Mount Holly Rehabilitation & Healthcare Center

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 resident was free from neglect and received adequate supervision, resulting in a fall and injury. The resident, who was severely cognitively impaired and required extensive assistance with activities of daily living, was found lying on the floor complaining of severe pain. The resident had a history of falls and required a one-person physical assist with toileting. Despite these needs, the assigned Certified Nurse Aide (CNA) neglected to supervise the resident and was found sleeping at the nurse's desk. The incident occurred when a loud thud was heard, and staff found the resident on the floor by their room door. The resident stated they needed to go to the bathroom and was in pain, holding their left leg. The on-call Medical Doctor assessed the resident via video chat and ordered an emergency transfer to the hospital, where the resident was diagnosed with a closed fracture of the left hip requiring surgical repair. The facility's investigation revealed that the CNA assigned to supervise the resident refused the assignment and was sleeping instead of watching the resident. The facility's documentation and investigation were inadequate, as the Director of Nursing (DON) was unaware of the CNA's refusal to supervise the resident. The facility's report to the New Jersey Department of Health lacked statements and a signed conclusion. Additionally, the incident was not documented in the employee files of the staff involved, and the facility's policy on reporting and investigating abuse and neglect was not followed. The facility failed to provide adequate supervision and documentation, leading to the resident's fall and injury.

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 adequate monitoring and supervision to prevent falls with injury for a resident assessed as high risk for falls. On 12/23/24, a resident who was on one-to-one monitoring experienced two falls within one hour, resulting in severe injuries that required emergency services and hospitalization. The injuries included multiple fractures to the facial bones, contusions, and a laceration requiring sutures. Despite being on one-to-one observation, the resident sustained a second fall shortly after the first, indicating a lapse in supervision. The resident had a history of multiple falls, with fifteen documented incidents prior to the severe fall on 12/23/24. The resident was admitted with diagnoses including unspecified dementia, major depressive disorder, restlessness, agitation, and gait abnormalities. The resident's comprehensive Minimum Data Set (MDS) indicated severe cognitive impairment and a high risk for falls, requiring supervision or assistance for mobility and transfers. Despite this, the care plan often lacked new interventions following falls, and the resident continued to experience frequent falls with injuries. The facility's Director of Nursing (DON) acknowledged the resident's impulsivity and need for constant redirection but could not explain the failure in supervision that led to the second fall on 12/23/24. The facility's Falls-Clinical Protocol required staff to identify causes of falls and implement interventions, but this was not consistently done. The lack of effective interventions and supervision contributed to the resident's repeated falls and the severe injuries sustained on 12/23/24.

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 the kitchen environment and equipment in a clean and sanitary manner, which could potentially lead to bacterial growth and foodborne illness. During an initial tour of the kitchen, the surveyor, accompanied by the Regional Dining Director (RDD), observed several deficiencies. The first walk-in refrigeration unit had a soiled gasket and debris on the ceiling and fan, which the RDD acknowledged needed immediate attention. Additionally, debris was found throughout the floor and on a shelf liner in the dry food storeroom. The RDD mentioned that a new Food Service Director was in place and a cleaning schedule was being developed. Furthermore, a meat slicer, which was covered and presumed clean, was found to have debris on the base and by the blade upon inspection. The RDD admitted that it was not as clean as it should be. The facility's Sanitization Policy, revised in November 2022, states that the food service area should be maintained in a clean and sanitary manner, which was not adhered to in this instance.

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 residents were explicitly informed of and understood the binding arbitration agreement (AA) before entering into it as part of the Admission Agreement. This deficiency was identified for three residents who were reviewed for arbitration agreements. The facility's Admission Agreement included an Alternative Dispute Resolution Agreement, which was legally binding and required residents to waive their right to a trial. However, the facility did not adequately assess the residents' understanding of this agreement, particularly for those with cognitive impairments. Resident #71, who had severe cognitive impairment with a BIMS score of 07, was documented to have signed the AA. However, the resident's power of attorney was unaware of the agreement, indicating a lack of proper communication and understanding. Similarly, Resident #123, with moderately impaired cognition, and Resident #370, with severe cognitive impairment, were also documented to have signed the AA without a clear assessment of their understanding. The facility staff responsible for presenting the AA did not have a formal process or documentation to ensure residents comprehended the agreement. Interviews with facility staff revealed that there was no specific training or documentation process in place to assess residents' understanding of the AA. The staff relied on verbal presentations and informal assessments of cognition, such as asking general questions, without documenting the residents' comprehension. The facility lacked a policy or procedure to guide this process, leading to the deficiency in ensuring residents were informed and understood the binding nature of the arbitration agreement.

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 address a significant safety hazard in the kitchen, where a strong smell of natural gas was detected. During an inspection, surveyors observed that the staff used a lighter to ignite the stove burners due to a malfunctioning pilot light. The Regional Director of Dining (RDD) confirmed the presence of the gas smell and admitted that the lighter was used regularly to light the stove, although he could not recall informing the Licensed Nursing Home Administrator (LNHA) about the issue. Further investigation revealed that the Maintenance Director (MD) was aware of the lighter being used but was not informed about the stove's malfunction. A repairman later confirmed that several pilot lights had failed, causing gas to leak. The repairman indicated that the stove required new parts to fix the issue, and the gas leak was confirmed to be a result of the failed pilot lights. The facility's failure to promptly address the gas leak and reliance on a lighter to ignite the stove created an Immediate Jeopardy situation, posing a risk of explosion or fire. The LNHA was not aware of the problem until the surveyors brought it to his attention, highlighting a breakdown in communication and safety protocols within the facility.

Removal Plan

• The staff were instructed to stop manually lighting the pilot light.
• The gas line was disabled to prevent further manual lighting until repairs were made.
• The stove was replaced.

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 sufficient and competent nursing staff to meet the needs of residents, resulting in multiple deficiencies. Observations revealed that residents were not receiving timely incontinence care, with some residents left in soiled briefs for extended periods. Additionally, nail care was neglected, with several residents having long, jagged, and dirty nails, which were not addressed despite repeated observations and requests from residents. The lack of adequate staffing was evident, as the facility did not meet the required staffing ratios on numerous occasions, leading to inadequate care and supervision. Resident supervision was also insufficient, as evidenced by an incident where a resident fell and sustained a hip fracture. The fall occurred after a CNA was found sleeping instead of supervising the resident, and the facility's investigation into the incident was incomplete, lacking necessary statements and documentation. Furthermore, communication barriers were present for a resident who primarily spoke Spanish, as the facility failed to provide a communication board or effective means for the resident to express their needs, relying instead on hand gestures. The facility's failure to maintain required staffing levels and provide adequate care and supervision affected all residents across multiple units. The report highlights specific instances where residents were left without access to call bells, further compromising their ability to request assistance. The deficiencies were compounded by the facility's inadequate response to staffing shortages and lack of adherence to established care protocols, as outlined in the job descriptions for CNAs and LPNs.

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 serve food to residents at an appetizing temperature and taste, as evidenced by observations and interviews conducted during a survey. During a resident council meeting, five residents reported that the food was always cold and tasted bad. On a subsequent day, a surveyor observed the delivery of breakfast meal trays to the Maple Unit, noting a delay of 26 minutes from the time the meal cart arrived to when the last tray was distributed. A test meal conducted by the surveyor and the Food Service Director (FSD) revealed that the breakfast items, including sausage, juice, and milk, were not at acceptable temperatures, with the FSD acknowledging that the cold temperatures were not okay. Further investigation during lunch meal preparation showed similar issues with food temperatures. The surveyors and FSD tested a meal that included fish, rice, zucchini, and a hamburger patty, finding that none of the hot items met the required temperature of 135 degrees Fahrenheit. Additionally, the zucchini and rice were described as bland and mushy. The facility's Food Temperature Log confirmed that hot foods must be above 135 degrees before service, and cold foods below 41 degrees, but the policy provided by the Licensed Nursing Home Administrator did not specify these temperature requirements. This deficiency was documented under NJAC 8:39-17.4(e).

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 follow physician orders for medication administration and safety measures for several residents. For Resident #82, the facility did not adhere to the physician's order to hold Hydralazine when the systolic blood pressure (SBP) was less than 120. Despite the order, the medication was administered on multiple occasions when the resident's SBP was below the specified threshold. Interviews with the LPN and Unit Manager revealed a lack of adherence to the holding parameters, which could potentially lead to adverse effects such as further lowering of blood pressure. Resident #19, who was at risk for falls, had a physician's order for bilateral floor mats to be placed on both sides of the bed. However, observations revealed that only one floor mat was consistently placed on the left side of the bed, contrary to the physician's order. The LPN and CNA acknowledged the discrepancy, indicating a failure to ensure the safety measures were properly implemented and documented. Additionally, Resident #23's medication administration was not in compliance with the physician's order, as the required blood pressure and heart rate monitoring prior to administering Olmesartan was not documented. Similarly, Resident #44 received Esomeprazole after beginning their meal, despite the order to administer it at least half an hour before meals. Furthermore, Resident #89 did not receive the prescribed Midodrine due to unavailability, and there was a delay in notifying the physician and obtaining the medication from the backup supply. These instances highlight a pattern of non-compliance with medication administration protocols, as outlined in the facility's policy.

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 adequate communication means for a resident with a language barrier, identified as Resident #122, who primarily spoke Spanish. The deficiency was observed when the surveyor noted that the resident was unable to communicate effectively with staff due to the absence of a communication board, which was supposed to be provided as per the resident's care plan. Despite the resident's care plan indicating the need for an interpreter and a communication board to assist with daily needs, staff members relied on hand gestures to communicate, which was insufficient for understanding the resident's needs. Interviews with staff members, including CNAs and an LPN, revealed that they were aware of the resident's language barrier but did not have effective tools to facilitate communication. The CNAs admitted to using hand gestures, and the LPN mentioned occasionally using a Spanish-speaking CNA to assist. However, the communication board, which was part of the facility's policy for residents with language difficulties, was not present in the resident's room. The Director of Nursing acknowledged the oversight during a meeting with the survey team, confirming that the communication board should have been available to the resident.

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 call bell was accessible and within reach for all residents, as evidenced by observations and interviews with staff and residents. Resident #29 was observed multiple times with the call bell out of reach, either on top of the bedside table or tucked underneath the mattress. Despite the resident's ability to use the call bell, their severe cognitive impairment and physical limitations made it difficult for them to locate it. The care plan for Resident #29 included ensuring the call bell was within reach, but this intervention was not consistently implemented by the staff. Similarly, Resident #22 was observed with the call bell hanging from the bed frame, out of reach, during multiple observations. This resident also had severely impaired cognition and required maximal assistance with toileting hygiene. The care plan for Resident #22 included encouraging the use of the call bell for assistance, but the resident was unable to reach it when needed. Interviews with the Director of Nursing and other staff confirmed that the call bell should have been secured and within easy reach of the residents, as per facility policy.

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 incontinence care and personal hygiene for residents, as evidenced by multiple observations and interviews. Resident #100 was found in bed with a soaked brief and a call device on the floor, indicating a lack of timely assistance. Despite having a care plan for incontinence care, the resident reported not being changed since the previous night. Similarly, Resident #89 was observed with long, jagged nails and unshaven, despite expressing a desire for nail trimming and shaving. The care plan for Resident #89 indicated a need for assistance with activities of daily living due to weakness and deconditioning, yet these needs were not met. Resident #132 was also observed with thick facial hair and a soaked brief, indicating a lack of personal hygiene care. Despite having a care plan for assistance with activities of daily living, the resident's needs were not addressed. Resident #150 was found with long, discolored nails and unshaven, despite a care plan goal for being clean and well-groomed daily. The Unit Manager confirmed the need for nail trimming and shaving, yet these actions were not taken. Other residents, such as Resident #370, #123, #71, #122, #82, #77, and #35, were observed with similar deficiencies in personal hygiene and incontinence care. These residents had long, jagged nails with substances underneath, and some were found with soaked briefs. The facility's policies and job descriptions for nursing staff and CNAs outlined the responsibilities for providing daily care, including nail care and incontinence care, but these were not consistently followed. Interviews with staff revealed a lack of awareness and adherence to these responsibilities, contributing to the deficiencies observed.

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 appropriate pressure ulcer care and prevent new ulcers from developing for two residents. For Resident #10, the surveyor observed a deep wound to the sacral area without a dressing during an incontinence tour. The dressing was found dislodged in the resident's brief, and the CNA stated it might have come off during repositioning. The nurse confirmed that the dressing was to be changed every three days and as needed, but the order was not transcribed correctly. Additionally, the LPN was observed using scissors without disinfecting them, which was corrected by the Unit Manager during the surveyor's observation. Resident #29 was transferred to the facility and initially assessed with no skin issues. However, upon readmission from the hospital, the resident was found to have a deep tissue injury surrounding an open skin pressure injury, which was not documented or treated in a timely manner. The facility failed to measure the wound or notify the physician and resident representative promptly. The wound care was not initiated until several days after the resident's return, and there was no documentation of wound care prior to the wound care team's initial visit. The facility's failure to adhere to professional standards of practice in wound care and prevention of pressure ulcers was evident in both cases. The lack of timely and appropriate wound care, failure to transcribe physician orders, and inadequate communication and documentation contributed to the deficiencies observed by the surveyor.

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 develop an initial baseline care plan for pain management for a resident admitted for rehabilitation following hip surgery. The resident, who had a history of a fall resulting in a non-displaced intertrochanteric fracture of the right femur, was discharged from the hospital with a primary diagnosis of a right intertrochanteric fracture proximal femur. The hospital discharge summary included a plan for pain control as needed, and the discharge medication list specified oxycodone-acetaminophen for pain management. Upon admission to the facility, the resident's pain level was recorded as 6, with an acceptable pain level of 3. Despite the resident's need for pain management, the facility's care plan did not include a focus area for pain management. The care plan only addressed areas such as activities of daily living, risk for falls, skin breakdown, leisure activities, and nutrition. During an interview, the Director of Nursing acknowledged that the resident should have been care planned for pain. The facility's Pain-Clinical Protocol Policy, revised in October 2022, outlines the need for establishing goals of pain treatment with input from the resident, physician, and staff, which was not adhered to in this case.

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 pain assessment was completed and documented for a resident who required pain management services. The resident, who had a history of a fall resulting in a non-displaced intertrochanteric fracture of the right femur and Type 2 Diabetes Mellitus, was admitted to the facility for sub-acute rehabilitation following surgery for an open reduction and internal fixation of the right hip. Upon admission, the resident's pain level was documented as 6, with an acceptable pain level of 3. However, the Medication Administration Record (MAR) showed that the pain medication order for Oxycodone-Acetaminophen was not administered until nearly 20 hours after admission, despite the resident's documented pain level. The Director of Nursing (DON) stated that pain medication is only administered if the resident requests it, indicating a lack of proactive pain assessment and management. The facility's Pain-Clinical Protocol Policy requires nursing staff to assess pain upon admission and monitor the use of analgesics, but this was not followed. The surveyor's review found no pain assessment or documentation of medication administration in the MAR until much later, highlighting a deficiency in the facility's pain management practices.

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 consistent process for addressing concerns raised by residents during monthly Resident Council Meetings (RCM). This deficiency was identified for all five residents who attended the RCM, as they reported being unaware of any follow-up to their expressed concerns. The surveyor's interview with these residents revealed that they were not provided with documented follow-up at subsequent meetings. A review of the RCM minutes from October 2024 showed that residents had requested staff to refrain from wearing earbuds while providing care, and the Director of Nursing (DON) had stated an intention to reeducate staff on phone usage. However, there was no evidence of resolution or follow-up on this issue. The facility's policy, revised in February 2021, requires the use of a Resident Council Response Form to track issues and their resolution, with the relevant department responsible for addressing concerns. Despite this policy, the DON acknowledged the absence of documented resolutions from the RCM and stated that concerns should be addressed and revisited as old business in subsequent meetings. During the exit conference, facility management did not provide additional information or refute the findings, indicating a lack of adherence to the established process for addressing resident 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 that medications were administered without error, resulting in a medication administration error rate of 5.8%. During a morning medication administration observation, two surveyors noted errors involving two residents. The first error involved Resident #89, who did not receive their prescribed dose of Midodrine for hypotension because the medication was unavailable. The LPN responsible did not follow up with the physician or attempt to retrieve the medication from the facility's backup supply in a timely manner, leading to the resident missing their dose. The second error involved Resident #44, who was administered Esomeprazole, a medication for GERD, while actively eating breakfast. The physician's order specified that the medication should be given at least half an hour before meals. Despite being aware of the order, the LPN administered the medication incorrectly, which was not in accordance with the prescribed instructions. Both errors were observed during the same medication pass, highlighting a failure in adhering to medication administration protocols. The facility's policies and procedures for medication administration were not followed, as evidenced by the lack of timely follow-up for unavailable medications and the incorrect timing of medication administration relative to meals.

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 quality wound care in accordance with professional standards for a resident, leading to a significant deficiency. The resident, who was non-verbal and totally dependent on staff, had a history of multiple medical conditions including advanced multiple sclerosis, adult failure to thrive syndrome, and a sacral decubitus ulcer. The care plan for the resident included monitoring and documenting changes in skin status, administering treatments as ordered, and reporting to a physician as clinically indicated. However, there was no documentation that the wound was assessed daily or monitored, and no nursing progress notes were made regarding the resident's wound or possible infection from 2/09/23 to 2/15/23. On 2/9/23, a Wound Care Specialist noted that the resident's wound was deteriorating, with 20% slough and 80% granulation tissue, and recommended specific treatment changes. Despite these recommendations, the facility did not document any follow-up or monitoring of the wound. On 2/15/23, the resident was transferred to the hospital at the request of a family member, but there was no assessment indicating the reason for the transfer. The hospital admission revealed that the resident had cellulitis of the neck and chest, an infected sacral wound, and a fever, requiring treatment with intravenous antibiotics and a wound VAC. The Director of Nursing, who was on vacation at the time, later indicated that the nurse should have assessed the resident and contacted the physician before the hospital transfer. The facility's policy requires prompt notification of changes in a resident's condition to the resident, their representative, and the attending physician, but this protocol was not followed. The lack of documentation and failure to monitor and report changes in the resident's wound condition led to the deficiency.