Manhattanview Ctr for Rehabilitation and Healthcar

Inspectors wroteBased on interviews, record review, and a review of pertinent facility documents, it was determined that the facility failed to a.) provide oversight by a licensed Consultant Pharmacist (CP) in March 2024 for four (4) of five (5) residents, (Residents #17, #49, #75, and #80) and the entire month of April 2024, for five (5) of five (5) residents, (Residents #17, #22, #49, #75, and #80), b.) identify the irregularity with regard to physician's order for antipyschotic medication for one (1) of five (5) residents, (Resident #22) reviewed for unnecessary medications in accordance to facility's practice and policy. This deficient practice was evidenced by the following: 1. On 5/07/24 at 11:16 AM, the surveyor observed Resident #22 in the dayroom. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and review of documentation provided by the facility, it was determined that the facility failed to a) maintain proper kitchen sanitation practices and clean equipment, b) properly store foods in a safe manner to prevent the development of food borne illness, and c) maintain three (3) of three (3) nursing unit pantry used for residents in a sanitary manner. This deficient practice was evidenced by the following: On 5/07/24 at 10:16 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD), the FSD Trainer (FSDT) and the Regional FSD (RFSD), and observed the following: ~In the walk-in freezer, several boxes of opened food items that were opened, unlabeled and exposed to freezer with freezer burn and frost on them. Those items were as follows: [...]

Inspectors wroteReference F-756 Based on observation, interview, record review, and review of other pertinent facility documentation it was determined that the facility failed to ensure a resident with history of post-traumatic stress disorder (PTSD) received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. This deficient practice was identified for one (1) of five (5) residents (Resident #80) reviewed for unnecessary medications and was evidenced by the following: Reference: 13:44G-3.3 PRACTICE AS A CSW; SCOPE c) A CSW shall not engage in clinical social work services. 13:44G-1.2 DEFINITIONS Clinical social work means the professional application of social work methods and values in the assessment and psychotherapeutic counseling of individuals, families, or psychotherapy group. [...]

Inspectors wroteBased on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) to consistently maintain accurate reconciliation, accountability of dispensed, and administered controlled dangerous substance (narcotic medication) for Resident #16, b.) ensure expired narcotic medications were detected, removed, and disposed from active inventory which was stored within the electronic back-up machine (EBM). The deficient practice was identified for one (1) of one (1) of the EBM observed during medication storage inspection. The evidence was as follows: 1.) On [DATE] at 8:57 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that she conducted the narcotic reconciliation (cycle counts) daily with a nurse supervisor or with the Infection Preventionist/Registered Nurse (IP/RN). [...]

Inspectors wroteBased on interview, record review and review of other pertinent facility documents, it was determined that the facility failed to provide the resident and/or the resident's representative written notification of the reason for transfer to the hospital for two (2) of two (2) resident's (Resident #93 and #97) reviewed for hospitalization. This deficient practice was evidenced by the following: 1. A review of Resident #93's electronic medical record included the following: Resident #93's discharge assessment-return anticipated Minimum Data Set's (DRAMDS), an assessment tool used to facilitate the management of care, dated 4/08/24 and 5/01/24, reflected that the resident was transferred to the hospital. [...]

Inspectors wroteBased on interview, review of the medical record and review of other pertinent facility documentation, it was determined that the facility failed to provide the resident or resident representative written notification of the facility's bed hold policy prior to transfer to the hospital for two (2) of two (2) resident's (Resident #93 and #97) reviewed for hospitalizations. This deficient practice is evidenced by the following: 1. A review of Resident #93's electronic medical record included the following: Resident #93's discharge assessment-return anticipated Minimum Data Set's (DRAMDS), an assessment tool used to facilitate the management of care, dated 4/08/24 and 5/01/24, reflected that the resident was transferred to the hospital. [...]

Inspectors wroteBased on interview, review of medical records, and other facility documentation, it was determined that the facility failed to adhere to acceptable standards of nursing practice in regards to the documentation of a resident's expiration. This deficient practice was identified for one (1) of three (3) residents (Resident #126) reviewed for closed records and 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 observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to post the accurate Nursing Home Resident Care Staffing Report daily. This failure could affect the knowledge of the availability of staff to care for the 120 residents, their family members, or their representatives. This deficient practice was evidenced by the following: On 5/07/24 at 8:35 AM, the surveyors entered the facility (on a Tuesday) and observed that the Nursing Home Resident Care Staffing Report (NHRCSR) posted in the front lobby was dated 5/02/24 (Thursday). The census (total number of residents) that was posted on 5/02/24 NHRCSR was 120. A review of the facility submitted Nurse Staffing Report for the week of 4/28/24 to 5/04/24 that was provided by the Director of Nursing (DON) showed that the census on 5/02/24 was 119. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure each resident was offered pneumococcal vaccination according to the current Centers for Disease and Control Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommendations. This deficient practice was identified for two (2) of five (5) residents reviewed for immunization status (Resident #75 and Resident 80). The deficient practice was evidenced by the following: Reference: A review of the CDC guidelines for Pneumococcal vaccination included: For adults 65 years and older who only received the Pneumococcal polysaccharide vaccine (Pneumovax/PPSV 23),Give (1) dose of Pneumococcal conjugate vaccine (PCV 15 or PCV20) at least one year after the most recent PPSV23 vaccination. Reference: A review of the ACIP included: [...]

Inspectors wroteBased on the interview and review of pertinent facility documents, it was determined that the facility failed to complete the discharge Minimum Data Set (MDS) assessment, an assessment tool, as required for one (1) of one (1) system selected for the resident with an MDS record over 120 days reviewed (Resident #107). This deficient practice was evidenced by the following: On 5/08/24 at 12:13 PM, the surveyor reviewed the system-generated Resident Assessment Task and showed that Resident # 107 was identified as the resident's MDS record over 120 days old. The surveyor reviewed the medical records of Resident #107 as follows: [...]

Inspectors wroteNJ #170244 Based on observation, interview, and review of medical records, and other facility documentation, it was determined that the facility failed to timely and thoroughly investigate allegations of abuse for one (1) of two (2) residents (Resident #46) reviewed for abuse. This deficient practice was evidenced by the following: On 5/07/24 at 10:19 AM, the surveyor observed the resident had a visitor who was discussing leaving the facility for a few minutes. The surveyor observed the resident lying in bed, awake, head of the bed was elevated, and was communicative. At 10:53 AM, the resident informed the surveyor that a nurse [name redacted] threw coffee at him/her. The resident narrated the following: She was snotty. The Resident recalled the nurse said to him/her I'm going to whip your ass. I pushed the table towards her then she threw coffee at my face, I called the police. [...]

Inspectors wroteC #: NJ00166740 Based on observation, interviews, and record review, as well as review of pertinent facility documents on 9/8/23, it was determined that the facility staff failed to document that the medication was administration in accordance with the professional standards of practice and to follow the facility policy Medication Administration for 1 of 3 sampled residents (Resident #2) reviewed medication administration documentation. This deficient practice is evidenced by the following: According to the admission RECORD, Resident #2 was admitted to the facility on [DATE], with diagnosis that included but were not limited to: Anemia. The Minimum Data Set (MDS), an assessment tool dated 8/2/23, indicated the Brief Interview for Mental Status (BIMS) interview was not conducted due to Resident #2 was rarely/never understood. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to evaluate residents for advance directives (AD) and/or Physician Orders for Life Sustaining Treatment (POLST) related to end of life preferences. This deficient practice was observed for 3 of 26 residents reviewed for Advance Directives and POLST, Residents #94, #95, and #98 and was evidenced by the following: 1. The admission Record for Resident #94 indicated that the resident was admitted to the facility with diagnoses which included but were not limited to Malignant Neoplasm of the Pancreas, Gastrointestinal Hemorrhage, and alcohol dependence. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to accurately transcribe a physician's order (PO) onto the March 2022 Medication Administration Record (MAR) and failed to accurately document proper placement on the Enteral Protocol (feeding directly by way of intestines) sheet in accordance with professional standards of practice. This deficient practice was identified for 1 of 24 residents reviewed for standards of practice, Resident #212 and 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 wroteBased on observation, interview, and record review, it was determined that the facility failed to report a witnessed fall incident, complete a thorough fall investigation, implement safety measures and revise interventions for a resident who had a history of falls. This deficient practice was identified for 1 of 6 residents, Resident #49, reviewed for falls and was evidenced by the following: On 2/28/22 at 11:32 AM, the surveyor observed Resident #49 out of bed seated in a wheelchair in the day room watching TV and conversing with another resident. The resident informed the surveyor, that they had a seizure disorder and that before they were admitted to the facility, they had a bad seizure and fell. The resident stated that when they were admitted to the facility after their fall, they were confused and unable to care for themselves. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain necessary respiratory care and services for a resident who was receiving continuous oxygen (O2) and nebulizer treatment according to the standards of practice. The deficient practice was identified for 1 of 3 residents (Resident #54) reviewed for respiratory care. This deficient practice was evidenced by the following: On 2/28/22 at 10:41 AM, the surveyor observed Resident #54 in bed in their room, with O2 in use via nasal cannula (N/C) at 2 LPM (liters per minute) attached to the humidified O2 concentrator (a medical device used for delivering O2). There was no date indicated in the O2 tubing when it was last changed. The surveyor also observed a nebulizer mask placed inside the drawer next to the plastic bag. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility's physician failed to conduct a face-to-face visit at a required interval and to assure that the physician responsible for supervising the care of the residents signed and dated the monthly physician's orders to ensure that the residents current medical regimen was appropriate. This deficient practice was observed for 2 of 24 Residents reviewed, Resident #48 and #50 and was evidenced by the following: 1.) On 2/28/22 at 10:23 AM, the surveyor observed Resident #48 in bed, awake, watching TV. The surveyor verified the last time the physician visited the resident. Resident #48 responded it's been a long time. [...]

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to maintain acceptable labeling and dating of foods in the dry storage room including discarding food items past their recommended expiration dates. This deficient practice was observed during kitchen tour and was evidenced by the following: On 2/28/2022 at 9:20 A.M., the surveyor toured the kitchen with the Dietary Director (DD). During the tour of the dry storage area with the DD, the surveyor observed: 1. Five boxes of 32 ounce (oz.) Baking Soda with an expiration date of 12/18/2021 on the shelf. 2. Five cans of 106 oz. Fruit Mix dated with an expiration date of 1/21/21. 3. Seven cans of 6 pounds (lbs.) 10oz Pineapple Chunks with an expiration date of 10/1/21. 4. Multiple items were noted received from the distributor without labels indicating, use by and/or expiration dates. [...]

Inspectors wroteBased on facility staff interviews and review of pertinent facility documentation on 3/3/2022, it was determined that the facility failed to provide a designated qualified Infection Prevention and Control Nurse. This deficient practice is evidenced by the following: During an interview on 3/2/2022 at 2:59 P.M., the Assistant Director of Nursing (ADON), stated that she has been certified as the Infection Prevention and Control Nurse (IPC) since 9/23/2021, and that she is the only Infection Prevention and Control Nurse at this time in the facility. The ADON further stated that she is working full time as the ADON and the IPC. She stated that on September 23, 2021, she completed her Centers for Disease Control and Prevention training, receiving her certification as a Nursing Home Infection Preventionist. [...]