Aristacare at Cedar Oaks

Inspectors wroteBased on observations, interviews, and review of facility provided documents, it was determined that the facility failed to store and prepare food in a manner which followed kitchen sanitation practices to prevent the potential development of food borne illness. This deficient practice was identified in 2 of 2 kitchens (main kitchen and ethnic specialty kitchen) reviewed, and was evidenced by the following: A.On 4/9/26 at 9:37 AM, during the initial tour of the main kitchen with the Food Service Director (FSD) and the Regional FSD (RFSD), the surveyor observed the following: 1. A stacked refrigerator against the back wall. On the top shelf inside the refrigerator, the surveyor observed a dark cloth bag with a paper attached. The paper had a name and Do not touch 4/10 written on it. [...]

Inspectors wroteBased on observations, interviews, record review and review of pertinent facility provided documents, it was determined that the facility failed to; a.) ensure kitchen staff followed hand hygiene practices to prevent the spread of infection or food borne illness; b.) wear appropriate Personal Protective Equipment (PPE) and use appropriate hand hygiene during tracheostomy care and c.) follow appropriate hand hygiene during meal service to prevent the potential spread of infection. This deficient practice was identified in 2 of 2 kitchens observed for hand hygiene, 1 of 1 resident (#16) reviewed for tracheostomy care, and 1 of 4 dining areas reviewed for infection prevention, and was evidenced by the following: 1. [...]

Inspectors wroteBased on observation, interview, and review of facility documents it was determined that the facility failed to maintain the dignity of an unsampled resident who required assistance to eat during lunch. This deficient practice was identified on 1 of 4 units (Cedar Unit) observed during lunch. This deficient practice was evidenced by the following:On 4/13/26 at 12:58 PM, the surveyor observed Certified Nursing Aide (CNA) #1 feeding an unsampled resident while standing up. At 1:01 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM) instructed CNA #1 to sit down. CNA #1 left the dining room and returned with a folding chair. CNA #1 sat behind to the right side of the resident and proceeded to feed them. On 4/13/26 at 1:15 PM, the surveyor interviewed CNA #1, who stated staff were supposed to be sitting on the side of the resident or next to the resident when assisting with feeding. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the resident's call bell (CB; a bell used to summon staff for assistance) was readily accessible and within reach of the resident. The deficient practice was identified for one (1) of one (1) resident, Resident #184, reviewed for accommodation of needs. This deficient practice was evidenced by the following:On 4/9/26 at 11:41 AM, the surveyor observed Resident #184 resting in their bed. The surveyor greeted the resident and the resident sat up to speak with the surveyor. The surveyor observed Resident #184's CB was out of reach on the floor, which was on the left side of the nightstand. The surveyor asked the resident how they would call the staff for help, the resident stated that they would call out (shout out) for help when needed. [...]

Inspectors wroteBased on interviews, review of the facility's policy, and other pertinent facility documents, it was determined that the facility failed to implement their abuse policy to a.) complete timely background checks for 4 out of 155 employees (Employee #1, #4, #12, and #14) and b.) complete timely reference checks for 3 out of 155 employees (Employee #3, #7, and #8). This deficient practice was identified for newly hired, since last survey of 11/21/2024, employee files reviewed. This deficient practice was evidenced by the following:On 4/9/26 at approximately 10:22 AM, during the entrance conference, the surveyor requested from the Licensed Nursing Home Administrator (LNHA), all newly hired employee files for active and inactive employees from 11/21/24 to the current date.a. [...]

Inspectors wroteBased on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to develop an individual comprehensive care plan (ICCP) to address the needs of a resident with Asthma (a condition that causes your airways to swell, narrow and fill with mucus), and nebulizer treatments (a way to deliver liquid medicine directly into the lungs by turning it into a fine breathable mist). This was identified for 1 of 3 residents (Resident #69) reviewed for Respiratory Care. This deficient practice was evidenced by the following:On 04/09/2026 at 10:21 AM, the surveyor observed Resident #69's nebulizer tubing and mouthpiece (a device used to deliver medication directly into the lungs) on the table in a clear plastic bag, dated 4/8/2026. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a low air loss (pressure reducing) mattress was functioning properly and accurately setup according to resident weight for a resident who was previously identified to have had an alteration in skin integrity. This deficient practice was identified for 1 of 4 residents (Resident #16) reviewed for pressure ulcers and was evidenced by the following:On 4/10/26 at 10:06 AM, the surveyor observed Resident #16 lying in bed, awake, on an air mattress. The air mattress pump was observed to be set to a weight of 380 pounds. Resident #16 was wearing a hospital gown and noted to have a tracheostomy site (a surgical hole in the neck to assist breathing). The resident was able to communicate with the surveyor using short one- or two-word answers. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to follow a physician's order for oxygen therapy. This deficient practice was identified for 1 of 3 residents (Resident #101) reviewed for respiratory care. This deficient practice was evidenced by the following: On 4/9/26 at 11:25 AM, during the initial tour of the facility, the surveyor observed Resident #101 lying in their bed watching television. The surveyor observed an oxygen concentrator (device that delivers oxygen) with a nasal cannula tubing (NC - device that delivers additional oxygen through the nose) administering oxygen at 3 liters per minute (lpm). The resident stated that they always wear the nasal cannula and receive oxygen continuously. On 4/10/26 at 9:49 AM, the surveyor observed the resident in their room lying in bed awake watching television. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure professional standards of nursing practice were followed by performing accurate verification of a resident's name on the label of a medication (Eliquis) (a medication used to thin the blood) prior to administration. The deficient practice was identified for one (1) of three (3) nurses administering medications to one (1) of five (5) residents, (Resident #3) observed during the medication administration observation. 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 observations, interviews, review of the medical record, and review of other facility documentation, it was determined that the facility failed to respond timely to the monthly Consultant Pharmacist (CP) recommendations. This deficient practice was identified for 2 of 5 residents reviewed for unnecessary medications (Resident #46 and #194). The deficient practice was evidenced by the following:1. On 4/9/2026 at 11:45 AM, during initial tour, the surveyor observed Resident #194 sitting in a wheelchair, in their room. The surveyor reviewed the electronic medical record (EMR) for Resident #194 A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observations, interviews, record review, and review of pertinent documentation, it was determined that the facility failed to obtain consent to ensure that the residents did not receive an unnecessary medication for 1 of 5 residents reviewed for unnecessary medications, (Resident #46). This deficient practice was evidenced by the following:On 04/10/2026 at 10:17 AM, Resident # 46 was observed sitting in a wheelchair in the activities, in the Day Room. The resident was quiet, calm, and not interactive. On 04/13/2026 10:40 AM, the resident was observed in the Day Room during religious activities, the resident was sitting in a wheelchair, not engaging in activities. The surveyor reviewed the electronic medical record (EMR) for Resident #46:A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteCOMPLAINT #: NJ00183422, NJ00186468 Based on observation, interviews, medical record review, and review of other pertinent facility documentation on 08/22/25, it was determined that the facility failed to immediately implement their abuse policy to ensure residents were protected from abuse by not removing the accused staff from resident care pending full investigation of an abuse allegation. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #1) and had the potential to affect all residents. According to Facility Reportable Event (FRE), at approximately 6:00 AM on 05/03/2025 Resident #6 (the roommate of Resident #1) reported to Registered Nurse #1 (RN #1) that Resident #1 moaned in pain while a Certified Nursing Assistant (CNA) was providing morning care (turning and repositioning) for the resident. [...]

Inspectors wroteBased on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, and b.) failed to maintain the kitchen equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 11/07/24 at 9:39 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and a second surveyor. The following was observed: 1. Two top reach in refrigerators that held milk. The refrigerator on the right stored four- and eight-ounce milks and the refrigerator on the left stored gallon milk. Both had gray gaskets on the doors which had a heavy buildup of a black substance on the underside of the top gaskets. [...]

Inspectors wroteBased on observation, interview, review of medical records, other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 3 of 37 residents reviewed (Resident #16, Resident #34, and Resident #429). This deficient practice was evidenced by the following: 1. On 11/7/24 at 11:08 AM, the surveyor observed Resident #16 to be out of bed, in a wheelchair, and in the dayroom participating in activities. On 11/8/24 at 1:10 PM, the surveyor observed Resident #16 in a wheelchair, outside smoking with staff supervision. A smoking apron was visible on Resident #16's lap. A review of the admission Record face sheet (an admission summary) reflected Resident #16 had diagnoses which included but not limited to: Alzheimer's disease. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the necessary respiratory care and services were provided in a manner to prevent the spread of infection for 1 of 4 residents (Resident #4) reviewed for respiratory care. This deficient practice was evidenced by the following: On 11/7/24 at 10:57 AM, the surveyor observed Resident #4's nebulizer machine (an electric machine that converts liquid medication to a fine mist) on the dresser in their room, surrounded by personal items. The tubing attached to the nebulizer was not labeled or dated. Additionally, the nebulizer mask was not covered and was left exposed to the air. The exterior of the nebulizer machine showed yellowish stains and a brown fuzzy debris accumulation on the surface. On 11/12/24 at 12:09 PM, the surveyor observed the same nebulizer machine. [...]

Inspectors wroteCompliant #: NJ169617 Based on observation, interviews, review of the medical record and other pertinent facility documents, it was determined that the facility failed to ensure that a resident received preferred and accurate meal items at lunch service and in accordance to what was indicated on the meal ticket. This deficient practice occurred for 1 of 8 residents observed during dining service (Resident #147), and was evidenced by the following: On 11/08/24 at 12:29 PM, during the lunch meal service, the surveyor observed Resident #147 sitting in a wheelchair in their room. The resident was accompanied by a family member who stated that the resident consistently received incorrect meals. The resident stated that he had ordered pork chops but was served fish instead. The resident confirmed he has previously informed the staff that he did not like fish. [...]

Inspectors wroteBased on observations, interviews, record review and review of pertinent facility documents, it was determined that the facility failed to a.) ensure a resident received liquids in the appropriate consistency at bedside in accordance with physician orders and b.) follow the guidance on the resident's individualized comprehensive care plan. This deficient practice was identified for 1 of 3 residents reviewed for nutrition (Resident #60). This deficient practice was evidenced by the following: On 11/13/24 at 10:40 AM, two surveyors observed Resident # 60 in bed awake and alert. The surveyors observed a 16-ounce (oz.) water cup with a straw on the bedside table which was not in the resident's reach. The resident was unable to state whether he/she had a thickened liquid diet order. [...]

Inspectors wroteBased on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) maintain, store, and hold potentially hazardous foods in acceptable temperatures to prevent food-borne illness; b.) maintain multi-use food-contact surfaces in a manner to prevent bacterial growth; c.) maintain kitchen equipment in a sanitary manner; d.) store potentially hazardous foods to prevent food-borne illness; and e.) maintain handwashing sinks to ensure appropriate infection control practices. This deficient practice was evidenced by the following: On 8/3/23 at 9:12 AM, the surveyor entered the kitchen and requested to wash their hands in the kitchen's handwashing sink. The Food Service Director (FSD) showed the surveyor the handwashing sink, and the surveyor proceeded to turn on the hot water handle, but the water came out in drops only. [...]

Inspectors wroteComplaint NJ#: 151826 Based on observation, interview, and review of pertinent facility documentation, it was identified that the facility failed to provide the residents with a safe, comfortable, clean, homelike environment. This deficient practice was identified on 4 of 4 nursing units, (Oak, Willow, Cedar, and Maple) and in 2 of 36 resident rooms, (Resident #112 & Resident #190) reviewed for residing in a clean, comfortable, homelike environment. This deficient practice was evidenced by the following: On 08/03/23 at 10:46 AM, the surveyor started the environmental tour on the [NAME] unit. Between rooms [ROOM NUMBERS], the surveyor observed a long, black in color indentation and scratch mark along the wall. There was an area to the left of the television screen on the wall where the peach-colored paint was peeling. Exposing green colored paint underneath. [...]

Inspectors wroteComplaint NJ#: 154501 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to develop and implement comprehensive person-centered care plans. This deficient practice was identified for 5 of 39 residents, (Resident #45, #57, #58, #81, and #418) reviewed for the development and implementation of a comprehensive person-centered care plan and was evidenced by the following: 1.) On 8/2/23 at 11:08 AM, the surveyor observed Resident # 58 in bed. Resident #58 stated that they have been on peritoneal dialysis (PD) for four years and performed their PD daily. The PD supplies were observed in boxes in the resident's room. The surveyor reviewed the medical records for Resident #58. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a.) obtain a physician's order to perform Range of Motion (ROM) exercises and b.) document the performance of ROM exercises in the resident's medical record for 1 of 3 residents, (Resident #45) reviewed for position and mobility. This deficient practice was evidence 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, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) appropriately discard unused medication and b.) properly label and date medication in accordance with manufacturer recommendations for medications being stored in 1 of 2 medication storage rooms inspected (Cedar unit medication room). This deficient practice was evidenced by the following: 1.) On 8/3/23 at 9:15 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN) in the room of Resident #145. The surveyor observed the LPN informing Resident #145 that she would be administering the resident's medications. The surveyor observed that the resident was in their bed and just finished eating breakfast. [...]

Inspectors wrote2.) On 8/2/23 at 11:29 AM, the surveyor observed Resident #117 in bed with his/her eyes open. The resident did not respond to the surveyor. The surveyor reviewed the medical record for Resident #117. A review of the resident's admission Record face sheet (admission summary) reflected that the resident was admitted to the facility in January 2019 and readmitted in June 2023 with diagnoses that included but were not limited to stage 3 sacral ulcer, tracheostomy, diabetes mellitus, dementia, aphasia (inability to speak), and cerebral infarction (stroke). A review of the quarterly MDS dated [DATE], reflected the resident had severely impaired cognition. The MDS further indicated that Resident #117 was dependent on staff for activities of daily living, and had a range of motion impairment on both sides of the upper and lower extremities. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to: a.) notify the physician or Nurse Practitioner (NP) of an abnormal urine lab result and b.) administer antibiotic treatment in a timely manner for 1 of 3 residents, (Resident #133) reviewed for antibiotic use. This deficient practice was evidenced by the following: On 08/02/23 at 10:42 AM, the surveyor observed Resident #133 sitting in a chair in his/her room. The resident stated that he/she had an infection but was unsure where. According to the admission Record, Resident #133 had diagnoses which included, but were not limited to, chronic kidney disease, end stage renal disease, and retention of urine. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that an air mattress was accurately set according to the resident's weight. This deficient practice was identified for 1 of 5 residents, (Resident #129) reviewed for pressure ulcers and was evidenced by the following: The surveyor observed Resident #129 lying in bed with his/her air mattress set to 360 to 400 pounds (lbs) on the following dates and times: -08/02/23 at 10:22 AM -08/03/23 at 9:24 AM -08/04/23 at 9:48 AM According to the admission Record, Resident #129 had diagnoses which included, but were not limited to, paraplegia and unspecified protein-calorie malnutrition. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents it was determined that the facility failed to maintain proper infection control practices during tracheostomy care. This deficient practice was identified for one of two residents reviewed for tracheostomy care, (Resident #117) and was evidenced by the following: On 8/2/23 at 11:29 AM, the surveyor observed Resident #117 in their room in bed. The resident had a tracheostomy (a hole made surgically through the front of the neck into the trachea (windpipe) with a tube placed through the hole to help the person breath) which was attached to an oxygen concentrator (machine that provides oxygen). The surveyor reviewed the medical record for Resident #117. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined the facility failed to: a.) ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 5 of 6 forms provided; and b.) accurately document the administration of controlled medication for 2 sampled residents, (Resident #27 and Resident #44) identified upon inspection of 1 of 5 medication carts (Willow unit, high-side cart). This deficient practice was evidenced by the following: 1.) On 8/9/23 at 12:52 PM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the [NAME] unit, high-side cart. The surveyor and the LPN reviewed the narcotic medication located in a secured and locked narcotic box. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure safe and appetizing temperatures of food for 3 of 4 meal entrees observed during 1 of 1 meal observations (lunch) for 1 of 2 residents reviewed for food (Resident #122). This deficient practice was evidenced by the following: On 8/2/23 at 12:57 PM, the surveyor observed Resident #122 in their room. The resident stated that they did not receive their lunch tray today; that it was not on the meal cart, and they were waiting for staff to bring their lunch tray to them. On 8/3/23 at 12:00 PM, the surveyor observed the lunch meal trays arrive to the Oak nursing unit day room. The surveyor made the following observations: At 12:03 PM, Certified Nursing Aide (CNA#1) placed milk on all the trays. [...]