Actors Fund Home

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 7/16/25 at 9:27 AM, the surveyor, in the presence of a Kitchen Supervisor/Cook (KS/C) observed the following during the initial kitchen tour:1. A milk chest which contained beverages including milk, juices and soda, the internal thermometer reading was observed at 49 degrees. The KS/C stated the cook was in refrigerator (ref) stocking items and that was why the temperature (temp) was high. The KS/C acknowledged the ref temp should be below 41 degrees. A temp log on the ref also indicated the ref temp should be 41 degrees or less. 2. A walk-in ref which stored food items, the internal thermometer was observed at 52 degrees. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete the Quarterly Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the specified timeframe as required. This deficient practice was identified for 1 of 21 residents (Resident #74), whose MDS assessments were reviewed and was evidenced by the following: The Centers for Medicare and Medicaid (CMS) MDS Version 3.0 Resident Assessment Instrument (RAI) Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. The Quarterly assessment was considered timely if 1). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to update and revise the comprehensive care plan of a resident. This deficient practice was identified for 1 of 21 residents reviewed, Resident#34, and as evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to; a.) follow the physician order with regard to application of an ointment and b.) ensure the skin assessment was accurate and completed in accordance with professional standards of practice and facility's policy and procedure, for 1 of 21 residents (Resident #8) reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteBased on interviews, record review, and a review of pertinent facility documents, it was determined that the facility's Consultant Pharmacist (CP) failed to identify irregularity for 1 of 21 residents (Resident #8) reviewed. This deficient practice was evidenced by the following: On 7/16/25 at 10:50 AM, the surveyor observed Resident #8 seated in a wheelchair with a leg rest and left leg immobilizer in use. The surveyor also observed an IV (intravenous) pole. The resident stated that they had an order for IV ABT (antibiotic) daily, on skilled nursing for their infected left surgery, and rehabilitation (rehab). The surveyor reviewed the electronic medical records (eMR) of Resident #8, and revealed the following: A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses (dx) that included but were not limited to; [...]

Inspectors wroteBased on interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure that the medications were administered in accordance with the physician's order, facility's policy, and accepted professional standards of practice. This deficient practice was identified for 1 of 21 residents reviewed for medications (Resident #8). The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteComplaint NJ#186231Based on observation, interview, and review of facility documentation, it was determined that the facility failed to dispose of garbage and refuse properly in a manner to maintain a sanitary environment and prevent potential pests for 1 of 2 days of observation. This deficient practice was evidenced by the following:On 7/16/25 at 10:06 AM, the surveyor in the presence of the Kitchen Supervisor/Cook (KS/C), toured the designated garbage disposal area outside the facility. The surveyor observed an enclosed white privacy fence, which the KS/C indicated the dumpster for recyclable items such as cardboard was disposed and picked up by the garbage company. The KS/C unlatched the fence, and the surveyor observed that there was one dumpster with both of its lids opened. Scattered on the floor around the dumpster were plastic items such as bottles, plastic bags, gloves; [...]

Inspectors wroteBased on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain a complete, accurate and readily accessible medical records. This deficient practice was identified for 1 of 21 residents reviewed, Resident #25. This deficient practice was evidenced by the following: On 7/16/25 at 10:48 AM, the surveyor observed Resident #25, sitting on a wheelchair (w/c) by the nursing station, with a tab alarm (personal safety alarm which alerts caregivers if someone attempts to get up from a bed or chair) attached to the back of their w/c. The resident was alert, pleasant and stated that they fell about 1 to 2 months ago, I slid on the floor, and broke something. The resident further stated that they were on therapy, healing, doing good and I'm just being careful. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to accurately post staffing information to include the total number and actual hours worked for licensed and unlicensed staff responsible for resident care. This deficient practice was evidenced by the following: On 01/29/24 at 01:22 PM, the surveyor observed the nurse staffing information posted at the nursing station on the South unit on a large visible monitor as follows: -Census Hours -January 29th, 2024 -Census: 93 -7am-3 pm Shift; RN (Registered Nurse)/LPN (Licensed Practical Nurse) Hous (hours): 48; CNA (Certified Nursing Aide) Hours:128 -3 pm-11 pm Shift; RN/LPN Hours: 40; CNA Hours: 88 -11 pm-7am Shift; RN/LPN Hours: 40 CNA Hours: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to properly label, store, and dispose of medications in 1 of 5 medication carts inspected. This deficient practice was evidenced by the following: On 02/1/24 at 11:20 AM, the surveyor inspected the Broadway unit medication cart in the presence of the Licensed Practical Nurse (LPN). The surveyor observed an unopened bottle of Xalatan eye drops (medication for pressure in the eye) stored in the medication cart and an opened Breo inhaler (medication for breathing) with an opened date of 12/15/23 that was expired. The surveyor interviewed the LPN who stated that an unopened bottle of Xalatan eye drops should have been stored in the refrigerator and once removed from the refrigerator it should have been dated. [...]

Inspectors wroteBased on record review, interviews and review of pertinent facility documents it was determined that the facility failed to notify a representative from the Office of the State of Long-Term Care Ombudsman about a resident's emergency transfer to the hospital. This deficient practice was identified for 1 of 1 resident, (Resident #74) reviewed for hospitalization as was evidenced by the following: Review of Resident #74s Face sheet (an admission summary), indicated that the resident was discharged on 9/16/23 with a return not anticipated. Review of the progress note dated 9/16/23 at 6:21 PM, reflected that Resident #74 was sent to the emergency room for evaluation. Review of a progress note dated 9/18/23 at 4:25 PM, reflected that Resident #74 was admitted to the hospital. [...]

Inspectors wroteBased on record review, interviews and review of pertinent facility documents, it was determined that the facility failed to transmit the Minimum Data Set (MDS) assessments, a tool to facilitate the management of care, in a timely manner and in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for 2 of 2 residents, (Resident #13 and #74). The evidence was as follows: According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Guide Version 1.17.1, October 2019 which included that an Entry (admission) MDS must be transmitted within 14 days of the Event Date (date of admission). Resident #13: The surveyor reviewed the Entry MDS dated [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a.) provide treatment, consistent with professional standards of practice to an existing pressure injury and b.) implement an element of the facility policy and procedure concerning a wound dressing, for 1 of 1 Resident (Resident#4) observed during wound treatment observation. This deficient practice was evidenced by the following: On 10/21/21 at 10:51 AM, the Registered Nurse (RN) informed the surveyor that Resident #4 currently received wound care treatment for a facility acquired stage 3 pressure wound to the sacrum. The RN further stated that the resident's wound to the sacrum was improving. On 10/21/21 at 11:07 AM, the surveyor observed the resident laying on a specialized mattress, positioned on the right side, with eyes closed and a pillow in between the resident's legs. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to assure that a resident received the appropriate diet consistency prescribed by a physician. This deficient practice was identified for 1 of 21 residents, (Resident #4) reviewed. This deficient practice was evidenced by the following: On 10/21/21 at 11:07 AM, the surveyor observed Resident #4 laying on a specialized mattress with eyes closed. A review of the resident's Face sheet (an admission summary), reflected that the resident was admitted to the facility with diagnoses that included Dementia without behavioral disturbance, anemia (low blood count), and hyperlipidemia (abnormally high levels of fats in the blood). [...]

Inspectors wroteBased on observation, interview and record review it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Assessment (MDS) for 1 of 21 residents reviewed, (Resident # 18) as evidenced by the following: On 10/27/21 at 10:13 AM, the surveyor reviewed the medical records of Resident # 18. The resident was admitted to the facility on [DATE] with diagnosis that included but not limited to; unspecified osteoarthritis, edema, diabetes mellitus without complications, pneumonia and sequelae of cerebral infraction. Review of the October 2021 Physician Orders (PO) indicated a PO dated 3/12/21 for Hospice Eval and Treat. The surveyor reviewed the MDS assessments for Resident # 18. There was no evidence in the electronic and paper chart that the SCSA MDS was completed. [...]