Llanfair House Care & Rehabilitation Center

Inspectors wroteBased on observation and interview, the facility failed to ensure food was served under sanitary conditions which included proper glove use for one of one kitchen. This failure placed 113 census residents at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure female residents had facial hair removed for two of four residents (Resident (R) 43 and R70) and fingernails were kept clean and trimmed for two of four residents (R65 and R92) reviewed for activities of daily living (ADL) of 35 sample residents. This failure had the potential to affect resident care including personal hygiene in the facility.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure medications were evaluated with clinical indications for use documented for as needed (PRN) psychotropic medication (lorazepam) beyond 14 days for one of five residents (Resident (R) 10) and ensure target psychotropic behavior monitoring was conducted for one of five residents (R4) reviewed for unnecessary medications of 35 sample residents. This failure had the potential to place the residents at risk of adverse consequences. (Cross Reference F756)

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure allegations of abuse were reported timely to the State Survey Agency (SSA) for one of one resident (Resident (R) 66) reviewed for abuse out of 35 sampled residents. This failure increased the risk of other vulnerable residents being abused.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure residents were appropriately screened and had documentation to support the use of wander guards for one of two residents (Residents (R) 4) reviewed for wander guards of 35 sample residents. This failure had the potential to affect all residents with wandering behaviors.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails for two of three residents (Resident (R) 12 and R54) reviewed for side rails out of 35 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure medication irregularities were responded to after the Consultant Pharmacist identified that there was a required stop date for one of six residents (Resident (R) 10) reviewed for medication regimens of 35 sampled residents. The Consultant Pharmacist identified that there was a required end date for an as needed (PRN) psychotropic medication (lorazepam) and the facility failed to respond and correct the order. This placed the residents at risk for unnecessary prolonged use of psychotropic medication.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure three of three medication storage rooms and one of four medication carts were free of expired medications, syringes, collections tubes for specimens, and COVID-19 test for 113 census residents. This practice had the potential to affect medications and biologicals efficacy.

Inspectors wroteBased on observations, interviews, and policy reviews, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) in rooms with enhanced barrier precautions (EBP) for one of one resident (Resident (R) 83) reviewed for infection control of 35 sample residents. These deficient practices had the potential to affect all residents and increase the risk for cross contamination and the spread of infections throughout the facility.

Inspectors wroteBased on interviews, record review, and facility assessment review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles for two of two staff (Registered Nurse (RN) 2 and Certified Nurse Aide (CNA) 1) reviewed for training with the potential to affect 113 census residents. This failure had the potential to lead to increased spread of infection.

Inspectors wroteComplaint #'s: NJ175457, NJ175482 Based on observation, interview, and record review, it was determined that the facility failed to report a newly developed pressure ulcer (PU) and implement a physician's order (PO) for wound care to treat a facility acquired PU for 1 of 3 residents reviewed for PU's, (Resident #110). The PU worsened from an excoriation (wearing off the skin) that was identified on 6/20/24 to an unstageable PU ( covered with slough (a soft, yellow or white, often stringy material that accumulates on the surface of a wound) or eschar (a layer of dry, dead tissue that forms over a deep wound) and cannot be staged which are caused by prolonged pressure, shear and friction and can lead to infection and complications). This deficient practice was evidenced by the following: [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed to: a.) follow a physician's order (PO) for a bolus feeding (method of giving tube feeding where large doses of formula are administered several times a day) in one (1) of two (2) residents (Resident #51) reviewed for tube feeding (TF) and b.) failed to document for accountability of medications and treatments administered for 4 of 5 residents (Resident #28, #83, #88 and #110) reviewed for unnecessary medication. This deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey states; [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed to ensure the resident's primary physician (MD #1, MD #4) accurately dated their physician progress notes (PPN) during their visit to ensure the resident's current medical regimen was up to date. This deficient practice was observed for 8 of 16 residents, (Resident #41, # 51, #110, #45, #66, #84, and #71). This deficient practice was evidenced by the following: 1. On 12/4/24 at 11:07 AM, the surveyor interviewed Resident #41 in their room. The resident further stated to the surveyor they could not recall the last time they were assessed by their physician. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) for 3 of 3 residents (Resident #30, Resident #83, and Resident #13) reviewed. This deficient practice was evidenced by: The SNF ABN provides information to beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. If the SNF provides the beneficiary with the SNF ABN, the facility has met its obligation to inform the beneficiary of his or her potential financial liability and related standard claim appeal rights. On 12/9/24 at 9:45 AM, the facility provided the surveyor with a list of residents who were discharged from the facility within the last 6 months and should have received the SNF ABN form. [...]

Inspectors wroteREPEAT DEFICIENCY Complaints # NJ175457, NJ175482 Based on observations, interviews, and record review, it was determined that the facility failed to revise the comprehensive care plans (CP) for 2 of 28 residents reviewed (Resident #51 and #110). This deficient practice was identified by the following: 1. On 12/4/24 at 11:10 AM, during initial tour, the surveyor observed the Resident #51 in bed with their eyes closed. The surveyor reviewed Resident #51's hybrid (paper and electronic) medical records. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain respiratory equipment in a sanitary manner for a resident who was receiving continuous oxygen (O2). The deficient practice was identified for 1 of 1 resident (Resident #95) reviewed for respiratory care. The deficient practice was evidenced by the following: On 12/4/24 at 11:46 AM, the surveyor observed Resident # 95 in bed with eyes closed with O2 in use via nasal cannula (a medical device used for delivering O2) at 4 Liters Per Minute (LPM.). The surveyor further observed the O2 tubing was dated 11/5/24. A review of the Face Sheet (an admission record) revealed that the resident was admitted to the facility with diagnosis that included but not were not limited to Pneumonia, Chronic Respiratory Failure, and Pulmonary Fibrosis. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least once every 30 days for Medicaid recipient residents and once every 60 days for Medicare recipient residents. This deficient practice was identified for 2 of 22 residents (Resident #95 and Resident 103), reviewed for physician visits and was evidenced by the following: 1. On 12/04/24 at 11:46 AM, the surveyor observed Resident # 95 with eyes closed. The surveyor reviewed the hybrid medical records (paper and electronic) (HMR) for the Resident #95 which revealed that the resident's primary physician (PP) (MD#2) no Physician Progress Notes (PPN) since Resident #95 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to respond to the Consultant Pharmacist's (CP) monthly recommendations in a timely manner for 1 of 22 residents (Resident #51) reviewed. The deficient practice was evidenced by the following: On 12/04/24 at 11:10 AM, during initial tour, the surveyor observed the Resident #51 in bed with their eyes closed. The surveyor reviewed Resident #51's hybrid medical records. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to properly label, dispose and secure medications in one (1) of five (5) medication carts and one (1) of five (5) treatment carts inspected. This deficient practice was evidenced by the following: On 12/9/24 at 9:15 AM, the surveyor during observation of medication administration observed the 1st floor long-side treatment cart that was unlocked and unattended. The treatment cart contained ointments and creams. The surveyor did observe any residents near the treatment cart. At that time, the surveyor interviewed the Licensed Practical Nurse (LPN#1) who acknowledged that the treatment cart was unlocked and further stated that the treatment cart must always be locked when unattended. On 12/12/24 at 11:35 AM, the surveyor inspected the 1st floor short-side medication cart in the presence of LPN#2. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain complete, accurate, readily accessible medical records, and legible physician's progress notes (PPN). This deficient practice was identified for 2 of 22 residents reviewed, Resident #5 and #51, and was evidenced by the following: This deficient practice was evidenced by the following: 1. On 12/4/24 at 11:10 AM, during initial tour, the surveyor observed the Resident #51 in bed with their eyes closed. The surveyor reviewed Resident #51's hybrid (paper and electronic) medical records (HMR). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure required monthly visits by the Consultant Pharmacist (CP) for the months of August, September, and October 2023. This irregularity was identified for 17 of 17 residents reviewed by the survey team for CP review, Resident #78, #8, #89, #71, #85, #40, #86, #90, #52, #91, #68, #75, #24, #46, #63, #59, #22, #70, #88 and #36. The deficient practice was evidenced by the following: On 10/30/23 at 12:30 PM, after completing the facility unit inspection, the surveyor asked the Director of Nursing (DON) for the Consultant Pharmacist (CP) 2023 previous unit inspections. The DON informed the surveyor that the facility had unit inspections performed by the CP until July 2023. [...]

Inspectors wroteBased on observation, interview, record review, it was determined that the facility failed to maintain dignity during mealtime for a resident. This deficient practice was observed for 1 of 18 residents reviewed for dining observation, Resident #64 and was evidenced by the following: On 10/30/23 at 12:19 PM, the surveyor observed Resident #64 in the first floor dining room seated in a wheelchair. Resident #64 was observed eating their lunch. The surveyor observed that the Licensed Practical Nurse #2 (LPN #2) feeding Resident #64 while standing over them. The surveyor further observed that LPN #2 was wandering around the dining room assisting other residents with their meal. On 10/30/23 at 12:25 PM, the surveyor interviewed LPN #2 who stated that staff should be seated next to the resident while assisting them during feeding time. [...]

Inspectors wroteBased on observation and interview it was determined that the facility failed to provide a homelike environment during meal service in both dining rooms located in the facility. The deficient practice was observed on 2 of 2 facility floors, dining room [ROOM NUMBER] (DR1) and dining room [ROOM NUMBER] (DR2) during lunch service observation. This deficient practice was evidenced by the following: On 10/30/2023 at 11:55 AM, during the lunch service located on 2nd floor dining room (DR2), the surveyor observed that all meals in DR2 were served and remained on meal trays throughout the meal. On 10/30/2023 at 12:02, during the lunch service located on 1st floor dining room (DR1), the surveyor observed that all meals in DR1 were served and remained on meal trays throughout the meal. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to revise the person centered comprehensive care plans (CCP) for 3 of 22 residents reviewed (Resident #63, #71, and #52). This deficient practice was identified by the following: 1. On 10/30/23 at 11:36 AM, the surveyor observed Resident #63 in bed, watching TV. The surveyor further observed a floor mat on both sides of the bed. The surveyor reviewed Resident #63's hybrid medical records. The admission Record (AR) reflected that Resident #63 was admitted to the facility with medical diagnoses that included but were not limited to, Fracture of neck of left Femur, Dementia and Cerebral Infarction. [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to consistently follow standards of clinical practice with regards to: accurately documenting medication administration for 1 of 1 dialysis residents, Resident #40. 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. Reference: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide safety measures and follow interventions for a resident who has a history of being at high risk for falls. This deficient practice was identified for 1 of 3 residents reviewed for falls, Resident #52. The deficient practice was evidenced by the following: On 10/30/2023 at 11:28 AM, the surveyor observed Resident #52 in their room. The resident was in bed, the bed was in the lowest position. Resident # 52 had a mattress against the wall, no bed rails and/or floor mats were observed. The surveyor reviewed Resident #52's hybrid medical record. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a) ensure that a resident identified with a significant weight loss was comprehensively evaluated and assessed, and b) ensure accurate weights were obtained for a resident identified with significant weight loss. This deficient practice was identified for 2 of 6 residents, Resident #89 and #85 reviewed for nutrition and was evidenced by the following: 1. On 10/30/2023 at 12:00 PM, the surveyor observed Resident #89 walking in the hallways of the unit. The resident was alert, oriented to self and verbally responsive. On 11/3/23 at 9:45 AM, the surveyor reviewed the electronic health record (EHR) of Resident #89 which revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a) ensure a resident's medication times were adjusted to accommodate their dialysis (a clinical purification of blood as a substitute for the normal function of the kidneys) schedule, b) monitor fluid intake for a dialysis resident on fluid restrictions, and c) ensure communication with a dialysis center regarding a resident's medication regimen. The deficient practice was evidenced for 1 out of 1 dialysis resident (Resident #40) reviewed, Resident #40. This deficient practice was evidenced by the following: a) On 10/30/23 at 12:40 PM, the surveyor observed Resident #40 sitting in the dayroom. The resident was alert, conversant and stated they were scheduled to go to dialysis later in the afternoon. Resident #40 was scheduled to go to dialysis every Monday, Wednesday, and Friday. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the resident's primary physician accurately dated physician progress notes (PPN) during his visit to ensure that the resident's current medical regimen was up to date. This deficient practice was observed for 1 of 6 residents, Resident #91. This deficient practice was evidenced by the following: On 10/30/2023 at 11:51 AM, the surveyor observed Resident # 91 in their room eating. During the interview progress, the resident stated they could not recall the last time they saw their physician. The surveyor reviewed the hybrid medical records (paper and electronic) for the Resident #91 which revealed that the resident's primary physician had inaccurately dated 10 physician progress notes written on 11/6/23 and 11/10/23. Per the guidelines, (Rev. 173, Issued: 11-22-17, Effective: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that expired medications were removed from a resident's active inventory after it had expired, and medications were administered according to manufacturer's recommendations. These deficient practices were identified for 1 of 2 units inspected during the facility unit inspection process and related to Resident #78. This deficient practice was evidenced by the following: On 10/30/23 at 10:00 AM, the surveyor inspected the 1st floor short hall medication cart. The surveyor noted a Novolog Insulin 100 units (u)/milliliter (ml) pen refill unit. The Novolog pen refill unit was stored in a plastic pharmacy provider bag labeled for Resident #78 and delivered to the facility on 8/25/23. [...]

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to properly clean and sanitize kitchen equipment as well as store, label, and discard potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was evidenced by the following: On 10/30/2023 at 09:19 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour: 1. On the Chef prep table, the surveyor observed on the inside of the microwave had caked on yellowish debris on microwave door and greyish debris observed on top and sides of microwave. The FSD stated the microwave should have been cleaned of debris after each use and at the end of the evening. 2. In the Standing freezer located next to the chef prep table, surveyor observed: a. [...]