Alaris Health at the Chateau

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to maintain the kitchen exhaust hood assembly in a safe operating condition by ensuring hood panels were properly fitted without gaps. This deficient practice had the potential to affect all residents residing in the facility due to the increased risk of grease accumulation and fire associated with gaps in the kitchen exhaust hood system and was evidenced by the following: On 5/28/26 at 9:40 AM, the surveyor conducted a kitchen tour with the Food Service Director (FSD). During the kitchen tour, the surveyor observed the kitchen exhaust hood system located above the stove and oven, approximately two one-inch gaps, one on each side of the hood panels. The gaps were visible between adjoining hood panel sections. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to treat residents with respect and dignity during mealtime. This deficient practice was identified for 9 of 18 Unsampled Residents (UR #1, #2, #3, #4, #5, #6, #7, #8, and UR #9) and 2 of 3 dining areas (North 3rd and 4th floors) observed during dining observations. This deficient practice was evidenced by the following:1. On 5/29/26 at 8:11 AM, the surveyor observed North 3rd (third) floor dining area for breakfast, there were 11 residents seated at five tables, with four staff assisting residents. The surveyor observed Unsampled Resident #1 (UR #1) grabbed one used tray on the side and wanted to eat from the left over, was seen by the staff, and the staff removed the used tray away. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide a safe, clean, and comfortable homelike setting. This deficient practice was identified for 4 of 4 dining areas (North 1st floor, North 3rd floor, North 4th floor, and South 1st floor), 2 of 2 shower rooms (North 3rd and 4th floors), 3 of 35 residents' rooms (Rooms #123, #257, and #360), and was evidenced by the following: 1. During the dining observation on 5/29/26 at 8:15 AM, of Surveyor #1 (S #1) in North 3rd (third) floor, in the presence of the Assistant Administrator (AA), both S #1 and the AA observed six ceiling tiles with gaps, the ceiling tiles near the ceiling fan was being used at that time with accumulation of grayish substances. [...]

Inspectors wroteBased on the interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to include in the written notification of emergency transfer and bed hold that was provided to the Resident or Resident Representative, the facility's bed hold reserve payment for 3 of 3 residents, (Residents #7, #16 and #18), reviewed for hospitalizations. This deficient practice was evidenced by the following: 1. On 5/29/26 at 9:31 AM, Surveyor #1 (S#1) observed Resident #7 asleep in bed. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to store medications and biologicals in accordance with facility policy by failing to ensure opened treatment items were labeled with the date opened for 5 of 5 treatment carts. The deficient practice was evidenced by:On 6/2/26 at 9:15 AM, the surveyor conducted a medication (med) storage inspection in the presence of the Assistant Director of Nursing (ADON). During inspection of treatment carts located in the North Building and South Building, the surveyor identified multiple opened treatment items that were not labeled with the date opened. [...]

Inspectors wroteBased on observation, interview, and review of other pertinent facility documentation, it was determined that the facility failed to: a.) follow appropriate hand hygiene practices for 1 of 3 staff (Registered Nurse Supervisor) during incontinence round and b.) replaced sharp containers for 4 of 4 residents (Residents #6, #7, #9, and #67), and follow appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24, it revealed . Key Times to Perform Hand Hygiene: Before having direct contact with residents. Before putting on gloves and immediately after removing gloves. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide documented evidence that written notification to the beneficiary of the potential liability charges for services not covered, when the resident was discharged from Medicare Part A services with benefit days remaining were provided for them to choose which option they wanted on the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) Forms for 2 of 3 residents reviewed for beneficiary notice (Resident #42 and Resident #178). This deficient practice was evidenced by the following: On 6/3/26 at 1:20PM, the surveyor reviewed the facility provided SNFABN Forms for Resident #42 and Resident #178 which revealed the following:ABN form had the following information: Note: If Medicare does not pay for D. below, you may have to pay. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure that a Significant Change in Status Assessment (SCSA) was completed for 1 of 38 residents, (Resident #17), reviewed for Minimum Data Set (MDS). This deficient practice was evidenced by the following:According to the CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, updated October 2025, reflected, a SCSA must be completed within 14 days of determining a significant change from baseline. The resident's condition is not expected to return to baseline within two weeks. Comparison with the most recent comprehensive and quarterly assessments is crucial. Criteria for SCSA include two areas of decline or improvement, or IDT (Interdisciplinary team) recommendation. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 2 of 38 residents, (Residents #17 and #23), reviewed for MDS accuracy. This deficient practice was evidenced by the following: 1. On 5/28/26 at 11:46 AM, Surveyor #1 (S #1) observed Resident #17 in activity room with other residents. Licensed Practical Nurse #1 (LPN #1) stated that for the past six months, the resident had fall incident in their room, the roommate stated that Resident #17 wanted to use the bathroom, fell, and complained of pain. LPN #1 further stated that the x-ray showed hip displacement, and no other falls after that. Surveyor #2 (S #2) reviewed the medical records of Resident #17, and revealed: [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to ensure that; a.) the physician orders (PO) were clarified with regard to duplicate orders for 2 of 38 residents (Residents #9 and #17), b.) the PO was followed for 1 of 5 residents (Resident #4) reviewed for unnecessary medications, c.) the PO was obtained for pressure relieving air mattress and set according to the resident's assessed needs for Resident # 3, and d.) the PO was clarified with regard to tube feeding orders for Resident #8, in accordance with standards of clinical practice and facility's policies and procedures. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. [...]

Inspectors wroteBased on observations, interviews, record review, and review of other pertinent facility provided documentation, the facility failed to ensure a.) the resident's current active care plan contained the interventions that were implemented after each resident's fall, in order to prevent any additional falls, b.) fall investigations interventions were appropriate, and c.) fall investigations were thoroughly completed in accordance with standards of practice and facility's policies and procedures for 1 of 2 residents (Resident #17) reviewed for falls. 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: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to, a.) ensure that a resident with indwelling catheter was monitored routinely for urine output and documented and b.) ensure the collection container used to empty drainage bag were maintained clean and stored properly, in accordance with physician's order and facility's policy and procedure for 1 of 2 residents (Resident #48) reviewed for urinary catheter. This deficient practice was evidenced by the following:On 5/28/26 at 11:40 AM, Surveyor #1 (S #1) observed Resident #48's outside door with posted signs for EBP (enhanced barrier precautions), PPE (Personal Protective Equipment, refers to specialized gear and clothing worn by healthcare workers, patients, and visitors to create a physical barrier against germs, bodily fluids, and infectious diseases), ABHR (alcohol base hand rub). [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a) ensure oxygen tubing was labeled and dated in accordance with physician orders and facility protocol for 1 of 8 residents (Resident #118) and b) provide ordered respiratory care consistent with professional standards of practice for 1 of 8 residents (Resident #206), reviewed for respiratory care. This deficient practice was evidenced by the following: Reference: National Institutes of Health defines oxygen (O2) as a colorless, odorless and tasteless gas. It will support life. It is noncombustible, but will actively support the burning of combustible materials. Some materials that will not burn in air will burn in O2. Materials that burn in air will burn more vigorously in O2. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure a.) residents received timely and appropriate incontinence care for 1 of 4 residents (Resident #59) and b.) controlled medications accountability log was accurately endorsed and accounted for 1 of 3 nurses (Licensed Practical Nurse) observed during medication administration, to achieve highest practical wellbeing of residents. This deficient practice was evidenced by the following: 1. On 6/1/26 at 6:23 AM, Surveyor #1 (S #1) went to North 2nd (second) floor nursing unit and met with the Registered Nurse Supervisor (RNS) who was currently on her medication (med) cart, and informed S #1 that she was helping the nurse in the 2nd floor unit. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure the accurate daily report of licensed nurses, certified nursing assistant staffing, and the resident census was posted at the beginning of the current shift for 2 of 6 days during the annual re-certification survey. This deficient practice was evidenced by the following:On 5/28/26 at 8:53 AM, the survey team entered the facility-North building reception area and Surveyor #1 (S #1) observed the Nursing Home Resident Care Staffing Report (NHRCSR) posted at the front desk by the main lobby. The posted NHRCSR was dated 5/27/26 for the [7:00 AM to 3:00 PM] day shift with a census of 189, with 21 Certified Nursing Assistants (CNA), and a ratio of 1 CNA to 7.9 residents. There was no NHRCSR posted for 5/28/26. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate documentation for the inventory of Resident #127's Methadone, a controlled substance (narcotic) for 1 of 3 medication carts (side A, third floor), identified during the medication pass. This deficient practice was evidenced by the following:On 6/1/26 at 8:15 AM, the surveyor observed Licensed Practical Nurse #1 (LPN #1) preparing medications (meds) for Resident #127. The surveyor observed that LPN #1 popped out five tablets (tabs) of methadone hydrochloride (HCl) 10 milligram (mg) tabs (an opioid medication used to manage severe pain) from Resident #127's bingo card (a multi-dose card containing individually packaged meds). [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation on 6/1/26, the surveyor observed 3 nurses administering medications to 6 residents. There were 38 opportunities, and 4 errors were observed which resulted in a medication error rate of 10.53%. This deficient practice was identified for 1 of 6 residents (Resident #82), that was administered by 1 nurse. This deficient practice was evidenced by the following:On 6/1/26 at 10:49 AM, the surveyor observed the Registered Nurse (RN) preparing medications (meds) for Resident #82. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services by ensuring the accurate administration of a medication, Midodrine, (medication used to increase the blood pressure), with a parameter according to the physician's order and professional standards of practice to meet the needs of the resident for 3 of 6 residents reviewed (Resident #4, #7 and #8). The deficient practice was evidenced by the following:1. On 6/2/26 at 9:39 AM, the surveyor observed Resident #4 sleeping in bed. [...]

Inspectors wroteBased on review of facility policy, record review, and interviews, the facility failed to ensure four Residents (R) (R6, R8, R9 and R10) out of fifteen residents reviewed for assistance with Activities of Daily Living (ADLs) were not bathed according to their plans of care. The facility's failure to ensure residents were bathed routinely created the potential for the residents to experience negative effects related to poor hygiene. A total of 15 residents were reviewed in the sample.

Inspectors wroteBased on review of facility policy, record review, observations, and interviews, the facility failed to ensure significant medication errors were not made during the administration of medication for one of one resident (Resident (R) 2) observed for medication administration. The facility's failure to ensure R2 received his/her medication as ordered created the potential for this and other residents to experience significant negative physical effects related to the incorrect administration of medication. A total of 15 residents were reviewed in the sample.

Inspectors wroteBased on review of facility policy, record review, and interviews, the facility failed to ensure one of three residents (Resident (R) R3) three residents reviewed for dental services received timely dental services related to a decaying tooth. The facility's failure to ensure timely dental care was provided for R3 created the potential for R3 to experience pain and/or infection related to the decaying tooth. A total of 15 residents were reviewed in the sample.

Inspectors wroteBased on review of facility policy, record review, observations, and interviews, the facility failed to ensure infection control procedures were followed during the administration of medication and feeding for one of one resident (Resident (R) R2) observed for medication administration. The facility's failure to ensure infection control procedures were followed for R2 created the potential for this and other residents to develop infection. A total of 15 residents were reviewed in the sample.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to ensure notification and/or timely notification was made to two resident's (Resident (R) 278 and R328) representatives (RR) when a change of condition occurred out of a total sample of 43 residents reviewed. This had the potential for the RRs to not be informed of the resident's condition and to be able to make informed decisions regarding the care of the residents.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure pharmacy recommendations were responded to by the physician for one resident (Resident (R)160) out of five residents reviewed for unnecessary medications out of a total sample of 43 residents. This had the potential for the resident to have unmet health needs by not providing medication management.

Inspectors wroteBased on observation, interview, review of the Maintenance Logbook, and facility policy review, the facility failed to ensure eight resident rooms (Rooms 225W, 213W, 209, 211D, 227P, 262, 230 and 229) on the second floor of the north building was maintained to promote a homelike environment. The facility further failed to ensure formica coverings on a half wall in the Activity room was repaired to potentially prevent injury. This affected eight rooms of 38 resident rooms occupied on the second floor of the north building and the Activity room. This had the potential for the residents not to have a home like room in good repair and had the potential to cause an injury.

Inspectors wroteBased on observation, interview, review of Maintenance Logbooks, and facility policy review, the facility failed to ensure handrails located in the corridors throughout the second floor of the north building on all four hallways had handrails in good repair and/or were not missing. This had the potential for the residents to potentially injure themselves when using the handrails during ambulation. This affected all four hallways of the second floor in the north building out of three floors in the building.

Inspectors wrote7. The surveyor reviewed the Discharge MDS 3.0 assessments, including all the completed MDS's for Resident #208 which revealed that the resident had a discharge MDS with an ARD of 9/5/22 and was due to be transmitted no later than 10/3/22. The MDS was not completed and transmitted until 10/4/22.8. Review of a Quarterly MDS with an ARD of 8/28/22 for Resident #41 was due to be transmitted to CMS no later than 9/25/22. The MDS was not transmitted to CMS until 9/26/22. 9. Review of an admission MDS with an ARD of 8/11/22 for Resident #124 was due to be transmitted to CMS no later than 9/8/22. The MDS was not transmitted to CMS until 9/21/22. 10. Review of a Quarterly MDS with an ARD of 7/10/22 for Resident #16 was due to be transmitted to CMS no later than 8/7/22. The MDS was not transmitted to CMS until 9/2/22. 11. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 1 of 38 residents (#207) reviewed. The deficient practice was evidenced by the following: The MDS is a comprehensive tool, that is a federal mandated process for clinical assessment of all residents. The MDS must be completed and transmitted to the Quality Measure System at Centers for Medicare & Medicaid Services (CMS). On 12/12/22 at 9:49 AM, the surveyor reviewed the discharge medical records for Resident #207. The resident was admitted to the facility on [DATE]. Further review of the medical records revealed that the resident was discharged to home on 9/17/22. The surveyor reviewed the MDS 3.0 assessments, including all the completed MDS's for Resident #207. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of nursing practice by 1. failing to label and date an Enteral Feeding container, 2. not following a physician's order for 1 of 4 sampled residents, Resident #41. 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 casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain necessary respiratory care and services for a resident who was receiving a nebulizer treatment according to the standards of practice. The deficient practice was identified for 1 of 2 residents (Resident #126) reviewed for respiratory care. This deficient practice was evidenced by the following: On 11/30/22 at 10:58 AM, the surveyor observed Resident #126 in bed in their room. The surveyor observed 2 nebulizer masks placed inside the resident's night stand drawer. The surveyor reviewed Resident #126's medical records that revealed the following: The admission Record revealed that Resident #126 was admitted to the facility with diagnoses that included but were not limited to Pneumonia, Unspecified Organism and Covid-19. [...]

Inspectors wroteBased on observation, interview and review of medical records, it was determined that the facility failed to a.) accurately follow facility policy related to the removing of back up control substances documentation for 4 of 12 reviewed control substances stored in the CUBEX system (automated medication dispensing system); b.) failed to remove expired medications in the medication storage room. This deficient practice was evidenced by the following: a.) On 12/1/22 at 11:00 AM, the surveyor reviewed the Back-Up Controlled Substance Administration Record form which documented the removal of controlled substances from the facility CUBEX system. The forms were noted with missing Witness signatures on numerous of the controlled substances reviewed. The surveyor reviewed each sheet which was delegated to a single controlled substance. The sheets reviewed were: 1. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure that 1. expired, discontinued medications were removed from the medication cart / room, 2. medications were maintained with appropriate labeling, and 3. medications were correctly administered during the medication pass. This deficient practice was identified for 2 of 4 floors inspected. The deficient practice was evidenced by the following: 1. On 12/1/22 at 9:50 AM, the surveyor inspected the North Building 2nd floor District 2 cart and found a box of Mucinex Extended Release 600 mg #32 belonging to Resident #123 with an order date of 5/4/22. [...]

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly label, date, and store potentially hazardous foods in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was evidenced by the following: 1. On 11/30/22 at 9:47 AM, during the initial tour of the South building kitchen with the Food Service Director (FSD) and Regional Registered Dietitian (RRD) the surveyors observed a buildup of a greyish colored debris under the griddle on the heating coils. A review of the facility policy Cleaning and Sanitation of Dining and Food Service Areas explained, The food service staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a.) adhere to infection control and isolation procedures for residents that were on contact isolation, Resident #195, #102, #168, b.) perform proper hand hygiene to prevent the spread of infection, Resident #195, #102, c.) adhere to accepted standards of infection control practices for the proper storage of a urinary drainage bag, Resident #195, and d.) ensure that clean linen was stored in a manner to prevent contamination and assist in the prevention of the spread of infection(s). This deficient practice was identified for 3 of 35 residents who were reviewed for infection control practices. The deficient practices were evidenced by the following: 1. On 12/12/22 at 8:18 AM, the surveyor was about to observe a nurse on the Subacute Unit in the North building. [...]