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F0838
D

Facility Assessment Lacks Ventilator-Dependent Resident Planning

Holmdel, New Jersey Survey Completed on 12-29-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that its facility-wide assessment (FA) adequately identified and addressed the required services and procedures necessary for ventilator-dependent residents. Upon review, the FA did not specify that the facility was licensed for 12 ventilator care beds in addition to 220 long-term care beds, nor did it include ventilator-dependent residents under the sections for diseases/conditions, resident support/care needs, staff training/education and competencies, or physical environment and equipment needs. The FA only referenced general respiratory conditions such as COPD, pneumonia, asthma, and respiratory failure, but did not specifically mention ventilator dependency or related requirements. During interviews, facility leadership confirmed that the FA was current but could not identify any vent-specific or related assessments within the document. When asked, the Vice President of Clinical stated that ventilator care was covered under the general respiratory category, and the President of Operations asserted that federal regulations do not require specific mention of ventilator care in the FA. The surveyor noted that the omission of ventilator-specific planning, licensing, and resources in the FA constituted a deficiency, as the facility did not comprehensively address the needs of ventilator-dependent residents as required.

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