Venetian Care & Rehabilitation Center, The

Investigation Allegations 1.

All allegations are thoroughly investigated.

The administrator initiates investigations . 6.

Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Venetian Care & Rehabilitation Center, The

275 John T O'Leary Boulevard South Amboy, NJ 08879

SUMMARY STATEMENT OF DEFICIENCIES

Based on interviews and record review, the facility failed to prevent an injury during an improper transfer for one of three residents (Resident (R) 2) reviewed for abuse out of 22 sample residents.

This failure increased the risk of residents experiencing injuries during transfers.Review of R2's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R2 was admitted to the facility in 04/15.Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/25, located in the EMR under the MDS tab, revealed R2's Brief Interview for Mental Status (BIMS) score was three out of 15 which indicated he/she was severely cognitively impaired.

The MDS revealed he/she required substantial/maximal assistance with chair/bed-to-chair transfers and had impairment on both sides of the lower extremities.Review of R2's Care Plan, dated 07/22/15 and located in the EMR under the Care Plan tab, revealed a focus of R2 wanting to assist with surface to surface transfers and requiring extensive assistance with surface transfers with interventions to use verbal cues to prompt his/her with transfers so he/she can assist the care partner and if not able to assist the care partner please refer R2 to rehab for a screening.

Review of R2's Progress Notes, dated 06/09/25 and located in the EMR under the Prog Note tab, revealed called by the Primary Nurse due to purplish discoloration noted on the left inner thigh.

Assessed with purplish discoloration extending from the right inner thigh to the right posterior thigh . MD [physician] was notified and made aware of the findings.Review of R2's Summary of Investigation for Injury of Unknown Origin, dated 06/09/25 and provided by the facility, documented issue/concern: during routine overnight care on 06/09/25, staff observed a bruise on the resident's left inner thigh and immediately informed nursing .

Review of the resident's care notes showed he/she had been placed back in bed earlier on 06/08/25 after appearing lethargic. A two-person transfer was performed, and it is believed that his/her thigh came into contact with the wheelchair armrest during positioning.

Plan of Action: Reinforce safe two-person transfer techniques for dependent residents.

Review of the facility's Investigation of Incident Employee Care Partner Statement, dated 06/10/25 and provided by the facility, revealed Certified Nursing Assistant (CNA) 1 and CNA2 saw R2 sleeping in the chair so CNA1 and CNA2 transferred her to the bed. CNA1 held R2 by his/her pants on the right side and CNA2 held R2 by his/her pants on the left side.An interview was attempted with CNA1 on 08/18/25 at 5:42 PM, 6:00 PM, and 6:15 PM and a message could not be left due to the voicemail not set up yet.An interview was attempted with CNA2 on 08/18/25 at 5:43 PM, 5:45 PM, and 5:55 PM and a return call was not received.During an interview on 08/18/25 at 6:29 PM, the Director of Nursing (DON) stated he interviewed CNA1 and CNA2 on 06/10/25 and they stated they stood on the opposite sides of R2 then lifted his/her by putting their arms under his/her armpits and the other hand on his/her pants and then swung his/her over the wheelchair armrest into the bed.

The DON stated the transfer was not performed properly because the nursing assistants should not have held onto his/her pants to transfer into the bed and should have removed the armrest from the wheelchair which caused the bruise to R2's thigh.

During an interview on 08/19/25 at 3:13 PM, the Director of Rehabilitation (DOR) stated the nursing assistants, CNA1 and CNA2, stated they lifted R2 by holding onto his/her pants during the transfer from the wheelchair to the bed on 06/08/25.

The DOR confirmed the transfer was not performed properly.

The DOR stated the armrest should have been removed from the wheelchair prior to the transfer and they should have used a gait belt to assist them in the transfer and not pulled on her pants.The transfer policy was requested from the Administrator and was not received prior to exit of the survey.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Venetian Care & Rehabilitation Center, The

275 John T O'Leary Boulevard South Amboy, NJ 08879

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 08/18/25 at 1:22 PM, Registered Nurse (RN) 4 confirmed the antiseizure and antibiotic medications were not delivered to the facility yet, but she contacted the pharmacy on 08/18/25 regarding the status of the antiseizure medication arrival, and the pharmacy stated a new order was needed from the physician. RN4 stated she contacted the physician, the new order was faxed to the pharmacy, and it would be delivered later today. An interview was attempted on 08/18/25 at 4:51 PM with Licensed Practical Nurse (LPN) 9 about ordering and following up on the delivery of R16's medications on 08/14/25 but she did not return the phone call.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Venetian Care & Rehabilitation Center, The

275 John T O'Leary Boulevard South Amboy, NJ 08879

SUMMARY STATEMENT OF DEFICIENCIES

Based on observations, interviews, record review, and policy review, the facility failed to ensure nursing staff stored medications not administered to residents in the locked medication cart not at bedside for one out of 22 sampled residents (Resident (R) 16) observed during the medication administration.

This failure had the potential for wandering residents to self-administer other residents' medications.

Review of R16's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed he/she was admitted in 08/24 with a diagnosis of epilepsy.

Review of R16's Physician's Orders, dated 08/13/25 and located in the EMR under the Orders tab, revealed an order for polyethylene glycol 3350 powder give 17 grams by mouth one time a day for constipation mix with 6-8 ounces (oz.) of water or juice and an order for Phenobarbital oral elixir 20 milligrams (MG)/5 milliliters (ML) give 11.3 ML by mouth every 12 hours for seizures.

Review of Registered Nurse (RN) 4's Medication Administration Competency, dated 08/13/25, revealed she completed the competency on 08/13/25 with another nurse.

The medication administration competency form revealed RN4 did not leave the medication at the bedside or on top of the medication cart after preparing them.

During an observation on 08/18/25 at 1:16 PM in R16's room, R16 was lying in bed with an assigned nursing assistant feeding lunch while sitting next to the chair. On the overbed table, there were two medication cups placed on it next to the lunch tray, one with white powder and the other one with red liquid in it.

Interview with R16 at this time revealed the nurse left them there and has not returned to give them to him/her yet.

During an interview on 08/18/25 at 1:22 PM, RN4 confirmed she left the two medications, Phenobarbital elixir and polyethylene glycol powder, on the overbed table because she did not have juice to administer the medications per the physician's orders. RN4 stated it was her third day working at the facility and she should have locked the medications in the medication cart to keep other residents from self-administering them. RN4 stated she was trained for two days by another nurse.

During an interview on 08/18/25 at 1:31 PM, the Director of Nursing (DON) observed the two medication cups on the bedside table in R16's room.

The DON stated RN4 was a newly hired employee at the facility, and she had successfully administered medications with a preceptor during orientation.

The DON stated RN4 should not have left the medications on the bedside table, she should have administered the medications to R16 and for the safety of the other residents so they would not wander into the room and ingest the medications.

During an interview on 08/18/25 at 1:42 PM, RN5, Nurse Manager, stated RN4 did not follow the medication administration rights when she left the two medications on the bedside table, and she should have located the juice before preparing the medications or locked the medications in the cart while she found the juice. RN5 stated that another resident could have walked in the room and ingested the medications.

During an interview on 08/20/25 at 8:40 AM, the Assistant Director of Nursing (ADON) revealed RN4 successfully completed the medication administration competency on 08/13/25 and the nurse should have watched R16 take the medications, medications were not allowed to be placed back in the medication cart after preparing them, and the medications were not allowed to be left at the bedside.

Review of the facility's policy titled Medication Labeling and Storage, revised February 2023, provided by the facility, revealed .

Policy Interpretation and Implementation Medication Storage . 4.

Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Venetian Care & Rehabilitation Center, The

275 John T O'Leary Boulevard South Amboy, NJ 08879

SUMMARY STATEMENT OF DEFICIENCIES

Based on observations, interviews, and policy review, the facility failed to ensure staff perform hand hygiene after serving and assisting residents with setting up their meals for one out of 22 sample residents (Resident (R) 22) observed during the lunch meal.

This failure had the potential to cause cross contamination and spread germs to vulnerable residents.

During an observation on the fourth floor in the common area on 08/19/25 at 12:19 PM, Recreation Aide (RA) 2 placed R21's meal tray on the table, removed the plate cover, lids on the cups, and then used the fork to cut up the food without performing hand hygiene afterward.

Next, RA2 walked to the food cart and picked up another food tray and placed it in front of R22.

During an interview on 08/19/25 at 12:23 PM, RA2 confirmed she did not perform hand hygiene after setting up R21's food tray and stated she was not told to sanitize or wash her hands after setting up the food trays for the residents, but it would be an infection control issue.

During an interview on 08/19/25 at 12:49 PM, the Assistant Director of Nursing (ADON), also the Infection Preventionist (IP), stated staff should either use hand sanitizer or wash their hands after setting up the resident's meal trays and staff were taught hand hygiene during orientation and during the annual skills training.

The IP stated she had not made observations of hand hygiene recently.

Review of the facility's policy titled Assisting the Resident with In-Room Meals, dated 2001, provided by the facility, revealed .

Preparation . 11.

Employees must wash their hands before serving food to residents. It is not necessary to wash hands between each resident tray; however, if there is contact with soiled dishes, clothing or the resident's personal effects, the employee must wash his/her hands before serving food to the next resident.

Facility ID: