Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greenwood House Home For The Jewish Aged during CMS and state inspections, most recent first.
Soiled and improperly stored kitchen utensils and cooking wares were observed in the dietary area. A serving spoon had a white substance on the handle, several sheet trays and hotel pans were stacked wet and greasy on counters and drying racks, and one hotel pan had a dried crusted substance on the rim. The 3-compartment sink sanitizer also tested above the product’s recommended range.
An LPN was observed moving between resident rooms, including a room on EBP, without cleaning hands between rooms, and the IP and DON confirmed staff should clean hands when entering and exiting resident rooms. The facility also failed to keep laundry processing sanitary: the ESS and a laundry aide moved between dirty and clean linen areas, handled soiled items, and did not consistently perform hand hygiene, while the DON stated laundry should not be cross-contaminated and staff should wash hands between dirty and clean linen handling.
Food was not consistently served at the proper temperature or with acceptable palatability. Two residents reported that meals lacked salt and seasoning, and a lunch observation found hamburger patties for two residents were plated at 132 degrees, below the required hot-food temperature. Staff also served inconsistent diet items for minced and moist trays, and a test tray was described as bland and unappealing. The RD stated the facility did not have a policy addressing food palatability.
The facility failed to provide the required written transfer notice to residents or their RRs after emergent hospital transfers for two residents. One resident was transferred after extreme agitation and ineffective PRN medication, and another was transferred after lethargy and severe hypotension with 911 transport to the ED. The Consultant Admin stated transfer notice forms were not being sent to residents or families, and the DON stated the notice should be provided when a discharge occurred.
A resident’s discharge return anticipated MDS was not completed and transmitted in a timely manner after discharge. The MDS Coordinator confirmed the tracking assessment was late and did not know why, while the DON confirmed the resident appeared on the missing assessment report. The RAI Manual requires discharge MDS completion and transmission within specified timeframes.
Inaccurate MDS Hospice Coding: The facility failed to submit an accurate MDS for a resident whose BIMS could not be completed because the resident was rarely understood. One quarterly MDS documented the resident was not receiving hospice care despite hospice orders being in place, and a later quarterly MDS documented hospice care despite hospice services having been discontinued. The MDS Coordinator stated both assessments were inaccurate, and the DON expected MDS assessments to be accurate before submission.
Unassessed Bed Rail Use: A resident admitted with weakness had side rails observed in the raised position on both sides of the bed even though the admission siderail assessment said side rails were not being considered. The record showed no risks-versus-benefits discussion, no informed consent, no care plan for side rails, and no current physician order. The resident stated the rails had been on the bed since admission and did not recall signing anything related to bed rail use; an LPN and the DON both stated that bed rails require assessment and related documentation.
A resident with heart failure, COPD, HTN, DM2, and atrial fibrillation had a duplicate physician order for potassium chloride ER 20 mEq once daily entered into the EMR and transcribed twice on the MAR. An LPN documented both MAR entries as administered, and the ADON stated the order was inadvertently duplicated on the physician orders and MAR.
The facility failed to suspend staff accused of abuse, violating its abuse policy. A resident reported verbal abuse and involuntary restraint by a nurse and CNA, but the facility allowed them to continue working without suspension. The investigation was inadequate, lacking witness statements and environmental assessments. In another case, a CNA accused of abuse was reassigned rather than suspended, despite policy requirements.
A resident reported verbal abuse and involuntary restraint by an RN and CNA, but the facility failed to conduct a thorough investigation. The accused staff continued working without suspension, contrary to the facility's abuse policy, leading to an Immediate Jeopardy situation.
The facility failed to provide nourishing snacks to all residents when there was a gap of more than fourteen hours between dinner and breakfast. Snacks were only provided upon request or with a physician's order, contrary to the facility's policy. Interviews and observations confirmed that snacks were not routinely offered, and the mealtime schedule revealed a 14.75-hour gap between dinner and breakfast, exceeding the recommended time span. This deficiency affected residents' nutritional needs during extended periods between meals.
A resident with a suprapubic catheter had their urinary collection bag visibly attached to the bed rail without a privacy cover, contrary to staff acknowledgment of the need for privacy. The facility's policy lacked instructions for covering the foley catheter bag, leading to a deficiency in maintaining resident dignity.
A resident with a history of hip fracture and hypertension developed a new skin condition, which was not communicated to the family as required by the facility's policy. The ADON confirmed that the family should have been notified, but the nurse responsible did not document any notification, leading to a deficiency finding.
A facility failed to conduct a criminal background check for a PT before employment, violating its abuse policy. The PT was hired and worked several shifts with residents without the required check. The oversight was confirmed by the MS, HRM, and DON, with the check only completed after surveyor inquiry.
The facility failed to update care plans and implement interventions for a resident who burned themselves with soup, and did not adhere to its smoking policy for another resident using an e-cigarette. The first resident, with severe cognitive impairment, was observed without a clothing protector despite a previous incident. The second resident, with moderately impaired cognition, was seen holding their e-cigarette, contrary to policy. Staff interviews revealed inconsistencies in policy implementation.
The facility failed to properly store and date respiratory equipment and include oxygen therapy in care plans for two residents. One resident's BiPAP machine and mask were improperly stored, and the oxygen tubing was found on the floor. Another resident's oxygen tubing was also improperly stored and not included in their care plan. Staff confirmed these practices did not meet infection control standards.
The facility failed to maintain an accurate inventory of controlled medications due to missing signatures on narcotic count logs across multiple nursing units. Observations revealed that both incoming and outgoing nurses did not consistently sign off on the medication counts, as confirmed by the LPN and RN involved. The DON stated that the procedure required both nurses to count and sign, which was not adhered to.
A facility failed to implement proper infection control protocols for a resident on Enhanced Barrier Precautions (EBP). A CNA was observed entering multiple rooms without performing hand hygiene after doffing gloves, contrary to the facility's policy. The resident involved had an indwelling urinary catheter and a stage four pressure ulcer, necessitating EBP to prevent MDRO transmission. Interviews with staff and leadership confirmed the CNA's actions were not in line with infection prevention expectations.
Soiled and Improperly Stored Kitchen Utensils
Penalty
Summary
Kitchen utensils and cooking wares were not stored in a clean and sanitary manner. During the initial kitchen inspection with the Dietary Manager and Executive Chef, a serving spoon in a bin of utensils had a white substance on the handle that the Dietary Manager identified as mayonnaise. On the three-compartment sink counter, four of 13 full sheet trays were stacked wet, and a mixture of two-inch, four-inch, and six-inch hotel pans was also present; six of those pans were stacked wet and greasy to touch. In addition, five two-inch hotel pans were observed stacked wet and greasy on one of the drying rack carts, and the Dietary Manager stated the pans had been washed the prior night because the drying rack was full. On follow-up inspection, one two-inch hotel pan on a drying rack cart had a dried crusted substance on the inside of the rim, which was confirmed by the Dietary Manager. The three-compartment sink sanitizer was also tested and registered between 700 and 848 PPM, while the product instructions for the sanitizer used by the facility indicated a range of 272 to 700 PPM. The facility policy stated that clean dishware, utensils, and cooking wares were to be air dried before storage and stored in a manner to prevent food soil, dust, or other debris from adhering to the surfaces.
Hand Hygiene and Laundry Cross-Contamination
Penalty
Summary
The facility failed to ensure appropriate hand hygiene when staff moved between resident rooms, including a room with enhanced barrier precautions (EBP). On 03/23/26 at 3:13 PM, an LPN was observed entering and exiting multiple resident rooms and touching surfaces in the rooms without washing or sanitizing hands between rooms. The resident in one of the rooms was on EBP due to having an indwelling catheter. When interviewed immediately afterward, the LPN stated staff are supposed to gown if providing care to residents and was unsure about hand hygiene between residents' rooms, stating only that hands would be washed before and after administering medications. The Infection Preventionist stated on 03/26/26 that staff were expected to wash and/or use hand sanitizer when going into resident rooms, and that even when a resident was not on EBP, staff were expected to sanitize their hands. The DON also confirmed that staff should clean their hands when entering and exiting resident rooms. Observation of the EBP signs posted outside resident doors showed instructions to wash hands when entering and exiting. The facility policy titled, Hand Washing/Hand Hygiene, stated hand hygiene is the primary means to prevent the spread of healthcare-associated infections and that all personnel are expected to adhere to hand hygiene policies and practices. The facility also failed to process laundry in a clean and sanitary manner and did not ensure laundry staff consistently washed their hands. During observation on 03/26/26, the ESS demonstrated receiving dirty laundry from the utility closet, placing bagged laundry in a cart, covering it with a sheet, and transporting it through areas near the kitchen and clean linen spaces before entering the dirty laundry area. The ESS sorted laundry, handled items with feces on them, removed gloves, and left the dirty laundry room without washing hands before returning to the dirty laundry room and entering the clean laundry room. LA1 was also observed moving between dirty and clean laundry areas, including removing gloves at the clean linen room door, opening the door with bare hands, and later returning to the dirty laundry room. The ESS stated the dumbwaiter area had visible crumbs and that the kitchen door was open frequently, and the DON stated laundry should not be cross-contaminated and staff should wash hands between handling clean and dirty linen.
Food Served Below Temperature and Lacked Palatability
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and served at a safe and appetizing temperature for multiple residents during meal service. Two residents, R70 and R135, reported dissatisfaction with the food, stating that the facility did not salt or season the food. R70’s quarterly MDS showed a BIMS score of 11 out of 15, indicating moderate cognitive impairment, while R135’s admission MDS showed a BIMS score of 15 out of 15, indicating cognitive intactness. R135 also stated that family brought in food because the facility food was only edible and lacked salt or seasoning. During lunch observation, hamburger patties plated for R19 and R90 were taken from the oven warmer at 132 degrees Fahrenheit, below the FDA Food Code standard of greater than 135 degrees Fahrenheit for hot foods. The meal service also showed inconsistencies in diet preparation: regular diets received beef stew, noodles, and mixed vegetables with carrots, while minced and moist diets received ground beef, mashed potatoes, and steamed minced vegetables without carrots. The Dietary Manager stated the vegetables should have been the same for all diet consistencies and contained carrots, and the Registered Dietician confirmed the minced and moist diets should have received a variation of beef stew and chopped noodles rather than ground beef and mashed potatoes. A tasting of a minced and moist test tray found the ground beef, mashed potatoes, and steamed vegetables were bland, not seasoned, and the vegetables were not appealing. The Registered Dietician stated the facility did not have a policy addressing the palatability of food.
Failure to Provide Required Transfer Notices
Penalty
Summary
The facility failed to provide residents and their resident representatives with the required written transfer notice after emergent hospital transfers for two residents reviewed for hospitalization. One resident was admitted with a history of extreme physical and verbal agitation toward staff, and progress notes documented that PRN medication was not effective before the resident was transferred to the hospital for evaluation, with the spouse and daughter present for the transfer. The resident’s admission MDS showed a BIMS could not be completed because the resident was rarely understood. For the second resident, progress notes documented lethargy, a blood pressure of 53/46, transfer back to bed, Trendelenburg positioning, physician notification, and a new order to transfer to the ER for further evaluation and treatment; the resident was then sent to the ED by 911. The resident’s admission MDS showed a BIMS score of 7 out of 15, indicating severe cognitive impairment. During interview, the Consultant Admin stated the facility was not sending or providing transfer notice forms to residents or families when a resident was transferred, and the DON stated the transfer notice should be provided to the resident or representative when a discharge occurred.
Late Transmission of Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that one resident, R18, had a tracking discharge assessment completed and transmitted in a timely manner after discharge. R18 was admitted to the facility and discharged on 08/24/25, and the discharge return anticipated MDS with an ARD of 08/24/25 was not batched and accepted until 02/04/26. During interview, the MDS Coordinator confirmed the tracking assessment was late but was unsure why it was late, and stated that the DON pulls the missing assessment report every Friday and informs her of residents on the report while she transmits assessments weekly. The DON confirmed that R18 was on the January 2026 missing assessment report. The RAI Manual states that for a discharge assessment, the MDS completion date is no later than discharge date plus 14 calendar days and the transmission date is no later than MDS completion plus 14 calendar days.
Inaccurate MDS Hospice Coding
Penalty
Summary
The facility failed to ensure that a comprehensive MDS assessment was submitted accurately for one resident, R83, during review of MDS assessments. Review of the admission record showed R83 was admitted to the facility on [DATE]. Physician orders showed hospice services were ordered on 07/16/24, and the quarterly MDS with an ARD of 10/21/25 documented that the BIMS could not be completed because R83 was rarely understood, but also documented that the resident was not receiving hospice care. A later review of the physician orders showed hospice services were discontinued on 11/19/25. The quarterly MDS with an ARD of 02/19/26 again documented that the BIMS could not be completed because R83 was rarely understood, but this assessment documented that the resident was receiving hospice services. During interview, the MDS Coordinator stated both assessments were completed inaccurately and said it was an error on his/her part. The DON stated he/she expected MDS assessments to be completed accurately before submission.
Unassessed Bed Rail Use
Penalty
Summary
The facility failed to ensure that side rails were not in use for one resident who had not been assessed for their use. R139 was admitted with a diagnosis of weakness, and the admission siderail evaluation completed by an LPN on 03/05/26 indicated that side rails were not being considered at that time. The record also showed no discussion of risks versus benefits and no informed consent related to bed rail use. R139's admission MDS showed a BIMS score of 13 out of 15, indicating intact cognition. R139's care plan did not address half side rails on both sides of the bed, and there was no current physician order for side rails. During observations on 03/23/26, 03/24/26, and 03/26/26, side rails were seen in the raised position on both sides of R139's bed. In interview, R139 stated the bed rails had been on the bed since admission and did not recall signing anything related to the risks and benefits of bedrail use. The LPN stated that a resident should have an assessment, physician order, and care plan for bed rails, and agreed another bed rail assessment should have been completed before implementing them for R139. The DON stated a resident should not have bed rails unless assessed to require them, and that residents with bed rails should be assessed prior to use, have an order, and be care planned.
Duplicate potassium order was transcribed twice on the MAR
Penalty
Summary
The facility failed to maintain accurate resident medical records for one resident reviewed for medication administration and record accuracy. The resident was admitted with diagnoses of heart failure, COPD, hypertension, type 2 diabetes mellitus, and atrial fibrillation, and was later discharged to an assisted living facility. A review of the electronic medical record showed a physician order for potassium chloride extended release 20 mEq once daily for low potassium that was entered by the RN/UM on 06/30/25 to start on 07/01/25, and the same order was duplicated in the physician orders. The duplicate order was also transcribed twice on the resident’s July 2025 MAR, where it appeared on 07/01/25 through 07/05/25. The MAR showed that LPN 1 documented both entries as administered on those dates. The ADON stated the order had been inadvertently transcribed twice on the physician orders and MAR, that the RN/UM entered the duplicate order, and that LPN 1 signed off on both MAR entries during that period. The facility policy required documentation in the medical record to be objective, complete, and accurate.
Failure to Suspend Staff Following Abuse Allegations
Penalty
Summary
The facility failed to adhere to its abuse policies and procedures, resulting in a deficiency related to the protection of residents from abuse. Specifically, the facility did not suspend a Registered Nurse (RN) and a Certified Nursing Aide (CNA) who were accused of verbal abuse and involuntary restraint against a resident. The resident, who had diagnoses including arthritis, anxiety, and depression, reported that the staff were rude, yelled at them, and blocked their access to the restroom with a chair. Despite these allegations, the facility allowed the accused staff to continue working without suspension, and the investigation was deemed unsubstantiated without thorough witness interviews or environmental assessments. The investigation into the incident was inadequate, as it did not include statements from potential witnesses or other residents who interacted with the accused staff. The Director of Nursing (DON) obtained statements from the accused staff but failed to gather comprehensive evidence, such as verifying if a chair was used to block the resident's bed or assessing the resident's condition post-allegation. The facility's abuse policy required immediate suspension of accused staff pending investigation, but this was not followed, allowing the staff to work across all nursing units, posing a risk to other residents. In another incident, the facility did not suspend a CNA accused of verbal and physical abuse against a different resident. The resident alleged being pushed against a wall and having their phone taken away. The facility's investigation concluded the allegations were unsubstantiated based on the resident's roommate's testimony and the resident's inconsistent statements. However, the facility did not remove the accused CNA from the premises, instead reassigning them to another unit, which was contrary to the facility's abuse policy requiring suspension pending investigation.
Removal Plan
- RN #1 and CNA #1 were suspended
- Facility Administration including the LNHA, DON, ADON, Assist Admin, and DSS reviewed and were inserviced by the RN Nurse Consultant on the facility's abuse policy
- A thorough investigation was started
- Staff were inserviced on abuse
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse and involuntary restraint involving a resident who reported that a Registered Nurse (RN) and a Certified Nursing Aide (CNA) were verbally abusive and placed a chair beside the resident's bed, preventing access to the restroom. The incident was reported to the Social Worker, but the investigation was deemed unsubstantiated on the same day it was reported. The Director of Nursing (DON) obtained statements from the accused staff members, but did not suspend them or conduct a comprehensive investigation, which should have included obtaining statements from potential witnesses and other residents, and conducting a resident interview and assessment. The resident involved had diagnoses including arthritis, anxiety, and depression, and reported the incident during the night shift. Despite the resident's report, the facility allowed the accused staff to continue working across all nursing units, posing a risk to other residents. The facility's abuse policy required immediate removal of the accused staff pending investigation, but this was not followed. The DON acknowledged the policy but did not suspend the staff, citing the resident's history of complaints as a factor in the decision. The investigation lacked thoroughness, as no other potential witnesses were interviewed, and no assessment of the resident was conducted. The facility's failure to adhere to its abuse policy and conduct a proper investigation resulted in an Immediate Jeopardy situation, as the accused staff continued to work without restrictions, potentially endangering other residents. The facility's process for handling abuse allegations was inconsistent, with decisions based on personal judgments rather than policy adherence.
Removal Plan
- RN #1 and CNA #1 were suspended
- Facility Administration including the LNHA, DON, ADON, Assist Admin, and DSS reviewed and were inserviced by the RN Nurse Consultant on the facility's abuse policy
- Upper management which included the DON, ADON, and RN Supervisor were re-educated on the facility's abuse policy
- A thorough investigation was started
- Staff were inserviced on abuse
Failure to Provide Nourishing Snacks Between Meals
Penalty
Summary
The facility failed to provide nourishing snacks to all residents when there was a gap of more than fourteen hours between dinner and breakfast, as required by their policy. This deficiency was identified during a survey where it was observed that snacks were not routinely offered to residents unless specifically requested or ordered by a physician. The facility's policy stated that nursing staff were responsible for offering snacks, but it was found that snacks were only provided upon request, and not proactively offered to all residents. This practice was confirmed through interviews with the Dietary General Manager, Unit Manager/Registered Nurse, and other staff members, who indicated that snacks were available but not distributed unless specifically requested by residents. The surveyor's review of the facility's mealtime schedule revealed a 14.75-hour gap between dinner and breakfast, exceeding the recommended time span of less than fourteen hours without a snack. Interviews with residents during a Resident Council meeting confirmed that bedtime snacks were not offered, and the list of residents receiving HS snacks did not include those who attended the meeting. The Registered Dietitian acknowledged the importance of providing snacks within the specified time frame and confirmed that the facility's practice did not align with this guideline. Despite the availability of snacks in the pantry, the facility's failure to offer them proactively resulted in a deficiency in meeting residents' nutritional needs during extended periods between meals.
Failure to Maintain Resident Dignity with Urinary Bag Privacy
Penalty
Summary
The facility failed to store a resident's urinary drainage bag in a dignified manner, as observed by surveyors. The resident, who had a suprapubic catheter and wore a leg bag during the day, had their urinary collection bag attached to the bed rail without a privacy cover, making it visible from the hallway. This was observed on multiple occasions, and the facility's policy did not include instructions for covering the foley catheter bag with a privacy cover. Interviews with facility staff, including an LPN, RN/UM, and the ADON, confirmed that the foley bag should have been covered with a privacy cover to ensure the resident's dignity and privacy. The staff acknowledged the importance of covering the bag, but the practice was not followed, leading to the deficiency. The resident involved was cognitively intact and had medical conditions including urinary retention, type II diabetes mellitus, and obstructive and reflux uropathy.
Failure to Notify Family of Change in Resident's Condition
Penalty
Summary
The facility failed to notify a resident's family after a change in the resident's condition, which was identified during a survey. The deficiency involved a resident who was admitted with a displaced intertrochanteric fracture of the right femur, hypertension, and a history of falling. The resident had a moderately impaired cognition with a BIMS score of 9 out of 15. On a specific date, a Certified Nurses Aid (CNA) reported to a nurse that the resident had developed an open area on the mid-back, measuring 2 cm by 1.6 cm, with reddening around the wound bed but no drainage or odor. The nurse treated the wound and recommended a low-pressure bed but did not document any notification to the resident's family about this new skin condition. The Assistant Director of Nursing (ADON) confirmed during an interview that the family should have been notified of the new skin condition, as per the facility's policy. The surveyor requested documentation of family notification, but the ADON admitted that it was not completed. The ADON, along with the Licensed Nursing Home Administrator (LNHA) and other staff, acknowledged that the nurse was responsible for notifying the family and that there should have been documentation in the medical record. This failure to notify the family was a violation of the facility's policy and the resident's rights.
Failure to Conduct Timely Criminal Background Check for Employee
Penalty
Summary
The facility failed to implement its abuse policy by not completing a criminal background check for a physical therapist (PT) prior to the start of employment. This deficiency was identified during a review of the facility's policies and employee files. The facility's Abuse Policy, dated January 2024, mandates that all employees and volunteers undergo a criminal background check before working with residents. However, the review of Employee #4's employment file revealed that no such check was conducted before their hire date on September 6, 2023. Interviews with facility staff, including the Medical Secretary (MS), Human Resources Manager (HRM), and Director of Nursing (DON), confirmed the oversight. The MS acknowledged the absence of a background check for Employee #4, and the HRM admitted responsibility for ensuring these checks are completed. The HRM stated that a background check was only conducted on August 8, 2024, after the surveyor's inquiry. Employee #4 had already worked several shifts with residents before the background check was completed, as evidenced by their timesheet.
Deficiencies in Care Plan Updates and Smoking Policy Implementation
Penalty
Summary
The facility failed to update the care plan and implement necessary interventions for a resident with a high risk of injury during dining, resulting in the resident burning themselves with soup. The resident, who had severe cognitive impairment, was observed without a clothing protector during meals, despite a previous incident where they spilled soup on their chest, causing redness. The facility's policies required documentation and implementation of interventions to prevent future incidents, but the resident's care plan did not reflect these measures. Additionally, the facility did not adhere to its smoking policy for a resident who smoked an electronic cigarette. The resident, with moderately impaired cognition, was observed holding their e-cigarette, contrary to the facility's policy that required smoking devices to be kept in a secure location and provided by staff when needed. The resident's care plan indicated that they should not keep the e-cigarette in their room, yet they were seen with it multiple times. Interviews with staff revealed inconsistencies in the implementation of safety measures and care plans. Licensed nurses and unit managers provided conflicting information about the use of clothing protectors and the handling of smoking devices, indicating a lack of communication and adherence to established policies. The facility's failure to ensure proper supervision and implementation of care plans for these residents resulted in identified deficiencies during the survey.
Deficiencies in Respiratory Equipment Storage and Care Planning
Penalty
Summary
The facility failed to ensure proper storage and dating of respiratory equipment in accordance with professional standards, as well as to include oxygen therapy in an individualized comprehensive care plan for two residents. Resident #319, who was diagnosed with chronic obstructive pulmonary disease, chronic respiratory failure, and morbid obesity, was observed with a BiPAP machine and face mask improperly stored on a nightstand without a protective plastic bag. The oxygen tubing was found lying on the floor next to a trash receptacle, neither stored in a plastic bag nor labeled and dated as required. Interviews with facility staff, including a CNA, LPN, and the Infection Preventionist, confirmed that the equipment was not stored properly, which could lead to contamination and potential illness. Resident #101, who had a history of dementia and pneumonia, was observed with oxygen tubing attached to a concentrator lying on the floor, not stored in a plastic bag, and not labeled or dated. The resident's comprehensive care plan did not include a focus area for oxygen therapy, which was confirmed by the ADON upon review. Interviews with the facility's nursing staff reiterated the importance of proper storage and dating of respiratory equipment to prevent contamination and ensure infection control. The facility's policies on oxygen administration and care planning were not adhered to, as evidenced by the improper storage of respiratory equipment and the lack of an updated care plan for oxygen therapy. The DON and ADON acknowledged the deficiencies in storage practices and care planning, confirming that the equipment should be stored in clean plastic bags and dated to prevent contamination and ensure proper infection control measures.
Deficiency in Controlled Medication Inventory Management
Penalty
Summary
The facility failed to maintain an accurate inventory of controlled medications, as evidenced by missing signatures on the Record of Narcotic Count logs across multiple nursing units. During a medication storage observation, it was found that the controlled substances inventory and count logs for the B Wing North nursing unit had missing signatures from outgoing nurses on several shifts in early August 2024. The Licensed Practical Nurse (LPN) confirmed the absence of signatures, acknowledging that they should have been present. Further observations revealed similar issues in the A Wing North and E Wing South nursing units. In the A Wing North unit, the Registered Nurse (RN) admitted to not counting the medications because it was already done, resulting in missing signatures for both incoming and outgoing nurses. The E Wing South unit also had missing signatures for both incoming and outgoing nurses on specific shifts. The Director of Nursing (DON) stated that the procedure involved both incoming and outgoing nurses counting the narcotic inventory together and signing off on the count, which was not consistently followed.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to implement proper infection control protocols for residents on Enhanced Barrier Precautions (EBP), as observed during a survey. Specifically, a Certified Nursing Aide (CNA #1) was seen exiting a resident's room, doffing gloves, and then entering multiple other resident rooms without performing hand hygiene. This was contrary to the facility's EBP policy, which requires the use of personal protective equipment (PPE) such as gowns and gloves during high-contact activities and mandates hand hygiene after removing gloves. The CNA misunderstood the requirements, believing that hand hygiene was unnecessary if no direct resident care was performed in the subsequent rooms. The deficiency was identified for a resident with an indwelling urinary catheter and a stage four pressure ulcer, who was on EBP due to the risk of multi-drug resistant organism (MDRO) transmission. The facility's policy, revised in August 2024, clearly outlined the need for PPE and hand hygiene to prevent the spread of infection. Despite this, the CNA failed to adhere to these protocols, as confirmed by interviews with other staff members, including another CNA and a Licensed Practical Nurse (LPN), who both emphasized the importance of hand hygiene in infection control. Interviews with the Director of Nursing (DON) and Assistant DON further confirmed that the CNA's actions were not acceptable and did not align with the facility's infection prevention expectations. The DON and ADON reiterated that hand hygiene is crucial after doffing gloves, even if the staff member intends to return to the same resident. The deficiency was acknowledged by the facility's leadership, including the Assistant Director of Nursing (ADON) and the Licensed Nursing Home Administrator (LNHA), during a meeting with the survey team.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Trenton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Preferred Care At Mercer | 0.1 mi | — | 10 | 0 |
| Belle Care Nursing And Rehabilitation Center | 2.5 mi | — | 18 | 0 |
| Avant Rehabilitation And Care Center | 3.2 mi | — | 0 | 0 |
| Lawrence Rehab & Hcc/the Meadows At Lawrence | 3.8 mi | — | 1 | 1 |
| Lawrence Rehabilitation Hospital | 4 mi | — | 30 | 0 |
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