Inspection Reports for
Preferred Care at Cumberland

The facility failed to ensure that the baseline care plan included sufficient information to provide person-centered care for one of three sampled residents reviewed for new admission. Specifically, the baseline care plan did not include key respiratory conditions and orders for the resident.

The facility was found deficient in timely transmission of resident assessment data, incomplete baseline care plans for new admissions, failure to provide activities aligned with resident preferences, lack of implementation of recommended passive range of motion interventions, and improper cleaning and storage of kitchen pots and pans, all posing potential risks to residents' health and quality of life.

Complaint Number NJ175824 triggered the investigation. The complaint was substantiated as the facility failed to document ADL care properly for Resident #2, with multiple days of missing documentation noted.

The facility was found not in compliance with New Jersey Administrative Code standards due to failure to consistently document Activities of Daily Living (ADL) status for Resident #2, with multiple days of missing documentation across all shifts. The facility's policy and job descriptions require timely and accurate documentation, which was not met.

Complaint NJ175824 was substantiated based on review of medical records, interviews, and documentation showing missing entries for turning and repositioning care for Resident #2, who had severe cognitive impairment and required extensive assistance with mobility.

The investigation found multiple days across three shifts where documentation for turning and repositioning Resident #2 was missing, indicating either care was not provided or not documented. Interviews with staff confirmed expectations for documentation and acknowledged the presence of blank documentation entries.

Complaint numbers NJ 001052177, NJ 00150683, NJ00150837, NJ 00151536, NJ00152223, NJ00153534, NJ00159116 were investigated as part of this survey.

The facility was found to be in substantial compliance with emergency preparedness but had deficiencies in maintaining a safe, clean, and homelike environment, pressure ulcer treatment, respiratory care, nursing staffing, pharmacy services, food temperature control, infection prevention and control, and life safety code requirements including fire alarm system and sprinkler installation.

Complaint # NJ00158190 regarding food temperature issues; substantiation status not explicitly stated.

The facility was found deficient in maintaining a clean environment in shower rooms, providing appropriate pressure ulcer care with incomplete treatment documentation, ensuring registered nurse coverage for required hours, and maintaining palatable food temperatures during meal service.

Complaint # NJ00158190 related to food temperature and other issues triggered the investigation. The complaint was substantiated based on observations and interviews.

The facility was found deficient in maintaining a clean environment in shower rooms, ensuring physician orders for oxygen therapy, providing adequate RN staffing, proper medication storage and narcotic accountability, serving food at safe temperatures, enforcing infection control precautions including PPE use, and installing handrails in corridors.

Complaint NJ166796 was substantiated as the facility failed to meet minimum CNA staffing ratios on multiple day shifts. No care concerns were reported related to the staffing deficiencies.

The facility was found to be in substantial compliance with federal requirements but not in compliance with New Jersey state staffing ratio requirements, failing to meet minimum CNA staffing ratios on 10 of 14 day shifts reviewed.

The facility failed to maintain the required minimum direct care staff to resident ratios for the day shift on 3 of 14 days reviewed, as mandated by the State of New Jersey. The facility submitted a plan of correction to address staffing shortages, including increased hiring, use of agency staff, and monitoring by the Director of Nursing.

The facility was found noncompliant with several life safety code requirements including inadequate illumination of means of egress, failure to maintain self-closing devices on fire-rated doors to hazardous areas, and lack of audible and visible fire alarm notification devices in two outside enclosed courtyards. Corrective actions were implemented promptly by the maintenance director.

The facility failed to accurately complete the Minimum Data Set (MDS) for one resident receiving hospice care, resulting in a data entry error. Additionally, the facility failed to maintain a sanitary environment around the dumpster area, with garbage and debris observed on the ground.

The visit was complaint-related due to concerns about infection control practices during the COVID-19 pandemic, including PPE use and hand hygiene. The immediate jeopardy was identified on 1/21/2021 and removed by 1/25/2021.

The facility failed to implement appropriate infection control practices, including improper use of Personal Protective Equipment (PPE) such as not changing gowns between residents on the PUI unit and staff wearing surgical masks instead of N95 masks despite CDC and NJDOH guidance. This posed a serious and immediate threat to residents. The facility was found to have corrected the immediate jeopardy by the date of the onsite removal plan verification survey.