MHSA5226 – Long Term Care // Site Visit Report // Dr. Kellen Hassell
MHSA5226 – Long Term Care // Site Visit Report // Dr. Kellen Hassell
Demographic Information
Facility name & address.Care One at King James 1040 Rt. #36 Atlantic Highlands, NJ 07716
Administrator/visit guide name & contact info.
Donna Montanelli/Director of Admissions 732-291-3400 x6507 [email protected]
Population served.
Mid Atlantic and New England Markets 29 Locations in NJ Admits and discharges 20,000 patients every year.
History of the Organization
Establishment and existence.
45 years of family ownership, Care-One is a national health care management company.
Ownership, including partnerships and IHS.
Founder- Daniel E. Strauss
4 Local partnered hospitals: Riverview Medical Center 6.5 miles, Monmouth Medical Center RWJ Barnabas Health 9 miles, Bayshore Medical Center 13 miles, Jersey Shore University Medical Center 21 miles.
Philosophy of Care.
Holistic approach, embracing mind, body, and spirit as essential elements of health and wellness. They believe quality care, is personalized.
Current Status
Specific services provided.
Long term care, respite care, Post hospital rehabilitation, assisted living, Alzheimer’s/Memory care. Specialty programs: Stroke rehabilitation, orthopedic rehabilitation, general surgery care and rehabilitation, Palliative, respite and hospice care, IV therapy, Respiratory care and rehabilitation, post-trauma care and rehabilitation, wound care, cardiac care. Dementia capable care program, Short stay rehabilitation, Sensory Spa
Accreditation.
Medicare and Medicaid certified center and are contracted with most managed care plans.
Regulation and its influence.
5 Star rated by the centers for Medicare and Medicaid Services.
Financing.
Most patients pay out of pocket for services. Preferred provider with most insurance plans.
Market forces.
Staff and human resources.
Higher staff to patient ratio vs. NJ and U.S. averages. CareOne employed nurses, not contracted. All directors of nursing with 10 years or more experience. In house therapy program. Rehab directors are therapists not assistants. Certified nursing assistants.
Legal and ethical considerations.
Special leadership and management considerations.
Providing a supportive environment for patients and their families.
The Future
Influence of recent healthcare reform/legislation/pending revisions.
Emerging leadership and management aims and goals.
Current renovations being done to one wing of the facility for continuous improvement.
Problem(s) to be addressed; most pressing concerns.
Maintaining a 5 star Medicare and Medicaid rating from site inspections.
***There were some questions that were left unanswered. I sent an email to Donna my c.
MHSA5226 – Long Term Care Site Visit Report Dr. Kellen Has.docx
1. MHSA5226 – Long Term Care // Site Visit Report // Dr. Kellen
Hassell
MHSA5226 – Long Term Care // Site Visit Report // Dr. Kellen
Hassell
Demographic Information
Facility name & address.Care One at King James 1040 Rt. #36
Atlantic Highlands, NJ 07716
Administrator/visit guide name & contact info.
Donna Montanelli/Director of Admissions 732-291-3400 x6507
[email protected]
Population served.
Mid Atlantic and New England Markets 29 Locations in NJ
Admits and discharges 20,000 patients every year.
2. History of the Organization
Establishment and existence.
45 years of family ownership, Care-One is a national health care
management company.
Ownership, including partnerships and IHS.
Founder- Daniel E. Strauss
4 Local partnered hospitals: Riverview Medical Center 6.5
miles, Monmouth Medical Center RWJ Barnabas Health 9 miles,
Bayshore Medical Center 13 miles, Jersey Shore University
Medical Center 21 miles.
3. Philosophy of Care.
Holistic approach, embracing mind, body, and spirit as essential
elements of health and wellness. They believe quality care, is
personalized.
Current Status
Specific services provided.
Long term care, respite care, Post hospital rehabilitation,
assisted living, Alzheimer’s/Memory care. Specialty programs:
Stroke rehabilitation, orthopedic rehabilitation, general surgery
care and rehabilitation, Palliative, respite and hospice care, IV
therapy, Respiratory care and rehabilitation, post-trauma care
and rehabilitation, wound care, cardiac care. Dementia capable
care program, Short stay rehabilitation, Sensory Spa
5. Regulation and its influence.
5 Star rated by the centers for Medicare and Medicaid Services.
6. Financing.
Most patients pay out of pocket for services. Preferred provider
with most insurance plans.
Market forces.
Staff and human resources.
Higher staff to patient ratio vs. NJ and U.S. averages. CareOne
employed nurses, not contracted. All directors of nursing with
10 years or more experience. In house therapy program. Rehab
directors are therapists not assistants. Certified nursing
assistants.
7. Legal and ethical considerations.
Special leadership and management considerations.
Providing a supportive environment for patients and their
families.
8. The Future
Influence of recent healthcare reform/legislation/pending
revisions.
Emerging leadership and management aims and goals.
Current renovations being done to one wing of the facility for
continuous improvement.
9. Problem(s) to be addressed; most pressing concerns.
Maintaining a 5 star Medicare and Medicaid rating from site
inspections.
***There were some questions that were left unanswered. I sent
an email to Donna my contact thanking her for her time and to
see if she could offer any insight. She was very helpful during
my tour. I was impressed by the quality that was apparent
throughout.
CENTERS FOR MEDICARE & MEDICAID SERVICES
DEPARTMENT OF HEALTH AND HUMAN SERVICES
10. POST-CERTIFICATION REVISIT REPORT
STREET ADDRESS, CITY, STATE, ZIP CODE
B. Wing
Y1
DATE OF REVISIT
A. Building
315087
NAME OF FACILITY
MULTIPLE CONSTRUCTIONPROVIDER / SUPPLIER / CLIA
/
IDENTIFICATION NUMBER
CARE ONE AT KING JAMES 1040 ROUTE 36
ATLANTIC HIGHLANDS, NJ 07716
6/21/2019
Y2 Y3
This report is completed by a qualified State surveyor for the
Medicare, Medicaid and/or Clinical Laboratory Improvement
Amendments
program, to show those deficiencies previously reported on the
CMS-2567, Statement of Deficiencies and Plan of Correction,
that have been
11. corrected and the date such corrective action was accomplished.
Each deficiency should be fully identified using either the
regulation or LSC
provision number and the identification prefix code previously
shown on the CMS-2567 (prefix codes shown to the left of each
requirement on
the survey report form).
Y4
ITEM
Y5
DATE
Y4
ITEM
Y5
DATE DATE
Y5
ITEM
Y4
ID Prefix F0761 Correction
Reg. #
483.45(g)(h)(1)(2)
12. Completed
LSC 06/21/2019
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
13. Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
14. Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
REVIEWED BY
STATE AGENCY
REVIEWED BY
CMS RO
REVIEWED BY
(INITIALS)
REVIEWED BY
(INITIALS)
DATE
DATE SIGNATURE OF SURVEYOR
15. TITLE DATE
DATE
FOLLOWUP TO SURVEY COMPLETED ON CHECK FOR
ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY
OF
UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE
FACILITY? YES NO6/7/2019
Form CMS - 2567B (09/92) EF (11/06) Page 1 of 1
TIYL12EVENT ID:
CENTERS FOR MEDICARE & MEDICAID SERVICES
DEPARTMENT OF HEALTH AND HUMAN SERVICES
POST-CERTIFICATION REVISIT REPORT
STREET ADDRESS, CITY, STATE, ZIP CODE
B. Wing
Y1
DATE OF REVISIT
A. Building
315087
NAME OF FACILITY
16. MULTIPLE CONSTRUCTIONPROVIDER / SUPPLIER / CLIA
/
IDENTIFICATION NUMBER 01 - MAIN BUILDING 01
CARE ONE AT KING JAMES 1040 ROUTE 36
ATLANTIC HIGHLANDS, NJ 07716
6/21/2019
Y2 Y3
This report is completed by a qualified State surveyor for the
Medicare, Medicaid and/or Clinical Laboratory Improvement
Amendments
program, to show those deficiencies previously reported on the
CMS-2567, Statement of Deficiencies and Plan of Correction,
that have been
corrected and the date such corrective action was accomplished.
Each deficiency should be fully identified using either the
regulation or LSC
provision number and the identification prefix code previously
shown on the CMS-2567 (prefix codes shown to the left of each
requirement on
the survey report form).
Y4
ITEM
Y5
17. DATE
Y4
ITEM
Y5
DATE DATE
Y5
ITEM
Y4
ID Prefix Correction
Reg. #
NFPA 101
Completed
LSC 06/21/2019K0321
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
18. ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
19. ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
ID Prefix Correction
Reg. # Completed
LSC
20. REVIEWED BY
STATE AGENCY
REVIEWED BY
CMS RO
REVIEWED BY
(INITIALS)
REVIEWED BY
(INITIALS)
DATE
DATE SIGNATURE OF SURVEYOR
TITLE DATE
DATE
FOLLOWUP TO SURVEY COMPLETED ON CHECK FOR
ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY
OF
UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE
FACILITY? YES NO6/7/2019
Form CMS - 2567B (09/92) EF (11/06) Page 1 of 1
TIYL22EVENT ID:
21. A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 07/17/2019
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB
NO. 0938-0391
315087 06/07/2019
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF
PROVIDER OR SUPPLIER
1040 ROUTE 36
CARE ONE AT KING JAMES
ATLANTIC HIGHLANDS, NJ 07716
22. PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 000 INITIAL COMMENTS F 000
STANDARD SURVEY: 6/7/2019
23. CENSUS: 99
SAMPLE SIZE: 21 (Plus 3 Closed Records)
The facility is not in substantial compliance with
the requirements of 42 CFR Part 483, Subpart B,
for long term care facilities.
F 761
SS=D
Label/Store Drugs and Biologicals
CFR(s): 483.45(g)(h)(1)(2)
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be
labeled in accordance with currently accepted
professional principles, and include the
appropriate accessory and cautionary
instructions, and the expiration date when
applicable.
§483.45(h) Storage of Drugs and Biologicals
§483.45(h)(1) In accordance with State and
24. Federal laws, the facility must store all drugs and
biologicals in locked compartments under proper
temperature controls, and permit only authorized
personnel to have access to the keys.
§483.45(h)(2) The facility must provide separately
locked, permanently affixed compartments for
storage of controlled drugs listed in Schedule II of
the Comprehensive Drug Abuse Prevention and
Control Act of 1976 and other drugs subject to
abuse, except when the facility uses single unit
package drug distribution systems in which the
quantity stored is minimal and a missing dose can
be readily detected.
F 761 6/12/19
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
06/21/2019Electronically Signed
Any deficiency statement ending with an asterisk (*) denotes a
deficiency which the institution may be excused from correcting
25. providing it is determined that
other safeguards provide sufficient protection to the patients .
(See instructions.) Except for nursing homes, the findings
stated above are disclosable 90 days
following the date of survey whether or not a plan of correction
is provided. For nursing homes, the above findings and plans of
correction are disclosable 14
days following the date these documents are made available to
the facility. If deficiencies are cited, an approved plan of
correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete
TIYL11Event ID: Facility ID: NJ61315 If continuation sheet
Page 1 of 4
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
26. PRINTED: 07/17/2019
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB
NO. 0938-0391
315087 06/07/2019
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF
PROVIDER OR SUPPLIER
1040 ROUTE 36
CARE ONE AT KING JAMES
ATLANTIC HIGHLANDS, NJ 07716
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
27. PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 761 Continued From page 1 F 761
This REQUIREMENT is not met as evidenced
by:
Based on observation, interview and record
review, it was determined that the facility failed to
properly store and label medications in 1 of 3
medication storage rooms and 1 of 4 medication
carts inspected.
This deficient practice was evidenced by the
following:
28. On 06/04/19 at 11:42 a.m., the surveyor
inspected the medication storage room
and refrigerator in the presence of the License
Practical Nurse (LPN) Unit manager (UM) and
observed the following:
1. The medication refrigerator temperature read
50 degrees Fahrenheit (F). A review of the
Refrigerator Temperature Log (RTL) dated June
2019, revealed that on 06/03/19, the refrigerator
temperature was 48 degrees F. Further review of
the RTL, under the corrective action column
revealed no documentation of corrective action.
The instructions on the RTL indicated that the
refrigerator needs to be between 36-46 degrees
F.
The surveyor interviewed the LPN UM who stated
that the staff should have notified maintenance
right away when the temperature read 48 degrees
29. F on 06/03/19. The LPN UM said she was not
aware of this and stated she did not know why the
staff did not inform herself or maintenance of the
issue.
2. In the medication refrigerator the surveyor
observed an opened and undated
solution.
#1 How the corrective action will be
accomplished for those residents found to
have been affected.
The medications in the refrigerator were
transferred to another refrigerator and the
medication refrigerator was removed by
maintenance for 72 hours and placed
back into service as there no abnormal
temperatures observed.
The vial not dated was removed and
disposed of immediately. The
30. that was recently delivered to the facility
was discarded as it did not have the date
opened. The and
while not required to be dated
(manufacture expiration date) was
discarded as well.
#2 How the facility will identify other
residents having the potential to be
affected by the same deficient practice.
Medication carts and rooms were
checked and no other residents were
affected.
#3 What measures will be put in place or
systematic changes will be made to
ensure that the deficient practice will not
recur
Daily checks of Medication refrigerators
temps will be documented on the log
31. sheet and temperatures out of range will
be immediately reported to Supervisor
FORM CMS-2567(02-99) Previous Versions Obsolete
TIYL11Event ID: Facility ID: NJ61315 If continuation sheet
Page 2 of 4
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 07/17/2019
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB
NO. 0938-0391
32. 315087 06/07/2019
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF
PROVIDER OR SUPPLIER
1040 ROUTE 36
CARE ONE AT KING JAMES
ATLANTIC HIGHLANDS, NJ 07716
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
33. SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 761 Continued From page 2 F 761
The surveyor interviewed the LPN UM who stated
that the vial should have been dated when
opened. She further stated that the vial will be
removed from use and destroyed.
3. On 06/14/19 at 11:25 a.m., the surveyor
inspected the med cart #1,
in the presence of the Registered Nurse (RN), the
surveyor observed the following:
One box of , a
liquid medication used as and
, was opened
and not dated and one box of , an
used to was opened and
not dated.
34. The surveyor interviewed and asked the RN, what
is the facility policy for storing and dating
medication. The nurse stated, "I know the
medications should have been dated, but I don't
know the policy, I am just a per-diem nurse, I
don't work everyday, but I dated the medications
that I opened this morning".
On 06/05/19 at 1:10 p.m., the survey team met
with the Administrator and the DON and
discussed the above observations and concerns.
The DON stated that nurses are required to date
any medication that is opened.
A review of the Facility's Policy titled Medication
Storage revealed the following under procedure:
#3 "Medications will be stored at the appropriate
temperature in accordance with the pharmacy
and/or manufacturer labeling." #8 "Medications
requiring refrigeration will be stored in a
35. refrigerator that is maintained between 2 to 8
and designee (e.g. Maintenance) for
evaluation of medication and appliance.
Education to nursing staff was provided to
include the above assessment and action.
Education of Clinical Staff on proper
Medication Storage and dating was also
conducted.
#4
How the facility will monitor its corrective
actions to ensure that deficient practice is
being corrected and will not recur, i.e.
what QA program will be put into place to
monitor the continued effectiveness of the
systemic change.
Unit Managers (or designee) will conduct
random audits of two medication
refrigerators to monitor the proper
36. temperature and if action was
needed(e.g.temp high or low, it was
communicated. In addition, audits will
include four medication carts per week to
evaluate for proper dating. Audits will
continue for period of 4 weeks.
The results of these audits will be
submitted to Quality Assurance and
Performance Improvement
(QAPI)Committee for review for two
months to determine further action to plan
if needed
FORM CMS-2567(02-99) Previous Versions Obsolete
TIYL11Event ID: Facility ID: NJ61315 If continuation sheet
Page 3 of 4
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
37. STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 07/17/2019
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB
NO. 0938-0391
315087 06/07/2019
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF
PROVIDER OR SUPPLIER
1040 ROUTE 36
CARE ONE AT KING JAMES
ATLANTIC HIGHLANDS, NJ 07716
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
38. (X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 761 Continued From page 3 F 761
degrees Celsius (36 to 46 degrees F)." #9
"Refrigerators used for medications storage will
contain a thermometer to indicate the
temperature within." #10 Temperature will be
checked daily to ensure it is within the specified
39. range. If temperature is out of range, the
refrigerator thermostat will be adjusted."
A review of the Facility's Policy titled Labeling of
Medication Containers revealed the following
under #3 "Labels for individual resident
medications include all necessary information,
such as: "h. The expiration date when applicable."
A review of the Facility Policy titled Labeling of
Medication Containers #3 "Labels for individual
resident medications did not include the dating of
individualized medication upon opening the
medication.
NJAC: 8:39-29.4 (a)(h)(d)
FORM CMS-2567(02-99) Previous Versions Obsolete
TIYL11Event ID: Facility ID: NJ61315 If continuation sheet
Page 4 of 4
A. BUILDING 01
(X1) PROVIDER/SUPPLIER/CLIA
40. IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 07/17/2019
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB
NO. 0938-0391
315087 06/07/2019
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF
PROVIDER OR SUPPLIER
1040 ROUTE 36
CARE ONE AT KING JAMES
ATLANTIC HIGHLANDS, NJ 07716
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
41. CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E 000 Initial Comments E 000
This facility is in substantial compliance with
Appendix Z-Emergency Preparedness for All
Provider and Supplier Types Interpretive
42. Guidance 483.73, Requirements for Long Term
Care (LTC) Facilities.
K 000 INITIAL COMMENTS K 000
LIFE SAFETY CODE 101:2012
THIS FACILITY IS NOT IN SUBSTANTIAL
COMPLIANCE WITH THE MINIMUM LIFE
SAFETY CODE REQUIREMENTS AS
SURVEYED UNDER CMS-2786R.
K 321
SS=D
Hazardous Areas - Enclosure
CFR(s): NFPA 101
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier
having 1-hour fire resistance rating (with 3/4 hour
fire rated doors) or an automatic fire extinguishing
system in accordance with 8.7.1 or 19.3.5.9.
43. When the approved automatic fire extinguishing
system option is used, the areas shall be
separated from other spaces by smoke resisting
partitions and doors in accordance with 8.4.
Doors shall be self-closing or automatic-closing
and permitted to have nonrated or field-applied
protective plates that do not exceed 48 inches
from the bottom of the door.
Describe the floor and zone locations of
hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9
Area Automatic Sprinkler
Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
K 321 6/21/19
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
06/21/2019Electronically Signed
Any deficiency statement ending with an asterisk (*) denotes a
44. deficiency which the institution may be excused from correcting
providing it is determined that
other safeguards provide sufficient protection to the patients .
(See instructions.) Except for nursing homes, the findings
stated above are disclosable 90 days
following the date of survey whether or not a plan of correction
is provided. For nursing homes, the above findings and plans of
correction are disclosable 14
days following the date these documents are made available to
the facility. If deficiencies are cited, an approved plan of
correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete
TIYL21Event ID: Facility ID: NJ61315 If continuation sheet
Page 1 of 3
A. BUILDING 01
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
45. PRINTED: 07/17/2019
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB
NO. 0938-0391
315087 06/07/2019
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF
PROVIDER OR SUPPLIER
1040 ROUTE 36
CARE ONE AT KING JAMES
ATLANTIC HIGHLANDS, NJ 07716
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
46. ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
K 321 Continued From page 1 K 321
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
47. Hazard - see K322)
This REQUIREMENT is not met as evidenced
by:
Based on observation and interview on 6/4/19, it
was determined that the facility failed to ensure
that rooms over 50 square feet, and that are used
to store combustible supplies had doors that were
capable to automatically close.
This deficient practice was evidenced by the
following:
During a tour of the building with the facility's
Maintenance Director and Regional Plant
Operations Director, the surveyor observed the
Medical office at station 3 had over 20 large filled
combustible cardboard boxes, a large volume of
paper files were being stored in an open area of
the office. The surveyor noted that the room
measured is greater than 50 square feet and the
48. door was not equipped with a self-closure to force
the door to automatically close upon being
opened.
On 6/4/19 at 11:55 a.m., an interview was
conducted with the facility's Maintenance Director
and the Regional Plant Operations Director who
stated and acknowledged that the Medical
Records office that is greater that 50 square feet,
should have an auto closing device installed on
the door to force the door to automatically close.
#1- The automatic closing device was
immediately installed to door in question
#2- All residents have the potential to be
affected by deficient practice. This plan off
correction applies to all future and current
residents
#3- To ensure the deficient practice does
not recur, the facility will conduct weekly
49. Maintenance rounds and check all
storage areas over 50 sq. ft. and use
combustible supplies have automatic door
closures. Weekly checks will be logged on
Maintenance log sheets. Additionally staff
were in-services
#4 To monitor corrective action, the
weekly maintenance logs will be review by
Maintenance Director for 4 weeks.
#5 The results of weekly audits will be
presented to centers QAPI team at
quarterly meeting
FORM CMS-2567(02-99) Previous Versions Obsolete
TIYL21Event ID: Facility ID: NJ61315 If continuation sheet
Page 2 of 3
A. BUILDING 01
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
50. STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 07/17/2019
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB
NO. 0938-0391
315087 06/07/2019
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF
PROVIDER OR SUPPLIER
1040 ROUTE 36
CARE ONE AT KING JAMES
ATLANTIC HIGHLANDS, NJ 07716
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
51. (X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
K 321 Continued From page 2 K 321
NJAC 8:39-31.2(e)
FORM CMS-2567(02-99) Previous Versions Obsolete
TIYL21Event ID: Facility ID: NJ61315 If continuation sheet
Page 3 of 3
A. BUILDING ______________________
52. (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 07/17/2019
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB
NO. 0938-0391
315087 08/08/2018
C
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF
PROVIDER OR SUPPLIER
1040 ROUTE 36
CARE ONE AT KING JAMES
ATLANTIC HIGHLANDS, NJ 07716
53. PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 000 INITIAL COMMENTS F 000
COMPLAINT: NJ11311
54. CENSUS: 89
SAMPLE SIZE: 4
T HE FACILITY IS IN COMPLIANCE WITH THE
REQUIREMENTS OF 42 CFR PART 483,
SUBPART B, FOR LONG TERM CARE
FACILITIES BASED ON THIS COMPLAINT
VISIT.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
08/28/2018Electronically Signed
Any deficiency statement ending with an asterisk (*) denotes a
deficiency which the institution may be excused from correcting
providing it is determined that
other safeguards provide sufficient protection to the patients .
(See instructions.) Except for nursing homes, the findings
stated above are disclosable 90 days
following the date of survey whether or not a plan of correction
is provided. For nursing homes, the above findings and plans of
correction are disclosable 14
days following the date these documents are made available to
the facility. If deficiencies are cited, an approved plan of
correction is requisite to continued
55. program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete
3OZ711Event ID: Facility ID: NJ61315 If continuation sheet
Page 1 of 1
7917.pdfW147917_Redacted.pdfCare One King James-Federal-
OPRA-W147917.pdfTIYL12-F-6-21-19.pdfTIYL22-K-6-21-
19Care One King James-Complaint-OPRA-W147917
MHSA 5226
FINAL PROJECT DETAILS
LTC SITE VISIT/TOUR
STATEMENT OF DEFICIENCIES
PLAN OF CORRECTION
YEAH, BUT HOW WE GONNA PAY FOR IT?!... BUDGET
VARIANCE
PPT FILE PRESENTATION
F l o r i d a I n t e r n a t i o n a l U n i v e r s i t y
Nicole Wer theim College of Nursing and Health Sciences
Master of Health Services Administration Program
MHSA 5226: Management of Long Term Care Systems
CLASS AGENDA
• Final Project Expectations
56. FINAL LTC CONSULTATION PROJECT
• Final Project Components
FINAL LTC CONSULTATION PROJECT
• Final Project Components
• Site Visit Report Completed (clean; typed please)
FINAL LTC CONSULTATION PROJECT
• Final Project Components
• Site Visit Report Completed (clean; typed please)
• Statement of Deficiencies
FINAL LTC CONSULTATION PROJECT
• Final Project Components
• Site Visit Report Completed (clean; typed please)
• Statement of Deficiencies
• Plan of Correction
FINAL LTC CONSULTATION PROJECT
• Final Project Components
• Site Visit Report Completed (clean; typed please)
57. • Statement of Deficiencies
• Plan of Correction
• Budget Variance
FINAL LTC CONSULTATION PROJECT
• Final Project Components
• Site Visit Report Completed (clean; typed please)
• Statement of Deficiencies
• Plan of Correction
• Budget Variance
• PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
FINAL LTC CONSULTATION PROJECT
• Final Project Components
• Site Visit Report Completed (clean; typed please)
• 10-points
• Statement of Deficiencies
• 3-points
• Plan of Correction
• 5-points
• Budget Variance
• 5-points
• PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
• 13-points
58. FINAL LTC CONSULTATION PROJECT
• Final Project Components
• PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
FINAL LTC CONSULTATION PROJECT
• Final Project Components
• PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
• General Site Takeaways
FINAL LTC CONSULTATION PROJECT
• Final Project Components
• PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
• General Site Takeaways
• Site Visit Report Rundown
FINAL LTC CONSULTATION PROJECT
• Final Project Components
• PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
• General Site Takeaways
• Site Visit Report Rundown
• Problem to Be Addressed
FINAL LTC CONSULTATION PROJECT
59. • Final Project Components
• PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
• General Site Takeaways
• Site Visit Report Rundown
• Problem to Be Addressed
• Statement of Deficiencies
FINAL LTC CONSULTATION PROJECT
• Final Project Components
• PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
• General Site Takeaways
• Site Visit Report Rundown
• Problem to Be Addressed
• Statement of Deficiencies (if “created,” use reg’s/tags)
FINAL LTC CONSULTATION PROJECT
• Final Project Components
• PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
• General Site Takeaways
• Site Visit Report Rundown
• Problem to Be Addressed
• Statement of Deficiencies
• Plan of Correction (as written) …. (or would be written)
FINAL LTC CONSULTATION PROJECT
• Final Project Components
60. • PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
• General Site Takeaways
• Site Visit Report Rundown
• Problem to Be Addressed
• Statement of Deficiencies
• Plan of Correction (as written)
• Plan of Correction (in-reality… THIS is where you are
making
your new pitch….)
FINAL LTC CONSULTATION PROJECT
• Final Project Components
• PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
• General Site Takeaways
• Site Visit Report Rundown
• Problem to Be Addressed
• Statement of Deficiencies
• Plan of Correction (as written)
• Plan of Correction (in-reality… THIS is where you are
making
your new pitch….)
• Budget Variance (And, here’s the best part… you can
ALREADY afford to do it…)
FINAL LTC CONSULTATION PROJECT
• Final Project Components
• PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
61. • General Site Takeaways
• Site Visit Report Rundown
• Problem to Be Addressed
• Statement of Deficiencies
• Plan of Correction (as written)
• Plan of Correction (in-reality… THIS is where you are
making
your new pitch….)
• Budget Variance (And, here’s the best part… you can
ALREADY afford to do it…)
• Make documents and PPT look sleek & Pro
CLASS AGENDA
• Final Project Expectations
• Statement of Deficiencies
CLASS AGENDA
• Final Project Expectations
• Statement of Deficiencies
http://ahca.myflorida.com/MCHQ/WebDmHelp/
http://apps.ahca.myflorida.com/dm_web/(S(skozo2hdvr12yt101n
ijmvb1))/
doc_results.aspx?
file_number=25930119&provider_type=INTERMEDIATE+CAR
E+FACILITY&cl
ient_code=25&provider_name=SUNRISE+COMMUNITY%2c+I
62. NC.&lic_id=10
260&lic_status=20
CLASS AGENDA
• Final Project Expectations
• Statement of Deficiencies
• Plan of Correction
CLASS AGENDA
• Final Project Expectations
• Statement of Deficiencies
• Plan of Correction
• Budget Variance
CLASS AGENDA
• Final Project Expectations
• Statement of Deficiencies
• Plan of Correction
• Budget Variance… How to actually demonstrate affordability
for
your projected plan!
REFLECTION
u Additional Questions?
u Specific Concerns?
u Reflections?
63. CONTACT:
Dr. Kellen Hassell
BBC – AC1 – Room #361
Office Hours: [Mondays: 12p-5p]
[email protected]
MHSA 5226
Final Project Details
LTC Site Visit/Tour
Statement of Deficiencies
Plan of Correction
Yeah, But how we gonna pay for it?!... Budget Variance
PPT File Presentation
Dr. Kellen Hassell
Clinical assistant professor
(Final Project Details File)
F l o r i d a I n t e r n a t i o n a l U n i v e r s i t y
Nicole Wertheim College of Nursing and Health Sciences
64. Master of Health Services Administration Program
MHSA 5226: Management of Long Term Care Systems
1
Class Agenda
Final Project Expectations
Final LTC Consultation Project
Final Project Components
Final LTC Consultation Project
Final Project Components
Site Visit Report Completed (clean; typed please)
65. Final LTC Consultation Project
Final Project Components
Site Visit Report Completed (clean; typed please)
Statement of Deficiencies
Final LTC Consultation Project
Final Project Components
Site Visit Report Completed (clean; typed please)
Statement of Deficiencies
Plan of Correction
Final LTC Consultation Project
Final Project Components
Site Visit Report Completed (clean; typed please)
Statement of Deficiencies
Plan of Correction
66. Budget Variance
Final LTC Consultation Project
Final Project Components
Site Visit Report Completed (clean; typed please)
Statement of Deficiencies
Plan of Correction
Budget Variance
PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
Final LTC Consultation Project
Final Project Components
Site Visit Report Completed (clean; typed please)
10-points
Statement of Deficiencies
3-points
Plan of Correction
5-points
Budget Variance
5-points
PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
13-points
67. Final LTC Consultation Project
Final Project Components
PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
Final LTC Consultation Project
Final Project Components
PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
General Site Takeaways
68. Final LTC Consultation Project
Final Project Components
PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
General Site Takeaways
Site Visit Report Rundown
Final LTC Consultation Project
Final Project Components
PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
General Site Takeaways
Site Visit Report Rundown
Problem to Be Addressed
Final LTC Consultation Project
Final Project Components
PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
General Site Takeaways
69. Site Visit Report Rundown
Problem to Be Addressed
Statement of Deficiencies
Final LTC Consultation Project
Final Project Components
PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
General Site Takeaways
Site Visit Report Rundown
Problem to Be Addressed
Statement of Deficiencies (if “created,” use reg’s/tags)
Final LTC Consultation Project
Final Project Components
PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
General Site Takeaways
Site Visit Report Rundown
Problem to Be Addressed
70. Statement of Deficiencies
Plan of Correction (as written) …. (or would be written)
Final LTC Consultation Project
Final Project Components
PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
General Site Takeaways
Site Visit Report Rundown
Problem to Be Addressed
Statement of Deficiencies
Plan of Correction (as written)
Plan of Correction (in-reality… THIS is where you are making
your new pitch….)
Final LTC Consultation Project
Final Project Components
PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
General Site Takeaways
71. Site Visit Report Rundown
Problem to Be Addressed
Statement of Deficiencies
Plan of Correction (as written)
Plan of Correction (in-reality… THIS is where you are making
your new pitch….)
Budget Variance (And, here’s the best part… you can
ALREADY afford to do it…)
Final LTC Consultation Project
Final Project Components
PPT Presentation; pitch to Prof Hassell as CEO of LTC Site
General Site Takeaways
Site Visit Report Rundown
Problem to Be Addressed
Statement of Deficiencies
Plan of Correction (as written)
Plan of Correction (in-reality… THIS is where you are making
your new pitch….)
Budget Variance (And, here’s the best part… you can
ALREADY afford to do it…)
Make documents and PPT look sleek & Pro
72. Class Agenda
Final Project Expectations
Statement of Deficiencies
Class Agenda
Final Project Expectations
Statement of Deficiencies
http://ahca.myflorida.com/MCHQ/WebDmHelp/
http://apps.ahca.myflorida.com/dm_web/(S(skozo2hdvr12yt101n
ijmvb1))/doc_results.aspx?file_number=25930119&provider_ty
pe=INTERMEDIATE+CARE+FACILITY&client_code=25&pro
vider_name=SUNRISE+COMMUNITY%2c+INC.&lic_id=10260
&lic_status=20
Class Agenda
Final Project Expectations
Statement of Deficiencies
73. Plan of Correction
Class Agenda
Final Project Expectations
Statement of Deficiencies
Plan of Correction
Budget Variance
Class Agenda
Final Project Expectations
Statement of Deficiencies
Plan of Correction
Budget Variance… How to actually demonstrate affordability
for your projected plan!
Reflection
Additional Questions?