Advanced Subacute Rehabilitation Center At Sewell

F-F812

A review of the Administrator's job description provided by the facility revealed the following:

The Administrator's primary purpose is to direct the day-to-day functions of the center in accordance with current federal, state, and local standards, guideline, and regulations that govern nursing centers to assure that the highest degree of quality care can be provided to the residents at all times.

Duties and Responsibilities included but not limited to: plan, develop, organize, implement, evaluate, and direct the center's programs and activities; Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the center; Review the facility's policies and procedures at least annually and make changes as necessary to assure continued compliance with current regulations; Ensure that all employees, residents, visitors, and the general public follow the center's established policies and procedure; Make routine inspections of the facility to assure that established policies and procedures are being implemented; Ensure that all facility personnel, residents, visitors, etc., follow established safety regulations.

On 3/3/25 at 8:13 AM, during the entrance conference, the Director of Nursing (DON) stated the LNHA was

on vacation and would be returning on Wednesday, 3/5/25. She then stated that the LNHA had been there for three (3) years.

On 3/4/25 at 10:47 AM, the surveyor accompanied the Director of Maintenance (DM) to Resident room [ROOM NUMBER]. The DM, with a calibrated digital probe thermometer, obtained a hot water temperature from the resident's sink which registered 138 degrees Fahrenheit (F).

At that time, a Certified Nursing Assistant (CNA #2) was assisting Resident #108 with morning care. The surveyor observed a wash basin filled with water on the sink. The DM obtained a hot water temperature in

the wash basin which registered 113 degrees F.

On 3/4/25 at 10:52 AM, the DM obtained a hot water temperature in Resident room [ROOM NUMBER], which registered 140 degrees F.

On 3/4/25 at 10:54 AM, the DM obtained a hot water temperature in the central LTC shower room, which registered 118 degrees F.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 23 315516 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315516 B. Wing 03/07/2025

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

Advanced Subacute Rehabilitation Center at Sewell 685 Salina Road Sewell, NJ 08080

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Upon discovery of the high temperatures, the surveyor and the DM inspected other rooms on all three (3) units. Level of Harm - Minimal harm or potential for actual harm A review of the facility's Water and Air Temperature Log from 1/1/25 to 3/5/25, revealed water temperatures above 120 degrees F in resident rooms. Residents Affected - Many Further review of the Water and Air Temperature log from 1/1/25 to 3/5/25, reflected water temperatures that were documented above 110 degrees F, ranging from 111 degrees F to 119 degrees F on all 3 units, which included resident's rooms, the shower rooms, the activities rooms, and the hair salon.

There was no documented evidence that the affected rooms with water temperatures above 120 degrees were rechecked prior to surveyor inquiry.

On 3/6/25 at 2:15 PM, the LNHA acknowledged the concerns that were brought to his attention in the presence of the DON and the survey team.

On 3/6/25 at 2:17 PM, the surveyor interviewed the LNHA, in the presence of the survey team, who stated his role was to manage the entire facility and to ensure the residents, the staff and the visitors were safe. He stated that he was the leader of the building and responsible for operating the entire facility.

NJAC 8:39-9.2(a); 9.3(a); 27.1(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 23 315516