Manahawkin Health and Rehabilitation Center

Inspectors wroteBased on observations, interviews, medical record review, and review of other pertinent facility documentation on 03/05/2026, 03/09/2026, and 03/10/2026, it was determined that the facility failed to provide a safe environment for its residents. The facility failed to ensure that a resident (Resident #9) who had smoked inside the facility against facility policy on four previous occasions since 08/02/2025 did not have smoking materials in their possession or smoke in the facility and in the presence of a resident (Resident #16) who was receiving oxygen therapy on 01/28/2026. The facility failed to provide adequate supervision to prevent smoking in the resident's room on 12/18/2025 when the resident refused to surrender their smoking materials; [...]

Inspectors wroteBased on interviews, review of the medical records, and review of other pertinent facility documents, it was determined that the facility failed to ensure a safe discharge for a resident. This deficient practice was identified for 1 of 18 residents reviewed (Resident #18). Resident #18, who had a history of intravenous (IV) drug use and was admitted to the facility with endocarditis to receive IV antibiotics, was discharged from the facility with their Peripherally Inserted Central Catheter (PICC) in place. The PICC is thin, flexible tube inserted into a large upper arm [NAME] and guided to the large [NAME] near the heart. Resident #18 had documented complications of up to 9 dislodgements of their PICC line. [...]

Inspectors wroteComplaints:2794269, 2679147, 2588899, 2639889, 2789654, 2789700 Based on interviews, review of medical records, and review of pertinent facility documents on 03/05/2026, 03/09/2026 and 03/10/2026, it was determined that the facility failed to a.) ensure that physician ordered medication was obtained and available to be administered and b.) maintain records of, receipt, accountability, and removal from inventory of controlled drugs, for 4 out of 5 residents (Resident #9, Resident #10, Resident #15, and Resident #18) reviewed for methadone (opioid medication that treats severe, chronic pain and substance use disorder). The deficient practice was evidenced by the following:A. According to the admission Record (AR), Resident #9 was admitted to the facility with diagnoses which included but were not limited to: [...]

Inspectors wroteComplaint: 2639889Based on interviews, medical record reviews and reviews of other pertinent facility documentation on 3/5/26, 3/9/26, 3/10/26, and 3/18/26, it was determined that the facility failed to develop and implement a comprehensive, person-centered Care Plan (CP) for residents: with a Peripherally Inserted Central Catheter (PICC) line, methadone use, oxygen use, smoking and a history of substance abuse. The CPs lacked foci, goals and interventions addressing proper line integrity, monitoring dislodgement, safe administration of methadone, safe utilization of oxygen, addressing residents who were found smoking in their rooms, and for residents with history of substance abuse. [...]

Inspectors wroteBased on interviews, medical record reviews and reviews of other pertinent facility documentation on 3/5/26, 3/9/26, 3/10/26, and 3/18/26, it was determined the facility failed to ensure residents medical records were complete, accurate and readily accessible as evidenced by: a.) the facility not being able to provide surveyors with Activities of Daily Living (ADL) logs, b.) the facility not being able to provide surveyors with declining sheets for residents on methadone, c.) the facility not being able to provide surveyors with complete and correctly documented 1:1 logs, and d.) the facility not being able to provide surveyors with a personal belongings log for a resident that was being admitted to the facility. [...]

Inspectors wroteBased on interviews and review of facility documents, it was determined that the facility failed to develop and maintain a comprehensive facility assessment that accurately identified the mental and behavioral health needs of its resident population and the resources necessary to provide appropriate care. On 2/11/26 at 11:54 AM, the surveyor requested a copy of the Facility Assessment (FA). On 2/11/26 at 1:25 PM, the surveyor reviewed the FA dated 7/22/25. The FA under Purpose Statement: The purpose of this assessment is to determine what resources are necessary to care for our residents competently during both day-to-day operations (including nights and weekends) and emergencies. The FA under, Scope identified: The facility's resident population, including but not limited to: the number of residents and the facility's resident capacity. [...]

Inspectors wroteBased on interview and review of Nurse Staffing Report (NSR) it was determined that the facility failed to ensure a Registered Nurse worked seven days a week for at least eight consecutive hours a day for 4 of 14 days reviewed. This deficient practice was evidenced by the following: 0n 2/3/26, the surveyor requested the NSR to be completed for the 2 weeks of staffing prior to survey from 01/18/2026 to 01/31/2026. A review of the NSRs completed by the facility for the above requested weeks revealed the facility had no RN coverage for all shifts on 1/18/26, 1/21/26, 1/28/26 and 1/31/26. On 2/11/26 at 8:06 AM, during a telephone conversation, the Licensed Nursing Home Administrator confirmed she was aware there was no RN coverage for the above mentioned dates. She stated, It was due to call outs. NJAC 8:39-25.2(h)

Inspectors wroteComplaint #2731638 Based on interviews and review of facility provided documents, it was determined that the facility failed to provide residents with their breakfast meal at a regular time comparable to normal mealtimes, with no more than 16 hours elapsing between the evening meal and the breakfast meal the following day. This deficient practice was identified for one of one breakfast meal (1/31/26) reviewed and was evidenced by the following: On 2/3/26 at 11:48 AM, the surveyor interviewed the second floor Licensed Practical Nurse (LPN) who stated breakfast usually was delivered to her residents between 7:45 AM and 8:15 AM. She further stated that on Saturday (1/31/26) breakfast was not delivered until approximately 11 AM. The LPN stated she provided some of her residents with snacks from the pantry while they were waiting for breakfast that morning. [...]

Inspectors wroteComplaint #: 2701205 Based on interviews, review of medical records, and review of other pertinent facility documents on 12/29/2025, it was determined that the facility failed to create a safe environment and provide adequate supervision to prevent the elopement of a resident (Resident #2) with poor decision-making abilities. The deficient practice was identified for 1 of 3 residents reviewed for elopement (Resident #2). During the survey a finding that constituted Immediate Jeopardy (IJ) was identified under CFR 483.12(a)(1) F689. The facility failed to: a) provide adequate supervision to prevent the elopement of a resident with poor decision-making abilities (Resident #2), b) develop appropriate interventions to prevent elopement, and c) follow their elopement and wandering policy. [...]

Inspectors wroteComplaint #: 2701205Based on observations, interviews, medical record reviews, and review of other pertinent facility documentation on [DATE], it was determined that the facility failed to a.) obtain a physician order for a resident (Resident #4) to go out of the facility on pass (OOP) or take leave of absence (LOA) from the facility, and b) update care plans for two residents (Resident #4 and Resident #6) with focuses and interventions related to the residents going OOP or LOA from the facility. This deficient practice was identified for 2 of 6 residents reviewed for care plans 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 wroteComplaint #: 2701205 Based on observation, interviews, medical record review, and review of other pertinent facility documentation on [DATE] and [DATE], it was determined that facility staff failed to document interventions intended to prevent elopement that were provided to a resident with a history of elopement from the facility (Resident #2). This deficient practice was identified for 1 of 6 residents (Resident #2) reviewed for documentation. This deficient practice was evidenced by the following: On [DATE], at 11:24 A.M., the Surveyor conducted an interview with Resident #2 and observed a wandeguard (system that uses wearable tags to limit access to areas of the facility) tag on the resident's ankle. Resident #2 explained that they wore the tag because they had escaped, from the facility 5 or 6 days prior. The Surveyor reviewed the medical record for Resident #2. [...]

Inspectors wroteComplaint: 2564823Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain refrigerated potentially hazardous foods at appropriate temperatures to prevent potential microbial growth, b.) discard foods that were past their date of expiration and showed signs of spoilage, c.) maintain the kitchen in a sanitary manner, e.) accurately record appropriate cooking and holding temperatures, and f.) accurately record refrigeration temperatures. This deficient practice was evidenced by the following: 1.) On 07/18/2025 at 9:30 A.M., the surveyor and the [NAME] toured the kitchen and observed the needle of the dial type external thermometer on the chest refrigerator was resting in the lowest possible position (below -40 degrees Fahrenheit (F)). The thermometer did not appear to be functioning. [...]

Inspectors wroteComplaint # 2564823 Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain a safe and comfortable room temperature levels in residents' shower rooms and in the facility elevator. This deficient practice was identified in 2 of 4 resident shower rooms and in 1 of 1 facility elevator (elevator car 1). This deficient practice was evidenced by the following:On 07/18/2025 at 10:23 A.M., the surveyor checked temperatures in different locations throughout the facility in the presence of the Maintenance Person (MP) and the following were obtained: The second-floor East shower room has room temperature of 84.4 degrees Fahrenheit (F). which is above the required temperature range of 71 to 81 F. There were no residents present at this time. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a family member's concern regarding missing clothing and personal items were filed as a grievance and investigated for one of nine sample residents (Resident (R) 3) reviewed for grievances. This had the potential for residents' rights not being supported, to have their lost belongings searched for, and/or reimbursed. Review of the facility's policy titled, Grievance Guideline, revised on 05/31/23, revealed Purpose: To provide a process to voice grievances (such as those about treatment, care, management of funds, lost clothing, or violation of rights) and respond with prompt efforts to resolve while keeping the resident and/or resident representative appropriately apprised of progress toward resolution. Grievance Official: [...]

Inspectors wroteComplaint # 2564823 Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 07/18/2025, it was determined that the facility failed to administer medications according to the acceptable standards of nursing practice. This deficient practice was identified for 1 of 3 residents reviewed (Resident #3). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. [...]

Inspectors wroteBased on record review, review of hospital records, interview, and review of facility policy, the facility failed to ensure ordered treatments were completed for fungal dermatitis (skin infection) and arterial ulcers for one of three residents (Resident (R) 2) reviewed for skin integrity out of a total sample of nine residents. This had the potential for fungal dermatitis and arterial ulcers to worsen and a potential for infection. Review of the facility's policy titled, Skin Integrity-Incontinence Associated Dermatitis (IAD) with a date implemented 02/14/23, revealed Residents who are incontinent will receive appropriate treatment and services for the prevention and management of IAD.e. For residents with fungal skin infection, apply antifungal products as ordered by the physician. [...]

Inspectors wroteBased on record review, review of hospital records, interview, and review of facility policy, the facility failed to ensure ordered treatments were completed for pressure ulcers for one of three residents (Resident (R) 2) reviewed for pressure ulcers out of a total sample of nine residents. This had the potential for the pressure ulcers to worsen and a potential for infection. Review of the facility's policy titled, Pressure Injury Prevention and Management with a date implemented 02/14/23, revealed This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection, and the development of additional pressure ulcers/ injuries.2. [...]

Inspectors wroteBased on interview, review of Nursing Staffing Report sheets and facility provided documents, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 2 of 14 days reviewed 11/17/2024 through 11/30/2024. Based on interview and review of Nurse Staffing Report sheets, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 2 of 14 days reviewed. This deficient practice was evidenced by the following: A review of the Nurse Staffing Reports completed by the facility for the week of 11/17/2024 through11/23/2024, revealed the facility had no RN coverage for all shifts on 11/18/2024 and 11/23/2024. [...]

Inspectors wroteRepeat deficiency from recertification survey of 09/23/2023 Based on observations, interviews, and review review of other facility documentation, it was determined that the facility failed to follow the planned, written menu and ensure residents were notified in advance of menu changes for 3 of 3 meals observed. This deficient practice was evidenced by the following: 1. On 12/03/2024 at 12:12 PM, the surveyor observed the lunch meal on the 2nd floor dining/activity room. The surveyor observed Resident #48 and seven (7) additional residents at the lunch meal. All eight (8) residents were observed to have received diced peaches in a clear plastic portion control cup for dessert at the lunch meal. According to the 12/3/2024 Week 4 cycle menu provided to the surveyor on entry to the facility, residents were to receive yellow cake for the dessert at the lunch meal on 12/03/2024. [...]

Inspectors wroteBased on observation, interview, and review of there facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 12/02/2024 at 9:23 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. On the top shelf of a multi-tiered rack in the dry storage area, a previously opened pack of coffee filters were removed from their original packaging and left uncovered. The usable surface was exposed to contamination. 2. On a middle shelf of the walk-in freezer contained frozen pizza box previously opened. The lids to the box were open and the plastic bag inside that contained the pizza was opened and the pizza was exposed to the air and contamination. 3. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a clean, safe, and sanitary environment. This deficient practice was identified for 2 of 2 units (1st floor and 2nd floor) and was evidenced by the following: On 12/03/2024 at 11:22 AM, Surveyor #1 observed the wheels on 2 East and 2 [NAME] medication carts. There was hair and strings wrapped around the wheels. On 12/03/2024 at 11:26 AM, Surveyor #1 observed hair and debris wrapped around the wheels of the Hoyer lift on 2nd floor. On 12/03/2024 at 11:33 AM, Surveyor #1 observed 1/2 PB&J sandwich under the bed of room [ROOM NUMBER]. On 12/03/2024 at 11:42 AM, Surveyor #1 observed the 1 west treatment cart with hair wrapped around the wheels. [...]

Inspectors wroteBased on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to ensure that an accurate Minimum Data Set (MDS), an assessment tool, was completed. This deficient practice was identified for 6 of 28 residents reviewed (Residents #35, Resident #107, Resident #99, Resident #67. Resident #102, and Resident #1). and was evidenced by the following: 1. During the initial tour of the facility on Resident #35 was observed lying in bed using a cell phone with his/her left hand. Resident #35's right hand was observed to be contracted. A review of the Electronic Medical Record (EMR) on 12/02/2024 at 2:14 PM revealed the following: According to the admission Record, Resident #35 was admitted to the facility with diagnoses including but not limited to: Cerebral Infarction due to Thrombosis (stroke due to a blood clot). [...]

Inspectors wroteBased on observation, interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to develop a person-centered comprehensive care plan to address the use of A. an anticoagulant (blood thinner) medication, B. oxygen therapy, C. a splint used to prevent further contracture, and D. a wander alarm used to prevent elopement. This deficient practice was identified for 4 of 28 sampled residents, (Resident #8, Resident #18, Resident #35, and Resident #99) and was evidenced by the following: A.) On 12/2/2024 at 11:01 AM, during the initial tour, Resident #8 was identified as being on an anticoagulant. A review of Resident #8's EMR on 12/02/2024 at 02:11 PM, revealed the following: A review of Resident #8's admission Record revealed that he/she had diagnoses that included but were not limited to: [...]

Inspectors wroteBased on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure that treatment for range of motion limitations were provided for 3 of 3 residents (Resident #102, Resident #1, and Resident #35) reviewed for limited range of motion. This deficient practice was evidenced by the following: 1. On 12/03/2024 at 10:21 AM, Surveyor #1 observed Resident #102 lying in bed with a black splint on his/her left lower arm and wrist area. He/she stated that the orthopedic doctor provided the black arm splint and a black cam boot due to a broken left arm and ankle, but he/she no longer wears the cam boot. He/she puts the splint on his/her left lower arm and wrist at night and removes it when he/she chooses. On 12/03/2024 at 9:00 AM, Surveyor #1 reviewed the EMR for Resident #102 as follows: [...]

Inspectors wroteBased on observation, interviews, record review and review of other facility documentation, it was determined that the facility failed to obtain a physician's order for supplemental oxygen and not replacing and properly storing a nasal cannula (tube used to deliver oxygen to a person) in accordance with facility policy. This deficient practice occurred for 3 of 3 residents (Resident #54, Resident #261, and Resident #18) reviewed for respiratory care. The deficient practice was evidenced by the following: 1. On 12/3/2024 at 1:38 PM, Surveyor #1 observed Resident #54 in their room sitting on their bed and was being administered oxygen via nasal cannula. The resident informed the surveyor they had COPD (chronic obstructive pulmonary disease) and would use the oxygen concentrator when in their room but when they wanted to go outside their room, they used the portable canister. [...]

Inspectors wroteBased on observation, interview, review of the Electronic Medical Record (EMR) and review of other documentation, it was determined that the facility failed to ensure a resident was transported from one area of the unit to another in a dignified manner for 1 of 28 sampled residents, (Resident #84). This deficient practice was evidenced by the following: On 12/04/2024 at 11:37 AM, the surveyor observed the Licensed Practical Nurse/Unit Manager (LPN/UM #1) to pull a resident (Resident #84) backward in his/her wheelchair (w/c) from the nurse's station to the dining/recreation room. Resident #84's feet on which he/she was wearing slippers, were dragging on floor. There were no foot rests observed on the w/c for the resident to put his/her feet on. The surveyor reviewed the EMR on 12/04/2024 11:54 AM, as follows: [...]

Inspectors wroteBased on interview and review of other facility documentation, it was determined that the facility failed to issue the required beneficiary notices for 2 of 3 residents reviewed for SNF (Skilled Nursing Facility) Beneficiary Protection Notification (SNF BPN), (Resident #9 and #22). This deficient practice was evidenced by the following: On 12/04/2024 at 09:35 AM, the surveyor presented the facility certified social worker (CSW) with three (3) SNF BPN, one (1) resident discharged to home and two (2) residents that remained in the facility with Medicare A time remaining. The CSW explained to the surveyor that she just started issuing the SNF BPN forms in October after her predecessor left the facility. The CSW further told the surveyor on 12/04/2024 at 10:28 AM, I was unable to find the other form for the residents that went home (NOMNC CMS 10123). [...]

Inspectors wroteBased on observation, interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to develop and implement a baseline care plan (BCP) within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident. This deficient practice was identified for 1 of 28 sampled residents (Resident #102) and was evidenced by the following: On 12/03/2024 at 10:21 AM, Surveyor #1 observed Resident #102 lying in bed with a black splint (medical device used to immobilize, support, or protect a body part) on his/her left lower arm and wrist area. [...]

Inspectors wroteBased on the interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to document a discharge summary which included a recapitulation of the resident's stay and a final summary of the resident's status for 1 of 1 resident reviewed for hospitalization, (Resident #109). This deficient practice was evidenced by the following: On 12/4/2024 at 1:49 PM, the surveyor reviewed the closed medical record for Resident #109 which revealed the following: Resident #109's admission Record indicated the resident had been admitted to the facility with medical diagnoses that included myocardial infarction (heart attack), anxiety and adult failure to thrive (a syndrome in older adults characterized by a significant decline in physical and mental health). [...]

Inspectors wroteBased on interview and record review it was determined that the facility failed to address recommendations made by the Consultant Pharmacist (CP) in a consistent and timely manner. This deficient practice was identified for 2 of 5 residents reviewed for medication management (Resident #22 and Resident #90) and was evidenced by the following: The deficient practice was evidenced by the following: 1. On 12/2/24 at 10:28 AM, during initial tour the Surveyor #1 observed Resident #22 in their room seated in a chair dressed and well-groomed. When asked if the staff took good care of them the resident responded by shaking their head yes then proceeded to get up from the chair and walk out of the room and down the hallway. Surveyor #1 reviewed Resident #22's medical record on 12/03/2024 at 09:51 AM as follows: [...]

Inspectors wroteBased on interviews, record reviews, and policy reviews on 10/31/2024, the facility failed to notify the Physician of laboratory results for 1 of 3 Resident (Resident #3.) reviewed for laboratory services. Specifically, the facility failed to notify the Physician of Resident#3 of the abnormal urinalysis results. The Surveyor reviewed the Electronic Medical Record (EMR) was as follows: According to the admission Face Sheet Resident #3 was admitted to the facility with diagnoses which included but not limited to: Acute Kidney Failure and Acute Ethmoidal Sinusitis. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 08/23/2024 showed a Brief Interview for Mental Status score of 15. This indicated that resident #3's cognition was intact. [...]

Inspectors wroteComplaint #: NJ173948 Based on interviews, medical record review, and review of other pertinent facility documentation on 06/26/2024 and 06/27/2024, it was determined that the facility failed to follow standards of clinical practice for documenting the administration of medications in the electronic Medication Administration Record (EMAR). This deficient practice was identified for 1 of 3 residents reviewed for medication administration (Resident #3) 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: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 9/11/2023 from 9:15 to 9:58 AM, the surveyors, accompanied by the facility Food Service Director (FSD), observed the following in the kitchen: 1. Upon entry to the kitchen the surveyors observed a staff member at the ice machine inside of the kitchen door. The staff was actively filling a cooler on top of a wheeled cart with ice obtained from the ice machine. The staff member identified him/herself as a Recreation Assistant (RA). The female RA had lengthy hair and no hair net. The RA's hair was exposed while in the kitchen. The FSD agreed that all staff should don a hair net while in the kitchen. 2. [...]

Inspectors wroteBased on interview and review of other facility documents, it was determined that the facility failed to ensure that their Quality Assurance and Performance Improvement (QAPI) Program was being implemented, and failed to provide sources of qualitative data that showed the facility had analyzed or identified quality deficiencies and evaluated program effectiveness. This deficient practice was evidenced by the following: On 09/15/2023 at 10:17 AM, the Administrator and the Director of Nursing (DON) advised the surveyor that they were unable to provide any sign-in sheets or documentation of a comprehensive QAPI program. During an interview with the surveyor on 09/15/2023, at 11:55 AM, the Administrator stated that the facility prior to his arrival in September 2023, was not conducting QAPI committee meetings. [...]

Inspectors wroteBased on interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure that all Certified Nursing Assistants (CNAs) received 12 hours of mandatory in-service training and Dementia training as required. This was identified for 5 of 5 CNA files reviewed for in-service training under Sufficient and Competent Nurse Staffing task. The deficient practice was evidenced by the following: A review of five randomly selected CNA education files did not reveal the mandatory 12 hours in-service training and Dementia training. A review of Mandatory In-service sheets for year 2022 revealed that CNA #1 was hired on 11/11/2021 and completed 5.5 hours of the training. CNA #2 was hired on 06/16/2022 and completed 5.5 hours of the training. CNA #3 was hired on 07/26/2021 and completed 5.0 hours of the training. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure a homelike atmosphere for 1 of 2 dining rooms, 2nd floor. This deficient practice was evidenced by the following.: On 9/11/2023 at 12:18 PM, the surveyor observed the lunch meal on the 2nd floor dining room. 14 total residents were in the dining room. 14 of 14 residents were served their meal on the tray and the food remained on the tray throughout the meal. On 9/13/2023 at 11:50 AM, the surveyor observed the lunch meal on the 2nd floor. 16 of 16 residents were served their meal on the tray and the food remained on the tray throughout the meal. On 9/15/2023 at 12:24 PM, the surveyor observed lunch meal on the 2nd floor dining room. All residents were served their meal on the tray and the food remained on the tray throughout the meal. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to identify the use of a merry walker (a folding wheeled walker with a seat designed for use by individuals with balance or walking disabilities) as a physical restraint for 2 of 5 residents (Resident #77 and Resident #79) reviewed for falls. This deficient practice was evidenced by the following: 1. On 09/11/2023 at 10:23 AM, during the initial tour of the facility, the surveyor observed Resident #77 in the 2nd floor dining room positioned in a merry walker. Resident #77 was non-interview able and pleasantly confused. Resident #77 was observed to be able to ambulate independently in the merry walker. The gate bar was observed to be in the closed position. [...]

Inspectors wroteBased on observation, interview, and review of medical records and facility documents, it was determined that the facility failed to 1.) follow fall prevention interventions as written on the resident's plan of care and ordered by the physician and 2.) ensure a resident who sustained multiple falls and cause determined to be Seizure activity, was followed by a specialist. This deficient practice was identified for 2 of 5 residents (Resident #79, and Resident #167) reviewed for falls and accidents and was evidenced by the following: 1. On 09/11/2023 at 10:18 AM, Surveyor #1 observed Resident #79 lying in bed. Resident #79 was unable to be interviewed at the time but was awake and alert. Resident #79 had a splint on their lower left arm and was wrapped with an ace bandage. Resident #79 was unable to tell the surveyors what happened to his/her left arm when asked. [...]

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility 1.) failed to follow the planned, written menu and ensure residents were notified in advance of menu changes for 2 of 2 meals observed and 2.) failed to post the menu in area that was accessible to residents. This deficient practice was evidenced by the following: 1. On 09/13/2023 at 12:03 PM the surveyor observed the lunch meal in the 2nd floor dining/recreation room. The surveyor observed Resident #77. Resident #77 received an 8oz skim milk, coffee, lemonade 4oz, mechanical pork tenderloin with gravy, mashed potato with onions, wax beans, and applesauce. On 09/13/23 at 12:13 PM the surveyor reviewed the facility menu for the lunch meal on Wednesday 9/13/2023. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that the residents' dining experience was provided in a manner to promote the dignity and respect of the residents, who were not served their meal at the same time while seated at the same table as well as serving all residents who are seated in the dining room at the same time. This deficient practice was observed for 1 of 2 dining rooms, 2nd floor and was evidenced by the following: On 9/11/2023 at 12:18 PM, the surveyor observed the lunch meal in the 2nd floor dining room. On the 2nd floor a meal cart indicated was DR (dining room) cart. However, in the dining room was 14 total residents and 1 resident was actively eating and the other 13 were not yet served. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to inform the beneficiaries of potential financial liability and related standard claim appeal rights for 1 of 3 residents (Resident #368) reviewed for the Beneficiary Notification task. The deficient practice was evidenced by the following: On 09/15/2023 at 11:14 AM the surveyor randomly selected three residents that the facility identified on the Entrance Conference Worksheet, Beneficiary Notice - Residents discharged Within the Last Six Months for the Beneficiary Notification task. A review of the facility-completed, Skilled Nursing Facility Beneficiary Protection Notification Review forms revealed that Resident #368 did not have the Notice of Medicare Non-Coverage (NOMNC). [...]

Inspectors wroteBased on interview, record review and review of pertinent facility documents, it was determined that the facility failed to complete criminal background checks on employees prior to employment as well as to complete reference checks on employees before their start date. The deficient practice was identified for 6 of 10 employees reviewed for criminal background checks and 10 of 10 employees reference checks reviewed under Sufficient and Competent Nurse Staffing task. The deficient practice was evidenced by the following: A review of employee personnel files revealed that six of ten employees did not have a criminal background check completed prior to the start of the employment. A review of the same ten requested employee files revealed that all ten did not have reference checks done prior to start of the employment. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to implement a care plan for nail care as identified in the facility policy for 1 of 1 residents (Resident #101) investigated for Activities of Daily Living. On 09/11/2023 at 09:42 AM, during the initial tour, the surveyor observed Resident #101 in a wheelchair in his/her room. At that time, the surveyor observed Resident #101's fingernails on his/her left hand. The fingernails were long and discolored. Resident #101 said to the surveyor that he/she needs them cut. On 09/12/2023 at 11:09 AM, during an interview with the surveyor, Resident #101 said that a doctor came to cut his/her toenails. Resident #101 told the surveyor again that he/she wants their fingernails cut. Resident #101's fingernails continued to appear long, discolored, and dirty. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to provide necessary services to maintain good personal hygiene for a resident specifically by not providing fingernail care. The deficient practice was observed for 1 of 1 residents (Resident #101) investigated for Activities of Daily Living and was evidenced by the following: On 09/11/2023 at 09:42 AM, during the initial tour, the surveyor observed Resident #101 in a wheelchair in his/her room. At that time, the surveyor observed Resident #101's fingernails on his/her left hand. The fingernails were long and discolored. Resident #101 said to the surveyor that he/she needs them cut. On 09/12/2023 at 11:09 AM, during an interview with the surveyor, Resident #101 said that a doctor came to cut his/her toenails. [...]

Inspectors wroteBased on observation, interview and record review, and review of other facility documentation, it was determined that the facility failed to consistently provide services to treat and prevent a decline in Range of Motion (ROM) for a resident with a contractures of the right hand. This deficient practice was identified for 1 of 2 residents reviewed for limited ROM (Resident #2) and was evidenced by the following: On 09/12/2023 at 08:54 AM, Resident #2 was observed in bed and being assisted with the breakfast meal by staff. Resident #2's hands were covered with bedding on this observation and the surveyor was unable to observed for right hand contracture. On 09/13/23 09:55 AM, Resident #2 was observed lying in bed and the soft comfy splint was observed to be on top of the bedside nightstand. On 09/13/20233 at 11:54 AM, the surveyors visited the room of Resident #2. [...]

Inspectors wroteBased on interview, record review and review of pertinent facility documents, it was determined that the facility failed to complete a performance review of a Certified Nurse Aide (CNA) at least every 12 months. The deficient practice was identified for 1 of 5 Certified Nurse Aides reviewed under Sufficient and Competent Nurse Staffing task. The deficient practice was evidenced by the following: A review of the facility-provided CNA annual performance evaluations revealed that 1 of the 5 CNAs did not have an annual performance evaluation. On 09/15/2023 at 12:01 PM, during an interview with the surveyor, the Human Resources Director confirmed one performance evaluation was not completed for one of the five CNAs. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 7/19/2021 from 7:45 to 8:23 AM, the surveyor, accompanied by the cook, observed the following in the kitchen: 1. A stand up fan at the entrance of the dry storage room and facing the food production area was in operation. The fan was observed to be covered with brown dust and debris on the fan guard. When interviewed the cook stated, We had it on every day because it's been so hot in here. [NAME] or the dishwasher could clean it. 2. On a lower shelf in the walk-in refrigerator a 1/6 pan was covered with plastic wrap and labeled sauce. The label was dated 7/13-7/16. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation. it was determined that the facility failed to maintain the call light within reach of the resident according to the facility policy. This deficient practice was observed for 2 of 20 sampled residents, (Resident #56 and #69) and was evidenced by the following: 1. On 7/19/2021 at 9:04 AM, during the initial tour of the facility, the surveyor observed Resident #56 in their room. On interview Resident #56 was unable to show the surveyor where his/her call light was located. The surveyor observed Resident #56's call light on the floor in front of their roommates bedside table. The call light was not within reach of Resident #56. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a clean and sanitary environment on 2 of 2 units. The deficient practice was evidenced by the following: 1. On 7/19/21 at 7:53 AM, during the initial tour on the first floor of the facility, the surveyor observed cracked drywall and ripped wallpaper in room [ROOM NUMBER]. The surveyor also observed what appeared to be a broken door stop among crumbled drywall behind the room door. Resident #63 was present in the room during the observation. He/she stated, the room is filthy. On 7/20/21 at 8:46 AM, the surveyor entered room [ROOM NUMBER]. Resident #63 was present. The cracked drywall and ripped wallpaper from the previous day were observed again. The broken doorstop, and crumbled drywall from the previous day were also observed. [...]

Inspectors wroteBased on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to follow a physician ordered consult for Pain Management for 1 of 1 resident reviewed for pain management, (Resident #87). This deficient practice was evidenced by the following: On 7/20/21 at 12:15 PM, they surveyor observed resident #87 lying in bed watching television. The resident stated that he/she has suffered from chronic pain for 20 plus years. Resident #87 stated as long as he/she gets his/her pain medication on time, he/she can maintain a comfort level to function. Resident #87 added that he has not had a pain management consultation. A review of the medical record indicated that Resident #87 had a diagnosis of Multiple Trauma, Spinal Cord Injury, Neuropathy (nerve pain) and Chronic Pain Syndrome. [...]

Inspectors wroteBased on observation, interview and review of other facility documentation, it was determined that the facility failed to detect and remove expired medication from 1 of 2 facility medication rooms reviewed during the Medication Storage task. This deficient practice was evidenced by the following: On [DATE] at 10:49 AM, in the presence of the Licensed Practical Nurse (LPN), the surveyor observed 37 tablets of Oxycontin CR ( a controlled narcotic pain medication) 30 mg tablets in the first-floor medication room lockbox that had an expiration date of [DATE]. The LPN confirmed that the tablets were dated and expired on [DATE]. During an interview on [DATE] at 11:16 AM, the Registered Nurse (RN #1) stated that one tablet of the expired Oxycontin CR was given to Resident #16 on [DATE] at 9:00 AM. [...]