Morris View Healthcare Center

Inspectors wroteBased on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy by thoroughly investigating an allegation of staff-to-resident physical abuse to a cognitively intact resident (Resident # 194) who reported the abuse allegation to the Registered Nurse (RN #1) on 01/01/26. This deficient practice was identified for 1 of 5 residents (Resident # 194) reviewed for abuse. On 1/28/26 at 1:00 PM, the surveyor interviewed Resident # 194, who stated that during the 11 PM to 7 AM shift on 12/31/25, the resident was in the day room with Resident # 158 watching the ball drop before midnight. [...]

Inspectors wroteBased on record review, interview, and policy review, it was determined that the facility failed to implement their abuse policy to ensure residents were protected from abuse including physical and verbal abuse. During the 11 PM to 7 AM shift on 12/31/25, the Licensed Practical Nurse (LPN #1) got into a witnessed physical altercation with Resident # 194, which included yelling and poking their finger in Resident # 194's face and stomping on the resident's right foot. The resident reported after the altercation, they did not trust LPN #1 and they had to watch LPN #1 get their medications out of the cart before Resident # 194 ingested them, and the resident stated they could no longer go to the day room to watch television with their fellow residents because it had bad memories. [...]

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure that food was not expired according to professional standards for food service safety in one of one kitchen. This failure had the potential to cause the spread of foodborne illness to all 256 census residents.

Inspectors wroteBased on interviews, record review, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff, as well as himself, implemented the facility's abuse policies and procedures to ensure resident safety and well-being by a.) protecting all residents from an alleged perpetrator pending a thorough investigation for an allegation of staff-to-resident physical abuse; and b.) thoroughly investigating an allegation of staff-to-resident physical abuse. This deficient practice was identified for 1 of 5 residents (Resident #194) reviewed for abuse, and was evidenced by the following: [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to complete grievances with resolution related to missing personal items after he/she was moved on 08/21/25 by the facility for one of three residents (Resident (R) 133) reviewed for missing items of 40 sample residents. This failure had the potential to affect the resident ability to obtain resolution to grievances.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to implement their abuse policy and report an allegation of staff to resident abuse for one of five residents (Resident (R) 194) reviewed for abuse out of 40 sample residents. This had the potential to affect residents in the facility who were at risk for abuse.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure two of three residents (R) 254 and R230) and their resident representatives reviewed for emergent hospital transfer out of a total sample of 40 residents were provided with a written bed hold policy and transfer notice that contained the appeal process. This failure had the potential to affect the resident and their resident representative (RR) by not having the knowledge of how to appeal the transfer, if desired, and had the potential to contribute to the possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital.

Inspectors wroteBased on observation, document review, and interview, the facility failed to ensure assistive devices were provided for one of one resident (Resident (R) 32) reviewed for assistive devices out of 40 sample residents. This had the potential to cause a decrease in the residents' dietary intake.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure proper hand hygiene and use of personal protective equipment (PPE) in the implementation of enhanced barrier precautions, for one of one resident (Resident (R) 12) reviewed for enhanced barrier precautions during a nephrostomy dressing change. In addition, the facility failed to ensure the proper sanitization of a glucometer used to obtain blood glucose results for one of one resident (Resident (R) 90) of three residents reviewed during medication administration observation. This failure had the potential to lead to serious illness and death related to the transmission of blood borne pathogens from resident to resident via the un-sanitized glucometer.

Inspectors wroteComplaint #: NJ00180247 Based on interview, record review, and review of facility documents on 05/06/2025 and 05/12/2025, it was determined that the facility failed to report an allegation of misappropriation on 08/10/2024 to the New Jersey Department of Health (NJDOH) being made for a resident (Resident #1) missing items [four vapes]. This was observed in 1 of 1 resident reviewed for misappropriation. This deficient practice was evidenced as follows: According to Resident #1's admission Record (AR), Resident was admitted to the facility with the following diagnoses which included but not limited to: Achalasia of cardia [swallowing disorder], narcolepsy with cataplexy [loss of muscle tone associated with excessive sleepiness], anxiety disorder, post traumatic stress disorder, major depression, and bipolar disorder. [...]

Inspectors wroteComplaint#s: NJ00179392, NJ00184406, NJ00184468, NJ00180247 Based on interviews, medical record review, and review of other pertinent facility documentation on 05/06/2025 and 05/12/2025, it was determined that the facility failed to: (a) update the care plan (CP) with interventions for a resident [Resident #7] when the diet consistency of was observed changed by a family member and (b) implement and revise care plan (CP) interventions for a resident (Resident #1) who was a smoker while in the facility and had history of smoking incidents. This deficient practice was identified for 2 of 8 residents reviewed for care plans and was evidenced by the following: [...]

Inspectors wroteComplaint #: NJ00178065 Based on observation, interview, and review of pertinent facility documentation on 10/24/2024, it was determined that the facility failed to protect the confidentiality of residents' health related information when the facility introduced to the residents the Newave Care, an external medical practice that specializes in preventive care for geriatric patients, which involved data collection and disclosure of residents' PHI (Protected Health Information). This deficient practice was identified in 2 of 4 residents (Resident #7 and Resident #8) and was evidenced by the following: On 10/24/2024, the Surveyor requested a review of the Newave Care program from facility staff. The Newave Care program documents titled, [New Wave]: [...]

Inspectors wroteComplaint #s: NJ00176773 Based on observation, interview, and review of medical records on 10/23/24, it was determined that the facility failed to ensure Licensed Registered Nurse (LPN) #1 followed: a) a physician order for a mist humidifier (a device that adds moisture to the air by releasing a fine mist or vapor) for a resident (Resident #1), b) acceptable standards of nursing practice when LPN #1 signed and initialed [indicating it was administered] on the above mentioned order in Resident #1's electronic Medication Administration Record (eMAR) while the order was not carried out. 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 documents it was determined that the facility failed to a.) to maintain proper kitchen sanitation practices in a manner to prevent food borne illness, and b.) discard potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was evidenced by the following: On 7/08/24 at 9:34 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. The juice dispenser machine which was attached to several large juice boxes to be dispensed included: -An Unsweetened black iced tea juice box had a manufacturing label with a Best if Used by date of 5/20/2024. -A Cranberry Juice Fusion juice box had a manufacturing label with a Best if Used by date of 11/28/2023. [...]

Inspectors wroteBased on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure a.) license verification was checked for three (3) out of seven (7) licensed staff (Staff #1, #3, and #6) b.) criminal background check done for one (1) out of 10 staff (Staff #10) and c.) obtain current and past-employer reference checks for six (6) out of 10 staff (Staff #1, #3, #7, #8, #9, #10). This deficient practice was evidenced by the following: 1. On 7/17/24 at 9:00 AM, two surveyors reviewed ten randomly selected facility employee files and revealed the following: A review of Staff #1 (S#1), the Certified Nursing Assistant (CNA), hired 02/06/24. S#1 file did not have a New Jersey Division Consumer Affairs (NJDCA) license verification printout or the copy of the license. There was no evidence of reference checks from past employers in the file. [...]

Inspectors wroteBased on interview and record review it was determined that the facility failed to ensure that a.) the residents' Attending Physician signed and dated monthly physician orders for residents under their care for one (1) of 38 residents (Resident #466) reviewed for physician order and b.) the residents Attending Physician visited and documented monthly visits or alternately visited every other month when the Advanced Practice Nurse visited on the subsequent month for five (5) of 38 residents (Resident #18, #80, #227, #257, and #466), reviewed for physician visits. This deficient practice was evidenced by the following: 1. On 7/09/24 at 12:44 PM, the surveyor reviewed Resident #18's electronic medical record (EMR) which revealed that the resident's Attending Physician (AP) did not document any visit for March, April, May or June 2024. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and review of medical records and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene practices during dining observation for one (1) of three (3) dining rooms, and for one (1) of two (2) staff (Housekeeper #1 [HK#1]) and b.) follow transmission-based precautions (TBP) to prevent the potential spread of infection for two (2) of two (2) residents (Residents #41 and #111) and not utilizing personal protective equipment (PPE) for a resident on contact precautions for two (2) of two (2) staff (Attending Physician and HK#2) reviewed for TBP, in accordance with the Center for Disease Control and Prevention (CDC) guidelines and facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to maintain a clean, safe, and sanitary environment for a.) one (1) of three (3) residents' rooms (Resident #32) and b.) two (2) of two (2) common rooms (toilet and chapel room) This deficient practice was evidenced by the following: 1. On 7/15/24 at 10:09 AM, the surveyor met and interviewed Resident#83. The resident requested the follow-up personal meeting after the resident council meeting with another surveyor on 7/10/24. The resident discussed the 1 A/B public toilet room safety railing was loose which Resident #83 had previously reported to the Housekeeping Director (HD) and the Licensed Nursing Home Administrator (LNHA) via email. The resident further stated that the 1 A/B public toilet room was being used by residents. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that residents were served their meals in a dignified manner during meal service. This deficient practice was observed for one (1) of five (5) residents (Resident #105), in one (1) of three (3) dining rooms. The deficient practice was evidenced by the following: On 7/08/24 at 11:40 AM, the surveyor observed the lunch food truck parked in front of the nursing station of 3D unit. The Concierge staff took the lunch truck into the Dining room wherein there were five residents inside the room. At that time, the surveyor observed the Certified Nursing Aide (CNA) enter the 3D dining room and five residents were served lunch trays except for Resident #105. Resident #105 was seated at one table where there were two other residents. [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to complete the Comprehensive Assessment in accordance with the Resident Assessment Instrument (RAI) for three (3) of 39 residents reviewed for comprehensive assessments (Residents #6, #14, and #135). This deficient practice was evidenced by the following: Reference: The Centers For Medicare and Medicaid (CMS) RAI Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the Minimum Data Set (MDS). The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete a quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for two (2) of two (2) residents, Resident #6 and #135, system selected for MDS over 120 days and was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. The Quarterly assessment was considered timely if 1). The Assessment Reference Date (ARD) of the Quarterly MDS (QMDS) was within 92 days after the ARD of the previous MDS and; [...]

Inspectors wroteREPEAT DEFICIENCY Based on the interview, record review, and review of pertinent facility documentation it was determined that the facility failed to accurately code the Minimum Data Set (MDS) for three (3) of the 38 residents reviewed, Residents #135, #138, and #198. This deficient practice was evidenced by the following: 1. The surveyor reviewed the system selected resident for MDS discrepancy and revealed the following: [...]

Inspectors wroteComplaint: NJ#169038 Based on the interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) follow the physician's orders for one (1) of 38 residents, Resident #106, with regard to medications with parameters, and b.) specify a site for a pain medication patch for one (1) of one (1) resident, Resident #316 reviewed for pain management according to standards of clinical practice. 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: [...]

Inspectors wroteBased on the interview, record review, and review of pertinent documents it was determined that the facility failed to ensure a resident was provided with an accurate discharge summary at the time of discharge, including a documented medication reconciliation, post-discharge instructions, and physician's prescription per the facility policy. The deficient practice occurred for one (1) of one (1) closed records reviewed (Resident #106) for appropriate discharge. This deficient practice was evidenced by the following: On 7/09/24 at 11:10 AM, the surveyor reviewed the closed medical records of Resident #106 and revealed the following: [...]

Inspectors wroteBased on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to ensure a.) that the unwitnessed fall investigation included a conclusion for root cause analysis and b.) a new non pharmacological intervention was implemented after each fall for one (1) of three (3) residents reviewed for falls (Resident #227) according to standards of clinical practice and facility's policy and procedure. 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: [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) administer oxygen therapy according to the physician's order, b.) ensure respiratory tubing, cannula, and masks were stored properly. This deficient practice was identified for two (2) of two (2) residents (Residents #111 and #466) reviewed for respiratory care according to the standard of clinical practice, and the facility's policy and procedure. 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: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to ensure the daily posting of licensed nurses, certified nursing aide staffing, and the resident census on three (3) of 10 days during the survey. This deficient practice was evidenced by the following: On Monday, 7/08/24 at 9:00 AM, upon entry into the facility, the surveyor observed a Nursing Home Resident Care Staffing Report (NHRCSR) which was posted in the reception area of the lobby. The NHRCSR posted for day shift was dated 7/07/24. There was no NHRSCR posted for 7/08/24 day shift. On Tuesday, 7/09/24 at 8:40 AM, the surveyor observed the NHRCSR posted in the lobby. The NHRCSR posted for day shift was dated 7/08/24. There was no NHRSCR posted for the 7/09/24 day shift. [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to ensure that medications were stored securely and appropriately. This deficient practice was identified in one (1) of three (3) medication carts observed during the medication pass observation. This deficient practice was evidenced by the following: On 7/10/24 at 9:03 AM, the surveyor observed the medication (med) nurse assigned to the South Side of the 2A Unit (med RN) prepare and administer medications (meds) to an unsampled resident. The surveyor observed the med RN remove the resident's med cards (packaging that contains individual doses of med in a numbered plastic blister) and place them on top of the med cart. [...]

Inspectors wroteComplaint number #169038 Based on interview, record review, and review of pertinent documentation, it was determined that the facility failed to a.) timely assess a resident after the resident had an unwitnessed fall on 9/16/23 at 01:20 AM. Subsequently, the resident had increased pain and limited mobility requiring transfer to the emergency room on 9/30/23 at 11:54 AM, with a diagnosis of acute fracture of the intertrochanteric portion of the left femur and acute fracture of the left pubic ring; b.) provide adequate pain management; c.) failed to report the injury to the New Jersey Department of Health (NJDOH). This deficient practice was identified for one (1) of five (5) residents (Resident #316) reviewed for accidents and was evidenced by the following: [...]

Inspectors wroteComplaint# NJ00174351 Based on interview and record review of pertinent facility documents, it was determined that the facility's Consultant Pharmacist (CP) failed to identify and notify the facility of a medication irregularity for a resident. On 1/11/2024, a nurse documented a Physician order in the medical record for Resident #2 for Warfarin Sodium,( Coumadin) a blood thinner. This medication order was for another resident. Resident #2, was already on a Xarelto, a blood thinner. Resident #2 was administered the Coumadin for eighteen (18) doses from 1/12/2024 to 1/29/2024. On 1/15/2024, the CP conducted an on-site visit and had reviewed Resident #2 chart, however, there was no documented evidence for the recommendations for Coumadin and Xarelto in the report. The administration of both blood thinners caused Resident #2 to become symptomatic and decline in health. [...]

Inspectors wroteComplaint# NJ00174351 Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident (Resident #2) who was currently being administered daily Xarelto, a blood thinner, was incorrectly transcribed a new medication Coumadin (Warfarin Sodium), another blood thinner by Registered Nurse #1 (RN). The Coumadin medication was prescribed by a Physician for another resident (Resident #1). Resident #2 remained on prescribed daily dose of Xarelto and also received daily doses of the Coumadin from 1/12/2024 to 1/29/2024 for 18 days for a total of eighteen (18) doses . This resulted in Resident #2 to become symptomatic and decline in health. The resident eventually needed acute inpatient hospitalization. [...]

Inspectors wroteNJ#00163219, NJ# 00164434 Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to provide a discharged resident a requested copy of their medical records. This deficient practice was identified for 1 of 2 residents (Resident #1) reviewed for medical record requests. This deficient practice was evidenced by the following: According to the admission record, Resident #1 was admitted to the facility in December of 2022, with diagnoses which included but were not limited to: Myasthenia Gravis (weakness and rapid fatigue of muscles under voluntary control) and Anxiety. According to the Minimum Data Set (MDS), an assessment tool dated 12/28/2022, indicated Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was cognitively intact. [...]

Inspectors wroteComplaint # NJ00161074 Based on observations, interviews, and review of pertinent facility documentation, it was identified that the facility failed to provide a sanitary and homelike environment on 1 of 6 units toured (2 D) for 3 of 13 resident rooms (Resident #11, #13 and #14). This deficient practice was evidenced by the following: On 09/08/23 at 12:38 PM, during the initial tour of unit 2 D, the surveyors observed a brown, cloth recliner chair in Resident #13's room. The recliner had multiple areas of dark brown and circular stains on the arms, back rest, seat, and leg rest. There was an unused adult brief on the seat of the chair. Resident #13 was not in the room at the time of the observation. On 09/08/23 at 12:40 PM, in the presence of the surveyors, the Registered Nurse/Unit Manager (RN/UM) stated that Resident #13's recliner chair should not be that way. [...]

Inspectors wroteComplaint, #NJ157771, #NJ157773, #NJ157831 Based on observations, interviews, record review, and review of other pertinent facility documentation, it was determined that on 09/21/22, the facility failed to ensure: a.) a resident with moderate cognitive impairment, who was at risk for elopement, and had a known history of wandering and exit seeking behavior was appropriately supervised and monitored to ensure safety, prevent elopement, or exiting of the building, and staff failed to follow their facility's policy and procedure on Wandering/Elopement. This deficient practice was identified for one of five residents, (Resident #206) reviewed, who had moderate cognitive impairment, and were at risk for elopement. [...]

Inspectors wroteREFER TO F610 REFER TO F609 Based on observation, interview, and record review, it was identified that the facility failed to report to the New Jersey Department of Health (NJDOH) and follow facility policy and procedures for reporting: a.) an unwitnessed event which resulted in a major injury for Resident #75, b.) an allegation and investigation of a resident to resident altercation, for Residents #27 and #228, c.) an allegation of abuse made by a resident representative for Resident #99, d.) an injury of unknown origin for Resident #99, and e.) an observed incident and investigation in which serious bodily injury occurred to Resident #191. The deficient practice was identified for five (5) of six (6) residents reviewed for alleged violations, (Resident #27, #75, #99, #191, and #228) and was evidenced by the following: 1. [...]

Inspectors wroteREFER to 609 Based on interview, observation, and record review, it was determined that facility failed to conduct a timely and through investigation, as well as, follow their own facility policy on Abuse Investigation and Reporting was consistently implemented for five (5) of six (6) residents (Resident #27, #75, #99, #102 and #228) reviewed for alleged violation investigations. This deficient practice was evidenced by the following: 1. On [DATE] at 11:28 AM, the surveyor interviewed the responsible party (RP) for Resident #75 in the presence of a second surveyor. The RP informed the surveyors that Resident #75 sustained a right hip fracture which required surgery. The RP stated that this occurred the day after Resident #75 had an incident whereby his/her finger got caught in the bed frame which Emergency Services (ES) were required to release by cutting the metal bed frame. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accurately assess and properly code residents' status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 7 of 39 residents (Residents #13, #69, #102, #106, #177, #198 and #206) reviewed under Section C for cognition. This deficient practice was evidenced by the following: According to the CMS's (Centers for Medicare & Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual dated October 2019 Section C: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation it was identified that the facility failed to: a.) follow the Physician's Order (PO) for the use of oxygen equipment b.) appropriately store portable oxygen tank to the back of resident wheelchair and c.) store respiratory equipment in a way to prevent the spread of infection. This deficient practice was identified for three of three residents' reviewed for respiratory care, (Resident #111, #159 and #191) and was evidenced by the following: The surveyor observed Resident #111. 1. On 9/01/22 at 11:32 AM, the surveyor observed the resident sitting in their high back wheelchair in their room watching TV. The surveyor observed an Oxygen (O2) concentrator in Resident #111's room next to Resident #111's bed. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure that a.) medications that were ordered by the physician were available for administration during the months of April, May, and July 2022 for one (1) of 18 residents, (Resident #99) reviewed for medication management, b.) medications were observed as accurately and timely administered to one (1) of seven (7) residents, (Resident #121) reviewed for medication administration, and c.) a treatment medication was accurately administered and properly stored for one (1) of two (2) residents, Resident #69, reviewed for treatment medications. The deficient practices were evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to document non-drug interventions that were attempted and the need for an as needed psychoactive medication (Ativan) to be administered according to documented behaviors from April, May, June and July. The deficient practice was identified for one (1) of five (5) residents (Resident #101) reviewed for unnecessary medications, and was evidenced by the following: On 9/1/22 at 11:24 AM, the surveyor observed Resident #101 in a wheelchair in the Day Room. The resident waved the surveyor over to him/her. The resident stated that he/she wanted to get up and would then be able to walk out of the room. At that time, a Certified Nursing Aide (CNA) came over to the resident and asked if the resident would like to be taken somewhere else. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the facility in a clean and sanitary environment. This deficient practice was identified for 2 of 6 units, (Unit 1 D and 2 A) and was evidenced by the following: 1. On the 1 D unit the surveyor observed the following: - On 9/9/22 at 10:53 AM, the surveyor observed on 1 D unit hallway (that covered both the high and low side), black colored stains on the floor and on the walls. - On 9/9/22 at 11:00 AM, the surveyor observed missing wall tiles in multiple areas of the 1-D hallway. - On 9/9/22 at 11:15 AM, the surveyor observed the unit D shower area (the only available shower room on 1-D) and observed the shower head on the shower stall floor. - On 9/9/22 at 11:15 AM, the surveyor observed a large dark stain on the tile floor of the 1-D shower stall. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide information and educate residents on the Grievance process. This deficient practice was identified for 5 of 5 residents (Residents #44, #51, #67, #150, and #15) interviewed for the grievance process at the Resident Council meeting conducted on 9/15/22 at 10:30 AM and was evidenced by the following: On 9/15/22 at 10:40 AM, during the resident council meeting with five alert and oriented residents, the surveyor asked the residents if they were aware of what a grievance was and how to file a grievance with the facility if necessary. Five of the five residents present during the meeting told the surveyor they did not know the definition of a grievance or how to file a grievance. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed a.) to implement a comprehensive person-centered care plan intervention with regard to communication and b.) to develop a comprehensive person-centered care plan to address a behavior. The deficient practice was identified for 2 of 39 residents reviewed for care plans, (Residents #102 and #150), and evidenced by the following: 1. On 8/31/22 at 11:02 AM, the surveyor observed Resident#102 laying on the bed with the responsible party (RP) at the bedside. The RP stated that Resident#102 was cognitively intact, unable to speak appropriately but able to utilize the personal computer for communication. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to update and revise an Interdisciplinary Comprehensive Care Plan (IDCCP) to include interventions for 1 of 11 residents, (Resident #121), reviewed for accidents. This deficient practice was evidenced by the following: On 9/13/22 at 11:10 AM, the surveyor observed Resident #121 who was alert, oriented, and seated in a wheelchair watching television. The surveyor reviewed the medical record for Resident #121. [...]

Inspectors wroteBased on observation, interviews, and record review, it was determined that the facility failed to accurately transcribe a physician's order for a wound treatment to a stage 4 sacral pressure ulcer onto the Treatment Administration Record (TAR) for 1 of 4 residents (Resident #181) reviewed for wound care. The deficient practice was evidenced by the following: On 9/09/22 at 11:13 AM, the surveyor observed Resident #181 lying in bed with head of bed elevated and bed covers on and up to Resident #181's waist. Resident#181 was awake and watching television. A review of Resident #181's Electronic Medical Record (EMR) indicated that Resident #181 was admitted to the facility with a diagnosis that included, but not limited to, multiple sclerosis (a disease in which the insulating covers of nerve cells in the brain and spinal cord are damaged. [...]

Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to maintain complete and readily accessible medical records. This deficient practice was identified for 2 of 39 residents, (Resident #159 and Resident #177), and was evidenced by the following: 1. On 9/13/22 at 11:00 AM, the surveyor reviewed Resident #159 physician progress notes in the electronic medical record (EMR). In review of the physician notes the surveyor noted that all the resident's progress notes were written by an Advanced Practice Nurse (APN). The surveyor could not locate any notes written by the attending physician within the medical record. The surveyor then asked the Director of Nursing (DON) to provide all the resident's physician progress notes for July and August. The surveyor reviewed the admission Minimum Data Set (MDS), an assessment tool dated 7/13/22. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a.) ensure that appropriate hand hygiene was performed by 2 of 13 staff observed during dining and wound care observation, and b.) disinfect the table for 1 of 2 staff observed for wound treatment in accordance with the Centers for Disease Control and Prevention (CDC) guidelines for infection control and facility policies. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included, When to Perform Hand Hygiene? Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an Alcohol-Based Hand Sanitizer: [...]