Lopatcong Center

Inspectors wroteBased on interview, and review of pertinent facility documents, it was determined that the facility failed to serve and document residents received a nourishing snack in the evening (HS) when there was more than a 14-hour span between dinner and breakfast mealtimes. This deficient practice was identified for 6 of 6 residents (Resident #5, #14, #48, #54, #58, and #67) during the 6/11/25 resident council group meeting and evidenced by the following: On 6/11/25 at 10:32 AM, the surveyor conducted the resident council meeting with six residents (Residents #5, #14, #48, #54, #58, and #67) who were alert and oriented, and selected by the facility to attend the group meeting. All six residents stated that they were not offered nor received snacks in the evening. [...]

Inspectors wroteBased on observations and interviews on 06/13/2025 and 06/16/2025 in the presence of the Senior Maintenance Director (SMD) and the Maintenance Director (MD), it was determined that the facility failed to ensure that all devices used to identify call bell notifications were properly functioning in accordance with State Operations Manual (SOM) Appendix PP Subsection 483.90 (g). This deficient practice had the potential to affect all residents and was evidenced by the following: An observation on 06/16/2025 at 10:26 AM revealed that resident room [ROOM NUMBER]-bathroom call bell did not activate the call bell light over the room door when tested. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to inform the resident or their representative in advance of treatment risks and benefits, options, and alternatives to a resident receiving antipsychotic medications. This deficient practice was identified for 4 of 7 residents (Residents #27, 34, 60, and #72) reviewed for unnecessary medications. This deficient practice was evidenced by the following: 1. On 6/9/25 at 10:25 AM, the surveyor observed Resident #27 lying in bed asleep. On 6/11/25 at 10:51 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #27, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #27 was admitted with diagnoses that included, but were not limited to, mood disorder and depression (a feeling of sadness). [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed a.) to follow a Physician's Order and b.) create a Physicians Order for an oxygen dependent resident in accordance with professional standards of practice for 5 of 5 residents, (Resident #21, #28, #41, #68 and #109), reviewed for respiratory care. The 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: [...]

Inspectors wroteBased on interviews 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 1 of 26 residents (Resident #72), who were reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: On 6/9/25 at 10:29 AM, the surveyor observed Resident #72 asleep in bed. On 6/11/25 at 11:39 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #72, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #72 was admitted with diagnoses that included, but were not limited to, mood swings and anxiety (feeling of worry or nervousness). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan (CP) that included refusal of care. This deficient practice was identified for 1 of 26 residents (Resident #60) reviewed for comprehensive person-centered CP. This deficient practice was evidenced by the following: On 6/9/25, at 10:35 AM, the surveyor observed Resident #60 out of bed and in a wheelchair, able to respond to the surveyor's questions. Although Resident #60 was scheduled for a shower today, they mentioned that they sometimes refuse to take a shower because they do not feel like it. On 6/11/25 at 12:58 PM, the surveyor reviewed the electronic Health Record (eHR)/hybrid medical record (paper and electronic) of Resident #60, which revealed the following: [...]

Inspectors wroteRepeat Deficiency. Based on observations, interviews, record reviews, and other facility documentation, it was determined that the facility failed 1.)failed to follow infection control procedures with 3 of 5 residents on Oxygen (O2) Therapy and 2.) failed to follow appropriate hand hygiene procedures during medication administration. This deficient practice was identified 3 of 5 residents (Resident #21, Resident #28 and Resident # 109) reviewed for O2 therapy and 1 (one) of 3 nurses who was observed during medication administration. 1. On 6/9/25 at 10:25 AM, the surveyor observed and interviewed Resident #28 awake in bed, with oxygen (O2) via nasal cannula (NC) (medical device to provide supplemental oxygen therapy to people who have lower O2 levels) at 1.5 liters/minute (LPM), O2 running. The surveyor further observed the O2 tubing laying directly on the floor of the resident's room. [...]

Inspectors wroteC #: NJ00173585 Based on interviews, medical record review, and review of other pertinent facility documents on 6/25/24 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 facility policies and procedures for 1 of 4 residents (Resident #3) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #3 was admitted on [DATE], with diagnoses that included but were not limited to: Fracture of Unspecified Part of the Neck of the Right Femur, Parkinson Disease, and History of fall. [...]

Inspectors wroteFRI NJ00162201 Based on observation, interview, and record review of pertinent documentation, it was determined that the facility failed to implement their abuse policy and written regulations based on protecting their residents after the abuse investigation. This deficient practice was identified for one of two residents (Resident #91) reviewed for following the facility's abuse policy. The deficient practice was evidenced by the following: The surveyor investigated the Facility Reported Incident (FRI) sent in by the Executive Director, Licensed Nursing Home Administrator (LNHA) to the Department of Health (DOH) on 3/8/23 based on a resident to resident altercation between the Resident #91 and the Resident #39, which revealed the following: The facility reported that on 3/8/23, a staff member heard yelling from room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent facility documentations, it was determined that the facility failed to evaluate the basis use or discontinuation of a gastrostomy tube device consistent with the resident's goals and wishes. This deficient practice was identified for one of two residents (Resident #83) reviewed. This deficient practice was evidenced by the following: On 1/30/24 at 11:20 AM, the surveyor observed the resident lying in bed. The resident stated, I have a tube, but I have not been using it for a long time. I have been asking them to remove it since I was admitted here about 2 1/2 years ago, everyone knows but they told me they can't find a doctor who can remove it because of my insurance. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a) assure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders. This deficient practice was observed for 18 of 27 residents reviewed (Resident #110, 57, 4, 72, 9, 40, 69, 1, 91, 83, 48, 103, 62, 74, 10, 35, 79, and 102); and b) wrote physician progress notes (PPN) at least every 60 days with alternating nurse practitioner (NP) visits for 2 of 27 residents reviewed (#35 and #79). The deficient practices were evidenced by the following: 1. The surveyor reviewed the Order Summary Report (OSR) for Resident #110 which revealed that the physician did not sign and date the monthly OSR for the month of December 2023. 2. [...]

Inspectors wroteComplaint NJ00163544 and NJ00161527 Based on observation, interview, and review of pertinent facility documentation, it was determined the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficient practice was evidenced by the following: Reference: NJ State requirement, CHAPTER 112. An Act concerning staffing requirements for nursing homes and supplementing Title 30 of the Revised Statutes. Be It Enacted by the Senate and General Assembly of the State of New Jersey: C.30:13-18 Minimum staffing requirements for nursing homes effective 2/1/21. 1. a. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring a.) clarification of a physician's order for the frequency of the application time of a medicated patch (Lidocaine) (an anesthetic medicated patch applied to relieve pain) for one (1) of five (5) residents, (Resident #53), observed during the medication administration observation, b.) vital parameters, blood pressure and heart rate, were obtained just prior to administration of medications that had physician's orders that based the results of the parameters on whether to administer the medications for (2) of five (5) residents, (Resident #53 and #113), observed during medication administration observation and c.) accurate documentation on the electronic medication administration records for four (4) of [...]

Inspectors wroteBased on interview, observation and record review, it was determined that the Consultant Pharmacist (CP) failed to report irregularities found in the medical records to the facility. This deficient practice was observed for the following residents: 1. On 2/2/24 at 11:15 AM, the surveyor reviewed the electronic medication administration records (eMAR) of Resident #74. Resident #74 was admitted to the facility on [DATE] with diagnoses that included hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease (a condition where the kidney does not function properly resulting in increased blood pressure). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation on 2/1/24, the surveyor observed two (2) nurses administer medications to five (5) residents. There were 34 opportunities, and five (5) errors were observed which calculated to a medication administration error rate of 14.7%. This deficient practice was identified for three (3) of five (5) residents, (Resident #99, #111 and #182), that were administered medications by two (2) of two (2) nurses that were observed. The deficient practice was evidenced by the following: 1. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow appropriate measures to prevent and control the spread of infection during a Covid-19 outbreak on the ground floor of the facility for: a.) failure to properly wear N95/respirator masks for 4 of 4 staff members observed on the ground unit, and b.) failure to wear a fit tested N95/respirator mask for 2 of 4 staff members observed on the ground unit. The deficient practices were evidenced by the following: On 2/6/24 at 2:00 PM, the surveyor toured the ground floor unit. At the nurse's station, the surveyor observed Licensed Practical Nurse (LPN) who was wearing a DS-N95-1 mask with the straps cut, tied and the straps were then tied behind her ears. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to issue the proper required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for 1 of 3 residents (Resident #71) reviewed for facility change notifications. The deficient practice is as follows: The facility presented the surveyor with a list of residents who were discharged from the facility within 6 months and should have received Beneficiary Notices. The surveyor reviewed Resident #71's Beneficiary Notification list which indicated that the resident was discharged from a Medicare Part A stay at the facility and was documented as having a discontinuation of their Medicare Part A insurance payment to the facility. Resident # 71 was admitted to the facility on [DATE]. The last documented covered day of coverage for Medicare Part A service was 1/11/24. [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to accurately assess a resident utilizing the Minimum Data Set (MDS) assessment tool. The deficient practice was identified for 1 (#57) of 30 residents reviewed for accuracy of assessment and is detailed as follows. On 1/30/24 at 11:36 AM, the surveyor observed Resident #57 seated in a wheelchair in the nursing unit hallway. The surveyor again observed the resident on 01/31/24 at 09:45 AM seated in a wheelchair in the day room. A review of the electronic medical record revealed the following information. The resident was admitted to the facility receiving hospice services and continued receiving services without interruption up to the time of the Standard survey. A review of the 12/31/23 Quarterly MDS, Section O, indicated the resident was no longer receiving hospice services. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive, person-centered care plan (CP) for 1 of 27 residents reviewed for comprehensive care plans (Resident #79). This deficient practice was evidenced by the following: On 1/30/24 at 11:40 AM, the surveyor observed Resident #79 out of bed to a wheelchair, watching TV. The resident's room front door had a signage stop instructing the use of specific personal protective equipment (PPE) during care and before entering the room. Outside the resident's room are two plastic storage carts containing a box of gloves, gowns, masks, and goggles. The surveyor reviewed Resident #79 hybrid medical record (paper and electronic) which revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to revise a resident's care plan to reflect their current needs related to a fall and fracture. The deficient practice was cited for 1 of 30 residents (#57) reviewed for comprehensive resident-centered care planning and is evidenced by the following. On 1/30/24 at 11:36 AM the surveyor observed Resident #57 seated in a wheelchair in the nursing unit hallway. The surveyor again observed the resident on 01/31/24 at 09:45 AM seated in a wheelchair in the day room. A review of the electronic medical record revealed the following information. An 11/2/23 progress noted written at 17:50 revealed the resident fell from their wheelchair while self-propelling the chair in the hallway of the nursing unit. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to maintain the necessary respiratory care and services of residents in accordance with professional standards of practice for one of two residents, (Resident #1) reviewed for respiratory care. This deficient practice was evidenced by the following: On 1/30/24 at 11:30 AM, the surveyor observed the oxygen signage by the door of Resident #1. The surveyor observed Resident #1 lying in bed, the oxygen concentrator by the left side of the bed with oxygen at 2 1/2 liters/minute, nasal cannula laying on the side of the mattress, no shortness of breath noted, oxygen tubing dated 1/19/24. The resident stated, I use my oxygen on and off every day. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive care to address the treatment needs for Resident #64 and Fall Risk for Resident #600, 2 of 23 residents reviewed. The deficient practice was evidenced by the following: 1. On 10/15/21 at 12:16 PM, surveyor observed Resident #64 in bed with Oxygen going at 2 liters/minute (l/m) via a nasal cannual. The resident was awake watching television. There was a pressure relieving mattress on the resident's bed. The resident's lower extremities were wrapped with ace bandages. The surveyor reviewed Resident #64's electronic medical record (EMR) that revealed the following: According to the admission Record, Resident #64 was admitted to the facility with diagnoses that included Cellulitis of the right lower limb, Lymphedema, Type II Diabetes Mellitus, and Morbid Obesity. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to maintain professional standards of practice by not documenting that a resident was receiving oxygen and not monitoring oxygen saturation (O2 sats)levels according to the physician's orders for 1 of 2 residents (Resident #37) reviewed. This deficient practice was evidenced by the following: On 10/13/21 at 10:23 AM, the surveyor observed Resident #37 sitting on the bed with oxygen (O2) on via nasal cannula at 2 liters/minute (l/m). On 10/14/21 11:37 AM, the surveyor observed Resident #37 lying across the bed with oxygen running at 2 l/m via nasal cannula, watching television. The resident informed the surveyor that the resident uses the oxygen all the time. The surveyor reviewed Resident #37's electronic medical records that revealed the following: [...]

Inspectors wroteBased on observation, interviews, and review of pertinent facility documentation, it was determined that the facility staff failed to follow appropriate infection control guidelines for Personal Protective Equipment (PPE), handwashing, and disinfection of shared medical equipment for 1 of 3 nurses observed during medication pass observation. This deficient practice was evidenced by the following: On 10/18/21 at 8:20 AM, the surveyor observed a Registered Nurse (RN) during medication pass observation on the ground floor of the facility. The RN was wearing a N 95 mask (a filtering facepiece respirator) with the two straps of the face mask around her neck. At 8:28, the RN entered the room of Resident #550 and donned (put on) clean gloves. [...]