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Detailed inspection reports for one-star rated facilities

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Posted: Saturday, June 25, 2011 11:51 pm

The Press reviewed state Department of Health and Senior Services inspection reports, more than 1,500 pages, from 2009 and 2010 for the seven lowest-rated nursing homes in the region for 2010. The Press also reviewed the 2011 inspections done thus far on three of these homes, as well as 2010-11 inspection reports for three area nursing homes that fell to a one-star rating this year. Some violations led to fines, and all required a Plan of Correction, or POC, to remedy the problems. All of the details reported in these summaries came from the state nursing home inspection reports for the facilities.

Absecon Manor Nursing and Rehabilitation Center, Absecon

Owner: DePaul Healthcare Systems, which operates six facilities in New Jersey and three in Philadelphia

Inspectors found poor handing of food, unsanitary dish washing, a soiled meat slicer and other kitchen issues at the 162-bed facility on Pitney Road.

A metal pan full of moldy pork chops was found in a box used to hold hot foods. There was no system in place to track food expiration dates.

There were also fire code violations including failures in smoke detectors and alarm systems. The maintenance director said the alarms were not being replaced because they were planning to install a new system.

The fire sprinkler system also had problems and inspectors noted Absecon Manor had been notified eight times to fix it since February 2008.

Quality of care was also an issue. In one case it took 17 days to treat a urinary tract infection.

Arcadia Nursing and Rehabilitation Center, Little Egg Harbor Township

Owner: Harbor Care, LLC, with a second New Jersey home in Hamilton Square, Mercer County

It took 12 days to treat a urinary tract infection at the 115-bed facility on Ninth Avenue.

A nurse noted increased confusion with a resident who had a history of urinary tract infections. The family said such an infection often leads to confusion in their loved one. Testing was ordered and was positive for the infection, but it took 12 days for the resident to get antibiotics.

In 2010 a resident complained that a nurse stole her bottle of perfume out of her drawer. The aide said she picked it up by accident while gathering equipment. It was returned half full.

The home was cited for failure to maintain clean and sanitary conditions at all three of its nursing units. An inspection found large amounts of dirt and dust while medication carts were soiled with spillage and a "dried beige substance." There was a brown substance smeared on the wall of the shower room. Showers and toilets had a black mold-like substance. A shower stretcher used for invalid residents had mold and hair debris on it. Dirt, cobwebs and dry spillage were found in the kitchen storage area.

Inspectors also found medication errors. In one instance a resident was supposed to stop receiving a medication, but doses continued.

The facility failed to develop and implement an infection control program, which the state said had the potential to affect all residents. The nurse in charge was found to have an outdated copy of infection control regulations.

One resident was supposed to have his blood pressure and pulse taken weekly, but this was not done for almost a month.

Inspectors found improper monitoring of morphine usage. Each dose of this narcotic pain reliever must be accounted for.

Housekeeping had to receive training because they were mopping and leaving floors wet in the rooms of residents who had a history of falling.

One resident kept losing weight, and it was discovered that liquid supplements called "healthshakes" a physician ordered for weight gain were not being given to her. This was blamed on an oversight by a nurse.

The inspectors also found unsanitary kitchen conditions and failure to maintain and test an automatic fire sprinkler system.

Barnegat Rehabilitation and Nursing Center, Barnegat

Owner: Seniors Management North of Cherry Hill

This Nov. 5 inspection was spurred by a complaint involving verbal abuse of a resident. A resident who had dementia and neurotic disorders asked to be helped out of bed frequently overnight. A nurse and an aide were alleged to have told the woman that she was not allowed out of bed before 4 a.m. The inspection report said the staffers threatened to remove her wheelchair from her room, kicked her room door, withheld snacks and threatened to keep the resident in her bed longer if she complained. A new nurse was told this was the behavior management "system" employed for this resident.

The report said the resident shook in fear in the presence of the nurse and aide and asked not to be left alone with them. Another staffer overheard the woman telling the aide not to hit her.

After other staff complained about the resident's treatment, the nurse, the aide and another staffer were suspended, the reports said. Staff training on avoiding abuse and neglect was provided, and a penalty of $2,100 was recommended to the federal health department.

Courthouse Convalescent Center, Cape May Court House

The Office of the State Ombudsman for the Institutionalized Elderly investigated on Jan. 18 an allegation of abuse of a resident by the resident's family. The report says the nursing home failed to investigate the claims of abuse and to supervise family visits of the resident.

The inspection report says a resident suffering from dementia was verbally abused by family members on visits to the home. Staff told home officials that the relatives called the resident "stupid," "crazy," and in need of shock therapy. The family told the woman that nursing home staff wanted to send her jail and that she was "useless and worthless," the report said. The abuse upset the resident. The abuse continued even after nursing home officials talked to the family.

The ombudsman's office told the nursing home to formally investigate and to allow the family to have only supervised visits in the presence of facility staff. However, the home failed to follow up on either directive.

A plan of correction was filed by the home. But a March 7 document noted that the resident no longer lives at the facility.

Eastern Pines Convalescent Center, Atlantic City

Owner: Eastern Pines, LLC of Englishtown, Monmouth County

Residents suffered abuse and theft from staff, visitors and other residents at Eastern Pines on Vermont Avenue in Atlantic City. Management did not protect them, investigate or notify proper authorities.

Inspectors looked but could find no documentation of an assault by one resident on another that they knew took place. There should be a written report on any assault.

There was no investigation into complaints that somebody was rummaging through drawers and stealing from rooms in the middle of the night.

Inspectors found rampant theft of residents' possessions. Thefts included debit cards, clothes, perfume, money, cigarettes, a clock, socks, sneakers, cigars, raffle tickets and other items. Residents were not provided locks for their drawers until after thefts occurred and they complained.

The report blamed the administration for failing to stop theft and abuse, provide basic care and services, or treat residents with dignity.

Eastern Pines failed to post a surety bond large enough to match the funds residents had in private accounts and did not give residents quarterly statements on these accounts. Eastern Pines also failed to return money in a timely manner to the estates of residents who passed away. This was due to failure of the home to notify corporate offices that residents had died.

Numerous physical problems with the building were found, and inspectors said the home did not supply a "hazard-free environment" on two of the three floors. Hot water at one sink was a dangerous 126 degrees. Hand rails residents relied on for balance moved when touched.

Doors meant to close for fire safety would not close all the way. The fire sprinkler system suffered from corrosion, and some sprinkler heads had a paint-like substance over them. The oxygen system was not vented properly. Electrical problems included loose wall outlets, no covers on junction boxes. Missing smoke detectors and fire sprinklers were documented. The home failed to provide the required one-hour fire rated construction for hazardous areas and one area did not even have sprinkler coverage.

Unsanitary conditions were found in two of three wings. Issues included dust, stains, dry spillage and dirt.

There was no comprehensive and systematic infection control program. State hotline numbers for the Department of Health and Senior Services were not posted as required.

Inspections found one resident given antipsychotic drugs without medical justification and another given a hypnotic medication for insomnia, also without justification.

A facility by law must have medication error rates of less than 5 percent. A Jan. 13, 2011 inspection observed four nurses administer 50 medications to 13 residents and logged an error rate of 5 percent. The requirement that drug regimens must be reviewed at least once a month by a licensed pharmacist was not met.

The 2011 inspection found Life Safety Code violations, including: exits were not accessible at all times, sprinkler systems were not maintained, and electrical wiring did not conform to code.

Lincoln Specialty Care, Vineland

Owner: SK Nursing Homes Associates, LLC

Residents at the 180-bed facility on South Lincoln Avenue in Vineland have a right to personal privacy and dignity, but on March 24, 2010 an inspector found a nursing aide providing care to a resident with the privacy curtain open and a naked resident in bed with no covers.

His roommate could see him naked and so could anybody walking outside the window because the blinds were up.

"There was an incontinent brief under the resident's buttocks, but it had not been used to cover his genitalia," states the report.

In another case, a female resident was left with her body exposed from her abdomen to her feet, but the nurse did not close the privacy curtain or adjust her gown. All employees were given training on maintaining privacy.

Residents complained about responses from nursing aides when they answer the call lights. "What do you want?" and "What do you need now?" are two responses they mentioned. Residents said the tone of the voice in the responses was demeaning to them, but there were no changes after sensitivity training was required.

They said aides often come in rooms without knocking on the door. One said a nurse came into her bathroom and gave her medication while she was on the toilet.

"The (resident) stated that this same nurse told her to make sure she washes herself because she smells. This resident stated that she felt embarrassed and ‘like a dog' when the nurse did and said those things to her," the report said.

In other case a male resident yelled from the shower room "It's cold. It's cold." A nurse's aide responded by telling the man to "shut up."

In two cases the inspector intervened on behalf of residents who were in pain to get them medication.

"For both residents, despite staff being aware of pain, nursing staff did not proceed immediately to administer pain medications," said the report.

In other case a recent amputee was heard crying out: "I'm in pain. God help me. Oh my God." The nurse initially told the resident she would have to wait two hours, but after reviewing her chart realized she was allowed more drugs. The amputee got medication 25 minutes after she requested it. The inspector noted the same nurse was 20 minutes late the next day administering pain medication to the woman.

One resident said getting pain medication on time is "my biggest problem here."

A 2010 inspection determined the facility did not maintain a sanitary building. Problems were found in all four nursing units and common areas including the main dining room. This included peeling paint, dirt, overflowing trash cans, stains, and spillage identified only by its color. The facility hired a private company to do housekeeping and maintenance.

The facility failed to develop and implement an effective infection control program in food handling, medication administration, personal hygiene, and disposal of bandages.

Inspectors also found fire code issues, ventilation system problems, deficient wiring and numerous other building issues. They also found the facility was not verifying that newly hired nurse's aides were qualified. This was found in 10 of 15 hires reviewed.

On March 7, 2010, a resident with dementia disappeared. Police located him off-site at his old address a couple of miles away. The resident was an runaway risk who had to be carefully watched and he was later transferred to a secure unit.

The attending physician ordered an evaluation and treatment by a psychologist, but this still had not been done on March 24 . The nurse did not know the procedure for notifying the consulting psychologist when a physician orders treatment. The evaluation was done 18 days after it was ordered.

This was not the only runaway case. On Aug. 10, 2010, a resident was reported missing. An aide searching in her car found him, and another resident who they didn't know was missing, several blocks away standing on a sidewalk talking to each other. Their freedom was short-lived. They went back willingly.

An inspector interviewed a resident on March 2, 2011 who said she came into her room and staff members had taken her dolls and other personal items. She claimed the home refused her request to have the police called and said she would have to use the pay phone and do it herself. The inspector found the right to file grievances without reprisal was violated.

On Feb. 28, 2011, the home was found in violation of making the latest survey results readily available as 14 of 14 residents interviewed did not know where the results were. The results were found in an area that was not wheelchair-accessible.

A resident was improperly restrained on at least four occasions this year, the recent report said.

A nursing assistant slapped and pushed a resident suffering from dementia and depression, but the home failed to thoroughly investigate and allowed the aide to continue working eight more shifts before being fired on March 3, 2011. The facility's policy and procedures on abuse investigation and reporting were revised.

On Feb. 24, 2011, a resident was found to have bruises and lacerations that were not fully reported and there was no documented explanation of how they happened.

On Feb. 24, 2011, a resident claimed money was stolen. The administrator said it was reported missing but nobody working with the resident had seen anybody take the money. The money was eventually refunded by the home.

On Feb. 24, 2011, two staff members were observed texting on cell phones when they were supposed to be caring for residents. This is against policy and they were disciplined.

Residents have a right to activities and to pursue interests. A blind resident was taken to activities but given a newspaper in one case and a child's toy that sat untouched in front of him for several hours in another. Under a plan of correction, the resident now enjoys appropriate activities.

Dust, dirt, a brown substance that smelled of fecal matter, trash, dried stains and other sanitary problems were found at all four nursing units in February 2011 inspections. The 2011 inspection found numerous facility problems.

A resident suffered burns from hot coffee and the wound became infected due to a breach in professional standards of the nursing staff.

The 2011 inspection found insufficient medical records on one-third of the resident records reviewed.

The facility was not in compliance during the 2011 inspection for the minimum Life Safety Code requirements. Emergency exits were not easily accessible. On Feb. 23, 2011, a cement ramp and pathways off the emergency exit were covered in snow and ice. Egress from one walkway led to a chained gate while another was blocked by a dumpster. The fire sprinkler system and the ventilation system were not maintained properly.

New employees need a medical exam for infection control purposes but a review of six employees found four were not done in time.

A social worker was found to not have a license. The state found the worker was hired with nobody asking to see a license. The employee was let go and a licensed social worker was hired.

Linwood Care Center, New Road & Central Avenue, Linwood

Owner: Revera Health Systems Inc. of Meriden, CT, which has 30 care centers nationwide

A number of issues involving dignity and resident respect were uncovered, the Oct. 25 inspection report said. Some residents complained it takes up to an hour after they ring for someone to help them get to the bathroom. One was quoted: "The aides know that when I ring I have to go to the bathroom and I can't wait. That time I had to wait for almost an hour for someone to help me, and I had an accident. I wet myself. I really felt if they had come a little sooner, I wouldn't have wet the bed and myself. I was so upset and so embarrassed I could have cried." One resident was found with a medically unnecessary catheter. When asked why it was never removed, the resident said he or she wanted to keep it because it takes so long for someone to help them get to the bathroom that the catheter keeps the resident from having accidents.

The report said sanitation problems were found with dishwashing machine water not being hot enough to meet standards and kitchen workers not fully covering their hair. There were no screens on the dish room windows, so bugs got in and a plant was even growing through one window. Blood from defrosting pork puddled in a refrigeration room, and the facility had no policy on the maximum number of days by which raw meat should be used.

There were also fire safety problems, with fire doors not fully closing. An inspector could not find a wet chemical fire extinguisher for the kitchen, and was told it was in the dietary director's office, which was locked each night two hours before the kitchen closed. Combustible and flammable materials were not stored according to safety requirements, the report said.

Also, electrical wiring and electric outlet use was found to not meet safety standards.

Our Lady's Residence, Pleasantville

Non-profit; one of multiple homes operated by the Diocese of Camden

One inspection at the 215-bed facility in Pleasantville found fire code failures including a lack of required sprinklers in sections of the building. Inspectors also found an "obvious lack of cleanliness" throughout the building.

An inspector noted that prior surveys found the same unsanitary conditions, but despite multiple discussions, the facility was "not clean or well maintained."

The kitchen had dirt, debris and dried food. There were broken floor tiles. Equipment was rusty. Linens were not cleaned to prevent the spread of infection. Bleach was not used, and the required 160-degree washing water temperature was not reached.

There was a "lack of housekeeping" evident in nursing units, hallways, bathrooms, common areas, dining rooms and resident rooms. Paint was peeling. Furniture was soiled. Privacy curtains had stains and dried substances on them. Inspectors used descriptions such as "sticky brown substance," "dried beige spillage," and "dried red liquid" on the reports. One resident used Clorox wipes to clean the toilet before using it.

Several nurse call cords were tied or shortened, meaning a resident could not signal for help when needed. Resident rooms had broken night lights and missing plaster.

The facility also failed to provide acceptable exits. Portable space heaters were allowed in resident rooms even though they are prohibited. That could be a problem since inspectors also found electrical wiring was not up to code.

The home was also criticized for failure to make timely notification when a resident died, which is supposed to be done within one hour. A resident died at 3:45 p.m. on July 21, 2009. A guardian was the primary emergency contact with a family member listed as an alternate. The guardian was called at 2:15 p.m. the following day, although he said he was never notified. The nurse said she called but nobody answered, and there was no answering machine. She did not call the alternate contact number.

The inspectors found a lack of investigation in three incidents in which residents suffered injuries of unknown origin. One was found in a pool of blood. Another had multiple rib fractures.

Inspectors found medication errors. One resident was prescribed an anti-psychotic medicine for hallucinations but didn't get it for three weeks due to a paperwork error. Paperwork showed another resident was getting kidney disease medication at 4:30 p.m. each day but the resident was actually out of the building on dialysis at this time.

Residents in danger of falling were not monitored properly and kept falling. One resident fell three times, and follow-up inspections found no evidence that monitoring increased.

One resident needed a mechanical device and two aides to be lifted from a bed to a wheelchair, but one nursing assistant tried to do it without the device and the resident hit her head on the wheelchair, drawing blood. The assistant said the lift was being used by another staff member at the time.

Drug regimens are supposed to be reviewed once a month, but inspectors found this wasn't happening for 20 percent of residents reviewed. One resident was found to be getting too many drugs. A nurse was observed preparing to administer the wrong type of insulin to a resident, which could have led to unhealthy blood sugar levels. Drugs supposed to be served with meals were given to residents on an empty stomach.

Inspectors also found fire code violations including covered exit signs and failure to maintain emergency generators.

Residents have a right to be free of physical restraints, but inspectors said they found one resident with cognitive problems and a history of seizures strapped into a wheelchair with a helmet on his head. The home was not meeting the policy of releasing his restraints every two hours.

The state found that six of 13 cognitively impaired residents did not have programs to maintain their sense of self-respect, usefulness, physical abilities and interests. They were observed in darkened rooms and left seated on wheelchairs with no interaction.

The Shores at Wesley Manor. a 60-bed facility in Ocean City

One of a number of homes in New Jersey that are part of United Methodist Homes.

Officials did not respond to requests for comment about inspection reports from 2009, 2010, and 2011.

Taking care of the skin of aged residents is often a challenge, especially when they are bed-ridden or have had surgery or radiation treatments. A home is required to prevent pressure sores unless it is unavoidable. The home was cited for allowing a male resident on radiation treatment to arrive with skin intact and develop multiple pressure sores. The resident's skin was not checked regularly but a physician stated the sores were "an ugly looking wound" that would not happen overnight. The state's remedy was to require skin assessments on all residents.

Resident rights include being treated with "dignity and respect." The home did not meet this requirement with one resident who was not fed in a dignified manner. It was the only violation in a review of 13 residents for this category.

The home was also found in violation of completing discharge summaries and in two cases failed to provide staff assistance to residents who needed it.

Residents also have the right to be free of unnecessary drugs. The home was in violation earlier this year for administering a higher than recommended dose of anti-anxiety medication to a 92-year-old, who was lethargic, slumped over and would not recognize family members. The dosage was reduced and the resident was less lethargic and had an increased appetite.

A 2011 inspection found three of four residents checked were not getting timely physician visits. One resident with a fractured hip, cancer, cardiac disease, and depression was admitted on Dec. 3, 2010 and had not seen a physician as of Jan 31, 2011. By law a resident must see a physician at least once every 30 days for the first 90 days after admission and once every 60 days thereafter. In another case, there was no documentation a physician saw a resident from December 2009 to Jan. 31, 2011.

The home was also cited for not maintaining the fire alarm system, failing to maintain proper kitchen sanitation, and missing a sprinkler system inspection.

South Jersey Extended Care, Bridgeton

Owner: H.W. Weidco Ren, LLC., of Hackensack, Bergen County

An inspector entered a resident's room that smelled like feces on Oct. 6, 2009 and found "a brown substance" on the resident's gown and bed sheets. There was a soiled bandage on the bed. Multiple flies were observed flying around and landing on the resident's soiled gown, her arms and face. Although the nurse's aide saw the flies landing on the blind and cognitively-impaired resident, it was the inspector who swatted the flies away. There was dried excrement on the resident's thigh.

The resident wore socks on her hands. The aide said it was because "she scratches herself." Gloves are supposed to be used, but the aide said gloves go to the laundry and do not come back. The resident was cleaned, but the inspector noted the soiled socks remained and flies continued pestering her as she was unable to swat them away.

The report also noted skin issues. The resident had sensitive skin that required a certain type of soap for washing, but the aide used the wrong type of soap. The resident also had a physician's order to have her clothes and linens washed in hypoallergenic detergent but this wasn't being done.

Oral hygiene was another problem. And the resident had an injured ear, probably from it being folded over when oxygen equipment was put on poorly.

The story of that resident was just part of an extensive report on the 167-bed facility on Manheim Avenue in Bridgeton. There were also medication errors at a clip of 18.4 percent. One resident with dementia and severe behavioral outbursts did not get prescribed anti-anxiety medication for three days because they ran out of it. Another resident was given the wrong medication for her dialysis treatment. Another was supposed to get morphine every three hours but was given a second dose after two hours.

Several cases were found in which residents were given unnecessary drugs. Others were found where medication was not given with food as prescribed.

A nurse was disciplined after it was discovered she filled out paperwork that medication was administered at times when the resident was actually outside the facility in dialysis.

Care plans for residents failed to identify the unique needs some of them have. Physician visits were few and far between. A physician is supposed to visit within 10 days after a visit is requested. In one case, a resident arrived on Sept. 17, 2010, and during a Nov. 17 interview said she had never seen her physician. A nurse practitioner had signed all her physician orders.

There were also sprinkler system and ventilation issues, as 11 of 22 exhaust fans in resident rooms did not work. Other violations related to fire codes and the lack of a required plan to evacuate residents in an emergency.

Another violation concerned resident rights, including the right to easily view state inspection reports. Residents also have the right to not be unduly restrained. Inspectors found restraints were used in excess on some residents. In one case, a Velcro vest that went around a resident's waist and shoulders to strap her to a wheelchair violated the physical restraint policy.

A nurse's aide was terminated for verbal abuse after an altercation with a resident. Several workers witnessed it and did nothing about it.

The report found the facility did not provide appropriate care for all residents including bathing, oral hygiene, nutrition, fluids, and incontinency care.

The state found the home did not have the staff for residents who needed specialized services, such as restorative range of motion or ambulatory exercises. Only one nurse's aide did this for 36 residents. She said she had to skip sessions on some days. The remedy was hiring a second restorative aide.

The reports show there were often repercussions and the state visits do lead to improvements. A nursing director was terminated for not reporting or initiating an investigation on an injured resident. A nurse's aide was fired for neglect and not reporting violations. Another aide was terminated for telling a resident who had to use the bathroom to just go in her diaper. A nurse was terminated after ignoring a resident's pain by not giving medication or calling a physician.

 

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