Livia Health And Senior Living

During an interview on 02/26/2025 at 12:12 PM, the Unit Manager (UM) stated that when admissions came into the facility a CP was generated automatically.

The UM stated that UMs were responsible to personalize CPs with goals and interventions.

The UM further stated that residents should have input in their CPs and should be informed of what is in the CP so that they knew what care to expect.

The UM stated that residents who wore incontinence briefs should have a CP focus related to incontinence.

During an interview on 02/26/2025 at 3:20 PM, the Assistant Director of Nursing (ADON) stated that UMs were responsible for updating CPs and including resident preferences.

The ADON stated that it was important that CPs were kept up to date so that everyone knew how to care for the resident.

During an interview on 02/26/2025 at 4:50 PM, the Director of Nursing (DON) stated that CPs were started when residents were admitted and should have been individualized to each resident.

The DON stated that any member of the Interdisciplinary Team could have updated a CP and the best practice was to update CPs when new issues came up.

The DON stated that the CP for Resident #4 should have included information about the resident's GI/GU (gastrointestinal/genitourinary) systems.

The DON further stated that Resident #6's CP did not meet expectations because it was not customized with the resident's name and diagnosis.

Review of the facility policy titled Care Plan Comprehensive Person-Centered, with an effective date of 04/01/2024, revealed under Policy Interpretation and Implementation, 7.

The care planning process will: [ .] c.

Incorporate the resident's personal and cultural preferences in developing the goals for care.

This section of the facility policy further revealed, 8.

The comprehensive, person-centered care plan will: [ .] g. incorporate identified problem areas; N.J.A.C. 8:39-11.2 (e)2

315529 02/26/2025

Livia Health and Senior Living 1 South Ridgedale Avenue East Hanover, NJ 07936

orders for wound treatments from admission or the 02/14/2025 wound care recommendations.

The

#5 during wound care observation should not have been dated 2/23 if dressing changes were

important for wound healing and infection control.

A review of the facility's Wound Care policy with a revised date of 6/19/24 revealed under the Preparation included Verify that there is a physician's order for this procedure.

Further review of the same facility policy under Steps in the Procedure, 5.

Put on exam glove[s].

Loosen tape and remove dressing. 6.

Pull glove over dressing and discard into appropriate receptacle.

Further review of the policy revealed 14.

Dress wound. [ .] [NAME] tape with initials, time, and date and apply dressing.

NJAC 8:39-27.1(e)

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Livia Health and Senior Living 1 South Ridgedale Avenue East Hanover, NJ 07936

log.

The receptionist will also ask the driver to sign the tracking log to confirm that they brought the

jeopardy to resident health or staff that resident has returned; 5. If the resident does not return to the building within the expected safety duration, the receptionist will alert the nursing supervisor that the resident has not yet returned; 6. If the resident does not return to the building prior to reception change of shift, the receptionist will

A review of the facility's policy titled: Resident Transportation date revised 2/11/25, Under Procedure: .6.Resident Tracking Log is completed by receptionist.

Driver signs tracking log upon return of resident. 7.

Resident Transport Checklist is completed by [facility name] driver .

N.J.A.C. 8:39-27.1(a)

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Livia Health and Senior Living 1 South Ridgedale Avenue East Hanover, NJ 07936

for repositioning, but no direct care staff was able to do it.

The DON further stated that it was the

that if the DSR contained blank spaces, there was no way to know if the care was provided or not.

NJAC 8:39-35.2 (f)

According to the facility's New Jersey Universal Transfer Form (NJUTF) dated 02/10/25 with Time of Transfer: 11 pm [11:00 PM] and Reasons for Transfer: Resident [came] back from (hemodialysis) H.D.

Hypothermia (low body temperature) exposed to the cold x 5 hours [for 5 hours].

A review of the facility's Summary of Investigation (SOI) under Description: On Monday, 2/10/25 at approximately 2227 [10:27 pm], [Resident #1's name] was observed lying on the floor in the transport van.

She/he was picked up by [van driver's name] from [dialysis center name] and was transported back to [facility's name] parking lot at 1700 [5:00 pm].

The SOI provided the following timeline:

- 1009 [10:09 am] Transfer log indicates [the] time Resident #1 [name] left the facility.

- 2148 [9:48 pm], the nurse assigned [name], Licensed Practical Nurse (LPN) #1, reached out to the nursing supervisor to inquire about the Resident's return.

- 2149 [9:49 pm], [the] nursing supervisor called the dialysis center x 3 [ three times] and the main center x 3, but there was no answer. A building search was initiated, and the transfer log was checked.

- 2202 [10:02 pm], the nursing supervisor called the Resident's [family member]. [The] building search continued.

- 2204 [10:04 pm], the nursing supervisor called the van driver [name] to confirm the Resident [name] returned to [the] facility.

Search continued.

- 2221[10:21 pm], the nursing supervisor exited the front of the building to check the van.

315529

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 315529 B.

Wing 02/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Livia Health and Senior Living 1 South Ridgedale Avenue East Hanover, NJ 07936