Preakness Healthcare Center

In the surveyor’s words

From the most serious findings on record at Preakness Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Nov 26, 2024

  Complaint#: NJ00179720 Based on interviews and review of pertinent facility documents, it was determined that the facility failed to follow the Medical Emergency Response policy for a resident (Resident #2) in respiratory distress. This deficient practice was identified for 1 of 3 residents reviewed for medical emergency response procedures. The facility also failed to provide the needed emergency transportation services to manage the acute respiratory symptoms of Resident #2, which resulted in the Resident's failure to improve. In addition, the facility failed to develop a policy and procedure for the staff to follow to determine the use of emergency or non-emergency transportation services based on residents presenting symptoms. […]

• No harm, potential for more than minimal, widespreadF812Jan 22, 2025

  Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 1/15/25 at 9:24 AM, the surveyor in the presence of the Dietary Supervisor (DS#1) and the Registered Dietitian (RD) observed the following during the kitchen tour: 1. The surveyor observed in the dry storage room: a dented can of sliced potatoes in the regular rotation of non-dented canned goods; 3 boxes stored above 18 inches (in) from the ceiling, and the following items were observed opened without an open/use by label: one 3 pound (lb.) bag of tri-color pasta, 1 gallon container of white vinegar, one 32 oz (ounces)… […]

• No harm, potential for more than minimal, patternF607Jan 22, 2025

  Based on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure reference checks were completed for 10 out of 10 newly hired staff (Staff #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) prior to their start date of employment. This deficient practice was evidenced by the following: The surveyor reviewed 10 randomly selected new employee files for reference checks for 10 of the 10 new employees revealed the following: A review of Staff #1's file, a Recreation Activity Aide (RA), date of hire (doh) on 10/30/23, showed there were no reference checks in their file. […]

• No harm, potential for more than minimal, patternF640Jan 22, 2025

  Based on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with the federal guidelines. This deficient practice was identified for 17 of 17 system selected residents, Resident #2, #12, #34, #38, #46, #48, #69, #70, #139, #166, #199, #205, #209, #220, #233, #267, and #271) and was evidenced by the following: On 1/21/25 at 9:09 AM, the surveyor reviewed the facility assessment task that included the Resident's MDS assessment. The MDS was a comprehensive tool that was federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. […]

• No harm, potential for more than minimal, patternF759Jan 22, 2025

  REPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more during the medication administration, 4 nurses administered medications to 5 residents. There were 25 opportunities for error, 2 errors were observed which calculated to a medication administration error rate of 8%. This deficient practice was identified for 2 of 5 residents, (Resident #55 and Resident #122), that were administered medications by 2 of 5 nurses that were observed. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. […]