Inspection Reports for
Accelerate Skilled Nursing And Rehab Piscataway
10 Sterling Drive, Piscataway, NJ, 08854
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
11.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
115% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
60% occupied
Based on a December 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, legal duties of NJDHSS, and the rights of individuals to access, amend, and restrict their health information.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 10, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding neglect of a cognitively impaired resident who was found unresponsive outside on the patio during a heat wave and subsequently sent to the emergency room for heat stroke.
Complaint Details
The complaint investigation focused on Resident #1 who was found unresponsive on the patio during a heat wave on 07/29/25. The resident had severe cognitive impairment and required assistance with mobility and supervision. The resident was exposed to extreme heat for approximately 30-40 minutes, suffered heat stroke, and was sent to the emergency room. The facility failed to provide adequate supervision, failed to report the incident timely to the NJDOH, and did not fully investigate the incident including obtaining a statement from the resident's companion. Immediate jeopardy was identified and a removal plan was implemented.
Findings
The facility failed to protect Resident #1 from neglect by not providing adequate supervision, resulting in the resident being exposed to extreme heat and suffering heat stroke. The facility also failed to report the incident timely to the state health department and did not thoroughly investigate the incident to rule out neglect.
Deficiencies (3)
Failure to protect a cognitively impaired resident from neglect resulting in heat stroke and immediate jeopardy to resident health or safety.
Failure to timely report suspected neglect to the New Jersey Department of Health within two hours.
Failure to thoroughly investigate an incident of resident heat stroke to rule out neglect.
Report Facts
Resident's temperature: 103.8
Resident's heart rate: 124
Resident's BIMS score: 3
Incident date and time: 2025-07-29T11:15:00
Removal Plan submission date: 2025-11-13T16:52:00
Dayroom CNA assignment time: 11:00-11:30
Resident transfer time to hospital: 13:15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Nurse who found resident unresponsive and provided initial care |
| CNA #1 | Certified Nursing Assistant | Assigned to dayroom during incident and provided care to Resident #1 |
| DON | Director of Nursing | Interviewed regarding incident and facility policies |
| LNHA | Licensed Nursing Home Administrator | Interviewed regarding incident and facility policies |
| UM | Unit Manager | Interviewed regarding resident location and supervision on incident date |
| RR #1 | Resident's Companion | Companion who found resident unresponsive on patio and called for help |
Inspection Report
Routine
Deficiencies: 2
Date: Aug 8, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident medical record access and pressure ulcer care.
Findings
The facility failed to provide timely access to medical records for residents or their legal representatives, delaying essential health information for three sampled residents. Additionally, the facility failed to provide timely and appropriate care for an unavoidable pressure ulcer in one resident, resulting in an unstageable pressure ulcer and hospitalization for sepsis.
Deficiencies (2)
Failure to ensure medical records were provided to residents or their legal representatives in a timely manner, delaying access to essential health information for three residents.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including failure to properly assess a wound for seven days, resulting in an unstageable pressure ulcer and hospitalization for sepsis.
Report Facts
Residents affected: 3
Residents affected: 1
Sample size: 6
Sample size: 20
Pressure ulcer wound measurements: 10.5
Pressure ulcer wound measurements: 9.5
Pressure ulcer wound measurements: 0.02
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Noted wound condition and notified NP; involved in wound care and documentation |
| WCN | Wound Care Nurse | Conducted wound assessments and treatment; noted unstageable pressure ulcer |
| NP WCN | Nurse Practitioner Wound Care Nurse | Evaluated worsening pressure ulcer and documented findings |
| MD | Medical Doctor | Expected nurses to notify him of skin condition changes and gave orders for wound care |
| DON | Director of Nursing | Oversaw nursing staff expectations for skin assessments and documentation |
Inspection Report
Annual Inspection
Census: 75
Capacity: 124
Deficiencies: 15
Date: Dec 2, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Complaint Details
Multiple complaints NJ00161955, NJ00168225, NJ00169881, NJ00169291, NJ00172462, NJ00177778 were investigated during this survey.
Findings
Deficiencies were cited related to resident rights, abuse prevention, complaint reporting, accuracy of assessments, care plan implementation, medication administration, staffing ratios, infection control, immunizations, emergency preparedness, and life safety code compliance.
Deficiencies (15)
Failed to maintain dignity of residents and address resident rights violations.
Failed to implement abuse prevention policies including timely background checks and reference verifications for new hires.
Failed to report alleged violations including injuries of unknown source to the State Department of Health in a timely manner.
Failed to accurately complete Minimum Data Set (MDS) assessments, including vaccine documentation.
Failed to ensure care plan implementation and timely medication administration for pressure ulcer prevention and treatment.
Failed to provide sufficient nursing staff to meet minimum state staffing ratios.
Medication administration error rate exceeded 5%, including improper insulin pen priming technique.
Failed to store and maintain food and kitchen equipment in a sanitary manner, including soiled surfaces and undated food items.
Failed to follow infection prevention and control program requirements including hand hygiene and cleaning of glucometers.
Failed to offer or document pneumococcal and COVID-19 immunizations or refusals for residents.
Failed to complete pre-employment health examinations and tuberculosis screening for new employees within required timeframes.
Failed to inspect sprinkler system gauges monthly and maintain documentation.
Penetrations in smoke barriers were unsealed and smoke dampers lacked required four-year testing documentation.
Failed to conduct quarterly fire drills on all shifts as required.
Failed to maintain generator weekly visual inspections and battery electrolyte and gravity checks with documentation.
Report Facts
Census: 75
Total Capacity: 124
Medication administration error rate: 12
Staffing ratios: 6.5
Staffing ratios: 3.7
Staffing ratios: 3.6
Staffing ratios: 4.7
Staffing ratios: 8.4
Staffing ratios: 8.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | RN#1 involved in medication administration errors and improper insulin pen priming technique | |
| Director of Nursing | Interviewed regarding staffing ratios, infection control, immunization policies, and corrective actions | |
| Director of Maintenance | Responsible for sprinkler system inspections, generator maintenance, and smoke barrier repairs | |
| Administrator | Responsible for staffing compliance and fire drill scheduling |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Dec 2, 2024
Visit Reason
The inspection was conducted based on multiple complaints alleging failure to maintain resident dignity, failure to report injuries, inadequate care plan implementation, delayed medication administration, insufficient incontinence care, and inadequate staffing.
Complaint Details
Multiple complaints (NJ00169291, NJ 174731, NJ 177778, NJ 00168225, NJ 00172462, NJ 00161955, NJ 00177778, NJ 00169881, NJ 00168886) triggered the investigation. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in maintaining resident dignity, timely reporting of injuries, implementing care plans for pressure ulcers and medication administration, providing timely incontinence care, and ensuring adequate staffing levels. Several residents experienced undignified treatment, delayed medication administration, and inconsistent care documentation.
Deficiencies (5)
Failure to maintain dignity of 3 residents by Certified Nursing Aides.
Failure to timely report injury of unknown origin for Resident #75.
Failure to implement care plan for pressure ulcer treatment and timely medication administration for Resident #76.
Failure to provide timely incontinence care for 4 residents on 2nd floor unit.
Failure to provide sufficient nursing staff to meet resident needs and timely medication administration.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 1
Staffing deficiency days: 4
Total staff deficiency days: 1
Medication late administrations: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Aide | Named in dignity and incontinence care deficiencies |
| CNA #2 | Certified Nursing Aide | Named in dignity and incontinence care deficiencies |
| Licensed Practical Nurse (LPN) | Licensed Practical Nurse | Named in dignity and care plan deficiencies |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding multiple deficiencies and acknowledged issues |
Inspection Report
Complaint Investigation
Deficiencies: 14
Date: Dec 2, 2024
Visit Reason
The inspection was complaint-driven, investigating multiple complaints related to resident dignity, abuse prevention, incident reporting, assessment accuracy, medication administration, staffing, infection control, and vaccination practices.
Complaint Details
Complaint # NJ00169291 and multiple other complaint numbers related to dignity, abuse, incident reporting, medication errors, staffing, infection control, and vaccination.
Findings
The facility was found deficient in maintaining resident dignity, timely abuse background checks, incident reporting, accurate assessments, medication administration errors, insufficient staffing, infection control lapses including hand hygiene and glucometer disinfection, food safety violations, and failure to properly offer and document pneumococcal and COVID-19 vaccinations.
Deficiencies (14)
Failure to maintain dignity of residents during staff interactions.
Failure to timely review criminal background investigations and conduct reference checks for newly hired employees.
Failure to timely report injury of unknown origin to state authorities.
Failure to accurately complete Minimum Data Set (MDS) assessments, specifically pneumococcal vaccine documentation.
Failure to implement care plan for pressure ulcer treatment and timely medication administration.
Failure to provide timely incontinence care to dependent residents.
Failure to provide specialty pressure ulcer device (darco boots) in a timely manner.
Failure to administer oxygen therapy at the prescribed flow rate.
Insufficient nursing staff to meet resident needs and delayed medication administration due to staffing shortages.
Medication administration errors including improper insulin pen-injector technique causing inaccurate dosing.
Failure to maintain kitchen sanitation and proper food storage, including expired cheese and soiled equipment.
Failure to disinfect glucometer between residents and improper hand hygiene practices by staff.
Failure to offer pneumococcal vaccine or document refusal/education for residents.
Failure to offer COVID-19 vaccine to eligible residents and properly document vaccination status and refusals.
Report Facts
Medication administration error rate: 12
Staffing deficiency: 4
Medication administration delays: 7
Residents affected by dignity deficiency: 3
Residents affected by abuse prohibition deficiency: 10
Residents affected by injury reporting deficiency: 1
Residents affected by MDS assessment deficiency: 1
Residents affected by pressure ulcer care deficiency: 1
Residents affected by incontinence care deficiency: 4
Residents affected by pressure ulcer device deficiency: 1
Residents affected by oxygen therapy deficiency: 1
Residents affected by medication error deficiency: 2
Residents affected by food safety deficiency: Multiple kitchen sanitation and food storage issues observed.
Residents affected by infection control deficiency: Multiple staff hand hygiene and glucometer disinfection lapses observed.
Residents affected by pneumococcal vaccine deficiency: 2
Residents affected by COVID-19 vaccine deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in insulin pen-injector medication administration errors and glucometer disinfection deficiency. |
| CNA #1 | Certified Nursing Assistant | Named in dignity and incontinence care deficiencies. |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including dignity, abuse, incident reporting, medication errors, infection control, and vaccination. |
| LNHA | Licensed Nursing Home Administrator | Interviewed regarding dignity and medication administration deficiencies. |
| DOR | Director of Rehab | Interviewed regarding delay in providing specialty pressure ulcer device (darco boots). |
| IDON | Interim Director of Nursing | Interviewed regarding medication administration and wound care deficiencies. |
| CP | Consultant Pharmacist | Interviewed regarding medication pass observations and insulin pen-injector technique. |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 2
Date: Feb 15, 2024
Visit Reason
The inspection was conducted based on complaint numbers NJ00167535, NJ00167908, and NJ00170353 to investigate facility compliance with regulatory requirements.
Complaint Details
The complaint investigation revealed that the facility failed to provide the required 30-day written notice of discharge to residents, their representatives, and the Office of the Long-Term Care Ombudsman for Residents #3, #5, and #6. The facility's medical records lacked notification letters for these discharges. The Administrator acknowledged the requirement but did not provide proof of notification during the survey.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, specifically failing to provide required written notice before transfer or discharge to residents, their representatives, and the Office of the State Long-Term Care Ombudsman for 3 residents. Additionally, the facility failed to meet mandated minimum staffing ratios on multiple day shifts.
Deficiencies (2)
Failure to provide written notice of discharge to the resident, resident representative, and the Office of the Long-Term Care Ombudsman for 3 residents.
Failure to ensure staffing ratios met the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 26 of 28 day shifts.
Report Facts
Census: 58
Sample Size: 6
Deficient day shifts: 26
Total day shifts reviewed: 28
Minimum CNA to resident ratio: 8
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 15, 2024
Visit Reason
The inspection was conducted based on a complaint (#NJ00170353) regarding the facility's failure to provide timely written notice of discharge to residents, their representatives, and the Office of the Long-Term Care Ombudsman for three residents discharged from the facility.
Complaint Details
Complaint #NJ00170353 substantiated that the facility did not provide written notice of discharge to the resident, resident representative, and LTCO for 3 residents (Resident #3, Resident #5, Resident #6) as required by policy and regulation.
Findings
The facility failed to provide written notification of discharge to the resident, resident representative, and LTCO for Residents #3, #5, and #6. Medical records and electronic medical records lacked documentation of such notification letters despite discharge assessments and summaries indicating discharge occurred.
Deficiencies (1)
Failure to provide timely notification to the resident, resident representative, and ombudsman before transfer or discharge, including appeal rights, for 3 residents.
Report Facts
Residents affected: 3
Date of survey completed: Feb 15, 2024
Inspection Report
Routine
Census: 56
Deficiencies: 0
Date: Jun 22, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 8
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 22, 2023
Visit Reason
The inspection was conducted as a standard annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Immediate Jeopardy
Deficiencies: 11
Date: Jan 13, 2023
Visit Reason
The inspection was conducted due to concerns about infection control practices, antibiotic stewardship, medication administration, resident care planning, and compliance with COVID-19 regulations, including an immediate jeopardy situation related to COVID-19 outbreak management.
Findings
The facility failed to develop and implement comprehensive care plans for residents, ensure proper medication administration and documentation, maintain infection control practices including COVID-19 testing, contact tracing, and surveillance, provide adequate staff training and evaluations, maintain safe food handling and sanitation, and ensure proper notification of COVID-19 cases to resident representatives. Immediate jeopardy was identified due to failure to prevent COVID-19 spread.
Deficiencies (11)
Failure to develop and implement person-centered comprehensive care plans addressing all resident medical needs for multiple residents.
Failure to adhere to physician orders and facility policies during medication administration, including hand hygiene and documentation.
Failure to evaluate and complete wound assessments timely, complete weekly skin assessments, and discontinue wound treatment when resolved.
Failure to provide appropriate care to maintain or improve range of motion for a resident with contracture and lack of physician orders for splinting devices.
Failure to provide evidence of annual performance evaluations and 12 hours of mandatory in-service training for Certified Nursing Assistants.
Failure to act on consultant pharmacist recommendations in a timely manner and incomplete antibiotic stewardship tracking.
Failure to ensure expired medications and supplies were removed, medication room refrigerators locked and monitored, and crash carts maintained with unexpired supplies.
Failure to maintain food safety and sanitation in the kitchen, including improper thawing of food, expired produce, soiled equipment, and improper staff attire.
Failure to perform hand hygiene and assist residents with hand hygiene prior to meal service, risking infection transmission.
Failure to perform hand hygiene prior to medication administration and between residents, risking cross-contamination.
Failure to initiate contact tracing, conduct resident and staff testing, perform COVID-19 surveillance and monitoring, and notify resident representatives timely during a COVID-19 outbreak, resulting in immediate jeopardy.
Report Facts
Residents affected by care plan deficiency: 6
Residents assigned to COVID positive RN: 9
Missing refrigerator temperature log entries: 20
Expired items found: 21
Hand hygiene duration: 20
Hand hygiene duration observed: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Worked while symptomatic with COVID-19, failed to notify supervisor timely, and provided care to residents while infectious. |
| LPN #2 | Licensed Practical Nurse | Observed not performing hand hygiene prior to medication administration and between residents. |
| CNA #4 | Certified Nursing Assistant | Failed to perform hand hygiene and assist residents with hand hygiene prior to meal service. |
| DON | Director of Nursing | Acknowledged failures in infection control, antibiotic stewardship, and staff training oversight. |
| IP | Infection Preventionist | Newly assigned, incomplete competency, failed to initiate contact tracing and resident testing timely. |
| DSD | Dining Services Director | Observed poor hand hygiene and kitchen sanitation practices. |
| ADDR | Assistant Director of Rehabilitation | Reported on splinting training and nursing responsibilities. |
| QAC #1 | Quality Assurance Consultant | Involved in oversight of antibiotic stewardship and infection control. |
Inspection Report
Life Safety
Census: 53
Deficiencies: 7
Date: Jan 12, 2023
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 01/12/2023 to assess compliance with fire safety and life safety code requirements for Medicare/Medicaid participation.
Findings
The facility was found not to be in compliance with several life safety code requirements including missing required signage on delayed-egress exit doors, failure to maintain kitchen range hood suppression system inspections, improper smoke detector placement near ceiling fans, missing smoke detection sensitivity tests, corridor doors with louvers allowing smoke passage, unsealed penetrations in smoke barriers, and incomplete generator testing and maintenance.
Deficiencies (7)
Exit doors equipped with delayed-egress locking systems lacked required signage stating 'PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS' on eight stairway exit doors.
Kitchen range hood suppression system was not inspected, tested, and maintained at least every six months as required.
Two of 216 smoke detectors were installed less than 36 inches from ceiling fan blades, violating NFPA 72 requirements.
Facility failed to complete a smoke detection sensitivity test every two years for all 216 photoelectric smoke detectors.
Corridor doors on the third floor contained louvers that could not be closed, allowing passage of smoke into the main exit access corridor.
Penetrations in smoke barrier walls near multiple bedrooms were not sealed, compromising smoke barrier integrity.
The 600 KW diesel generator was not tested monthly under load and weekly inspections were not consistently performed as required.
Report Facts
Occupied beds: 53
Number of smoke detectors: 216
Number of exit stairway doors missing signage: 8
Number of unsealed holes in smoke barriers: 14
Generator load test missing months: 7
Generator weekly inspections missing: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding deficiencies and corrective actions for smoke detectors, fire doors, smoke barriers, and generator testing | |
| Regional Director | Interviewed regarding smoke barrier penetrations and facility maintenance |
Inspection Report
Plan of Correction
Census: 64
Deficiencies: 1
Date: Jul 26, 2022
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of long term care facilities, specifically focusing on staffing ratios and COVID-19 infection control practices.
Findings
The facility was found not in compliance with minimum direct care staff-to-resident ratios for the day shift on 13 of 14 days reviewed. However, the facility was found to be in compliance with COVID-19 infection control regulations.
Deficiencies (1)
Failed to maintain the required minimum direct care staff-to-resident ratios for the day shift as mandated by the State of New Jersey on 13 of 14 day shifts.
Report Facts
Census: 64
Deficiency count: 13
Staffing ratios: 1
Staffing levels: 5
Staffing levels: 6
Staffing levels: 6
Staffing levels: 6
Staffing levels: 7
Staffing levels: 7
Staffing levels: 7
Staffing levels: 6
Staffing levels: 7
Staffing levels: 7
Staffing levels: 7
Staffing levels: 6
Staffing levels: 5
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Date: Jun 29, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ142915, NJ142413, NJ141561, NJ141343, and NJ140873.
Complaint Details
The survey was triggered by multiple complaints but the facility was found compliant with no deficiencies cited.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Report Facts
Sample Size: 12
Inspection Report
Routine
Census: 108
Deficiencies: 0
Date: Dec 8, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Routine
Deficiencies: 6
Date: Oct 14, 2020
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in a skilled nursing facility, including medication regimen review, infection control, kitchen sanitation, and proper labeling and storage of IV fluids and tube feedings.
Findings
The facility was found deficient in labeling intravenous hydration and tube feedings, timely addressing pharmacist recommendations for medication regimen, maintaining kitchen sanitation and ice machine cleanliness, and ensuring staff compliance with infection control PPE protocols during an outbreak.
Deficiencies (6)
Failure to label intravenous (IV) hydration fluids and tubing with resident's name, date, and time.
Failure to label and properly store tube feedings, including open enteral feeding bottles not labeled or stored correctly.
Failure to address Consultant Pharmacist recommendations in a timely manner for medication regimen review, resulting in potential overdosage of Tylenol.
Failure to maintain proper kitchen sanitation practices, including improper drying and storage of trays, cutting boards, spices, and sugar bin contamination.
Failure to maintain ice machines in a sanitary manner, with visible contamination and inadequate cleaning documentation.
Failure to ensure staff wore appropriate personal protective equipment (PPE) when entering rooms under contact plus airborne isolation precautions during an outbreak.
Report Facts
IV fluid rate: 80
Tube feeding volume: 240
Tylenol dosage: 5600
Tylenol recommended max dosage: 4000
Ice machine last check date: Jul 1, 2020
Ice machine last check date: Apr 5, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | RN stated IV bag and tubing should be labeled with resident's name, date, and time | |
| Licensed Practical Nurse (LPN) | LPN stated IV fluid bag and tubing should be labeled with date and time | |
| Unit Manager (UM) | UM stated IV bag should be labeled with resident's name, IV solution, rate, date, time, and nurse's initials | |
| Director of Nursing (DON) | DON stated IV bags and tubing should be labeled and confirmed pharmacist recommendations were overlooked | |
| Consultant Pharmacist (CP) | CP recommended discontinuing as needed Tylenol orders for Resident #6 | |
| Registered Nurse Clinical Director (RN/CD) | RN/CD stated each shift responsible to review monthly pharmacy recommendations | |
| Food Service Director (FSD) | FSD identified kitchen sanitation issues including improper drying and storage | |
| Maintenance Employee | Maintenance employee stated housekeeping responsible for daily ice machine cleaning | |
| Housekeeper (HK) | HK stated ice machine was not clean and needed cleaning | |
| Environmental Services Director (ESD) | ESD stated housekeeping cleans ice machines daily and maintenance inspects monthly | |
| Certified Nursing Assistant (CNA) #1 | CNA #1 observed not wearing gown while passing trays despite isolation precautions | |
| Clinical Supervisor (CS) | CS instructed CNA #1 to wear gown when entering isolation rooms | |
| Infection Control Nurse (ICN) | ICN stated all staff must wear full PPE when entering isolation rooms including while delivering trays |
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