Leisure Chateau Rehabilitation

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure laundry staff performed hand hygiene immediately after removing personal protective equipment (PPE) worn while handling soiled linen prior to contacting clean laundry equipment and areas. This failure had the potential for contaminated hands to transfer pathogens from soiled linen to clean linen, equipment, and environmental surfaces, placing residents at risk for the development and/or transmission of infections. The facility housed a high-risk population with a census of 187 residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents were informed of and provided written information, upon admission, regarding their right to formulate advance directives for two residents (Residents (R) 95 and R201) of five reviewed for advance directives out of a total sample of 40 residents. This deficient practice placed residents at risk for more than minimal harm by limiting their ability to make informed decisions and communicate their healthcare preferences, including life-sustaining treatment, in the event they are unable to express their wishes.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNOC) notification was provided and that the responsible party was notified for one of three residents (Residents (R) 124) reviewed for beneficiary notification out of a total sample of 40 residents. This had the potential to affect all residents being discharged from services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from physical restraints for one resident (Resident (R) 125) reviewed for physical restraints out of 40 sampled residents. This failure had the potential to affect all residents' rights at the facility.

Inspectors wroteBased on record review, interview, and document review, the facility failed to ensure three of three residents (Resident (R) 10, R12, and R197) and their resident representatives (RR) reviewed for emergent hospital transfer were provided with a written bed hold policy and transfer notice out of a total sample of 40 residents. This failure had the potential to affect the resident and their RR by not having the knowledge of how to appeal the transfer, if desired, and had the potential to contribute to the possible denial of re-admission and loss of the resident's home following hospitalization for residents transferred to the hospital.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was submitted timely for two residents (Resident (R) 31 and R13) reviewed for MDS assessments out of a total sample of 40 residents. The failure to submit the discharge MDS did not allow for the closure of the residents' MDS cycle.

Inspectors wroteBased on interviews, record review, facility policy, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) was coded accurately for two residents (Resident (R)25 and R163) reviewed for MDS accuracy out of a total sample of 40 residents. This failure placed residents at risk of unmet care needs.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure residents did not have bedrails when they were not assessed to have them for one of four residents (Resident (R) 28) reviewed for side rails out of a total of 40 sampled residents. The lack of appropriate assessment could lead to potential restraint or side rail entrapment.

Inspectors wroteBased on observation, interview, and review of facility documentation, 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 10/01/2024 from 9:29 to 10:14 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. In the dry storage area on a lower rack of a multi-tiered, wheeled, can storage rack, a can of vegetarian beans had a significant dent on the side of the can. The FSD removed the can to the designated dented can area after agreeing that it was significantly dented. 2. In the meat walk-in on a middle shelf, a previously opened package of sliced turkey was wrapped in plastic wrap. The package had no dates. In addition, a clear plastic bag contained sliced bread. [...]

Inspectors wroteC# NJ172982 Based on observation, interview, and record review, it was determined that the facility failed to provide all the items that were on the menu. This deficient practice occurred during one lunch meal that was observed in the conference room of the facility during a test tray evaluation by the survey team and was evidenced by the following: On 10/08/2024 at 11:28 AM, the surveyor requested the main and alternate meal for lunch on 10/8/2024. According to the [facility name] Week at a Glance - New Menu 2020 the main entree for week 4 consisted of creamy carrot soup, cheese quesadilla, zucchini stuffed tomato, and cinnamon rice pudding. The alternate meal at lunch according to the menu consisted of grilled eggplant and roasted pepper sandwich, and potato salad, in addition the creamy carrot soup. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to have a cover over the opening of 1 of 2 garbage dumpsters. This deficient practice was evidenced by the following: On 10/03/2024 at 09:07 AM, the surveyor observed the facilities designated garbage area. The surveyor observed two (2) trash only dumpsters in the facility parking lot in an opened but fenced in area. The dumpsters were three (3) yard dumpsters and had two (2) separate black plastic lids to enclose the trash in the dumpster. The front dumpster contained bagged trash/garbage and 2 of 2 lids were open and left the bagged trash exposed. A residential housing complex is located directly behind the designated garbage area. [...]

Inspectors wroteBased on observation, interviews and review of facility documentation it was determined that the facility failed to: a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination and c.) maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 05/02/23 at 09:51 AM, in the presence of the Food Services Director (FSD), the surveyor toured the kitchen and observed the following: 1. In the dairy freezer, there was one (1) knotted clear plastic bag which contained several frozen brown coated squares of meat, which the FSD identified as breaded fish squares, with no label and no dates. [...]

Inspectors wroteNJ00154373 Based on interview and review of facility documentation, it was determined that the facility failed to follow upcoming policy changes within the timeframe provided to residents. This deficient practice was identified for 1 of 5 residents reviewed for smoking (Resident #104) and was evidenced by the following: On 05/08/23 at 10:26 AM, the surveyor interviewed Resident #104. The resident told the surveyor that when he/she came to the facility residents were allowed to smoke three times a day, and a few months ago it was changed to twice a day, about six I think. Resident #104 said, There are days when we can't smoke at all, maybe every other month because the staff doesn't show up. The resident could not give specific dates when the smoking was suspended. [...]

Inspectors wroteComplaint # NJ00163390 Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a.) maintain a clean, comfortable, homelike environment on the Florida unit, b.) maintain privacy curtains free from stains in a resident's room c.) maintain cleanliness behind the blinds in a resident's room, and d.) paint over the spackle in a resident's room. This deficient practice was identified for two (2) of 36 resident's, (Resident #4 and Resident #33) and on one (1) of four (4) nursing units, (Florida unit) reviewed for clean, comfortable, homelike environment. The deficient practice was evidenced by the following: 1.) On 05/04/23 at 10:39 AM, the surveyor toured the Florida unit and observed that the gold-colored wallpaper to the right of room [ROOM NUMBER] was ripped from the wall leaving a white mark. [...]

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide written notification of the emergency transfer to the resident, resident representative, and the Office of the Long-Term Care Ombudsman (LTCO) for one (1) of two (2) residents (Resident # 124), reviewed for hospitalizations. This deficient practice was evidenced by the following: The surveyor reviewed the medical records of Resident # 124. Review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to coronary artery disease, heart failure, diabetes, and hyperlipidemia. Review of the New Jersey Universal Transfer Form (NJUTF) dated 01/30/23 indicated the resident was transferred to the hospital for lethargy and weakness, abnormal labs and low pulse OX. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for three (3) of 38 residents, (Resident #65, Resident #104, Resident #144) reviewed for accuracy of MDS coding. This deficient practice was evidence by the following: 1. On 05/02/23 at 10:24 AM, the surveyor observed Resident #65 self-propelling in his/her wheelchair from the smoking section on the Florida unit to their room. At that time, the surveyor interviewed the resident whose speech was slightly garbled. The resident stated that he/she smoked cigarettes and the staff held his/her lighter and cigarettes for them. The surveyor reviewed the medical record for Resident #65. [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to apply a physician ordered splinting device to a resident with contractures. This deficient practice was identified for 1 of 2 residents' (Resident #41) reviewed for position and mobility and was evidenced by the following: On 05/02/23 at 11:00 AM, during the initial tour of the facility Resident #41 was observed out of bed in the room in a reclining chair. The residents right hand appeared contracted, and the surveyor did not observe a hand splint or palm guard. Review of the admission Record indicated that Resident #41 was admitted to the facility on [DATE]. Medical diagnoses included, but were not limited to traumatic brain injury, calorie malnutrition, major depressive disorder, stiffness of unspecified joint, and hypertension (high blood pressure). [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation it was determined, that the facility failed to provide a resident who was a smoker with a smoking apron. This deficient practice was identified for one (1) of five (5) residents, (Resident #65), reviewed for safe smoking practices and was evidenced by the following: On 05/02/23 at 10:24 AM, the surveyor observed Resident #65 self-propelling in his/her wheelchair from the smoking section on the Florida unit to their room. At that time, the surveyor interviewed the resident whose speech was slightly garbled. The resident stated that he/she smoked cigarettes and the staff held his/her lighter and cigarettes for them. On 05/05/23 at 10:17 AM, the surveyor observed Resident #65 seated in his/her wheelchair in the outside smoking section on the Florida unit with the smoking attendant present. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation it was determined that the facility failed to appropriately store an indwelling urinary catheter drainage bag in a manner to prevent against infection. This deficient practice was identified for one (1) of 1 resident, (Resident #4) reviewed for urinary catheter care. This deficient practice was evidenced by the following: On 05/02/23 at 11:10 AM, the surveyor entered Resident #4's vacant room and observed a blue privacy bag attached the resident's bed frame. The blue privacy bag was empty. The surveyor knocked on the door to the resident's unoccupied bathroom and observed a plastic bag tied to the handrail in the bathroom. Inside of the plastic bag, the surveyor observed an indwelling urinary catheter drainage bag with a blue cap attached to the end of the foley catheter tubing. [...]

Inspectors wroteBased on observation, interview and review of medical records and other pertinent facility documentation it was determined that the facility failed to assure that a resident received oxygen as ordered by the physician. This deficient practice was identified for 1 of 3 residents (Resident #25) reviewed for respiratory care and was evidenced by the following: According to the admission Record, Resident #25 was admitted to the facility with the diagnoses which included but was not limited to atelectasis (collapsed lung), Huntington's Disease (genetic neurological disease) and heart failure. The quarterly Minimum Data Set (MDS-an assessment tool utilized to facilitate the care of a resident), dated 03/03/2023, indicated that the resident was cognitively intact and required extensive assistance with activities of daily living. The MDS also indicated that the resident was on oxygen. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to issue the required beneficiary notices for 2 of 3 residents (Residents #77 and #122) reviewed for Beneficiary Protection Notification. This deficient practice was evidenced by the following: On 5/09/23 at 10:00 AM, the surveyor reviewed three residents that were discharged from Medicare part A with days remaining. Resident #77 had a last covered day for Medicare of 11/18/22. The Notice of Medicare Non-Coverage (NMNC) and the Skilled Nursing Facility Advance Beneficiary Notice of Non- Coverage (SNFABN) was not signed by the representative nor was there documentation that the representative was notified. On 5/9/23 at 10:00 AM the surveyor reviewed the SNF Beneficiary Protection Notification Review form for Resident #122. Resident #122 had a LCD for Medicare of 1/13/23. [...]