New Vista Nursing & Rehabilitation Ctr

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to thoroughly investigate an allegation of Staff to Resident Abuse and did not follow its policy titled Reporting & Investigation Policy, which states that all staff must receive periodic refresher training on the recognition of abuse and neglect. This deficient practice was identified for 1 out of 10 residents (Resident R#3) reviewed for abuse allegations, as evidenced by the following: Review of R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/26 revealed that R3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified dementia (without behavioral disturbance), psychotic disturbance, mood disturbance, anxiety, and Psychotic disorder with delusions due to a known physiological condition. [...]

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure a physician-ordered laboratory test was performed and failed to ensure results were reported to the ordering physician for one (1) of one (1) resident (R)2 reviewed.

Inspectors wroteBased on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness and, b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following:On 7/16/25 at 10:02 AM, in the presence of the Food Services Director (FSD), the surveyor observed the following:1. In the food preparation area, the surveyor observed red colored, sticky debris on the tubing of the juice dispenser and observed a spillage of clear liquid below the juice dispenser legging. 2. On oven number 1, the surveyor observed 5 of 12 oven knobs soiled with a white colored substance and 1 of 2 oven handles soiled with a white substance. [...]

Inspectors wroteBased on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards and ensure a.) removal of a discontinued antianxiety controlled drug (Clonazepam 0.5 milligrams half-tablet) from [DATE] until surveyor inquiry causing a medication error and accurate documentation on the declining inventory log for 1 of 6 medication carts inspected, b.) accurate documentation for the administration and removal of an antianxiety controlled drug (Alprazolam) for 1 of 6 medication carts inspected and c.) accurate documentation of medication administration and timely receipt of a medication (Lactulose [a medication that assists removal of ammonia from the body]) to prevent borrowing from another resident's supply for 1 of 5 residents observed during the medication [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 3 (three) of the 7 residents (Residents #24, #88, and #140) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: 1. On 7/16/2025 at 10:50 AM, the surveyor observed Resident #24 in bed, awake. The surveyor observed that there was no available call light near the resident's bedside. The surveyor observed a call bell unit on the wall that had two outlets, one for each resident. The outlet on the side of Resident #24, did not have a call light cord connected to it. The surveyor asked the resident about the location of the call light and they stated that they were unsure of its location. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician a.) signed and dated monthly physician orders and b.) wrote physician progress notes each month. The deficient practice was observed for 2 of 35 residents (Resident #53, #248) reviewed and occurred over a 3 month period. The evidence is as follows: 1. The surveyor reviewed the hybrid (electronic and paper) medical record for Resident #53 on 7/21/25, which revealed the primary medical doctor (PMD) had not signed monthly Medication Review Reports (MRR) for the prior 3 months. Additionally, the PMD had not documented monthly Physician Monthly Follow-Up Notes (PMFN) for the prior 3 months. The surveyor interviewed the Nurse Unit Manager (NUM) on 7/21/25 at 11:00 am. The NUM confirmed the medical record did not contain April, May, or June 2025 MRRs or PMFNs. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation performed on 7/17/25, the surveyors observed four (4) nurses administer medications to five (5) residents. There were 32 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 6.25 %. This deficient practice was identified for one (1) of five (5) residents, (Resident #212), that were administered medications by one (1) of four (4) nurses. The deficient practices were evidenced as follows: 1. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure enough linen supplies were available for staff to provide resident care including towels and washcloths for resident use for two of two residents (Resident (R) 4 and R10) and to include all 262 census residents in the facility. As a result of this deficient practice the facility had the potential of not meeting basic cleanliness needs of the residents to maintain a homelike environment.

Inspectors wroteBased on interviews, record reviews, and facility policy reviews, the facility failed to report three allegations of abuse for three of six residents (Resident (R) 12, R13, and R16) reviewed for abuse allegations and one allegation of misappropriation for one of three residents (R5) reviewed for misappropriation of property to the state survey agency within two hours out of a total sample of 19 residents. This had the potential to allow continued abuse and misappropriation of property for all residents in the facility.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to properly investigate two allegations of abuse for three out of seven residents (Resident (R) 12, R13, and R16) reviewed for abuse and one incident of misappropriation of property for one of three residents (R5) reviewed for misappropriation of property of 19 sample residents. This failure had the potential for ongoing abuse and misappropriation of property.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure Practitioner Orders for Life-Sustaining Treatment (POLST) was documented to clarify resident/resident representative the choice between cardiopulmonary resuscitation (CPR) and do not resuscitate (DNR), were thoroughly completed to include a date and physician signature for three of three residents (Residents (R) 9, R1, and R10) of 19 sample residents. This failure had the potential to affect the accuracy of POLST forms used when transferred from the facility to communicate resident/resident representative choice.

Inspectors wroteBased on interviews, record reviews, and facility policy reviews, the facility failed to resolve grievances for two of three residents (Resident (R) 3 and R5) reviewed for grievances of 19 sample residents. Specifically, the facility failed to resolve grievances related to misappropriation of funds and transportation concerns related to medical appointments. This failure had the potential to violate resident rights for all residents residing in the facility.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure that a medical appointment was identified and implemented following a surgical procedure according to professional standards of practice for one of three residents (Resident (R) 8) reviewed for medical appointments of 19 sample residents. This failure had the potential to negatively impact on the residents' health status.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to maintain a complete and accurate medical record for one of 19 sampled residents (Resident (R) 3). Specifically, the nursing staff failed to document the completion of physician orders on the resident's medication administration records. This failure had the potential to affect accuracy of records.

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices as well as store and discard potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 01/29/234 at 9:24 AM, the surveyor in the presence of the Food Service Director (FSD) and a Federal Surveyor (FS) observed the following during the kitchen tour: 1. On a tray cart, the surveyor observed multiple 6 ounce (oz) disposable individual cups that the FSD stated the contained rice crispy cereal. No labels with made or use by dates noted. FSD stated the cereal cups were put together yesterday but could not state why they were not labeled. 2. [...]

Inspectors wroteBased on interviews, and review of pertinent facility provided documents, it was determined that the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. This failure had the potential to affect all 273 residents who currently live in the facility. Refer to F607E, F728E, F730E, F804D, F883E, and S0560 The deficient practice was evidenced by the following: On 01/29/24 at 10:22 AM, during the entrance conference held with the facility's Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor in the presence of another surveyor requested information regarding the QAA (Quality assessment and assurance) committee, last three quarters sign in sheets for QAPI meetings, and QAPI plan. [...]

Inspectors wroteBased on the interview and review of pertinent facility documentation, the facility failed to have the Infection Preventionist present for three (3) of three (3) quarterly Quality Assurance Performance Improvement (QAPI) meetings. This failure had the potential to affect all 273 residents who currently live in the facility. The deficient practice was evidenced by the following: On 02/05/24 at 8:45 AM, the surveyor in the presence of the Social Services Director interviewed the Licensed Nursing Home Administrator (LNHA) regarding the submitted QAPI Attendance for the last three quarters: 5/11/23, 9/07/23, and 11/30/23. The surveyor asked the LNHA to confirm who attended the last three quarters of QAPI because the 5/11/23 QAPI Attendance did not include the title and department for some attendees. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide the residents with a safe, comfortable, clean, and homelike environment. This deficient practice was identified in one (1) of three (3) residents' rooms, (Resident #132) and one (1) of two (2) dining areas on the 4th floor observed during environmental rounds. This deficient practice was evidenced by the following: 1. On 01/30/24 at 8:25 AM, the surveyor observed Resident #132 on the bed with an air mattress, indwelling catheter in use, and head of the bed elevated approximately 45 degrees while on tube feeding (TF, a way to provide nutrition when a resident cannot eat or drink safely by mouth) pump, at 75 ml/hr (milliliters per hour). [...]

Inspectors wroteBased on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to ensure licensed staff credentials were verified upon hire. This deficient practice was identified for five (5) of seven (7) newly hired licensed staff reviewed, Staff #2, #4, #5, #7, and #10 evidenced by the following: On 02/05/24 at 10:03 AM, the surveyor reviewed ten randomly selected new facility employee files. The review for license verification for seven of the new licensed employees revealed the following: 1. Review of Staff Member #2 (SM2), an Occupational Therapist, hired on 5/02/22, had a New Jersey Division Consumer Affairs (NJDCA) license verification printout (used to verify the status of a license for license verification) dated 11/03/22. The verification was completed after the staff member was hired. [...]

Inspectors wroteBased on observations, interviews, and review of medical records and facility documents, it was determined that the facility failed to develop and implement a comprehensive plan of care to meet residents' preferences and goals and address the resident's medical, physical, mental, and psychosocial needs. This deficient practice was identified for four (4) of 38 residents (Residents #19, #36, #132, and #267) reviewed for a care plan. This deficient practice was evidenced by the following: 1. On [DATE] at 12:54 PM, the surveyor observed Resident #19 in their room with tube feeding (TF, a way to provide nutrition when a resident cannot eat or drink safely by mouth). [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and review of other pertinent provided facility documents, it was determined that the facility failed to ensure that oxygen care and services were provided according to the standard of clinical practice and physician's order for three (3) of five (5) residents, (Residents #19, #145, and #235 reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 02/01/24 at 8:48 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN#1) who informed the surveyor that Resident #19 was cognitively impaired and required total care with activities of daily living (ADL). He further stated that the resident was recently hospitalized and came back three weeks ago for pneumonia (an infection that affects one or both lungs). [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to ensure that the facility Certified Nursing Aides (CNA) received annual performance reviews for five (5) of five (5) CNA files reviewed. This deficient practice was evidenced by the following: On 1/29/24 at 10:22 AM, in the presence of a federal surveyor, the survey Team Coordinator met with the Licensed Nursing Home Administrator (LNHA) for an entrance conference and requested a list of the facility's CNAs with their date of hire and license numbers listed. On 2/1/24 at 11:02 AM, the LNHA provided the survey Team Coordinator an updated list of CNAs. The surveyor randomly chose five CNAs from the updated facility list and requested the education provided, annual performance reviews and competencies done for the five CNAs. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure: a) that the resident's medical record included documentation that indicated the consent for administration or refusal of the Influenza Annual Vaccination for four (4) of six (6) residents (Resident #7, #132, #149, and #214) reviewed for influenza immunizations, and b) the Pneumococcal vaccine was administered to the residents, (Residents #100 and #127) identified during the medication storage and labeling observation for one (1) of three (3) medication rooms. This deficient practice was evidenced by the following: Reference: A review of the Centers for Disease and Control Prevention (CDC) guidelines for Pneumococcal vaccination included: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to serve all residents seated at a table their lunch trays in a timely manner for one (1) of five (5) tables observed, involving a total of four residents (Residents #90, #91, #133, and #148) reviewed for Resident Rights. This deficient practice was evidenced by the following: On 1/31/24 at 12:11 PM, the surveyor observed the 4 East dining area having three Certified Nursing Aides (CNA), one (1) nurse, and 18 residents during lunch. There were five tables located in the 4 East dining area with residents seated for lunch. The 1st lunch truck was already in the process of being distributed at the time of the observation. On 1/31/24 at 12:12 PM, the surveyor observed table one, located near the wall with a total of 4 residents seated at the table. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that the resident or resident's representative were offered the opportunity to formulate an Advance Directive (AD), a written statement of a person's wishes regarding medical treatment, often including a living will be made to ensure those wishes are carried out should the person be unable to communicate to them. This deficient practice was noted to 1 of 39 residents reviewed for AD, Resident #77. This deficient practice was evidenced by the following: On 2/5/24 at 10:15 AM, the surveyor observed Resident #77 lying in bed with eyes closed. The surveyor reviewed Resident #77's hybrid medical records. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an injury of unknown origin in accordance with federal and state requirements for reporting such injury to the state agency. The deficient practice was identified for one (1) of five (5) residents reviewed for falls (Resident #185) and was evidenced by the following: Reference: According to Centers for Medicare and Medicaid Services (CMS) definition: Injuries of unknown source - An injury should be classified as an injury of unknown source when all of the following criteria are met: The source of the injury was not observed by any person; and The source of the injury could not be explained by the resident; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to complete a thorough investigation of a fall incident for one (1) of five (5) residents, (Resident #149) reviewed for falls. This deficient practice was evidenced by the following: On 01/30/24 at 12:56 PM, the surveyor asked the Director of Nursing (DON) for investigations and incidents/accident records of Resident #149, and the DON stated that she would get back to the surveyor. On that same date at 02:02 PM, the surveyor observed the resident laying on the bed, awake, nonverbal, and the tube feeding (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely) was off. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for three (3) of 38 residents, Residents #77, #145, and #242, reviewed for accuracy of MDS assessment coding. This deficient practice was evidenced by the following: 1. On 02/05/24 at 10:15 AM, the surveyor observed Resident #77 lying in bed with eyes closed. The surveyor reviewed Resident #77's hybrid medical (combination of paper and electronic) records. The admission Record (AR, admission summary) reflected that Resident #77 was admitted to the facility with medical diagnoses which included but were not limited to dementia, hypertension (elevated blood pressure), type II diabetes mellitus, and anxiety disorder. [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent documentation, it was determined that the facility failed to ensure: a) medication was administered in accordance with manufacturer's cautionary specifications and professional standards of clinical practice for one (1) of three (3) nurses administered medications to one (1) of three (3) residents (Resident #69, observed during medication administration and b) care and services were followed for resident who was at risk for wandering for one (1) of two (2) residents, (Resident #55) reviewed for elopement according to physician's order, assessment and 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 state: [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to provide wound care in accordance with the facility's policy and professional standards of clinical practice for one (1) of one (1) resident reviewed and observed for wound care observation, Resident #56. This deficient practice was evidenced by the following: According to the U.S. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure that the urinary output of resident's with indwelling catheters (IC) were monitored to ensure patency to further prevent any infections. This deficient practice was noted to two (2) of two (2) resident's reviewed with IC, Resident #242 and Resident #266. This deficient practice was evidenced by the following: 1. On 01/31/24 at 10:10 AM, the surveyor observed Resident #242 in the room lying in bed. The surveyor reviewed Resident #242's hybrid (combination of paper and electronic) medical records. [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure a) a non-certified Nurse Aide (NA) did not continue to work as an NA after the specified 120 days for one (1) of three (3) NAs reviewed during the Sufficient and Competent Nurse Staffing task (NA #1) and b) there was a delineated policy and/or program in place for the hiring, staffing, and assignments of non-certified NAs. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health memo dated April 21, 2023 sent to Nursing Homes included the following: On February 27, 2023, the Centers for Medicare and Medicaid Services (CMS) announced that all nurse aide emergency training waivers will terminate at the end of the Federal Public Health Emergency (PHE). The PHE is expected to end on May 11, 2023. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the 24-hour staffing report was posted in a prominent place within the facility and readily accessible to the residents and the visitors. This deficient practice was evidenced by the following: On 1/29/24 at 9:18 AM, the survey team entered the facility and observed that there was no Nursing Home Resident Care Staffing Report (NHRCSR) posted at the entrance area or elevator area. On 1/30/24 at 9:25 AM, after the surveyor did not observe a NHRCSR posted, the surveyor interviewed the Security staff in the front lobby regarding the posting of the NHRCSR. The Security staff stated that the Administration staff usually place the posting on the bulletin board that was behind the wall near the elevators. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a) labeling of medication with an expiration date, b) expired medication was removed from active inventory, c) beyond use date was in accordance with standard of practice, and d) discontinued medications were removed from active inventory. The deficient practice was identified for two (2) of six (6) medication carts, and (one) 1 of three (3) medication rooms and was evidenced by the following: Reference: USP Compounding Standards and Beyond-Use-Dates (BUDs; the date or time after which a compounded sterile preparation may not be stored or transported and is calculated from the date and time of compounding). [...]

Inspectors wroteComplaint #: NJ 167957 REPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of hot foods served to the residents. This deficient practice was identified for one (1) of one (1) resident complaint, Resident #107, and confirmed during the lunchtime meal service on 01/31/24 for one (1) of three (3) nursing units tested for food temperatures and was evidenced by the following: A review of a complaint in-take form indicated the food is not received on time. 1. On 01/29/24 at 10:41 AM, during the initial tour, the surveyor observed Resident #107 sitting on his/her bed. The resident was pleasant and stated, the food is bad here. [...]

Inspectors wroteBased on observation, interviews, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage compactor and dumpster free of garbage and debris. On 1/29/24 at 9:56 AM, the surveyor, in the presence of the Food Service Director (FSD) and a Federal Surveyor toured the kitchen and the designated garbage area observing the following: There was garbage debris that included food, cups, bottles, gloves, paper products, and brown paper bags, surrounding the garbage compactor and dumpster. The FSD stated that the area should have been cleaned by the maintenance and dietary departments. On 2/5/24 at 1:23 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) of the debris findings. [...]

Inspectors wroteComplaint NJ#162723, 162811 Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain complete and readily accessible medical records. This deficient practice was identified for two (2) of 38 residents reviewed (Residents #470 and #269). This deficient practice was evidenced by the following: 1. On 02/05/24 at 11:20 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) about where Certified Nurse Assistants (CNAs) documented resident care. The LPN showed the surveyor an ADL [Activities of Daily Living] binder at the nurses station. The ADL binder consisted of monthly forms which the CNAs would document CNA and ADL care for residents. The LPN stated the CNAs used to document electronically but now it was paper based. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to provide written notification of the emergency transfer to the Office of the Long-Term Care Ombudsman (LTCO) for one (1) of two (2) residents (Resident #149), reviewed for hospitalizations. This deficient practice was evidenced by the following: The surveyor reviewed the hybrid (a combination of paper, scanned, and computer-generated records) medical records of Resident #149. [...]

Inspectors wroteBased on interview and review of other pertinent facility documentation, it was determined that the facility failed to ensure facility-wide implementation of the Antibiotic Stewardship program, which included a system for routine feedback reports and tracking measures of outcome surveillance related to antibiotic use was followed, as per facility policy and national standards. This deficient practice was evidenced by the following: On 01/31/24 at 01:12 PM, the surveyor interviewed the Director of Nursing (DON) who stated the Infection Preventionist (IP) was responsible for Antibiotic (ABT)Stewardship. The DON further explained the newly hired IP was still in training and that the facility was in contact with the previous IP who left approximately two weeks ago. The DON stated the facility had access to the former IP's reports and antibiotic tracking documentation. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits at least once every sixty days and wrote progress notes to address nutritional issues for a resident with weight loss for one (1) of 10 residents, Resident #77 reviewed for nutrition, and was evidenced by the following: On 02/05/24 at 10:15 AM, the surveyor observed Resident #77 lying in bed with eyes closed. The surveyor reviewed Resident #77's hybrid (both paper and electronic) medical records. The admission Record (an admission summary) reflected that Resident #77 was admitted to the facility with medical diagnoses which included but not limited to dementia; hypertension (elevated blood pressure), type II diabetes mellitus; and anxiety disorder. [...]

Inspectors wroteBased on observation, interview and review of facility documentation it was determined that the facility failed to: a.) properly handle and store potentially hazardous foods in a manner to prevent the potential development of food borne illness, b.) maintain equipment and kitchen areas in a clean and sanitary manner to prevent microbial growth and cross contamination, and c.) maintain adequate infection control practices during the meal service in the kitchen. This deficient practice was observed and evidenced by the following: On 09/10/21 from 9:04 AM - 11:07 AM the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the following: 1. The FSD had visible facial hair that was not restrained. The FSD acknowledged he was not wearing a beard restraint and stated that he should have covered his facial hair. [...]

Inspectors wroteBased on interview and record review it was determined that the facility failed to ensure that residents who were admitted into a newly created behavioral unit received a pre-admission screening and resident review (PASRR) assessment, prior to admission, to determine the appropriateness of long term care (LTC) placement. This deficient practice occurred for 25 of 33 unsampled residents reviewed for PASRR and was evidenced by the following: On 09/10/21 at 10:05 AM, the surveyor conducted the facility entrance conference with the Director of Nursing (DON) and Administrator (LHNA). The LHNA stated there were 33 residents who were transferred from the temporary boarding home which was located on the the 6th floor, and now resided on the 5th floor East unit (5E) . [...]

Inspectors wroteComplaint #000148010 Complaint #000147748 Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to provide sufficient nursing staff to: a.) provide nursing and related services to ensure the residents safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments, individual plans of care and in accordance with the facility assessment, and b.) meet minimum staffing requirements. This deficient practice was identified on 3 of 3 nursing units, during interviews conducted with 2 of 10 residents (Resident #27 & Resident #57) who attended a resident council meeting, for 2 of 40 residents reviewed, (Resident #215 & Resident #240) for care concerns related to staffing and during a meal observation. [...]

Inspectors wroteBased on observation, interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to ensure the necessary services to maintain a resident's highest functional level were provided by failing to: a.) implement interventions designed by the Occupational Therapy Assistant (OTA) to promote mobility, positioning, and strength training exercises and b.) ensure the proper equipment was obtained and utilized for 1 of 1 residents (Resident #240) reviewed for rehabilitation and restorative care. The deficient practice was evidenced by the following: On 09/10/21 at 10:02 AM, during tour, the surveyor observed Resident #240 sitting upright in a bariatric bed (a bed for people who are overweight or obese). [...]

Inspectors wroteBased on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure: a.) resident re-weights were obtained per facility policy, and b.) a significant unplanned weight loss of 15.9% (18.8 pounds over a 16 day period) was identified and addressed. This deficient practice was identified for 1 of 5 residents reviewed (Resident #215) for weight loss and was evidenced by the following: On 09/15/21 at 9:57 AM, the surveyor observed that Resident #215 was seated on the side of the bed and appeared very thin. At that time, the surveyor interviewed Resident #215 and the resident stated that he/she weighed 130 pounds prior to hospitalization and now he/she weighed 100 pounds. During the interview, the resident's physician entered the room. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) post a cautionary and safety sign to indicate the use of oxygen (O2), and b.) accurately sign the Treatment Administration Record (TAR) for the administration of oxygen per a physician order. This deficient practice was identified for 2 of 3 residents reviewed, (Resident #144 & Resident #157) for respiratory care and was evidenced by the following: 1. The admission Record (AR) indicated that Resident #157 was admitted to the facility with diagnoses that included, but were not limited to, congestive heart failure (the heart fails to pump blood well - CHF) and stage 5 chronic kidney disease (the kidneys are close to failure - CKD). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to serve hot and cold foods at an acceptable temperature for the residents. This deficient practice was identified for 10 of 10 residents who attended a Resident Council group meeting, and on 1 of 3 nursing units during the lunch meal service. The deficient practice was evidenced by the following: 1. On 09/14/21 at 10:36 AM, the surveyors conducted a group meeting with ten residents who regularly attended the facility resident council meetings. Ten out of ten residents indicated the food was always cold. 2. On 09/16/21 two surveyors conducted a test tray with the Assistant Food Service Director (AFSD) and Food Service Director (FSD) which resulted in the following: At 11:53 the Surveyor #1 exited the kitchen with the test tray and the AFSD. [...]

Inspectors wroteBased on observation, interview and review of facility documentation, it was determined that the facility failed to follow infection control protocol to prevent the spread of infection during a wound care treatment observation. The deficient practice was identified for 1 of 1 sampled residents (Resident #215) and was evidenced by the following: On 09/15/21 at 9:57 AM, the surveyor observed Resident #215 seated on the bed. Resident #215 had a pressure relieving device attached to the bed. The surveyor interviewed, Resident #215 at that time and the resident stated he/she had a wound on his/her buttocks that was cared for by the staff. The surveyor reviewed Resident #215's medical record which revealed the following information: [...]