Careone At Middletown

Penalty

No penalty information released

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 have a system in place to ensure quarterly financial statements were provided to residents or resident representatives for residents who maintained Personal Needs Accounts (PNA) with the facility. During a resident council meeting, one resident with PNA funds stated that the facility had never provided a quarterly financial statement and said such a statement would be helpful to know how much money was in the account. The facility later provided a trial balance showing 42 total PNA accounts with a combined balance of $19,849.61. Additional interviews confirmed the same issue. One resident stated they did not know how much money they had in their account and had never received a quarterly statement. The Business Office Manager stated that residents and/or resident representatives were not provided quarterly financial statements for PNA accounts, although the facility would provide one if asked. A resident representative also stated they had not received quarterly statements and relied on the facility to inform them of the balance, while the LNHA stated they were not aware residents or resident representatives had not received quarterly financial statements and that he was responsible for ensuring the process was happening. The facility policy on Resident Trust Accounts addressed safeguarding resident funds and accurate record keeping, but did not include a process for providing quarterly financial statements.

Penalty

No penalty information released

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 have a system in place to ensure residents or their responsible parties were notified when funds held in Personal Needs Accounts reached the $2,000 SSI maximum or $200 less than that amount. This deficient practice was identified for 2 of 2 residents reviewed for PNA accounts and affected all 42 residents with PNA funds held by the facility. A review of the facility’s Trial Balance report showed one resident with a PNA balance of $3,155.97 and another with a balance of $1,938.69. During interviews, one resident stated they had been receiving $50 per month from their PNA and had previously gone to the business office to request money, but it had become more difficult because they were less mobile. The resident also stated they had limited clothing and would have liked to buy more, but needed help figuring out how to purchase items. A CNA caring for the other resident, who was confused and non-interviewable, stated the resident had only one pair of slip-on shoes from a donation box and could have used shoes with grip for transfers. The BOM stated she did not have a process to manage PNA funds to ensure residents did not lose Medicaid and relied on the resident representative, while the resident representative stated they were only informed by the facility that day that the resident had a lot of money and needed new clothing and shoes. The LNHA stated he was not aware the facility did not notify residents or resident representatives when PNA funds reached the SSI maximum or $200 less than the maximum.

Penalty

No penalty information released

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 adequate supervision and accident prevention for two residents. One resident with diagnoses including cerebral ischemia, chronic kidney disease, and a frontotemporal neurocognitive disorder was observed confused, wandering in the hallway, and asking for help finding the room. The resident was also observed in the dayroom with other residents and no staff present. The CNA stated the resident was confused at times and used a Foley catheter with a leg bag during the day. The resident had sustained two prior falls in the bathroom after attempting to toilet independently, but the comprehensive care plan still reflected only general fall interventions such as frequent rounds, toileting rounds, and reminders to call for assistance. Record review and interview showed that the resident’s fall investigations identified falls occurring when the resident tried to go to the bathroom alone, yet the care plan had not been revised after those falls. The DON stated that the causal factor for each fall should be identified and the care plan revised to implement or change interventions to prevent further falls. However, the surveyor and DON observed that no revisions had been made to the care plan after the falls, and the interdisciplinary notes showed the care plan was last updated months earlier. There was no documentation that the bathroom-related falls had been addressed in the care plan. Another resident with severe dementia and a high fall risk was observed entering another resident’s room after leaving the dayroom, and a CNA redirected the resident back to the dayroom. The resident’s care plan included interventions to prevent wandering into other residents’ rooms and to redirect the resident when wandering occurred. The record also showed multiple prior incidents, including a fall after entering another resident’s room and a physical altercation with another resident, as well as reports that the resident kept coming into another resident’s room during the night. The DON could not locate one investigation, and the resident was observed in the dayroom with other residents and no staff in attendance.

Penalty

No penalty information released

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 Resident #62 was assessed for the appropriate call bell device and that the device was within reach. On 5/19/26 and again on 5/22/26, the surveyor observed the resident in bed with the call bell placed on the bedside table and out of reach. When the surveyor and the LPN/UM checked the room, the LPN/UM verified that the resident could not access the call bell and stated the resident was very limited and could not reach it. The resident’s record showed diagnoses including muscle weakness, difficulty walking, lack of coordination, and major depressive disorder, and the quarterly MDS indicated extensive assistance was needed for toileting, bed mobility, and transfers, with functional limitations of the extremities and moderate cognitive impairment. The surveyor asked the resident about the call bell, and the resident could not locate it and stated that sometimes they yelled for assistance or waited for someone to come to the room. The LPN/UM later stated that the resident should have a call bell within reach and confirmed the resident could not reach the device where it was placed. When the call bell was changed to a tap bell, the MD stated he had only just been made aware that the resident needed that device, and the facility did not inform or explain how to operate it when it was placed on the bed. The resident was observed with tremors and deformities of both hands, and the CNA stated the resident would yell and scream and would not press the call bell, adding that she was not aware the tremors and deformities could prevent use of the device.

Penalty

No penalty information released

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 consistently provide appropriate and timely incontinence care for residents who were dependent on staff assistance for activities of daily living. The deficiency was identified for two residents who required extensive assistance with ADLs and were both incontinent of bowel and bladder. One resident had intact cognition and reported that during the 3:00 PM to 11:00 PM shift, incontinence care was not provided in a timely manner, stating that urine had to accumulate several times before being changed. During observation, one resident was found soaked with urine in bed, with the bedding also soiled and yellow stained. The resident stated they were wet and needed to be changed, and reported the last incontinence care had been provided about four hours earlier. Another resident was observed during care with a brief soaked with urine, and the resident’s sacral dressing was also soaked with urine. That resident could not state when incontinence care had last been provided. The CNA caring for that resident acknowledged that no incontinence care had been provided since the start of the shift and stated she had been waiting for the nurse to be available to change the sacral dressing. Record review showed both residents had care plans addressing ADL deficits and urinary incontinence. One resident’s care plan called for assistance with daily hygiene, grooming, dressing, eating, oral care, bathing, and showering as needed. The other resident’s care plan included assistance with toileting or incontinence care as needed and a goal to be free from skin breakdown. The DON stated that incontinence care was to be provided every 2 to 3 hours and as needed, and before meals to ensure residents were not soiled, with nurses and unit managers responsible for ensuring timely care.

Penalty

No penalty information released

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 a Registered Nurse documented a resident’s assessment after an unwitnessed fall. The resident had diagnoses including muscle weakness, macular degeneration, and difficulty walking. The fall occurred when a CNA heard a noise from the resident’s room and found the resident on the floor next to the bed, lying on the back. The resident was noted to have a hematoma to the back of the head, and neuro checks were initiated. The nursing note and change-of-condition note were both signed by an LPN, and there was no RN signature in the electronic medical record. The facility’s fall investigation stated that the resident fell while attempting to go to the bathroom and that an LPN documented the immediate actions taken, including that an assessment was completed, a hematoma was observed, neuro checks were initiated, and the resident was assisted back to bed. The investigation also reflected that the resident was assisted back to bed by a CNA and a nurse. During interview, the LPN could not recall the fall and stated that if a resident fell and hit their head, she would call an RN to assess the resident and, if no RN was available, would stay with the resident and have the CNA call for paramedics. The DON stated that an LPN can evaluate a resident who had a fall but only an RN could assess the resident, and also stated that an LPN was not allowed to transfer a resident back to bed after a fall until the resident is assessed by an RN. The DON and LNHA stated that an RN was in the building at the time of the fall, but they had no documentation from the RN regarding the resident’s fall. The RN job description required monitoring residents for acute changes of condition, conducting assessments, and maintaining documentation of nursing care and services.

Penalty

No penalty information released

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 obtain a physician’s order for removal of a resident’s BIPAP and failed to ensure the orders for changing the BIPAP mask and tubing were accurate. Resident #9 was admitted with diagnoses including interstitial pulmonary disease, COPD, and CHF, and the quarterly MDS reflected a BIMS score of 15 out of 15 and that the resident was receiving non-invasive mechanical ventilation. The care plan identified the resident as having or being at risk for respiratory impairment related to sleep apnea, acute respiratory failure, obesity, and heart failure, with an intervention for BIPAP use per physician orders. The physician orders and MAR/TAR for May 2026 showed an order to apply BIPAP at bedtime, an order to wash the mask daily in the morning, and two separate orders for changing the BIPAP mask and tubing: one stating every night shift every 6 months and another stating every evening every 1 month. The record did not contain a physician’s order specifying when to remove the BIPAP after it was applied. The TAR also reflected nurse’s initials and checkmarks for the mask and tubing change order on every date reviewed, which the unit manager acknowledged meant the treatment was documented as completed daily. During interviews, the RN stated the BIPAP was put on at night and was already off by the time she started her shift, but she did not know what time it was removed. The resident stated the BIPAP mask was applied at night and removed in the morning around 5 or 6 AM. The unit manager acknowledged there was no order to remove the BIPAP, that the wash order did not include removal, and that the daily initials on the TAR indicated the mask and tubing were changed every day, which she stated was not the proper facility protocol. The DON also acknowledged there was no order to remove the BIPAP, that the orders for changing the mask and tubing were conflicting, and that the respiratory therapist stated the mask and tubing should be changed monthly.

Penalty

No penalty information released

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 maintain a sanitary kitchen environment and properly functioning equipment, which could potentially lead to contamination or the spread of foodborne illness. During a kitchen tour, the surveyor observed that the metal baffles inside the exhaust hood were visibly soiled with black debris, grease, and grime. Additionally, the nozzles of the fire suppression system were covered in a grease-like substance. The Food Service Director (FSD) confirmed these findings and admitted to not having a cleaning schedule in place for the baffles. Furthermore, the surveyor noted that the only handwashing sink in the kitchen dispensed water at a temperature of 74 degrees Fahrenheit, which is below the required range of 90 to 110 degrees Fahrenheit for effective handwashing. The FSD acknowledged that cold water would not effectively remove bacteria. Additionally, insulated tray lids were found stacked with the food-covering side open and unprotected under a visibly soiled stainless steel table. The facility's cleaning policy, which was undated, stated that surfaces must be cleaned with a sanitizing agent and that grid panels in the fire suppression hood should be cleaned monthly, indicating a lack of adherence to these guidelines.

Penalty

No penalty information released

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 the resident call bell system was properly functioning, which had the potential to affect all residents. During observations and interviews conducted between January 8 and January 10, 2025, in the presence of the Maintenance Assistant, Regional Director of Maintenance, and Senior Regional Director of Maintenance, it was found that the call bell system in several rooms did not send activation signals to the nurse's station. Specifically, on January 9, 2025, the call bell in one room showed an ERROR CONNECTIVITY signal at the nurse's station on unit 3. Further investigation revealed that the annunciator cord was not fully inserted. Additionally, another room's call bell failed to send a signal because the annunciator at the nurse's station was unplugged and not powered on. These issues were brought to the attention of the facility's Administrator during the Life Safety Code exit conference.

Penalty

No penalty information released

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 update and maintain accurate care plans for activities for two residents, leading to deficiencies in their care. Resident #26, who primarily speaks Spanish, was observed without any activities or Spanish language materials in their room. The CNA assigned to Resident #26 was unable to communicate effectively with the resident due to the language barrier and was unaware of the resident's activity preferences. The electronic medical record indicated that the resident required an interpreter, yet the care plan inaccurately documented the resident's language as English and did not include any Spanish activities. The Activities Director was unable to provide evidence of any sensory programs or activities tailored to the resident's cognitive status and language needs. Resident #24's care plan was outdated and had not been revised since 2020, despite changes in the resident's condition and preferences. The activity calendar on the unit did not include all times and locations of activities, and there was no documentation of Resident #24's participation in activities. The resident's care plan indicated a preference for independent activities, but there was no recent evaluation or update to reflect the resident's current interests or participation levels. The Activities Director acknowledged the lack of documentation regarding the resident's activity attendance and preferences. The facility's policy on comprehensive person-centered care plans requires regular assessments and updates to reflect residents' strengths, needs, and preferences. However, the interdisciplinary team failed to review and update the care plans for both residents, resulting in a lack of personalized and culturally appropriate activities. The Director of Nursing acknowledged the oversight in Resident #24's care plan review and revision, and the facility had no additional information to provide regarding the deficiencies.

Penalty

No penalty information released

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 activity assessments accurately reflected the needs of all residents, particularly for a non-English speaking resident and another resident whose yearly activity assessment was incomplete. Resident #26, who primarily speaks Spanish, was observed multiple times without engaging in any activities and without the presence of activity staff. The resident's care plan inaccurately documented that the resident spoke English, and there were no activities provided in Spanish or tailored to the resident's cognitive status. The Activity Director admitted to not having any sensory type programs for cognitively impaired residents and could not provide documentation of activities offered in the resident's native language. Resident #24 was observed in their room or in the day room watching television, with no active engagement in activities. The resident's care plan indicated a preference for independent activities, but there was no documentation of the resident being invited to participate in activities of interest, such as music events. The facility's activity evaluation for this resident was outdated and incomplete, and there was no consistent documentation of the resident's participation or refusal of activities. The facility's policies on activity programs and documentation were not adhered to, as evidenced by the lack of documentation for resident participation in activities and the absence of tailored activities for residents with specific needs. The Activity Director acknowledged the deficiencies in documentation and the lack of tailored activities for residents with cognitive impairments or language barriers. The facility administration was unable to provide additional information to address these concerns.

Penalty

No penalty information released

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 a system was in place to inspect the emergency crash carts (ECC) for expiration dates and placement, as observed by surveyors across three resident sections. During the inspection, it was found that the ECCs were locked, but the checklists on top of the carts were incomplete and lacked instructions. Items such as the AED, suction machine, IV kit, and others were not documented as checked. Additionally, a resuscitation bag was observed hanging on the ECC, which was not included in the checklist. The Licensed Practical Nurse Infection Preventionist (LPN IP) and other staff members acknowledged the absence of a policy or procedure for inspecting the ECCs, and there was confusion about who was responsible for checking expiration dates. Further observations revealed that the ECCs contained expired items, such as a resuscitation bag and IV insertion kits. The Licensed Nursing Home Administrator (LNHA) and Registered Nurse (RN) Supervisor confirmed the lack of a policy and procedure for staff to follow when checking the ECCs. The facility administration was informed of these concerns, and although a new ECC checklist was created, it still did not include inspection of the resuscitation bag. The deficiency was identified as a failure to maintain a proper system for inspecting and ensuring the readiness of emergency equipment.

Penalty

No penalty information released

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 adhere to infection control standards, as evidenced by multiple observations and interviews. A Certified Nursing Assistant (CNA) was observed entering the room of a resident on Contact Precautions without wearing the required personal protective equipment (PPE), such as a gown and gloves, despite clear signage indicating the necessity of such precautions. The CNA admitted to not wearing PPE because she was only delivering a lunch tray and not providing direct care, although the facility's policy required PPE to be worn at all times in such rooms. The Licensed Practical Nurse/Unit Manager (LPN/UM) and the Infection Preventionist (IP) confirmed the importance of PPE usage in these situations. Another deficiency was noted with a resident who had an indwelling urinary catheter. The surveyor observed the resident's urinary drainage bag resting on the floor, which is against the facility's infection control policy that requires the bag to be secured to the bedframe to prevent contamination. The CNA and LPN acknowledged the error and stated that the bag should not have been on the floor. The facility's policy clearly states that catheter tubing and drainage bags must be kept off the floor to prevent infection. Additionally, a CNA was observed failing to perform hand hygiene after delivering a meal tray to a resident on Enhanced Barrier Precautions. Despite signage instructing staff to wash hands before entering and exiting the room, the CNA did not comply. The Infection Control Nurse confirmed that all staff had been educated on infection control prevention, yet the CNA did not follow the protocol. These observations indicate a lapse in adherence to established infection control procedures, as confirmed by interviews with facility staff.

Penalty

No penalty information released

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 adhere to physician orders for medication administration for a resident, leading to a deficiency. The resident, who had a history of acute kidney failure, repeated falls, and muscle weakness, was prescribed Midodrine HCL to manage hypotension, with specific instructions to hold the medication if the systolic blood pressure (SBP) exceeded 120. However, the electronic Medication Administration Record (eMAR) indicated that the medication was administered on multiple occasions when the resident's SBP was above the prescribed threshold, contrary to the physician's orders. Interviews with nursing staff, including an LPN and a Unit Manager, confirmed that the protocol was to check vital signs before administering the medication and to hold it if the SBP was greater than 120. Despite this, the medication was not held as required, and the staff acknowledged the oversight. The facility's policy on administering medications emphasized adherence to prescriber orders, yet this was not followed in the case of the resident, leading to the deficiency noted by the surveyors.

Penalty

No penalty information released

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 provide necessary grooming services for a resident who was dependent on staff for activities of daily living. The deficiency was observed in a resident who had been admitted with severe cognitive impairment and required total staff assistance for personal hygiene. Over several days, the resident was observed with long, thick facial hair, indicating a lack of grooming care. Despite being dependent on staff, the resident remained in bed for extended periods without receiving adequate grooming or personal hygiene care. The Certified Nursing Assistant (CNA) assigned to the resident was unaware that she could shave the resident, despite the facility's policy indicating that CNAs are responsible for such tasks. The Unit Manager and other staff members failed to notice or address the resident's grooming needs, resulting in the resident remaining unshaven for several days. The lack of supervision and communication among staff contributed to the oversight in providing necessary grooming care. The facility's policy on shaving and activities of daily living was not effectively communicated or enforced among the staff, leading to the resident's unmet grooming needs. The CNA's lack of awareness and the Unit Manager's failure to supervise and ensure proper care were significant factors in the deficiency. The resident's condition improved only after another CNA took the initiative to address the grooming issue, highlighting the need for better staff training and supervision.

Penalty

Inspection fine: $8,788

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 develop and implement a baseline care plan (BCP) within 48 hours of admission for a resident, which included the necessary healthcare information to address the resident's immediate needs. The resident was admitted with diagnoses including spinal stenosis, atherosclerotic heart disease, and type 2 diabetes. The Admission Minimum Data Set (MDS) indicated the resident had an intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and a moderate depression score of 10 on the Resident Mood Interview. However, no BCP was initiated to address the resident's mood. The Director of Social Services (DSS) acknowledged the responsibility to assess the mood section of the MDS and stated that a referral for psychological services was made, but could not provide documentation of the referral or services provided. The DSS admitted that a mood care plan should have been initiated due to the high mood score. The facility's policy required a baseline care plan to be developed within 48 hours of admission, including therapy and social services, but this was not done for the resident in question.

Plan Of Correction

1/24/25 1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. 1) Resident #1 NU Ex Order 26.4(b)(1) at the facility. On 1/22/2024 the Assistant Director of Nursing /FE (ADON/FE) completed an audit of all new admissions in the last 30 days to ensure a baseline care plan was initiated within 48 hours of admission and included person-centered care planning. There were no untoward findings. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. 2) All residents have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur. 3) On 12/27/2024 the Assistant Director of Nursing/Facility Educator (ADON/FE) immediately provided in-service education to all nurses including shift supervisors and unit managers on the procedure for developing a baseline care plan within 48 hours of admission. The baseline care plan must include the minimum healthcare information necessary to properly care for a resident including, but not limited to a) initial goals based on the physician orders; b) physicians orders; c) dietary orders; d) therapy orders; e) social services; f) PASARR recommendation, if applicable. On 1/22/2025 The ADON/FE provided in-service education to the [R] and U.S. FOIA (b) (6) regarding the process of developing a baseline care plan within 48 hours of admission. The baseline care plan must include the minimum healthcare information necessary to properly care for a resident. The Unit Manager or designee will review all new admission records daily to ensure a baseline care plan has been initiated within 48 hours of admission. This review will continue on an ongoing basis. On 1/22/2025 the ADON/FE provided in-service education to the [R] the [R] and U.S. FOIA (b) (6) on the importance of a personalized care plan for depression as well as psychology consult for any resident with a PHQ9 over the score of 10, which notes signs and symptoms of depression. The Director of Social Services and ADON/FE have created a formal record for tracking all referrals made to a psychologist. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change. 4) The Director of Nursing or designee will conduct audits of 100% of newly admitted residents to ensure a baseline care plan has been implemented within 48 hours of admission. The audits will continue daily on an ongoing basis to ensure compliance. The results of the audits will be reported to the Administrator and the Quality Assurance Performance Improvement (QAPI) Committee monthly x 3 months, then quarterly x 3 quarters. The Director of Social Services or designee will conduct audits of all residents who have referrals for psychology consults. The audits will be conducted weekly x 3 weeks, then monthly x 3 months, then quarterly x 3 quarters. The results of the audits will be provided to the Administrator and QAPI Committee monthly x 3 months then quarterly x 3 quarters. The QAPI Committee will review and determine need for further audits. The QAPI Committee meets on a monthly basis.

Penalty

Inspection fine: $8,788

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 maintain a safe environment and provide adequate supervision for a resident who was found with ligature marks around the neck. The incident involved a resident who had been admitted with diagnoses including spinal stenosis, atherosclerotic heart disease, and Type 2 diabetes. The resident had an intact cognition with a BIMS score of 15 out of 15 but was noted to be moderately depressed with a score of 10 on the Resident Mood Interview. Despite these indicators, there was no psychological assessment documented in the medical record. The incident report revealed that the resident had intentionally used the call bell cord, which had been disconnected from the wall, to attempt self-harm. On the morning of the incident, a CNA responded to the resident's call bell, which was ringing, and found the resident unresponsive with the call bell cord wrapped around their neck. The CNA untied the cord and called for help, after which the resident regained responsiveness. The Administrator was informed of the incident and noted that the call bell cord had been unplugged, which could occur inadvertently due to bed adjustments. However, the Administrator could not recall if the resident sustained any injuries, and no psychological assessment was completed prior to the incident, indicating a lack of adequate monitoring and supervision for the resident's mental health needs.

Plan Of Correction

1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 NJ Ex Order 26.4(b) (1) at the facility. The Assistant Director of Nursing/Facility Educator (ADON/FE) immediately conducted an audit of all residents who had physicians orders for a referral for psychology assessment to ensure the consult was completed. There were no untoward findings. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. All residents with referrals for psychology consults have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur. On 12/27/2024, The Assistant Director of Nursing/Facility Educator (ADON/FE) and the facility Administrator conducted in-service education to the psychology provider on the process for psychology consults. The practitioner has been advised of the implementation of a tracking form for all psych referrals to ensure compliance. The ADON/FE educated the psychology provider on the process of documenting refusal of referrals in the electronic medical record. The ADON/FE provided in-service education to all nurses on the implementation of a tracking form for all psychology referrals to ensure compliance. The ADON/FE provided in-service education to all staff on the process of keeping residents free from hazards and providing the necessary monitoring and supervision for those individuals who may have signs or symptoms of depression. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change. The Director of Nursing or designee will conduct audits of the psychology referral book to ensure all referrals for psychology or psychiatry consults are completed timely and documented. Audits will be conducted daily x 5 days, then weekly x 4 weeks, then monthly x 3 months. The results of all audits will be provided monthly x 3 months to the facility's Administrator and the Quality Assurance Performance Improvement (QAPI) Committee for review and comment. The QAPI committee meets on a monthly basis. The QAPI Committee will review and determine the need for further audits.

Penalty

Inspection fine: $8,788

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 Director of Social Services (DSS) at the facility failed to develop and implement policies and procedures for identifying and addressing the medically related social and emotional needs of a resident. This deficiency was identified during a survey when it was found that a resident, who had been admitted with diagnoses including spinal stenosis, atherosclerotic heart disease, and Type 2 diabetes, had a mood score indicating moderate depression. Despite this, there was no documentation of a referral for a psychological assessment or evidence that such an assessment was completed. The DSS claimed to have verbally referred the resident for psychological services, but no written documentation was provided to support this claim. Interviews with the DSS, the psychologist, and the facility's administrator revealed a lack of formal tracking and documentation of psychological referrals and assessments. The DSS admitted that there was no formal system in place to track whether residents identified as needing psychological assessments received them or if the services were effective. The facility's administrator acknowledged the expectation that concerns identified in screenings should be followed up with documented referrals, but was unaware of the lack of formal tracking until the survey. The facility's job description for the DSS required the development and implementation of policies to address residents' social and emotional needs, which was not fulfilled in this case.

Plan Of Correction

1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 NJ Ex Order 26.4(b) (1) at the facility. The Director of Social Services immediately conducted an audit of 100% of all residents to determine if their NJ Ex Order 26.4(b) (1) interview indicated a score of or greater, indicating the resident was NJ Ex Order 26.4(b)(1). The Director of Social Services identified 13 residents who had a score of or greater in section of the MDS and made a referral to the NJ Ex Order 26.4(b)(1) provider to ensure a NJ Ex Order 26.4(b)(1) assessment was conducted. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. All residents with a Resident Mood Interview (RMI) of 10 or greater have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur. On 12/27/2024 the Administrator provided in-service education to the U.S. FOIA (b) (6) with regards to the Directors responsibility which includes but is not limited to procedures for the identification of medically related social and emotional needs for residents and assisting residents in obtaining needed services from outside entities as needed. The Director of Social Services is the designated staff person who acts as the primary contact and coordinator for the contracted providers for psychiatry and psychology services. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change. The Director of Social Services or designee will conduct audits of 5 residents weekly to review the score of the Resident Mood Interview (RMI). Residents with a RMI equal to or greater than 10 will be referred by the Director of Social Services to the contracted psychology provider for consult. The audits will be conducted weekly x 3 weeks, then monthly x 3 months. The results of the audits will be provided monthly x 3 months to the facility's Quality Assurance Performance Improvement (QAPI) Committee for review and comment. The QAPI committee meets on a monthly basis. The QAPI Committee will review and determine the need for further audits.

Penalty

Inspection fine: $8,788

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 conduct a thorough investigation into an allegation of abuse involving a resident who no longer resides at the facility. The resident, who had a history of anxiety disorder, major depressive disorder, muscle weakness, difficulty in walking, and the presence of an artificial eye, was found on the floor beside their bed with their head under their wheelchair. The resident required substantial maximal assistance with activities of daily living and transfers and had some cognitive impairment. After a fall, the resident was sent to the hospital, where they reported being pushed, prompting an investigation by hospital social workers. However, the facility did not complete a thorough investigation as required by their policy. The facility's policy mandates that all reports of abuse, neglect, exploitation, or misappropriation are thoroughly investigated and documented. The investigation should include interviews with the person reporting the incident, any witnesses, the resident or their representative, and staff members who had contact with the resident. Despite this, the facility's investigation was incomplete, as acknowledged by the Administrator, who only became aware of the allegation after gathering documentation. The Director of Social Services, who was not employed at the time of the incident, stated that she would typically collect statements from the resident making the allegation but did not speak with other residents. The facility's failure to adhere to its policy resulted in an incomplete investigation of the abuse allegation.

Plan Of Correction

1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #2 NJ Ex Order 26.4(b)(1) at the facility. The Administrator immediately conducted an audit of all reportable events in 2024 involving allegations of NEXTER to ensure the allegation was thoroughly investigated. There were no untoward findings. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. All residents who report an allegation of abuse have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur. On 12/26/2024 the facility Administrator (LNHA) conducted in-service education with the U.S. FOIA (b) (6), the U.S. FOIA (b) (6), and Unit Managers (UM) on the policy titled, Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating. Education included but was not limited to all reports of resident abuse (including injuries of unknown origin), neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies & thoroughly investigated by facility management. On 12/26/2024 the FE/ADON conducted in-service education to line staff on the procedure for reporting allegations of abuse. On 12/26/2024 the Director Of Social Services conducted an audit of all grievances from 2024 to ensure all grievances were investigated and there were no allegations of abuse or mistreatment. There were no untoward findings. The LNHA is the designated individual at the Facility to investigate all allegations of Abuse, Neglect, Exploitation or Misappropriation. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change. The Director of Social Services or designee will conduct audits of all reported resident concerns or grievances to ensure allegations are immediately reported to the Administrator for a full and thorough investigation. Audits will be conducted daily x 5 days, then weekly x 4 weeks, then monthly x 3 months. The results of the audits will be provided monthly x 3 months, then quarterly x 3 quarters to the facility's Administrator and the Quality Assurance Performance Improvement (QAPI) Committee for review and comment. The QAPI committee meets on a monthly basis. The QAPI Committee will review and determine the need for further audits.

Penalty

Inspection fine: $8,788

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 maintain accurately documented and complete medical records for a resident, as evidenced by the absence of documentation for psychological assessment attempts and missing weight records. The resident, who was not present at the facility during the survey, had been admitted with diagnoses including spinal stenosis, atherosclerotic heart disease, and type 2 diabetes. The Admission Minimum Data Set (MDS) indicated an intact cognition and moderate depression. However, the psychologist's attempts to assess the resident were not documented, despite the psychologist stating that she had tried to see the resident multiple times but found him sleeping. Additionally, the facility did not document the resident's weekly weights for two consecutive weeks following admission, as required by the facility's policy. The Registered Dietician confirmed the missing weights and stated that new admissions should be weighed weekly for four weeks. The facility's policies on weight assessment and documentation were reviewed, revealing that all services and changes in the resident's condition should be documented to facilitate communication among the interdisciplinary team. The lack of documentation for both the psychological assessment attempts and the resident's weights led to the identification of this deficiency.

Plan Of Correction

1/24/25 1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 [R] NJ Ex Order 26.4(b) (1) at the facility. The Assistant Director of Nursing/Facility Educator (ADON/FE) immediately conducted an audit of all residents with referrals for J Ex Order 26.4(b)(1) assessment to ensure the assessment was completed timely. There were no untoward findings. The Dietician conducted an audit of all residents residing in the facility to ensure NJ Ex Order 26.4(b) (1) were obtained and entered in the electronic medical record for all new admissions. No residents had untoward effects related to this practice. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur. On 12/27/2024, The Assistant Director of Nursing/Facility Educator (ADON/FE) provided in-service education to all nurses on the importance of ensuring the contracted vendor for psychology services documented attempts for psychological assessments on residents. On 12/27/2024, The Assistant Director of Nursing/Facility Educator (ADON/FE) provided in-service education to all nurses, Certified Nursing Assistants (CNAs), and the U.S. FOIA (6) (6) on the procedure for documenting weights for new admissions. Weights will be obtained for all new admissions, on the date of admission to the facility. The Dietician or designee will review the admission weight the day after admission, to ensure it is documented in the electronic medical record. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change. The Unit Manager or designee will conduct audits of residents with psychology/psychiatry referrals to ensure the provider documents attempts to complete the psychological assessment. The audits will be conducted on 5 residents per week x 3 weeks, then 5 residents per month x 3 months, then 5 residents per quarter x 3 quarters to ensure compliance. The dietitian or designee will conduct audits of residents' admission weights to ensure proper completion. These results will be monitored weekly. The results of the audits will be provided monthly x 3 months, then quarterly x 3 quarters to the facility's Administrator and the Quality Assurance Performance Improvement (QAPI) Committee. The QAPI committee meets on a monthly basis. The QAPI Committee will review and determine the need for further audits.

Penalty

No penalty information released

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 meet the mandatory staffing ratios as required by New Jersey state law, specifically during the day shifts over a three-week period from December 1, 2024, to December 21, 2024. The deficiency was identified in 9 out of 21 day shifts, where the number of Certified Nurse Aides (CNAs) was insufficient to meet the mandated ratio of one CNA to every eight residents. This staffing shortfall was documented in several instances, with the number of CNAs ranging from 6 to 9, while the required number was at least 10 for the resident population during those shifts. The specific dates and staffing levels were as follows: On December 1, 4, 8, 9, 13, 14, 15, 16, and 21, the facility had fewer CNAs than required for the number of residents present. For example, on December 1, there were 7 CNAs for 79 residents, and on December 15, there were only 6 CNAs for 83 residents. These instances demonstrate a consistent failure to comply with the staffing requirements, which are crucial for ensuring adequate care and supervision of residents.

Plan Of Correction

1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice: The facility leadership team has met on an ongoing basis and continued to identify staffing challenges and areas of improvement for licenses and certified staffing needs. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur: The DON conducted an audit of staffing schedules with the current facility census to ensure fulfillment of staffing requirements per shift. The facility has implemented an incentive program including referral bonuses for employees referring staff where appropriate, conducted job fairs, immediate interviews with contingency offers, and expedited the onboarding process of new hires. The facility has contracted a vendor with agency staff as needed to meet staffing needs. The Director of Nursing and Director of Rehabilitation continue to partner in addressing staffing challenges. Where appropriate, the occupational therapy staff assist in providing care and activities of daily living to residents. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change: The DON and/or designee will meet with the staffing coordinator daily to review facility census, call outs if any, and staffing needs. The DON and/or designee will monitor callouts and staffing ratios weekly until the requirement is met. The results of the audits will be forwarded to the facility Administrator and QAPI Committee for further review and recommendations as needed.

Penalty

No penalty information released

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 meet the mandatory nurse staffing requirements as outlined in N.J.A.C. 8:39-25.2(b)(1)&(2) for two days during the weeks of 12/08/2024 and 12/21/2024. Specifically, on 12/08/2024, the facility provided 240 actual staffing hours, falling short by 2.25 hours from the required 242.25 hours. Similarly, on 12/15/2024, the facility provided 240 actual staffing hours, which was 4 hours less than the required 244 hours. This deficiency was identified based on the review of Nurse Staffing Reports and was associated with complaint numbers NJ00168416 and NJ00181485.

Plan Of Correction

1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. The facility leadership team has met on an ongoing basis and continued to identify staffing challenges and areas of improvement for licenses and certified staffing needs. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur. The DON conducted an audit of staffing schedules with the current facility census to ensure fulfillment of staffing requirements per shift. The facility has implemented an incentive program including referral bonuses for employees referring staff where appropriate, conducted job fairs, immediate interviews with contingency offers, and expedited the onboarding process of new hires. The facility has contracted a vendor with agency staff as needed to meet staffing needs. The Director of Nursing and Director of Rehabilitation continue to partner in addressing staffing challenges. Where appropriate, the occupational therapy staff assist in providing care and activities of daily living to residents. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change. The DON and/or designee will meet with the staffing coordinator daily to review facility census, call outs if any, and staffing needs. The DON and/or designee will monitor callouts and staffing ratios weekly until the requirement is met. The results of the audits will be forwarded to the facility Administrator and QAPI Committee for further review and recommendations as needed.