Inspection Reports for
Chatham Hills Subacute Care Center

Complaint #403805 involved failure to provide written notice of hospital transfer to a resident's guardian. Complaint #NJ403814 involved failure to provide timely incontinence care to dependent residents. Both complaints were substantiated based on observations, interviews, and record reviews.

The facility failed to provide written notice to a resident's guardian about the resident's hospital transfer and failed to provide timely incontinence care to dependent residents on two nursing units, resulting in residents being found in saturated briefs and pads.

The facility was found deficient in multiple areas including failure to maintain a safe and sanitary environment, inadequate documentation and monitoring of psychotropic medication use, failure to provide timely incontinence care, improper medication administration related to dialysis scheduling, failure to notify physicians of abnormal blood sugar levels, incomplete care planning for residents with mental health diagnoses, and improper food storage and sanitation practices.

The facility failed to ensure staff followed enhanced barrier precautions while providing Activities of Daily Living care for one resident on EBP, increasing the risk of infection spread. Observations and interviews revealed staff were unaware or did not follow EBP protocols due to lack of PPE availability and signage.

Complaint #NJ00167644 regarding pharmaceutical service deficiencies and infection control practices. The complaint was substantiated based on observations, interviews, and record reviews.

The facility failed to clarify duplicate physician orders for Ferrous Sulfate and failed to obtain pain medication for a resident, resulting in medication administration errors for 2 of 7 residents reviewed. Additionally, the facility failed to ensure staff wore appropriate PPE for residents on Enhanced Barrier Precautions, observed in 2 of 3 residents on two units, with missing signage and PPE bins at resident rooms and staff not donning gowns as required.

Complaint #157599 and NJ00167644 regarding meal assistance, mail delivery, medication errors, food safety, sanitation, and infection control.

The facility was found deficient in multiple areas including failure to serve meals in a dignified manner, inconsistent mail delivery, failure to provide meal assistance to dependent residents, medication errors including duplicate orders and missed medications, improper food storage and sanitation, inadequate waste management, and failure to implement proper infection prevention and control measures including use of PPE for residents on Enhanced Barrier Precautions.

Deficiencies were cited related to resident rights, communication, activities of daily living care, pharmacy services, food safety, waste management, infection control, life safety code violations including egress doors, emergency lighting, cooking facilities, fire alarm and sprinkler system maintenance, corridor doors, and smoke barrier integrity.

Complaint #NJ 00163449 involved Resident #1 who was a full code but found unresponsive without CPR initiated promptly. The complaint was substantiated with findings of delayed CPR and failure to activate emergency response system. Immediate jeopardy was identified but corrected prior to survey.

The facility failed to immediately initiate CPR and activate the emergency response system for Resident #1, who was a full code and found unresponsive without a pulse or respirations. The Licensed Practical Nurse (LPN #1), an agency nurse new to the facility, did not initiate CPR due to uncertainty about the resident's code status and lack of physician order for DNR. CPR was delayed until the nursing supervisor arrived and was instructed by the Director of Nursing to initiate CPR and call 911. The facility's policies require immediate CPR initiation unless a valid DNR order is present. The facility implemented corrective actions including staff education, policy reinforcement, and mock drills.

Complaint #NJ00163449 involved allegations that the facility failed to initiate emergency procedures for Resident #1 who was found unresponsive without a physician order for CPR. The complaint was substantiated with findings of Immediate Jeopardy past noncompliance.

The facility failed to immediately initiate and activate their emergency response system when Resident #1, who lacked a physician order for CPR, was found unresponsive in bed. This failure placed residents at risk and was determined to be an Immediate Jeopardy past noncompliance. The facility subsequently corrected the deficiency and implemented staff education and policy reviews.

The facility was found deficient in multiple areas including failure to document ordered behavioral monitoring and urinary outputs, improper oxygen cylinder storage and oxygen delivery inconsistent with physician orders, inaccurate narcotic accountability documentation, serving food at unsafe temperatures, poor kitchen sanitation and employee hygiene practices, and inadequate infection prevention and control practices including improper use of PPE and hand hygiene.

The facility was found to be in noncompliance with several Life Safety Code requirements including emergency lighting, corridor door smoke resistance, HVAC maintenance, essential electrical system testing, and gas cylinder storage. Deficiencies were observed in emergency lighting above the generator transfer switch, warped resident room doors, dirty PTAC filters, lack of generator transfer time certification, improper location of generator manual stop station, and unsecured oxygen cylinders.

The complaint investigation found that the facility did not send notifications to the Office of the State Long-Term Care Ombudsman for emergency transfers from November 2021 through January 2022, including Resident #6's emergency discharge.

The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, specifically failing to send timely notices of transfer or discharge to the Office of the State Long-Term Care Ombudsman for Resident #6 and other emergency transfers from November 2021 to January 2022.