Wedgwood Gardens Care Center

Inspectors wroteBased on interview, record review, and review of Centers for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating and Air-Conditioning (ASHRAE) recommendations, the facility failed to implement their water management program to reduce the potential for exposure to opportunistic waterborne pathogens including Legionnaire's disease (a serious pneumonia infection). This had the potential to affect 92 of 92 residents who resided at the facility. Findings Include: Review of the CDC document titled Legionella . Prevention and Control, dated 03/25/21 and located at https://www.cdc.gov/legionella/index.html, indicated . The key to preventing Legionnaires' disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella . Key Elements . [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the privacy of health information for one of two residents (Resident (R) 71) that tested positive for a virus out of a total sample of 26. This failure had the potential to affect the psychosocial well-being of any of the current 92 residents should they contract a communicable illness.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to develop a comprehensive care plan for one of two residents (Resident (R) 7) reviewed for oxygen in a total sample of 26. This had the potential for the resident not to receive appropriate monitoring and treatment.

Inspectors wroteBased on observation, review of the monthly resident council meeting minutes, interview, and facility policy review, the facility failed to ensure the State survey inspection results were readily accessible to residents and/or family members and posted in areas of the facility that are prominent and accessible to the public. This failure had the potential to affect all 92 residents residing in the facility. This had the potential to cause residents and visitors to be uninformed of survey, certification, and complaint investigation findings.

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined the facility failed to: a.) protect residents from the potential for significant medication errors by not following the standards of practice for the administration of medication, and b.) implement the facility policy for Medication Administration when 1 of 3 nurses (Licensed Practical Nurse) on 1 of 3 units (Garden) observed during a medication pass observation prepared and attempted to give high-risk medications to the wrong resident. On 02/22/23, the surveyor observed the Licensed Practical Nurse (LPN #1) attempt to administer six specific medications for lowering blood sugar and blood pressure, an anticoagulant (blood thinner), multivitamins, and a liquid protein supplement medication. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate infection control practices for proper hand hygiene during meal observation in 1 of 1 resident dining rooms (Main Dining Room), b.) ensure staff wore appropriate proper personal protective equipment (PPE) for a resident on transmission-based precautions (TBP) (Resident #57), and c.) provide proper hand hygiene and proper infection control practices for 1 of 3 nurses observed during medication adminsitration. This deficient practice was identified on 1 of 3 nursing units (Garden). This was cited at a level F as the deficient practice was cited at the last standard survey of 01/20/21. The deficient practice was evidenced by the following: 1. On 02/14/23 at 12:24 PM, the surveyor observed staff serve lunch to residents in the Main Dining Room. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for 1 of 2 residents reviewed for Hospice (Resident #29). This deficient practice was evidenced by the following: On 02/15/23 at 12:14 PM, the surveyor observed Resident #29 in the main dining room alert and confused, sitting in a reclining chair. A Certified Nurse Assistant (CNA #1) was sitting next to the resident and feeding the resident. CNA#1 stated that resident was a good eater and can consume 100% of the lunch meal. On 02/16/23 at 1:03 PM, the surveyor reviewed Resident #29's electronic medical record. The resident was admitted to the facility with diagnoses that included but were not limited to: [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure that the 24-hour staffing information was updated and accurately displayed daily. This deficient practice was evidenced by the following: On 02/21/23 at 12:09 PM, the surveyor observed the facility's Wedgwood Gardens Care Center NJ Dept of Health & Senior Services Resident Care Staffing Report dated 02/20/23, in a clear plastic sleeve at the front receptionist desk. On 02/22/23 at 8:45 AM, and 02/23/23 at 8:50 AM, upon entry into the building, the surveyor observed the facility's Wedgwood Gardens Care Center NJ Dept of Health & Senior Services Resident Care Staffing Report dated 02/20/23, in a clear plastic sleeve at the front receptionist desk. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain accurate accountability and reconcililation for controlled medications. This deficient practice was identified for 1 of 3 medication carts (Iris Unit) inspected and was evidenced by the following: On 02/22/23 at 9:24 AM, the surveyor, in the presence of the Licensed Practical Nurse (LPN), inspected the [NAME] Unit medication cart. On 02/22/23 at 9:30 AM, the surveyor, in the presence of the LPN, observed the narcotic medication located in the secured and locked narcotic box. [...]

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 observation performed on 02/22/23, the surveyors observed three nurses administer medications to four residents. There were 31 opportunities, and six errors were observed, which calculated to a medication administration error rate of 19.35 %. This deficient practice was identified for one of four residents, (Resident #49), that were administered medications by one of three nurses. The deficient practice was evidenced by the following: On 02/22/23 at 8:06 AM, the surveyor observed LPN #1 during medication pass on the Garden Unit. Resident #74, who was positioned by the bed near the window, did not have an identification (ID) band but was able to identify themself. [...]

Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to a.) offer residents hand hygiene prior to meals and b.) consistently don appropriate Personal Protective Equipment (PPE) (gowns, gloves and protective eyewear) to minimize the potential spread of infection. This deficient practice was observed on 3 of 3 units and was evidenced by the following: 1. On 01/13/21 at 12:06 PM, the surveyor observed the meal service in the [NAME] Dining Room for Residents #38, #42, #66, and #70. The surveyor observed the trays were brought into the [NAME] Dining Room by several staff members for Residents #38, #42, #66 and #70. With each observation, the staff member set up each resident's meal, opening lids, containers and cartons. The surveyor did not observe the staff member offer each resident hand hygiene. [...]