents in a total sample of 25 (Resident (R) 3, R32, R43, R101, and R103). The facility failed to develop a care plan for pain for R3, resident choices for R101, side rails for R32, behaviors for R43, and nutrition for R103. These failures placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observations, record review, interviews, and review of facility policy, the facility failed to ensure one of one resident's (Resident (R) 101) right to make choices about his life that were important to him, were encouraged. Specifically, the facility failed to ensure R101 could go out for walks into the community, interact with members of the community, and encouraged to promote the self determination of needs for resident. The facility also failed to ensure R101 was being included and updated in any discussions about his choice to go for walks in the community. By not promoting resident choices this resident was left feeling as though his needs were not being met to address his right to go into the community for walks.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure advance directives and Practitioner Orders for Life-Sustaining Treatment (POLST) information was completed and obtained for three of 25 sampled residents (Resident (R) 68, R62, and R105). The failure created the potential for residents to not have their wishes known should they suffer a health emergency.

Inspectors wroteBased on observation, interviews, record review, and review of the facility policies, the facility failed to report to administration when one of two residents (Resident (R) 68) in a total sample of 25 experienced a resident-to-resident altercation. This failure placed the residents at risk for further altercations and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to identify the need for a new Preadmission Screening and Resident Review (PASARR-a screening which looks for indicators that a person may have intellectual disability, related disability, or serious mental illness) when a resident had a new diagnosis of mental illness for one of three residents (Resident (R) 17) reviewed for PASARR. This failure placed R17 at risk for not receiving necessary services for her mental health.

Inspectors wroteBased on interview and record review, the facility failed to notify the state mental health authority after a significant change in condition for one (Resident (R) 68) of three sample residents who were reviewed for Preadmission Screening and Resident Review (PASARR- a screening which looks for indicators that a person may have intellectual disability, related disability, or serious mental illness). This has the potential for failure for the facility to identify the resident's needs and provided services appropriate for the residents mental health.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that the resident and/or the resident's responsible party (RP) for two of two residents (Residents (R) 61 and R103) reviewed for baseline care plans, had baseline care plans developed and implemented to address the resident's immediate needs within 48 hours of admission to the facility. The facility failed to ensure the residents and/or representatives were in attendance of a baseline care plan and provided with a written summary of the baseline care plan that included, at a minimum, the initial goals of the resident; medications, nursing, and dietary instructions; and services and treatments to be administered by the facility and personnel.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan was updated for one of 29 residents (Resident (R) 96) reviewed. The failure to keep a care plan current could affect the appropriateness of care provided to any of the 127 current residents receiving care in the facility.

Inspectors wroteBased on observations, interview, record review, and policy review, the facility failed to ensure one of seven residents (Resident (R) 66) reviewed for falls received appropriate care and services following an unwitnessed fall in which she sustained a bruise below her eye. Neurological (neuro) checks were not completed to rule out a head injury after the fall.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer two of five residents (Resident (R) 31 and R103) reviewed for pneumonia vaccinations and/or their representatives, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to offer R31 the opportunity to be vaccinated with Pneumococcal polysaccharide vaccine (PPSV23) and if this vaccination was not available to offer one dose of Prevnar 20 (PCV20). The facility failed to offer R103 the opportunity to be vaccinated with Pneumococcal 15-valent Conjugate Vaccine (PCV15) in accordance with nationally recognized standards.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders. This deficient practice continued over a two month period of time for 3 of 31 residents (Resident #8, #88, #117) reviewed and was evidenced by the following: 1. On 03/07/19 at 10:20 AM, the surveyor observed Resident #8 laying in bed eating breakfast. The surveyor reviewed Resident #8's medical record. According to the Admitting Face Sheet, Resident #8 was admitted to the facility on [DATE] with diagnoses that included Emphysema, Hypertension and Paraplegia. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 03/03/19, the facility assessed Resident #8 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. [...]

Inspectors wroteBased on observation, interview and record review, 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 60 days. This deficient practice continued over several months for 4 of 31 residents (Resident #8, #88, #89, #117) reviewed and was evidenced by the following: 1. On 03/07/19 at 10:20 AM, the surveyor observed Resident #8 laying in bed eating breakfast. The surveyor reviewed Resident #8's medical records. According to the Admitting Face Sheet, Resident #8 was admitted to the facility on [DATE] with diagnoses that included Emphysema, Hypertension and Paraplegia. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to: a.) perform an assessment of a resident's condition, b.) maintain documentation of monitoring for complications related to hemodialysis and c.) communicate with the hemodialysis center. This deficient practice was identified for 1 of 4 residents (Resident #69) reviewed for dialysis. The deficient practice was evidenced by the following: On 03/08/19 at 9:21 AM, the surveyor observed Resident #69 in the doorway of the room seated in the wheelchair. The surveyor reviewed Resident #69's medical records. A review of the Admitting Face Sheet, revealed that Resident #69 was admitted to the facility on [DATE] and with diagnoses that included End Stage Renal Disease (ESRD). The surveyor reviewed Resident #69's March 2018 Physician's Orders Form. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to implement a gradual dose reduction (GDR) of an anti-psychotic medication for 1 of 4 residents (Resident #35) reviewed. The deficient practice was evidenced by the following: On 03/07/19 at 10:50 AM, the surveyor observed Resident #35 during a morning activity in the day room. The resident was seated in a recliner chair with eyes closed. The surveyor reviewed Resident #35's medical record. The resident was admitted to the facility on [DATE] and according to the March 2019 Physician's Order Form (POF) Resident #35 had diagnoses that included Dementia with Behavioral Disturbances, Psychosis, Anxiety and Alcohol Abuse. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to promptly notify the physician of abnormal laboratory results that fall outside of the normal clinical reference range. This deficient practice was identified for 3 of 31 residents reviewed (Resident #52, #117, #128) and was evidenced by the following: 1. The surveyor reviewed Resident #52's medical records. According to the Admitting Face Sheet, Resident #52 was admitted to the facility on [DATE], with diagnoses that included Emphysema, Enlarged Prostate and Cerebral Vascular Accident. A review of the laboratory results dated [DATE], showed documentation that the result was faxed to the facility on [DATE], there was no documentation that the physician was notified of the results: high 140 Glucose level, high 107 Chloride level, low 19 CO2 (Carbon Dioxide) level and high 17 AGAP (Anion Gap) level. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to follow proper infection control procedures and perform proper hand hygiene during 1 of 2 wound treatment observations. This deficient practice was observed for Resident #117 and was evidenced by the following: 1. On 3/12/19 at 09:13 AM, the surveyor observed the Licensed Practical Nurse Unit Manager (LPN UM) provide wound care to a pressure ulcer on Resident #117's left ischium. The LPN UM was observed to wash her hands eight times during the above procedures and was observed to be inconsistent with her technique. Twice the surveyor observed the LPN UM apply liquid hand soap and immediately lathered and rubbed her hands together under the running water for a total of five seconds. On four occasions the surveyor observed the UM lather and rub her hands together for 11 seconds or less. [...]

Inspectors wroteBased on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to provide adequate maintenance to ensure that all the kitchen equipment was in safe operating condition. This deficient practice was evidenced by the following: On 03/07/19 at 10:08 AM, in the presence of the Food Service Director (FSD) the surveyor observed the following: 1. A large amount of water was at the threshold of the kitchen that spread over the threshold and into the hallway and back across the floor into the main area of the kitchen. The water trail was traced back and originated from a leak on top of the dish machine where the temperature gauges were located. No wet floor sign was present. 2. The hood lights were off during food preparation and when turned on two of five lights were not working. The cook stated we usually leave the lights off. 3. [...]