Llanfair House Care & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Llanfair House Care & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835Nov 3, 2022

  Complaint NJ00157677 Refer F689, and F836 Based on observations, interviews, review of medical records, and review of facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure that the policies and procedures were implemented to ensure resident safety and well-being to prevent serious harm, by failing to: a.) identify sufficient staffing numbers to address the population census and needs of their residents, and b.) ensure they were also meeting New Jersey state minimum staffing requirements for 32 of 42 total shifts over a two week period of time from 9/25/22 through 10/08/22, yet the LNHA continued to allow the admission of seven (7) new residents during this two week period prior to survey. […]

• Immediate jeopardy, widespreadF836Nov 3, 2022

  Complaint #NJ00157677 Reference F677 and F689 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) ensure the facility was meeting New Jersey state minimum staffing requirements, and b.) identify their own sufficient staffing numbers necessary to meet their census population and resident needs. The survey team reviewed the staffing levels for the two weeks prior to the survey (9/25/22 to 10/8/22). It was determined that the facility was significantly deficient in Certified Nursing Aide (CNA) staffing for 14 of 14 day shifts in which most days, the facility was only meeting half of the required CNA's for the day shift (CNA's had between 13 to 26 residents each on their assignment when the NJ state requirement is 1… […]

• Immediate jeopardy, patternF689Nov 3, 2022

  PART A Based on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to ensure that Resident #47 who was at risk for falls and with a diagnosis of Dementia was supervised, assessed, evaluated, and monitored to determine the cause of each fall and to prevent future falls, including a fall that resulted in serious injury. This deficient practice was identified for 1 of the 3 residents reviewed for falls. Resident #47 sustained 11 falls from 5/26/22 through 10/10/22 over a six month period of time. Seven (7) of the 11 of the falls were unwitnessed falls with most of the falls reoccurring in common areas (hallways and dining room). […]

• Immediate jeopardy, isolatedF600Nov 3, 2022

  Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined the facility failed to ensure that Resident #2 was free from physical abuse from a staff Licensed Practical Nurse. On 7/30/22 during the evening shift, Resident #2 was a victim of physical abuse by a Licensed Practical Nurse #1 (LPN#1) when LPN #1 punched Resident #2 on the left side of the face with a closed fist causing the resident to fall to the ground. This incident was witnessed by two facility staff, a Certified Nursing Aide (CNA #1) and a second Licensed Practical Nurse (LPN #2). The resident exhibited pain after the incident. […]

• Actual harm, isolatedF686Dec 16, 2024

  Complaint #'s: NJ175457, NJ175482 Based on observation, interview, and record review, it was determined that the facility failed to report a newly developed pressure ulcer (PU) and implement a physician's order (PO) for wound care to treat a facility acquired PU for 1 of 3 residents reviewed for PU's, (Resident #110). The PU worsened from an excoriation (wearing off the skin) that was identified on 6/20/24 to an unstageable PU ( covered with slough (a soft, yellow or white, often stringy material that accumulates on the surface of a wound) or eschar (a layer of dry, dead tissue that forms over a deep wound) and cannot be staged which are caused by prolonged pressure, shear and friction and can lead to infection and complications). […]