Roosevelt Care Center

Inspectors wroteBased on observation, interview, record review, document review, and policy review, the facility failed to ensure water was at a comfortable temperature in the shower rooms on the fourth floor for two (Resident (R)161 and R15) of three residents reviewed for a comfortable/homelike environment out of a total sample of 30 residents. Bathing in water that is not warm enough can have serious negative effects, particularly for those with underlying health conditions and can decrease their quality of life.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to implement an appropriate intervention to keep feet and legs elevated for a resident in a geriatric chair for one (Resident (R)106) out of a total sample of 30 residents. This failure had the potential for severe complications due to reduced circulation.

Inspectors wroteRefer to F-760 Based 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 to ensure a.) accurate documentation of the removal of a controlled substance for 1 of 5 residents (Resident #12), reviewed for an as needed (PRN) 5/325 milligram (mg) of Oxycodone/Acetaminophen (a narcotic medication, indicated for pain), b.) accurate reconciliation and administration of narcotic medication with potential for drug diversion for 2 of 5 residents (Resident #12 and #212) reviewed for a PRN pain medicine, c.) discontinued narcotic medications were removed from active inventory and disposed of after being discontinued on 11/27/23 (5 months) for Resident #80. [...]

Inspectors wroteRefer to F 755 Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that a resident received as needed (prn) narcotic (a controlled drug that produces pain relief) medication in accordance with the prescriber's orders and accepted professional standards. The deficient practice was identified for 1 of 5 residents (Resident #212) reviewed for prn narcotic administration. The deficient practice was evidenced by the following: On 04/30/24 at 10:35 AM, the surveyors requested a list of all residents receiving the prn narcotic oxycodone 5/325 mg (milligrams) from Director of Nursing (DON). [...]

Inspectors wroteBased 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, c) maintain 4 of 4 nursing unit kitchenettes used for residents in a sanitary manner, and d) properly dispose of used cooking oil according to regulations. These deficient practices observed as evidenced by the following: On 04/22/24 at 09:42 AM, in the presence of the Food Service Director (FSD) and the food service manager (FSM), the surveyor toured the kitchen and observed the following: 1. In the walk-in freezer, the surveyor observed 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 wroteBased on observation, interview, and review of the facility provided documents, it was determined that the facility failed to ensure: a) the staff handled, stored, and processed linens and other supplies in a clean manner and to prevent possible contamination for two (2) of two (2) rooms (Laundry and Linen Storage) according to facility's policy and Centers for Disease Control and Prevention (CDC) guidelines, b) routine, ongoing, and systematic monitoring and tracking of facility's water management, and c) policy was reviewed and updated to reflect and address the need of the facility according to clinical standard of practice and CDC guidelines, d) maintain the resident's Tube Feed hydration bag with proper infection control practices for one (1) of five (5) residents reviewed for Tube Feeding, and e) a urinary catheter drainage bag and a urinary catheter tubing were maintained and [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to maintain a safe and sanitary environment for: a) two (2) of two (2) rooms (Laundry and Linen Storage) and b) two (2) of two (2) shower rooms. This deficient practice was evidenced by the following: 1. On 4/25/24 at 11:41 AM, the surveyor in the presence of the Director of Housekeeping (DH) observed in the Laundry Room the following: Upon entry, there was a puddle of water near the door and the washer. There was one towel heavily wet with puddle water. The DH informed the surveyor that the puddle of water was from the washer and it was reported already to the maintenance department last week. The laundry room had one big garbage open container with stagnant water blackish in color with garbage and used surgical mask. [...]

Inspectors wroteBased on observation, interview and review of other facility documentation, it was determined that the facility failed to protect resident's privacy and independence in a dignified manner. This deficient practice was identified for one (1) of 30 residents reviewed for dignity and well-being (Resident #53). This deficient practice was evidenced by the following: On 4/22/24 at 10:58 AM, the surveyor observed on the front of Resident #53's room door (hallway side) signage that read, Attention, room [# redacted] [name redacted], needs to be fed by the nurse only! Please read and take note: Nurse Feeder, room [# redacted], [name redacted], dated 3/15/24. Another sign on the same door revealed, Stop and Read: Do not give [name redacted] the remote control for bed. Thank you. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to address a Do Not Resuscitate (DNR) (It's a medical order that instructs health care providers not to perform cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating) and Do Not Intubate (DNI) (a medical document that indicates a patient does not want to be intubated or receive CPR in event of cardiopulmonary arrest) code status order signed by the resident's family and Physician with no follow-up change of the physician's order (PO) or update of the comprehensive care plan to indicate a code status change. This deficient practice was identified for 1 of 33 residents, (Resident #55) reviewed for advanced directives. This deficient practice was evidenced by the following: [...]

Inspectors wroteComplaint # 171606 REPEAT DEFICIENCY Based on interviews, review of the medical records (MRs) and other facility documentation, it was determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) as required and according to the facility's policy for 2 of 3 residents (Resident #210 and # 211) reviewed for injury of unknown origin. This deficient practice was evidenced by the following: 1. According to the admission record (AR), Resident #210 was admitted to the facility with diagnosis which included but were not limited to: Chronic kidney disease Stage 4 (a gradual loss of kidney function) and chronic embolism and thrombosis of unspecified deep veins of left lower extremity (a blood clot in a deep vein that has lasted for at least a month). [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) follow physician's orders (PO), b.) ensure an individualized comprehensive care plan and interventions were developed and implemented, c.) ensure that the weekly skin review assessment was accurate, and d.) appropriately perform infection control practices during wound treatment observation in accordance to standards of clinical practice, CDC (Centers for Disease Control and Prevention) guidelines, and facility's policy and procedure. This deficient practice was identified for one (1) of five (5) residents (Resident # 122) reviewed for pressure ulcers. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. [...]

Inspectors wroteBased on observations, interviews, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure that residents with decreased range of motion and mobility received treatments to prevent contractures or further contraction specifically by a) not following a Functional Maintenance Program (FMP) recommendation for splints for 1 of 3 residents reviewed for position and mobility (Resident #20); and b) not following a FMP recommendation for range of motion (ROM) for 1 of 3 resident's reviewed for position and mobility (Resident #112). The deficient practice was evidenced by the following: 1. On 4/22/24 at 10:50 AM, the surveyor observed Resident #20 seated in a reclined wheelchair in the fourth floor unit dayroom. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to ensure that staff provided adequate routine monitoring for a resident after returning from receiving offsite hemodialysis and provided care and services in accordance with professional standards clinical practice for one (1) of three (3) residents (Resident #22), reviewed for dialysis services. The 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, review of the medical record and other facility documentation, it was determined that the facility failed to ensure that the documented coordination/communication was consistent and was provided between facility staff and hospice staff for one (1) of three (3) residents reviewed for hospice and end of life (Resident #93). This deficient practice was evidenced by the following: On 4/29/24 at 11:51 AM, the surveyor observed Resident #93 asleep in their bed. The surveyor reviewed the medical records of Resident #93. [...]

Inspectors wroteBased 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 one (1) of the 28 residents reviewed, Resident #147. This deficient practice was evidenced by the following: On 4/22/24 at 9:49 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM). The RN/UM informed the surveyor that Resident #147 was on contact precaution for C. diff (also known as Clostridioides difficile or C. difficile, is a germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon). On 4/22/24 at 10:04 AM, the surveyor observed Resident #147's room with a posted sign for contact precaution and PPE (personal protective equipment) hung outside the door. The resident was seated in a wheelchair with a responsible party (RP) inside the room wearing gloves and a gown. [...]

Inspectors wroteBased on observation, interview, record review, and pertinent facility documents, it was determined that the facility failed to a.) consistently follow physician's orders (PO) for off-loading bilateral heels to prevent the development of a stage IV facility acquired pressure injury, b.) ensure an individualized comprehensive care plan interventions were developed and implemented to a prevent facility acquired pressure injury wound from developing, and c.) ensure a Registered Nurse assessed and documented the development of a stage IV facility acquired pressure injury identified on 10/29/21; and d.) ensure weekly skin checks were conducted according to physician's orders. This deficient practice was identified for 1 of 5 residents (Resident # 117) reviewed for pressure injury wounds. On 12/13/21 at 1:36 PM, the surveyor observed Resident # 117 in bed sleeping. [...]

Inspectors wroteBased on observation, interview, record review, and pertinent facility documentation, it was determined that the facility failed to a.) ensure physician's orders were followed with accountability for an orthotic device and Restorative Nursing Program (RNP) from 7/7/20 through December 2021 for Resident # 34, b.) ensure physician's orders were followed for a right-hand palm protector with finger separator, c.) maintain accountability for the right-hand device from October through December 2021; and d.) develop and implement a care plan for the right- hand device for Resident # 23. This deficient practice was identified for 2 of 7 resident's, (Resident # 34 and Resident # 23) reviewed for limited range of motion (ROM). This deficient practice was evidenced by the following: 1. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) appropriately perform infection control practices during wound treatment observations for 2 of 2 residents, (Resident # 51 and Resident # 117), b.) appropriately don (put on) and doff (remove) Personal Protective Equipment (PPE), in accordance with Centers for Disease Control and Prevention (CDC) guidelines, before and after exiting a resident's room who was on Transmission Based Precautions (TBP) due to being a Person Under Investigation (PUI) for 1 of 1 resident (Resident # 266) on TBP on the yellow wing on the third floor, c.) appropriately disinfect multiuse medical equipment in a rehabilitation (rehab) gym area designated for PUI residents, d.) maintain a designated closed structure for the PUI gym to maintain appropriate social [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain the necessary respiratory care and services for a resident who was receiving continuous oxygen (O2), BiPAP (also known as Bilevel Positive Airway Pressure, a small breathing device that can help a person to breathe more easily), and nebulizer (neb) treatment according to standards of practice. This deficient practice was identified for 1 of 2 residents (Resident # 147) reviewed for respiratory care. This deficient practice was evidenced by the following: On 12/13/21 at 10:24 AM, the surveyor observed Resident #147 laying on a bed, eyes closed, with O2 in use via nasal cannula (n/c) at 2 LPM (2 liters per minute) attached to the humidified O2 concentrator (a medical device used for delivering O2). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication times of administration to accommodate for dialysis scheduled times and documenting accurate medication administration times. This deficient practice was identified for 1 of 4 residents, (Resident #267), reviewed for dialysis services and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]