Axia Care Center of Orange

Inspectors wroteBased on observation, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to 1) obtain/renew physician orders (POs) to ensure that a resident received the appropriate care to maintain a centrally inserted intravenous catheter (CVC) (a long, flexible tube inserted into a large vein that goes near the heart for long-term intravenous (IV) antibiotics), and 2) discontinue a CVC after the completion of IV antibiotics consistent with professional standards of practice. This deficient practice was identified for 1 of 1 resident (Resident #123) reviewed for IV therapy. [...]

Inspectors wroteBased on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that a resident received as needed (prn) narcotic (a controlled drug that produces pain relief) medication (med) in accordance with the prescriber's orders and accepted professional standards. The deficient practice was identified for 1 of 1 resident (Resident #67) reviewed for Hospice care. 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: [...]

Inspectors wrote2641999, 2562115 Based on interview and record review and review of other pertinent facility documents on 10/23/25, it was determined that the facility failed to ensure that the nursing services were provided and documented consistently on the Treatment Administration Record (TAR) in accordance with professional standards of practice. This deficient practice was identified for 2 of 3 residents reviewed for standards of practice (Resident #1, Resident #2). The evidenced was as follows: Reference: The practice of nursing as a Licensed Practical Nurse is defined as performing tasks, and responsibilities within the framework of case finding, 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 otherwise legally authorized Physician or Dentist. Reference: [...]

Inspectors wroteBased on interviews, medical record review, and review of pertinent facility documentation on 10/23/25, it was determined that the facility failed to consistently document Activities of Daily Living (ADL) as being provided to residents for 2 of 4 residents reviewed for ADLs (Resident #1, Resident #2).

Inspectors wroteComplaint #: NJ 185165 Based on observation, interview, record review and review of other facility documentation on 4/08/25 and 4/15/25, it was determined that the facility failed to implement and document an effective discharge plan to ensure a safe and effective transition of care for 1 of 3 residents reviewed for discharge planning, (Resident # 2). This deficient practice was evidenced by the following: The surveyor reviewed the admission Record of Resident #2 which revealed that the resident was admitted to the facility 02/2025 with diagnoses that included but not limited to: Spinal stenosis, Alzheimer's Disease, Repeated Falls, Muscle Weakness and Difficulty Walking. [...]

Inspectors wroteComplaint #: NJ00185165 Based on interviews, medical record reviews, and review of other pertinent facility documents on 04/08/25, it was determined that the facility's Director of Social Services (DSS) failed assist a resident in obtaining needed community services, as required by the Job Description for Social Services Director. The DSS also failed to follow the facility's Discharge Policy policy for 1 of 3 residents (Resident #2). This deficient practice was evidenced by the following: Review of the Electronic Medical Records (EMRs) is as follows: The surveyor reviewed the admission Record of Resident #2 which revealed that the resident was admitted to the facility 02/2025 with diagnoses that included but not limited to: Spinal stenosis, Alzheimer's Disease, fall from bed, muscle weakness and difficulty walking. [...]

Inspectors wroteComplaint NJ # 180392 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to a.) ensure effective interventions were implemented and monitored for a resident (Resident #143) who resided in a piped-in oxygen room and was identified as a smoker and was observed smoking inside their room on 10/19/24. This deficient practice occurred for 1 of 1 residents reviewed for safe smoking. Observations on 1/15/25, 1/16/25, and 1/17/25, confirmed Resident #143 who resided in a piped-in oxygen room, kept their smoking materials in their room. The facility's failure to ensure all residents were protected from serious injury, harm or death from explosion or fire, from smoking inside of a room that had oxygen piped in through the walls resulted in an Immediate Jeopardy (IJ) situation. [...]

Inspectors wroteComplaint # NJ 180392 Based on interview, record review and review of other pertinent documents, it was determined that the facility failed to ensure a thorough and complete investigation was completed to determine the causal factor of an injury of unknown origin to ensure that resident abuse or neglect had not occurred for a resident (Resident #264) who was in a persistent vegetative state (disorder of consciousness caused by brain damage), dependent on staff for all care, and required a mechanical ventilator for breathing. Resident #264 was found on 11/06/24, with a hematoma (blood filled injury) to the right eye, and ecchymosis (a bruise) to the right facial area measuring 16-centimeter (cm) x 10 cm. Resident #264 was transferred to the emergency room on [DATE], and was diagnosed with traumatic hematoma of the right eye. [...]

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) that approached the limit that could jeopardize a resident's eligibility for Medicaid or Supplimental Security Income (SSI). This deficient practice was identified for all residents who maintained Personal Needs Accounts at the facility and was evidenced by: A review of the Funds Balance Report for 01/15/2025 revealed a list of eighty five active resident names with a balance of $84, 036.27 Due to patients. There were twenty -one residents listed with PNA funds that range from $1,852.93 to $3,997.38. On 01/21/25 at 10:32 AM, the surveyor, in the presence of the survey team interviewed the Certified Social Worker (CSW) regarding the PNA accounts and if the CSW was involved with the PNA. [...]

Inspectors wroteBased on interview and document review it was determined that the facility failed to ensure that a Surety Bond was in place to protect all resident funds held by the facility. This deficient practice affected all residents who maintained a Personal Needs Account with the facility and was evidenced by the following: On 01/15/25 at 2:08 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) a copy of the facility's surety bond and a list of all the resident funds held by the facility. On 01/15/25 at 2:37 PM, the LNHA provided a copy of a Certificate of Liability Insurance Date: 01/15/2025 (the survey entrance date) with Crime- Including Burglery listed as the type of insurance coverage provided. The surveyor questioned the LNHA regarding the policy that he provided and he stated, this is what they (corporate oversight) gave me. [...]

Inspectors wroteBased on interview and review of pertinent documents it was determined that the facility failed to maintain an effective comprehensive data driven Quality Assurance and Performance Improvement program by failing to review all services provided including to ensure significant events were reviewed to determine root cause to prevent further occurrences. This deficient practice occurred for residents with a history of smoking in their room, holding drug paraphernalia and a lighter in their room (Resident #143 and Resident #34), and for a resident (Resident # 264) who was dependent on staff for all care, and sustained an injury of unknown origin that required hospitalization on 11/06/24. This deficient practice had the potential to affect all residents who resided in the facility and was evidenced by the following: Refer to 689L, 610G a. [...]

Inspectors wroteComplaint # NJ 168201, # NJ 179357 Based on observations, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure that a resident call light was readily accessible and within reach on 01/15/25, 01/16/25, and 01/21/25. The deficient practice was identified for 1 of 1 resident (Resident #43) reviewed for accommodation of needs and was evidenced by the following: On 01/15/25 at 10:45 AM, during an initial tour, the surveyor observed Resident #43 watching television (TV) in the bed. The resident stated, I am paralyzed (unable to move) from a stroke and not able to move my right arm. The surveyor observed resident's left hand elevated on a pillow. The surveyor observed the resident's call bell (a round disk-shaped flat device with a red cross in the middle) was placed close to their right shoulder. [...]

Inspectors wroteComplaint # NJ 167555 Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to provide appropriate incontinence care, and personal hygiene care for 2 of 2 residents (Resident #33 and Resident #8) reviewed for Activities of Daily Living. The deficient practice was evidenced by the following: 1. On 1/15/25 at 9:45 AM, the surveyor observed Resident #33 in bed and a strong urine odor was observed in the room. The resident was able to answer questions and informed the surveyor that they had not been changed since last night. On 1/15/25 at 10:15 AM, the surveyor returned to the room and observed the resident in the same position. The resident indicated that they had not had incontinence care. On 1/15/25 at 10:30 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who had Resident #33 on her assignment. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent documents it was determined that the facility failed to ensure there was no delay in treatment for a resident who required podiatry care that was ordered on 12/04/2024 and the podiatrist consult was completed 01/20/25, and the resident wore pressure relieving boots as per physician order. This deficient practice was identified for 1 of 1 resident (Resident #38) reviewed for foot care and was evidenced by the following: On 1/15/25 at 10:07 AM, the surveyor observed Resident #38 was in awake and alert in bed, with feet outside of covers and were not off loaded or in boots. Both feet were observed to be encrusted with a thick yellow, cracked and dry skin. The right foot had approximately a dime sized round black area above the right heel on the sole of the foot. [...]

Inspectors wroteBased on observations, interviews, record reviews, and review of pertinent documentation, it was determined that the facility failed to provide residents with a dignified environment by not providing bed linens, and not consistently emptying multiple urinals. This deficient practice was identified for 2 of 2 residents (Resident #113 and Resident #91) reviewed for dignity and was evidenced by the following: a. On 01/15/25 at 10:10 AM, Surveyor #1 observed Resident #113 in their room and in their bed, wearing a hospital type gown. There were no linens, pillows, or blankets on the bed and crumbs were observed in the bed. On 01/15/25 at 10:49 AM, Surveyor #1 and Surveyor #2 went to Resident #113's room. Both surveyors observed the resident was still sitting on the bed with no linens, pillows, or blankets on the bed as observed by the surveyor approximately 40 minutes prior. On 01/16/25 at 8: [...]

Inspectors wroteComplaint # NJ 177957, # NJ 180392 Based on interviews, record review, and pertinent facility documents provided by the facility from 01/15/25 through 1/22/25, it was determined that the facility failed to notify the family/responsible party when a resident (Resident #264) had a change in condition and required transport to the emergency room. This deficient practice occurred for 1 of 1 closed medical records reviewed for resident (Resident #264) who had a change in condition. The deficient practice was evidenced by the following: According to Resident #264's admission Record, the Resident was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Acute and chronic respiratory failure hypoxia, Epilepsy, tracheostomy status and dependence on respiratory ventilators. [...]

Inspectors wroteBased on observation, interview, and review of pertinent documentation, it was determined that the facility failed to maintain safe handrails on 1 of 5 Resident Units. This deficient practice was evidenced by the following: On 1/15/25 at 9:53 AM, the surveyor toured the 3rd floor and observed the following: Outside of room [ROOM NUMBER], the corner handrail was not securely connected to the next piece of handrail. Outside of room [ROOM NUMBER], the handrail was cracked. By the soiled linen room, the handrail was not secure. Across from room [ROOM NUMBER], the handrail was not secure to the wall. Outside of room [ROOM NUMBER], the handrail was not connected to the next piece. In the out cove by the telephone for resident use, the handrail was not secure to the wall. Outside of room [ROOM NUMBER], the handrail was cracked and not secure. [...]

Inspectors wroteBased on interview and record review 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, in accordance with federal guidelines for 2 of 36 residents (Resident #143 and Resident #26) reviewed for accuracy of MDS coding. The deficient practice was evidenced as follows: On 1/15/25 at 9:39 AM, during initial tour, Surveyor #1 observed a sign posted on the wall outside of Resident #143's room, No Smoking (in red), Piped in Oxygen in Use. Upon entrance to Resident #143's room, the surveyor observed the resident watching television (TV) in bed. The surveyor observed a pack of cigars on the table next to the resident and asked the resident what that was. The resident took a cigar out of the case and stated it's a cigar while showing it to Surveyor #1. [...]

Inspectors wroteBased on observation, interview and record reviews, it was determined that the facility failed to administer medication in accordance with the physician order and professional standards of nursing practice. This deficient practice was observed for one of 1 of 1 residents (Resident #60) reviewed for medications during the initial tour conducted on 01/15/25 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 pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician order, and ensure oxygen equipment was stored properly. This deficient practice was identified for 1 of 3 residents (Resident #47) reviewed for respiratory care 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 interview and document review, it was determined that the facility failed to ensure residents had cognitive ability before signing arbitration agreements. This deficient practice was identified for 1 of 3 residents (Resident #61) reviewed for arbitration agreements. This had the potential to result in resident representatives not being able to resolve disputes with the facility in a court of law. The deficient practice was evidenced by the following: On 1/15/25 at 10:18 AM, Surveyor #4 observed Resident #61 in bed. The resident did not respond to the surveyor when spoken to. A staff member was entering the room and stated the resident could not see. On 1/15/25 at 11:12 AM, the Licensed Nursing Home Administrator (LNHA) informed Surveyor #1 that the facility utilized arbitration agreements which were part of the admission agreement. [...]

Inspectors wroteBased on observations, interviews, record reviews, and review of pertinent documentation, it was determined that the facility failed to prevent the spread of potential infection by failing to don (put on) Personal Protective Equipment (PPE) prior to entering the room of residents on contact precautions. This deficient practice was identified for 2 of 2 residents (Resident #144 and Resident #147) reviewed for Transmission-based Precautions (TBP). The deficient practice was evidenced by the following: 1. On 01/15/25 at 8:57 AM, the surveyor observed Resident #144's room with signage outside the door alerting all to stop, Contact Precautions everyone must: . put on gown before room entry, put on gloves before room entry . There was a three-drawer plastic bin outside of the door with PPE gowns and gloves. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow acceptable standards of clinical practice with regards to 1. accurately following a physician's order (PO) in administering pain medication to treat varying pain levels (Resident #15, Resident #108); 2. ensure the positioning mobility to prevent contracture was applied prior to signing the administration record (Resident #15); 3. accurately documenting the urinary output for residents with a suprapubic catheter (Resident #39, Resident #78). 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 address a Full code status (code status that indicates a patient wants all resuscitation procedures to be provided to keep them alive in case of a medical emergency) order signed by the resident's family with no follow up from the Physician. This deficient practice was identified for 1 of 32 residents, Resident #15 reviewed for advanced directives. This deficient practice was evidenced by the following: On 9/5/23 at 11:14 AM, the resident was observed in the day room seated in a reclining Geri-chair watching TV. The surveyor reviewed Resident #15's hybrid medical record. Resident #15 was admitted to the facility with diagnoses that included but were not limited to Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Hypertension. [...]

Inspectors wroteBased on observation, interview, and record review 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, in accordance with federal guidelines for 2 of 32 residents (Resident # 147, and #15) reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 9/12/23 at 1:18 PM, the surveyor reviewed the closed medical chart for Resident #147 who was MDS coded for hospitalization. The surveyor reviewed the Discharge Summary (DS) created on 7/31/23 by the Social Worker (SW) for Resident #147. The DS documented that Resident #147 was discharged home per their family's request. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan (CCP) for 2 of 32 residents reviewed, Resident #127 and Resident #106. This deficient practice was identified by the following: 1. On 9/5/23 at 11:00 AM, the surveyor observed Resident #127 in the day room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor reviewed Resident #127's hybrid medical records. The admission Record (AR) reflected that Resident #127 was admitted to the facility with medical diagnoses which included but not limited to Congestive Heart Failure, Type 2 Diabetes Mellitus, Acute Kidney Failure and Hypertension. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to maintain a urinary catheter and provide services in a manner consistent with standards of practice for 2 of 3 residents reviewed for urinary catheter care (Resident #108, and #78). This deficient practice was evidenced by the following: 1. On 9/5/23 at 11:01 AM, Resident #108 was observed lying in bed, alert and able to communicate their needs. The resident was observed with a urinary catheter attached to a drainage bag hanging at their bedside. The surveyor smelled a strong urine odor at the resident's bedside. The resident verbalized no concerns. The surveyor reviewed the electronic health record (EHR) of Resident #108 which revealed the following: [...]

Inspectors wroteBased on observation, interview, record review and review of facility policy, it was determined that the facility failed to 1. enter weekly weights in the electronic medical record (EMR) for 3 of 4 residents, Resident #133, #16, and #85, 2. Address the cause(s) between current medical condition and significant (sig) weight losses for 4 of 4 residents, Resident #133, #16, #31 and #85 and 3. address identified actual or possible reasons of significant weight losses in the resident's care plan for 4 of 4 residents, Resident #133, #16, #31 and # 85, all reviewed for weight loss per facility policy. This deficient practice was evidenced by the following: 1. [...]

Inspectors wroteBased on observation, interview, and review of facility polices it was determined that the facility failed to maintain proper kitchen sanitation practices. This deficient practice was evidenced by the following: On 9/5/23 from 9:35 AM through 10:20 AM, the surveyor completed the initial kitchen tour with the Food Service Director (FSD) and Regional Registered Dietitian (RRD). Upon entering the dish room, the surveyor observed a dietary aide (DA) using the dish washing machine, that was filled with soiled breakfast dishes. The surveyor observed the wash and rinse cycle reaching 114 degrees Fahrenheit (F). The FSD stated, the dish machine is a low temperature machine. The wash and rinse cycles should be 120 F. The FSD ran the dish machine two more times, with the wash and rinse cycle temperature maintaining 114 F. [...]