Shady Lane Gloucester Co Home

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to develop and implement a comprehensive care plan that identified an assistive device to help maintain the resident's highest practical and physical well-being for a resident who required bilateral foot braces. This deficient practice was identified for 1 of 2 residents reviewed for positioning and mobility (Resident #29), and was evidenced by the following:On 9/2/2025 at 8:04 PM, during the initial tour of the facility, the surveyor observed Resident #29 with their eyes closed. The resident's foot braces were observed on the floor near the window. On 9/3/2025 at 10:16 AM, during a follow-up visit with the resident, they stated that they did not like to wear the braces, but would wear them occasionally. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) and the State Ombudsman, an unwitnessed fall which resulted in fractures to multiple right foot metatarsal heads (bones located in the mid-foot). This deficient practice was identified for 1 of 3 residents (Resident #22) reviewed for accidents and was evidenced by the following: A review of the facility provided policy and procedure, Incident and Accident Report/Falls reviewed 03/2024, which included but was not limited to; to accurately record any incident or accident when it occurs in accordance with legal liabilities and state and federal regulations. Procedure 1. Incidents or accidents include but are not limited to . any happening or experience which may be traumatic or inflict bodily injury . [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to ensure medications were dated upon opening and all medications were secured inside the medication cart. This deficient practice was identified in 1 of 2 medication carts observed and was evidenced by the following: 1. On [DATE] at 7:35 am, the surveyor observed the Licensed Practical Nurse (LPN) in an adjacent hallway. The surveyor approached the LPN and informed her that she would be observed for medication administration. The LPN had a Bingo card of medication in their hands. The LPN placed the Bingo card on top of the medication cart and wheeled the medication cart to the next hallway. On [DATE] at 7:57 AM, the LPN entered Resident #29's room and left the Bingo card on top of the medication cart. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent documents, it was determined that the facility failed to ensure that all staff used appropriate hand hygiene and proper disinfection while providing wound care to a resident, and were adhered to infection control practices in accordance with facility policy regarding medication administration. This deficient practice was observed for 1 of 1 resident (Resident #15) investigated for Pressure Ulcers/Injury and during the medication administration observation as evidenced by the following: On 04/01/2024 at 9:38 AM, the surveyor observed Resident #15 lying in bed awake and alert. Resident #15 is noted to be on enhanced barrier precautions (EBP). Resident #15 stated that he/she had a bone infection in the left heel that resulted in a left heel wound. [...]

Inspectors wroteBased on interview and review of other pertinent facility documentation, it was determined that the facility failed to 1.) include a standardized infection assessment tool or management algorithm when prescribing antibiotics, 2.) provide evidence of staff education about antibiotic stewardship and 3.) provide evidence of antibiotic monitoring during quarterly reviews. These deficient practices were identified during investigation of the Infection Control Task. The deficient practice was evidenced by the following: 1.) On 4/6/22 at 1:17 PM, during an interview with the surveyor, the Director of Nursing (DON) stated that the facility does not use any standardized criteria for determining infections. [...]

Inspectors wroteBased on interview, and review of other facility documentation, it was determined that the facility failed to develop and implement a policy to include contingency plans that address staff who are not fully vaccinated due to an exemption or temporary delay in vaccination, to include implementing additional precautions. This deficient practice was evidenced by the following: During Entrance Conference with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing on 4/1/22, the surveyor requested a copy of the facility policy and procedures regarding staff vaccination for Covid-19. On 4/6/22 at 9:44 AM, the LNHA provided the Surveyor a document titled Infection Control Employee Mantoux Testing, COVID 19 Vaccinations, that included the following vaccination related policies and procedures: [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to document bimonthly weights per the physician order and in accordance with professional standards for 1 of 17 sampled residents (Resident #29). 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, record review and review of other facility documentation, it was determined that the facility failed to follow their own policy for storage of respiratory equipment. This deficient practice was identified for 1 of 3 (Resident #33) residents reviewed for respiratory concerns and was evidenced by the following: During a tour of the facility on 4/1/2022 at 10:40 AM, Resident #33 was observed lying in bed. The surveyor observed the nebulizer machine (a nebulizer machine delivers aerosol medication to the person via a mouthpiece and chamber/cup that holds the medication, via tubing that is attached to the machine. It is used to treat respiratory conditions such as COPD, bronchitis, and asthma.) on a cabinet next to the resident's bed. The surveyor observed the tubing and mouthpiece of the nebulizer machine exposed to air and uncovered. [...]