North Cape Center

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure the second-floor secure unit were provided with meals consistent with the meal schedule to include two of two second-floor dining rooms (Back dining room BDR and Front dining room FDR) and two of two residents (Resident (R) 15 and R3) of 42 residents residing on the second-floor secure unit. This failure had the potential to affect residents' routines and preferences.

Inspectors wroteBased on observation, interviews, record reviews, and facility policy review, the facility failed to properly store nebulizer masks for two of two residents (Resident (R) 71 and R78) observed for breathing treatments. In addition, the facility failed to ensure Enhance Barrier Precautions (EBP) for one of one resident (R44) and failed to follow proper infection control protocols while dispensing medication for one of one resident (R16) of 27 sample residents. These failures in infection control practices could significantly increase the risk of infections among residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the interdisciplinary team had determined it was appropriate for a resident to self-care for a [NAME] tube for one of one resident (Resident (R) 27) out of 27 sample residents. This failure had the potential for R27 to develop a respiratory infection due to no assessment of R27's ability to care for his [NAME] tube.

Inspectors wroteBased on record review, facility document review, interview, and facility policy review, the facility failed to provide a resolution to the concern for one of nine residents (Resident (R) 151) reviewed for grievances of 27 sample residents. This failure had the potential to affect the outcome of concerns and grievances.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to develop and implement a comprehensive care plan for one of one resident (Resident (R) 27) reviewed for care plans out of 27 sample residents. This failure had the potential to not receive the necessary care.

Inspectors wroteBased on observations, record reviews, interviews, and facility policy review, the facility failed to ensure a splint device was placed according to physician's orders for one of one resident (Resident (R) 9) reviewed for range of motion of 27 sample residents. This failure had the potential to lead to further contracture of her right hand.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to obtain a physician's order prior to the administration of oxygen for one of three residents (Resident (R) 27) reviewed for oxygen of 27 sample residents. This failure had the potential for R27 to have adverse reactions from the administration of oxygen.

Inspectors wroteSurveyor: [NAME], [NAME] Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to create a homelike environment during dining by not removing food from serving trays and not posting the menu in the dining room. The deficient practice was observed on the first and second floor dining rooms. The deficient practice was evidenced by the following: On 2/06/2023 at 12:49 PM, during lunch in the dining room on the second floor, Surveyor #2 observed that all residents in the dining room had their meals served on trays. Food was not removed from the trays and set on the table during dining. On 2/07/2023 at 12:26 PM, during lunch in the dining room on the first floor, Surveyor #1 observed that the menu display on the wall was empty. [...]

Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to provide documented evidence that the facility had performed annual performance reviews of certified nurse aides (CNA) employed at the facility at least every 12 months. This deficient practice occurred for 5 of 5 CNA's reviewed for mandatory 12-hour in-service training and performance evaluations and was evidenced by the following: On 02/13/2023 at 8:57 AM, the surveyor reviewed 5 random facility CNA files for mandatory 12 hour in-service education and annual performance evaluations for the period of 1/1/2022 through 12/31/2022. Upon review of the 5 facility provided files it was determined that there was no documentation that the 5 CNA's reviewed received a performance evaluation for the aforementioned timeframe. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 2/6/2023 from 9:20 to 10:12 AM the surveyor, accompanied by the Account Manager (AM), observed the following in the kitchen: 1. Upon entry to the dry storage room the surveyor observed (3) bulk storage containers. On top of the middle bulk storage container, which contained sugar, the surveyor and AM observed a plastic scoop used to access the bulk containers. The scoop was not covered and was exposed. The AM stated, That doesn't belong there. 2. On an upper shelf in the dry storage room, an opened container of Rainbow Sprinkles had an open date of 6/8/2022. [...]

Inspectors wroteBased on interview and review of other facility documentation, it was determined that the facility failed to accurately track and document the COVID-19 vaccination status of the vendors/contracted staff . This deficient practice was evidenced by the following: On 2/6/2023, during entrance conference, the facility was asked to provide documentation of their staff and contracted staff vaccination status. During an interview with the surveyor on 2/8/2023 at 10:50 AM, the Infection Prevention Nurse (IPN) and the Director of Nursing (DON) stated that they failed to track and maintain records of COVID-19 vaccinations for outside vendors/contractors. During an interview with the surveyor on 02/08/23 at 1:55 PM, the DON stated they were not tracking the COVID-19 vaccination status of the contracted staff until today (2/8/23). [...]

Inspectors wroteBased on interview and review of other facility documentation, it was determined that the facility failed to notify in writing the representative of the New Jersey Long-Term Care Ombudsman's office of resident emergency transfers to the hospital/discharges, when practicable, as mandated by Federal law. This deficient practice was evidenced by the following: During an interview with the surveyor on 2/13/2023 at 1:20 PM, the Administrator said normally the Social Worker notifies the Ombudsman of discharges/transfers to the hospital. The Administrator went on to say when she left in September, there was a new Social Worker and she also left, and the current Social Worker has been here for 3 weeks. It seems it was dropped in the transition, and I can't find any reports in the current office but will look in the other office. [...]

Inspectors wroteBased on observation, interview, record review and review of 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 1 of 26 residents reviewed (Resident # 73) and was evidenced by the following: During the initial tour on 2/6/2023 at 10:47 AM, Resident # 73 was observed lying in bed with the head of bed elevated. The surveyor observed a piston irrigation syringe set (equipment used to provide a bolus tube feeding) at his/her bedside dated 2/6/23 6 am. On 2/7/2023 at 9:23 AM, Resident #73 was observed lying in bed with the head of bed elevated. A piston irrigation syringe set was observed at the bedside dated 2/7/23. According to the admission Record Resident #73 was admitted to the facility with diagnoses including but 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 develop a person-centered comprehensive care plan to address the use of Intravenous Medication to treat an infection for 1 of 3 residents reviewed for antibiotic use (Resident # 19). This deficient practice was evidenced by the following: During the initial tour of the facility on 2/6/2023 at 10:58 AM, Resident # 19 was observed lying in bed with the head of the bed elevated, nasal oxygen in use 2 liters per minute. An Intravenous pump and tubing was observed at the bed side. Per the Unit Manager Licensed Practical Nurse (UM/LPN) Resident # 19 was on 3 different antibiotics for an infected Total Knee Replacement and wound. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow their facility policy and procedure for residents who smoke for 2 of 2 residents (Resident #1 and #52) investigated for smoking. This deficient practice was evidenced by the following: 1. On 2/06/2023 at 10:39 AM during the initial tour Resident was interviewed in their room. Resident #1 stated he/she is a smoker and that they can smoke like 7 times a day. Resident #1 stated that he/she is allowed to possess their lighter and cigarettes. When asked by the surveyor if he/she currently had possessed their smoking materials Resident #1 pulled a white lighter out of their right front pocket and presented it to the surveyor. Resident #1 went on to say, Certain people are allowed to hold onto their lighter and cigarettes. [...]

Inspectors wroteBased on interview and record review it was determined that the facility failed to maintain a detailed record of receipts and accurate reconciliation of controlled medications. This deficient practice was evidenced by the following: 02/08/23 01:35 PM the surveyor requested all Drug Enforcement Administration (DEA) 222 forms (a form used for ordering controlled substances) for the last 6 months from the Director of Nursing (DON). The DON provided the surveyor with three (3) DEA 222 forms. The surveyor reviewed the facility's DEA 222 forms and found three of three forms were not completed and accurately documented as follows: 1. The DEA 222 form # 220481496 was written on 7/19/2022 and contained an order for 0.5 packages of 100 Oxycodone 5 mg tablet, 0.3 packages 100 Hydromorphone 2 mg tablet and 1 package of 30 ml Morphine Sulfate 20mg/ml 30ml bottle. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure staff properly wore the appropriate personal protective equipment (PPE; barriers, such as gowns, face shields, and gloves worn to protect the eyes, mouth, and skin from infectious disease), specifically eye protection and masks. The deficient practice occurred on the first and second floor. The deficient practice was evidenced by the following: On 2/06/2023 at 12:34 PM, during the initial tour on the second floor, Surveyor #2 observed multiple staff members wear their surgical mask below their nose. The staff members pulled the mask over their noses upon seeing Surveyor #2. On the same date at 12:41 PM during the initial tour on the first floor, Surveyor #1 observed three staff members not wearing eye protection while in the hallway. [...]

Inspectors wroteBased on interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to adequately monitor the use of an antibiotic by administering the antibiotic without a duration end date. This deficient practice was identified for 1 of 3 residents that were reviewed for antibiotic stewardship (Resident #44). This deficient practice was evidenced by the following: According to the admission Record, Resident #44 was admitted with the following diagnosis: Unspecified open wound of abdominal wall, encounter for surgical aftercare following surgery on the digestive system, and a urinary tract infection. A review of Resident #44's Physician Order Summary Report revealed an order: Nitrofurantoin Microcrystal Oral Capsule 100 MG. Give 1 capsule by mouth two times a day for UTI (Urinary Tract Infection). The order and start date were 1/12/2023. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to implement physician orders for 3 of 21 residents (Residents #66, #81 and #332) reviewed for physician orders. This deficient practice was evidenced by the following: 1. On 02/16/21 at 09:48 AM during a tour of the admission Observation Unit, the surveyor interviewed Resident #66 in their room. The resident was lying in bed. The resident was awake, alert, and speaking clearly. At that time, the surveyor observed the resident was wearing a nasal cannula (oxygen delivery device) that was attached to an oxygen concentrator (device used to produce oxygen). The oxygen concentrator was set at 3 liters per minute (L/Min). During a follow-up interview with the surveyor on 02/19/21 at 10:42 AM, Resident #66 was in his/her room seated in a wheelchair. The resident was awake, alert, and speaking clearly. [...]