Community Care of Rutherford

In the surveyor’s words

From the most serious findings on record at Community Care of Rutherford, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Nov 16, 2022

  Based on facility policy review, medical record review, facility document review, observation, and interview, the facility failed to implement a care plan for risk of elopement for 1 of 13 sampled residents (Resident #2) reviewed for risk of wandering and/or elopement with a diagnosis of Dementia. The facility's failure to implement the care plan and interventions for Resident #2 placed the resident in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). […]

• Immediate jeopardy, isolatedF689Nov 16, 2022

  Based on facility's policy review, medical record review, facility documentation review, observation, and interview, the facility failed to provide adequate supervision to prevent elopement for 1 of 13 sampled residents (Resident #2) reviewed for risk of wandering and/or elopement with a diagnosis of Dementia. The facility's failure to provide adequate supervision and implement interventions to prevent elopement for Resident #2 who eloped from the facility on 8/2/2022 on a hot summer day. This placed the resident in an Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). […]

• Immediate jeopardy, isolatedF835Nov 16, 2022

  Based on job description review, facility policy review, and interview, Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable wellbeing of the residents. The failure of Administration to ensure adequate supervision was provided and to ensure the care plan was updated, which placed 1 of 13 sampled Residents (Resident #2) reviewed for risk of wandering and/or elopement with a diagnosis of Dementia in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). […]

• Immediate jeopardy, isolatedF689Aug 6, 2021

  Based on facility policy review, facility investigation, medical record review, observation, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent elopement for 1 (Resident #1) of 9 sampled residents reviewed with wandering behaviors, which resulted in Immediate Jeopardy. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to supervise a vulnerable resident who was assessed as a high elopement risk which resulted in Resident #1's elopement. […]

• Actual harm, isolatedF656May 11, 2022

  Based on facility policy review, medical record review, and interview the facility failed to implement a care plan intervention for a fall for 1 of 4 sampled residents (Resident #44), which resulted in actual harm ([MEDICATION(S)] trauma to head with 3 staples needed for closure of a laceration). The facility also failed to implement a care plan for 1 of 35 sampled residents (Resident #76) reviewed for care plans. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 9/20/2016, revealed, .Plans of Care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident related to clinical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .[named facility] staff will refer to the goals and interventions… […]