Inspection Reports for The Actors Fund Home

Complaint NJ#186231 was substantiated based on observation, interview, and review of facility documentation regarding improper garbage disposal.

The facility was found to have an unclean garbage disposal area with debris scattered around the dumpster on one of two observation days. Follow-up observations showed the area was cleaned and maintained by dietary and housekeeping staff, with in-service education provided to dietary staff regarding maintenance of the recycling dumpster area.

The facility was found deficient in multiple areas including failure to complete timely quarterly resident assessments, incomplete and inaccurate care plans, medication administration errors, inadequate pharmacist review of medication irregularities, food safety violations including improper refrigeration temperatures and uncovered food items, improper garbage disposal, and incomplete medical record documentation.

Deficiencies were cited related to notice requirements before transfer/discharge, encoding/transmitting resident assessments, posted nurse staffing information, labeling and storage of drugs and biologicals, fire alarm system installation and testing, smoke detection, and electrical system maintenance.

The facility failed to notify the state Ombudsman timely about a resident's emergency transfer, transmitted MDS assessments late for two residents, inaccurately posted nurse staffing information, and improperly labeled and stored medications in one medication cart.

The visit was complaint-related due to failure to maintain minimum staffing ratios. The deficiency was substantiated based on interviews, documentation review, and staffing reports.

The facility was found to be in compliance with COVID-19 infection control regulations but was not in compliance with the State of New Jersey minimum staffing requirements for certified nurse aides (CNAs) on multiple day shifts from 12/9/22 through 12/15/22, being short by one CNA on those shifts.

Complaint #NJ00152257 involved an allegation by Resident #2's representative that a nurse was verbally abusive and rough towards Resident #2. The complaint was not reported to the Administrator or Director of Nursing, resulting in no investigation or reporting to the NJ Department of Health. The resident was discharged on 8/27/2021.

The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to failure to report an allegation of abuse involving one resident. The complaint involved a nurse verbally abusing and being rough with Resident #2, but the allegation was not reported to the Administrator or Director of Nursing and was not investigated or reported to the New Jersey Department of Health as required.

The facility was found to not be in substantial compliance with requirements related to nurse staffing information posting, labeling and storage of drugs and biologicals, and food safety requirements including sanitation and proper dish machine operation.

The complaint investigation substantiated deficiencies related to failure to complete a Significant Change in Status Assessment, inadequate pressure ulcer care including improper glove use during wound dressing, and failure to provide the correct diet consistency as ordered by the physician.

The facility failed to complete a federally mandated Significant Change in Status Assessment for one resident enrolled in hospice. The facility also failed to provide appropriate pressure ulcer care by not following proper wound dressing procedures, and failed to ensure a resident received the correct diet consistency as ordered by the physician, resulting in potential minimal harm to residents.

The facility failed to maintain the required minimum direct care staff-to-resident ratios for 4 of 42 shifts reviewed, as evidenced by staffing reports showing insufficient certified nursing assistants on several days. The facility acknowledged staffing challenges and described multiple interventions to recruit and retain staff.

The facility was found not in compliance with infection control regulations, specifically failing to practice appropriate hand hygiene for 4 of 12 staff members observed, contrary to CDC guidelines to mitigate the spread of COVID-19.