Aristacare at Cherry Hill

Inspectors wroteCOMPLAINT #2801510Based on interviews, review of medical records and other pertinent facility documentation on 6/4/26 and 6/5/26, it was determined that the facility failed to maintain an accurate and complete medical record in accordance with acceptable professional standards of practice, when staff failed to consistently document that wound care was provided on the Treatment Administration Record (TAR). This deficient practice was identified for 2 of 3 residents reviewed for wound care (Resident #3 & Resident #6) and was evidenced by the following:a). A review of the admission Record revealed that Resident #3 was admitted to the facility with diagnoses that included but were not limited to: paraplegia, injury of the thoracic spinal cord at the T7-T10 level, and chronic pain syndrome. [...]

Inspectors wroteCFR9s): 483.70(h)(1)S483.70(h) Medical records. S483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized Based on interviews, medical record reviews and reviews of other pertinent facility documentation on 1/16/26, it was determined the facility failed to ensure Medication Administration Record (MAR) documentation was accurate as evidenced by a.) the Licensed Practical Nurse #1 (LPN) not obtaining and transcribing an order for a resident who required medication administration to correct low blood sugar and b.) the Director of Nursing (DON) completing medication administration entries on behalf of LPN#1. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a) maintain kitchen equipment in a clean, safe and sanitary manner, and b) maintain the garbage dumpster area in a clean, safe manner, and free from pests as evidenced by the following:On 8/21/25 at 10:36 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following:1. The can-opener blade had a metal chip on the right side and brown sticky food debris on the blade and screw connection. The FSD acknowledged it had not been changed since she started working at the facility. The FSD acknowledged that the can-opener was not cleaned according to facility policy. The FSD was unable to produce a maintenance log to indicate when the blade should be replaced.2. The can-opener holder attached to the counter had a blue insert which was covered with brown sticky debris. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to: a) follow appropriate infection control protocol for hand hygiene during the medication pass observation b) ensure that essential personal protective equipment (PPE, equipment worn to prevent the spread of infection) was readily available for all staff and visitors: This deficient practice was identified for 1 of 2 nurses on 1 of 2 nursing units (Second Floor) during the medication pass observation and for 3 of 3 nursing units observed for adherence to infection control practices. This deficient practice was evidenced by the following:1) On 8/22/25 at 8:21 AM, the surveyor met with Licensed Practical Nurse (LPN) #4 at the medication cart to observe the medication pass. LPN #4 stated that she needed to clean the electronic blood pressure machine prior to use. [...]

Inspectors wroteBased on interview and document review, it was determined that the facility failed to ensure that all residents that maintained a Personal Needs Account (PNA): a.) received a written notification when approaching the limit that could jeopardize a resident's eligibility for Medicaid or Supplemental Security Income (SSI) and b.) funds and final accounting of those funds were conveyed within 30 days of the resident's discharge to the proper jurisdiction. This deficient practice was identified for 3 of 3 residents (Resident #50, #55 and #143) reviewed for PNA and was evidenced by: A review of the facility's Trial Balance revealed 3 (three) residents had balances that ranged from $1,901.47 to $6,917.52. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the resident's environment, equipment, and living areas in a safe, sanitary, and homelike manner for 3 of 3 nursing units (100 unit, 200 unit, and 300 unit) observed for environment. This deficient practice was evidenced by the following: 1) On 8/21/25 at 11:18 AM, during the initial tour of the first-floor unit, the surveyor observed an unsampled resident in room130-D lying in bed with his/her eyes closed. The surveyor observed brown liquid on the floor at the base of the tube feeding pole next to the head of the bed. There was a black fly observed on the linens on bed 130-D. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to: a) administer medications in a timely manner in accordance with the facility policy and professional standards of nursing practice b) ensure accountability of the narcotic shift count logs, c) accurately account for the administration of controlled medications d) follow a physicians order (PO) for both the application and the removal of a Lidocaine Pain Patch (transdermal pain reliever). This deficient practice was identified on one (1) of three (3) medication carts (Second floor, Low Cart), and the Automated Medication System (AMS) (an automated system, including robotic and intelligent dispensing cabinets to store and manage medications and supplies) in the First Floor Medication Room that was inspected during the medication storage observation. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a physician's order for an as needed (PRN) psychotropic drug was limited to 14 days for 1 of 5 residents (Resident #5) reviewed for unnecessary medications. This deficient practice was evidenced by the following:On 8/22/25 at 9:00 AM, the surveyor observed Resident #5 with his /her eyes closed sitting in a reclining chair in the day room. The surveyor reviewed the medical record for Resident #5. A review of the admission Record, (an admission summary), revealed the resident had diagnoses which included, but were not limited to, dementia, and encephalopathy (a medical condition that affects brain function, leading to changes in mental state, behavior, and cognitive abilities). [...]

Inspectors wroteIntake ID: 393868Based on interview, record review, and review of facility documents, it was determined that the facility failed to report an allegation of misappropriation of property to the New Jersey Department of Health (NJDOH) immediately, within two hours, or within 24 hours of the allegation if no harm occurred and submitted the outcome of the investigation within five working days in accordance with state and federal requirements. This deficient practice was identified for 1 of 5 residents (Resident #33) reviewed for abuse and was evidenced by the following:On 8/25/2025 at 12:23 PM, the surveyor reviewed the closed medical record of Resident #33. A review of the admission Record, an admission summary, revealed that the resident had diagnoses which included: [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to develop an individual comprehensive care plan to include a resident's a.) anti-anxiety medication and, b.) history of diabetes mellitus. This deficient practice was identified for 1 of 5 residents (Resident #5) reviewed for unnecessary medications and evidenced by the following:On 8/22/25 at 9:00 AM, the surveyor observed Resident #5 with his /her eyes closed sitting in a reclining chair in the day room. The surveyor reviewed the medical record for Resident #5. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to revise an individual comprehensive care plan (ICCP) for a resident with an order for a tracheostomy (a surgically created hole, also called a stoma, in your windpipe, also known as your trachea). This deficient practice was identified for 1 of 2 residents reviewed for respiratory care (Resident #14), and was evidenced by the following:On 8/21/25 at 11:13 AM, during the initial tour of the facility, the surveyor observed Resident #14 seated in their wheelchair in their room watching television. The surveyor did not observe a tracheostomy for Resident #14. On 8/22/25 at 12:45 PM, the surveyor observed Resident #14 seated in their wheelchair in their room. [...]

Inspectors wroteBased on observation, interview, review of medical records and facility documents, it was determined that the facility failed to ensure that residents with decreased range of motion and mobility received prescribed treatments to prevent contractures for 1 of 3 residents (Resident #6) reviewed for limited range of motion. This deficient practice was evidenced by the following:On 8/22/25 at 1:34 PM, the surveyor observed Resident #6 lying in bed awake. When interviewed, the resident stated that he/she had a history of a stroke and could not move their left arm. The resident stated that he/she had a splint in one of the drawers, but the staff had not put it on for a long time. The resident's left upper extremity was covered with a thin blanket. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to place a resident's urinary catheter drainage bag inside of a privacy bag to maintain resident dignity. This deficient practice was identified for 1 of 1 resident reviewed for urinary catheters (Resident #90), and was evidenced by the following:On 8/21/25 at 10:56 AM, during the initial tour of the facility, the surveyor observed Resident #90 lying in their bed awake. The resident stated that they had an issue with their suprapubic catheter (a type of indwelling catheter that drains urine from the bladder into a collection bag). The surveyor observed the indwelling catheter drainage bag secured to the bed frame, not placed in a privacy bag, exposing the contents (urine) in the bag. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that oxygen was administered in accordance with a physician's order. The deficient practice was identified for 2 of 2 residents (Resident #1 and #122) reviewed for Respiratory Care and was evidenced by:1.) On 8/21/25 at 11:13 AM, during the initial tour the surveyor observed Resident #122 awake and alert lying in bed wearing oxygen via nasal cannula (prongs that are placed in the nostrils) at three (3) liters (L). On 8/22/25 at 9:11 AM, the surveyor observed Resident #122 lying in bed with their eyes closed wearing oxygen via nasal cannula at 3L. On 8/25/25 at 9:00 AM, the surveyor reviewed the medical record for Resident #122. [...]

Inspectors wroteComplaint #: NJ185404 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 6/27/2025, it was determined that the facility failed to update the care plan (CP) with interventions for a resident (Resident #1) involved in a staff to resident abuse allegation. This deficient practice was identified in 1 of 7 residents reviewed for care plans and was evidenced by the following: According to the admission Record (AR), Resident #1 was admitted to the facility in April 2025 with diagnoses which included but were not limited to: Diabetes, Major Depressive Disorder, and Hypertension. According to the admission Minimum Data Set (MDS), an assessment tool dated 4/12/2025, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. [...]

Inspectors wroteCOMPLAINT#: NJ00183319, NJ00184308 Based on interview, medical record review, and review of pertinent facility documentation on 2/11/25, 2/12/25, and 2/14/25, it was determined that the facility failed to: a.) implement a care plan intervention for a physical therapy (PT) consult and b.) provide a resident with a Physical Therapy/Occupational Therapy (PT/OT) assessment after a fall as recommended by the Interdisciplinary Team (IDT). This deficient practice was identified for 1 of 6 residents (Resident #2) reviewed and was evidenced by the following: Resident #2 was no longer at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record revealed that Resident #2 was admitted to the facility with diagnoses that included but were not limited to: [...]

Inspectors wroteCOMPLAINT#: NJ00183319, NJ00184308 Based on interview, medical record review, and review of pertinent facility documentation on 2/11/25, 2/12/25, and 2/14/25, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted an initial comprehensive visit. This deficient practice was identified for 1 of 6 residents (Resident #2) reviewed and was evidenced by the following: Resident #2 was no longer at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record (AR) revealed that Resident #2 was admitted to the facility with diagnoses that included but were not limited to: Huntington's Disease (an inherited disorder that causes nerve cells in parts of the brain to gradually break down and die), severe protein-calorie malnutrition, and adult failure to thrive. [...]

Inspectors wroteCOMPLAINT#: NJ00181569 Based on observation, interview and review of medical records and other pertinent facility documents it was determined that the facility failed to maintain an accurately documented and complete medical records in accordance with acceptable standards and practice. This deficient practice was identified for 1 of 6 residents (Resident #4) reviewed and was evidenced by the following: Resident #4 was no longer at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record revealed that Resident #4 was admitted to the facility with diagnoses that included but were not limited to: seizures, severe protein-calorie malnutrition, and COPD. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health within two hours for a.) an allegation of exploitation and misappropriation of resident property and b.) an allegation of verbal abuse. This deficient practice was identified for 2 of 4 incidents of abuse reviewed (Resident #47), and was evidenced by the following: 1. On 2/28/24 at 12:14 PM, the surveyor interviewed Resident #47 who stated he/she had an issue with a Certified Nursing Aide (CNA #1) who no longer worked at the facility. The resident stated he/she developed a bond with CNA #1, and the aide asked the resident to borrow money which he/she provided. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate a.) an allegation of exploitation and misappropriation of resident property and b.) an allegation of verbal abuse. This deficient practice was identified for 2 of 4 incidents of abuse reviewed (Resident #47), and was evidenced by the following: 1. On 2/28/24 at 12:14 PM, the surveyor interviewed Resident #47 who stated he/she had an issue with a Certified Nursing Aide (CNA #1) who no longer worked at the facility. The resident stated he/she developed a bond with CNA #1, and the aide asked the resident to borrow money which he/she provided. The resident continued CNA #1 always paid them back the borrowed money, and there were multiple financial transactions, but CNA #1 stopped paying the resident back the money she borrowed. [...]

Inspectors wroteComplaint NJ #162587; 163869 Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to a.) administer medications within scheduled parameters on various shifts for two residents (Resident #38 & Resident #42); b.) complete the dialysis communication book for a resident on dialysis (Resident #37); and c.) follow a for physician's order to monitor a resident for urinary retention in accordance with professional standards of practice. This deficient practice was identified for 4 of 27 residents reviewed for professional standards of practice (Resident #37, #38, #42, & #45). 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 interview, review of Nurse Staffing Report sheets, and other pertinent facility documents, it was determined that the facility failed to ensure a Registered Nurse worked seven days a week for at least eight consecutive hours a day for 5 of 16 weekends reviewed. This deficient practice was evidenced by the following: During entrance conference on 2/27/24 at 10:13 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) how the facility's staff was, and the LNHA stated that staffing was good; that the facility primarily utilized agency staff for certified nursing aides (CNA); the facility did have callouts. At this time, the surveyor requested the Nurse Staffing Report to be completed for the following weeks: 1/1/23 through 1/7/23; 2/12/23 through 2/18/23; 2/19/23 through 2/25/23; 3/12/23 through 3/18/23; 5/21/23 through 5/27/23; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) properly label and date medication in accordance with manufacturer recommendations and b.) maintain a medication refrigerator temperature log to ensure safe medication storage. This deficient practice was observed in 1 of 2 medication storage rooms (Second-Floor) and 1 of 3 medication carts (low cart- Second-Floor) inspected, and was evidenced by the following: 1. On 3/4/24 at 10:47 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the Second-Floor nursing unit's low cart and observed the following multi-dose medications had been opened and undated: Incruse Ellipta 62.5 microgram (mcg) inhaler (medication used for symptoms of chronic obstructive pulmonary disease, COPD) dated opened 1/14. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure residents who received the standard serving of the main entree for a regular texture lunch meal was adequate in protein based on the nutritional needs of the residents; b.) ensure the menu was followed; c.) ensure the facility's Registered Dietitian reviewed the menus for nutritional adequacy; and d.) ensure that residents received food and beverage in accordance with their preferences (Resident #6, #21, and #99) This deficient practice was identified for 1 of 2 regular texture meals observed and 3 of 6 residents reviewed for food (Resident #6, #21, & #99), and was evidenced by the following: 1. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to serve residents a nourishing snack when there was more than a fourteen-hour span of time between the dinner and breakfast mealtimes. This deficient practice was identified for five of five residents sampled for bedtime snacks (Resident #18, #19, #51, #65, and #73), and was evidenced by the following: On 2/29/23 at 10:33 AM, the surveyor conducted a Resident Council meeting which included five residents (Resident #18, #19, #51, #65, and #73). All five residents informed the surveyor during the meeting that bedtime (HS) snacks were not offered every night. They further stated that they had to ask for a snack and if there were any snacks left in the bins kept under the nurses station, they were given chips, pretzels, or cookies. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store, label, and date potentially hazardous foods to prevent food-borne illness; b.) discard potentially hazardous foods past their date of expiration; and c.) maintain storage areas in a sanitary manner. This deficient practice was evidenced by the following: On 2.27/24 at 10:42 AM, the surveyor toured the kitchen with the Director of Dietary (DD) and observed the following: 1. In the walk-in refrigerator, one five-pound container of sour cream dated opened 2/1/24. The container had a manufacturer printed expiration date of 5/24/24, but the DD was unsure how many days the sour cream could be used for once opened. 2. In the walk-in refrigerator, one five-pound container of cottage cheese dated opened 2/13/24, with an expiration date of 2/24/24. 3. [...]

Inspectors wroteComplaint NJ# 162587 Based on interview and review of pertinent facility documents, it was determined the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 75 out of 105 day shifts reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 02/01/2021: One Certified Nurse Aide (CNA) to every eight residents for the day shift. [...]

Inspectors wroteComplaint # NJ161584 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that infection control practices were followed by a.) ensuring appropriate personal protective equipment was worn for residents on enhanced barrier precautions; b.) maintaining and storing medical supplies and tubing in a sanitary manner to prevent infection; c.) ensure medical equipment and privacy curtains were maintained in a sanitary manner to prevent infection; d.) ensure proper and hygiene was performed prior to dining; and e.) infection control practices were followed during medication observation. This deficient practice was identified on 2 of 3 nursing units (First and Second-Floor) and was evidenced by the following: 1. [...]

Inspectors wroteBased on interview and review of pertinent documents, it was determined that the facility failed to implement an adequate antibiotic stewardship program. This deficient practice was identified during a review of the last three months of antibiotic use and conducted surveillance from November 2023 through February 2024, and was evidenced by the following: This deficient practice was evidenced by the following: On 3/5/24 at 8:54 AM, the surveyor requested the facility's surveillance for the facility's Antibiotic Stewardship Program. At that time, the Infection Preventionist (IP) met with the surveyor, but the IP could not provide surveillance documentation for antibiotics used. The IP stated that the nurses filled out blue forms on the units for antibiotic use, and she reviewed them during the morning meeting. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain a resident bathroom sink (Resident room [ROOM NUMBER]) in a sanitary working condition and b.) maintain resident rooms and common area in a safe, sanitary, and comfortable environment for 1 of 3 nursing units (Second-Floor). The evidence was as follows: 1. During a water temperature tour on 2/29/24 at 10:50 AM, the surveyor observed in the presence of the Maintenance Director (MD) in Resident room [ROOM NUMBER]'s bathroom, the sink did not operate properly, that the water dripped out. The MD stated at the time of the observation, that he was unaware that Resident room [ROOM NUMBER]'s bathroom sink was not working. The MD stated all maintenance work that needed to be done was entered into the electronic work order system [name redacted]. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure residents were served their meals in a dignified manner during meal services. This deficient practice was identified on 1 of 3 nursing units (Second-Floor), and was evidenced by the following: On 2/27/24 from 12:18 PM to 12:49 AM, the surveyor made the following meal observations in the Second- Floor dining room: On 2/27/24 at 12:19 PM, the food truck arrived to the Second-Floor nursing unit. There were sixteen residents observed seated in the dining room at five different tables. The Certified Nursing Aide (CNA #1) placed a tray in front of Resident #30 and walked away. Resident #30's tablemate proceeded to take Resident #30's tray and removed the dome from the tray. [...]

Inspectors wroteComplaint #NJ160540 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) provide a wheelchair for resident use when out of bed(Resident #43); b.) maintain the call bell within reach of the resident (Resident #58); and c.) accommodate a resident whose preference was to smoke without getting wet during inclement weather (Resident #31). This deficient practice was identified for 3 of 28 residents reviewed for accommodation of needs (Resident #31, #43, and #58), and was evidenced by the following: 1. On 2/28/24 at 9:15 AM, the surveyor observed Resident #43 in bed and there was no wheelchair observed in the room. On 2/29/24 at 12:04 PM, the surveyor observed the resident in bed with head of bed elevated, eyes closed. The resident did not respond to surveyor inquiry. There was no observed wheelchair noted in the room. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident was free of exploitation and misappropriation of resident property. The deficient practice was identified for 1 of 6 residents reviewed for abuse (Resident #47), and was evidenced by the following: On 2/28/24 at 12:14 PM, the surveyor interviewed Resident #47 who stated he/she had an issue with a Certified Nursing Aide (CNA #1) who no longer worked at the facility. The resident stated he/she developed a bond with CNA #1, and the aide would ask the resident to borrow money which he/she provided. The resident continued CNA #1 always paid them back the borrowed money, and there were multiple financial transactions, but CNA #1 stopped paying the resident back the money she borrowed. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) develop an abuse policy that was in accordance with regulatory guidelines and b.) implement their abuse policy for an allegation of misappropriation of resident property. This deficient practice was identified for 1 of 6 residents reviewed for abuse (Resident #47), and was evidenced by the following: During entrance conference on 2/27/24 at 10:13 AM, the surveyor requested and provided the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) with the Centers for Medicare & Medicaid Services (CMS) Entrance Conference Worksheet which indicated in section 32. Abuse Prohibition Policy and Procedures to be provided to the surveyor for the next day. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) assessment for 1 of 5 residents reviewed for unnecessary medications (Resident #80), and was evidenced by the following: On 2/29/24 at 11:50 AM, the surveyor observed Resident #80 in a wheelchair in the hallway self-propelling using their feet. The surveyor reviewed the medical record for Resident #80. A review of the admission Record face sheet (an admission summary) reflected that Resident #80 was admitted to the facility with diagnoses that included schizophrenia, bipolar disorder, cerebral infarction (stroke- parts of the brain become damaged or die). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that identified services to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. This deficient practice was identified for 3 of 28 residents reviewed for comprehensive care plans (Resident #45, #80, and #102), and was evidenced by the following: 1. On 2/28/24 at 10:18 AM, the surveyor observed Resident #45 sleeping in bed on his/her right side. The surveyor reviewed the medical record for Resident #45. [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to a.) revise a comprehensive care plan and for pressure wounds and b.) revise a care plan to include a resident gave staff money. This deficient practice was identified for 2 of 27 residents reviewed for care plans revisions (Resident #47 & Resident #79) and was evidenced by the following: 1. On 2/28/24 at 11:50 AM, the surveyor observed the resident seated in a high-back wheelchair with foot pedals. The surveyor reviewed the medical record for Resident #79. A review of the admission Record face sheet (an admission summary) reflected that the resident had a diagnosis that included but was not limited to anemia, fracture of the right femur, and hypertension. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) assist a resident out of bed daily with the use of a hoyer lift as ordered by the physician. This deficient practice was identified for 1 of 28 residents reviewed for quality of care (Resident #102), and was evidenced by the following: On 2/29/24 at 12:00 PM, the surveyor observed Resident #102 in bed. The resident stated that he/she was waiting for their lunch meal and that he/she needed assistance getting out of bed and wished that the staff would get him/her out of bed. Resident #102 stated that he/she had not been out of bed for over a week. On 3/1/24 at 12:45 PM, the surveyor observed Resident #102 in bed eating their lunch. Resident #102 stated that he/she still had not been assisted out of bed. The surveyor reviewed the medical record for Resident #102. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident with limited range of motion of the right hand received appropriate services to prevent further decrease in range of motion. This deficient practice was identified for 1 of 3 residents reviewed for positioning/mobility (Resident #6), and was evidenced by the following: On 2/27/24 at 12:44 PM, the surveyor interviewed Resident #6 who stated that they had a contracture to the right hand. When asked if he/she was supposed to wear a brace, the resident opened their dresser drawer to show the surveyor a brace. Resident #6 stated that they do not wear it because it hurts. The resident stated that he/she had told the nursing staff, but nothing had been done. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident was assessed and the comprehensive care plan was updated post fall with safety interventions for a resident with a history of falls. This deficient practice was identified for 1 of 7 residents reviewed for falls (Resident #79), and was evidenced by the following: On 2/28/24 at 11:50 AM, the surveyor observed the resident seated in a high-back wheelchair with foot pedals in the dining area. The surveyor reviewed the medical records for Resident # 79. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses that included anemia, fracture of the right femur, and hypertension. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined the facility failed to accurately document the administration of a controlled medication for 1 sampled resident (Resident #171) identified upon inspection of 1 of 3 medication carts (low-cart Second-Floor), and was evidenced by the following: On 3/4/24 at 10:47 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the Second-Floor nursing unit low-side medication cart. A review of the narcotics located in the secured and locked narcotic box and reconciled to the controlled drug administration record, a declining inventory sheet, revealed Resident #171's tramadol 50 milligram (mg) tablet, a medication used to relieve pain, did not match. The blister packs contained 36 tablets and the declining inventory sheet indicated there should be 37 tablets remaining. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure safe and appetizing temperatures of food for 2 of 2 regular texture meals observed during 1 of 1 meal observations (lunch) on 1 of 3 nursing units (Second-Floor). This deficient practice was evidenced by the following: On 2/29/24 at 10:33 AM, the surveyor conducted a Resident Council meeting which included five residents (Resident #18, #19, #51, #65, and #73). Four of the five residents informed the surveyor during the meeting that the meals served at the facility were cold; room temperature if lucky. On 3/1/24 at 11:22 AM, the surveyor informed the Director of Dietary (DD) they wanted to observe the lunch meal for the day including food temperatures. The surveyor asked the DD to calibrate the facility's digital thin probe thermometer in their presence; [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to complete discharge Minimum Data Set (MDS) assessments, an assessment tool, as required for 2 of 2 system selected for residents with a MDS record over 120 days reviewed (Resident #13 and Resident #111), and was evidenced by the following: On 3/6/24 at 11:00 AM, the surveyor reviewed the system selected MDS record over 120 days which revealed Resident #13 and Resident #111 were overdue for a MDS assessment. On 3/6/24 at 11:45 AM, the surveyor interviewed the MDS/Registered Nurse (RN) who stated MDS assessments were completed upon admission, quarterly, annually, any significant changes in status, or at discharge. The MDS/RN continued that the assessments were completed within ninety-four days of the previous quarterly assessment or within fourteen days of discharge. [...]

Inspectors wroteComplaint #:NJ00164488 Based on observation, interview, record review, and review of other facility documentation on 11/28/23 and 11/30/23, it was determined that the facility failed to provide care for a resident with a suprapubic catheter (a tube used to drain urine from the bladder through a cut in the abdomen) in accordance with physician's orders. The deficient practice was identified for Resident #1, 1 of 3 residents reviewed for bladder and bowel care and was evidenced by the following: On 11/28/23 at 10:32 AM the surveyor observed Resident #1 lying in bed with a drainage bag hanging off their bed with a small amount of yellow liquid inside the bag. When interviewed, Resident #1 stated that it depended on which staff members were working if their drainage bag was emptied or their suprapubic catheter was flushed. [...]

Inspectors wroteComplaint #: NJ00163880, NJ00164147 Based on observation, interview, record review, and review of other facility documentation on 11/28/23 and 11/30/23, it was determined that the facility failed to follow up with a medical provider when a routinely scheduled medication was unavailable. The deficient practice was identified for Resident #2, 1 of 3 residents reviewed for medication administration, and was evidenced by the following: On 11/28/23 at 11:02 AM, the surveyor observed Resident #2 in their bed. The resident did not respond to the surveyor's questions. According to the admission Record, Resident #2 was admitted on [DATE], with medical diagnoses that included but were not limited to seizures, cerebral infarction (disrupted blood flow to the brain), and traumatic subdural hemorrhage (bleeding in the area between the brain and the skull) with loss of consciousness. [...]

Inspectors wroteComplaint #: NJ00164488 Based on observation, interviews, medical record review, and review of other pertinent facility documents on 11/28/23 and 11/30/23, it was determined that the facility staff failed to consistently document on the Documentation Survey Report the Activities of Daily Living (ADL) status and care provided to the resident. The deficient practice was identified for Resident #1, 1 of 3 residents reviewed for documentation and was evidenced by the following: On 11/28/23 at 10:32 AM, the surveyor observed Resident #1 lying in bed and interviewed him/her at this time. Resident #1 stated it depended which staff member was assigned as their CNA if they received timely ADL care. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 11/19/21 at 10:29 AM, the surveyor, in the presence of the Food Service Director (FSD), observed the following during the kitchen tour: 1. A stack of five aluminum pans was stored on a multi-tiered cart. The surveyor observed the five aluminum pans were wetnesting and noted a slimy unknown substance on the edge of the bottom aluminum pan. The surveyor wiped the edge of the bottom aluminum with a napkin and noted debris and a slimy unknown substance on the napkin. 2. A soiled dishware was stored on the top shelf of a multi-tiered cart alongside clean and sanitized dishware. 3. [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that the facility failed to administer medication in accordance with the physician's orders. This deficient practice was identified in 1 of 5 residents reviewed for unnecessary medications (Resident #95) and was evidenced by the following: According to the resident's admission Record, Resident #95 had a diagnosis including, but not limited to, essential (primary) hypertension (high blood pressure in which additional and underlying causes contributing to the high blood pressure are not present). [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to a.) provide residents' meals with food items as requested, b.) speak to the residents about alternate food items when the items first requested were not available and c.) provide food at a preferable and appetizing temperature. This deficient practice was identified for Residents #8, #21, #26, #37, #71, #247, #297, and #298 observed by the surveyors during a breakfast and lunch meal on 2 of 2 nursing units (1st Floor and 2nd Floor Units), and 5 of 5 residents who attended the Resident Council and was evidenced by the following: On 11/16/21 at 9:33 AM, during the initial tour of the 1st Floor Unit, Surveyor #1 observed Resident #247 sitting at beside with a disposable breakfast tray on the overbed table. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to maintain the call bell within reach for 1 of 4 residents (Resident #52) reviewed for accidents. This deficient practice was evidenced by the following: On 11/16/2021 at 9:40 AM, the surveyor observed Resident #52 lying in bed asleep and the call bell was on the floor, to the left side of the resident's bed. On 11/17/2021 at 1:04 PM, the surveyor observed Resident #52 lying in bed awake and the call bell was on the floor, at the foot of the bed. The resident stated he/she uses the call bell to call for help, but that the call bell is usually on the floor. On 11/18/2021 at 10:43 AM, the surveyor observed Resident #52 lying in bed awake and the call bell was on the floor, at the foot of the bed. [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that facility staff failed to complete neurological assessments after a resident fall, in accordance with professional standards. This deficient practice was identified for 1 of 4 residents (Resident #95) reviewed for accidents and 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, record review, and review of facility documents, it was determined that the facility failed to ensure a floor mat was in place for 1 of 3 residents (Resident #52) reviewed for falls. This deficient practice was evidenced by: On 11/17/2021 at 1:04 PM, the surveyor observed Resident #52 lying in bed. The resident's left side of the bed was against the wall and a floor mat was folded next to the resident's right side of the bed, exposing the bottom right half of the bed to the floor. On 11/18/2021 at 10:43 AM, the surveyor observed Resident #52 lying in bed. The resident's left side of the bed was against the wall and a floor mat was folded at the foot of the resident's bed, exposing the entire right side of the bed to the floor. [...]

Inspectors wroteBased on observation, interview, and review of other facility documents, it was determined that the facility failed to provide a sanitary environment for residents, staff and the public by failing to keep the garbage container area free of garbage and debris, and failed to have a cover over the openings of 1 of 2 garbage containers/dumpsters. This deficient practice was evidenced by the following: On 11/16/21 at 10:51 AM, the surveyor toured the kitchen with the Food Service Director (FSD), and requested to see the outside garbage receptacle area. The surveyor observed a garbage container (GC) that was uncovered and exposed to the elements. The GC had a closed lid on the left-side, but the right-side lid was open exposing multiple trash bags inside. The surveyor further observed that both the left-side and right-side doors of the GC was also open exposing multiple trash bags inside. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to ensure that the posted 24-hour staffing report was completed in its entirety. This deficient practice was evidenced by the following: On 11/19/2021 at 8:00 AM, the surveyor observed the facility's Nursing Home Resident Care Staffing Report, dated 11/19/21 Day Shift, posted at the visitor entrance, which omitted information in the # of Staff, Total Hours Worked, and Staff to Resident Ratio columns. During an interview with the surveyor on 11/19/2021 at 10:05 AM, the Receptionist stated the Staffing Coordinator posts the Staffing Report daily and provided a copy of all the Staffing Reports posted at the visitor entrance. Review of the following facility's New Jersey Department of Health Nursing Home Resident Care Staffing Report revealed: [...]