A list of the most recent deficiencies for Hope Creek Nursing and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-08 | 2023-11-24 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-12 | 2023-10-19 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2023-09-01 | 2023-09-25 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-09-01 | 2023-09-25 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-09-01 | 2023-09-25 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-09-01 | 2023-09-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-01 | 2023-09-25 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-09-01 | 2023-09-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-01 | 2023-09-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-01 | 2023-09-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-09-01 | 2023-09-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-01 | 2023-09-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-01 | 2023-09-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-23 | 2023-09-12 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-08-23 | 2023-09-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-23 | 2023-09-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-23 | 2023-09-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-23 | 2023-09-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-23 | 2023-09-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-08-23 | 2023-09-12 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-08-23 | 2023-09-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-23 | 2023-09-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-12 | 2023-04-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-14 | 2023-02-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-19 | 2023-02-06 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-09 | 2022-11-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-28 | 2022-10-07 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-20 | 2022-09-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-07-20 | 2022-09-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-20 | 2022-09-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-20 | 2022-09-06 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-07-20 | 2022-08-26 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-07-20 | 2022-08-26 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-07-20 | 2022-08-26 | N |
| Develop a communication plan. | Fire Safety | 2022-07-20 | 2022-08-26 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-07-20 | 2022-08-26 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-07-20 | 2022-08-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-07-20 | 2022-08-26 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-07-20 | 2022-08-26 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-07-20 | 2022-08-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-20 | 2022-08-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-20 | 2022-08-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-20 | 2022-08-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-01 | 2022-08-09 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-07-20 | 2022-08-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-07-20 | 2022-08-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-01 | 2022-08-04 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-07-01 | 2022-08-04 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-07-01 | 2022-08-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-07-01 | 2022-08-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-01 | 2022-08-04 | N |
| Respond appropriately to all alleged violations. | Health | 2022-07-01 | 2022-08-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-01 | 2022-08-04 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-07-01 | 2022-08-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-07-01 | 2022-08-04 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-07-01 | 2022-08-04 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-07-01 | 2022-08-04 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-07-01 | 2022-08-04 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-01 | 2022-08-04 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-07-01 | 2022-08-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-01 | 2022-08-04 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-07-01 | 2022-08-04 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-07-01 | 2022-08-04 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-07-01 | 2022-08-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-01 | 2022-08-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-13 | 2022-07-24 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-06-08 | 2022-06-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-08 | 2022-06-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-03 | 2022-06-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-03 | 2022-06-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-24 | 2022-06-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-16 | 2022-06-02 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-05-16 | 2022-05-31 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-04-15 | 2022-04-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-15 | 2022-04-27 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-03-24 | 2022-04-08 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-03-24 | 2022-04-08 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-24 | 2022-04-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-24 | 2022-04-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-09 | 2022-04-04 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-09 | 2022-04-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-09 | 2022-04-04 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-02-18 | 2022-03-11 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-18 | 2022-03-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-18 | 2022-03-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-12 | 2022-03-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-28 | 2022-02-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-28 | 2022-02-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-12 | 2022-02-10 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-01-12 | 2022-02-10 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-01-12 | 2022-02-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-12 | 2022-02-10 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-12 | 2022-02-10 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-01-12 | 2022-02-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-30 | 2022-01-27 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-10-27 | 2021-11-19 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-10-27 | 2021-11-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-17 | 2021-06-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-17 | 2021-06-19 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-27 | 2021-06-18 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-05-27 | 2021-06-18 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-05-27 | 2021-06-18 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-05-27 | 2021-06-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-27 | 2021-06-18 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-24 | 2021-05-12 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-03-24 | 2021-04-30 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-03-24 | 2021-04-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-03-24 | 2021-04-30 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-03-24 | 2021-04-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-03-24 | 2021-04-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-03-24 | 2021-04-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-03-26 | 2021-04-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-03-26 | 2021-04-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-26 | 2021-04-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-26 | 2021-04-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-26 | 2021-04-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-24 | 2021-04-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-03-24 | 2021-03-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-03-24 | 2021-03-26 | N |
