Belle Care Nursing and Rehabilitation Center

Inspectors wroteBased on interview, review of Nursing Staffing Report sheets and facility provided documents, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 10 of 42 days reviewed 09/21/2025 through 12/27/2025. The deficient practice was evidenced by the following: A review of the Nurse Staffing Reports completed by the facility for the week of 09/21/2025 through 12/27/2025, revealed the facility had no RN coverage for all shifts on 10/03/2025, 11/24/2025, 12/16/2025, 12/17/2025, 12/18/2025, 12/22/2025, 12/24/2025, 12/25/2025 and 12/26/2025. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:On 12/29/2025 from 09:30 AM until 09:55 AM during the initial tour of the kitchen, the surveyor, in the presence of the Director of Dining (DOD) observed the following:1. In the walk-in refrigerator, a covered pie had no label and was not dated. The DOD acknowledged it should be dated and the item was removed. 2. In the walk-in freezer, bagged frozen waffles, bagged frozen fish, frozen hamburger patties and an opened package of bacon had no label and were not dated. The DOD stated the waffles, fish, hamburger patties, and the bacon should be dated. The items were removed.3. [...]

Inspectors wroteBased on observation, interview and review of facility documentation, it was determined that the facility failed to provide immediate access to records and requested information necessary to conduct the survey. The deficient practice was evidenced by the following: On 12/29/2025 at 9:00 AM, the survey team entered the facility and was greeted by the Assistant Director of Nursing (ADON) who was instructed by the Survey Team Coordinator to provide an alphabetical roster of residents and a roster by room number, the Facility Matrix for admissions in the last 30 days, and a list of residents who smoke. On the same date at 9:56 AM, no facility staff member brought any of the requested documents except an alphabetical list of the residents. [...]

Inspectors wroteBased on interview and review of facility documents, it was determined that the facility failed to ensure that staffing data submitted to the Centers for Medicare & Medicaid Services (CMS) through the Payroll-Based Journal (PBJ) system was accurate and complete for 1 of 2 PBJ Staffing Data Reports reviewed under the Sufficient and Competent Nurse Staff Task. The deficient practice was evidenced by the following:The facility reported on the AAS-11 (Daily Nursing Staff Report) that no Registered Nurse (RN) services were available on 10/03/2025, 11/24/2025, 12/16/2025, 12/17/2025, 12/18/2025, 12/22/2025, 12/25/2025, and 12/26/2025. A review of the PBJ Staffing Data Report (CASPER Report 1705D) for Fiscal Year Quarter 1, 2025 (October 1, 2025, through December 31, 2025) revealed that the facility had not triggered No RN Hours for the dates identified on the AAS-11. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain a clean, safe and sanitary environment for 2 of 2 units, the 1st and 2nd floor units, reviewed for environment. This deficient practice was evidenced by the following: On 12/29/2025 at 9:45 AM, on the 2nd floor in Bedroom [ROOM NUMBER], surveyor # 1 observed a fall mat positioned next to a resident's bed that contained multiple brown debris spots. On 12/29/2025 at 10:00 AM, on the 2nd floor in Bedroom [ROOM NUMBER], surveyor # 1 observed unfinished spackling on the wall behind the headboard of the B bed. Three holes were observed in the wall near the dresser. A fall mat was present on the right side of the bed with multiple areas of white debris. [...]

Inspectors wroteBased on observations on 12/31/2025 and 01 02/2026 in the presence of the facility's Corporate Regional Maintenance (CRM) and Maintenance Director (MD), it was determined that the facility failed to ensure that corridors were equipped with firmly secured handrails on both sides, This deficient practice had the potential to affect the 101 Residents who reside in the facility and is evidenced by the following:During the building tour on 01/02/2026 in the presence of the facility's CRM and MD at approximately 9:50 AM, the surveyor observed on the ground floor corridor next to the elevator and lobby area had no evidence of hand rails on both sides of the corridor. [...]

Inspectors wroteBased on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure newly hired employees were properly screened for a history of abuse, neglect, exploitation, or misappropriation and failed to implement policies and procedures related to pre-employment screening. Specifically, the facility did not complete required license verifications, reference checks, or criminal background checks prior to the start of employment. This deficient practice was identified in 53 of 160 employee files reviewed (Employees #1 through # 53). The deficient practice was evidenced by the following: [...]

Inspectors wroteComplaint # 366635Based on interview and record review, it was determined that the facility failed to report an allegation of a resident-to-resident altercation to the Department of Health (State Agency) within the required 24-hour time frame. This deficient practice was identified for 2 of 8 residents (Resident # 113 and 114) reviewed under Abuse. The deficient practice was evidenced by the following:A review of the facility's AAS-45 (official report that a nursing home must send to the state government whenever an accident or incident happens to a resident) revealed that a resident-to-resident altercation occurred on 11/27/2024. A review of the AAS-45 revealed the form indicated that no injuries were reported because of the altercation. A review of the AAS-45 revealed the facility indicated the event was called into the Department of Health on 11/28/2024. [...]

Inspectors wroteComplaint # 366660Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to conduct a thorough investigation into an allegation of abuse by failing to document witness statements regarding the specific events of an alleged incident and instead focused on the character of the staff member involved. The deficient practice was identified for 1 of 8 residents (Resident # 112). The deficient practice was evidenced by the following:On 6/10/2025, Resident # 112 reported to the New Jersey Department of Health that on 5/02/2025, a nurse refused to give the resident needed supplies to perform their own care, kicked an oxygen concentrator, and refused to send the resident to the hospital. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observations conducted from 12/30/2025 to 01/02/2026, the surveyors observed four nurses administer medications to ten residents. There were 29 opportunities, and 3 errors observed, which resulted in a medication error rate of 10.34%. This deficient practice was identified for 2 of 10 residents, administered by 1 of 4 nurses. The deficient practice was evidenced by the following:On 12/30/2025 at 9:24 AM, the surveyor observed Licensed Practical Nurse (LPN) # 1 begin to administer medications for resident #63. [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure medications were properly labeled and stored in an orderly manner. The facility failed to label opened multi-dose insulin vials with an open or expiration date and failed to maintain a medication cart free from loose, scattered medication. This deficient practice was identified for 1 of 2 medication carts inspected under the Medication Storage and Labeling task. The deficient practice was evidenced by:On 12/30/2025 at 10:34 AM, the surveyor inspected the 2 High - Side, 2nd Floor medication cart in the presence of Licensed Practical Nurse (LPN) # 1. While inspecting the top drawer of the cart, the surveyor observed a multi-dose vial of Lantus insulin (long-acting insulin) prescribed to an unsampled resident. [...]

Inspectors wroteBased on observation, interview, and review of 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 containers closed and provide an area free of garbage and debris for 3 of 3 garbage containers. This deficient practice was evidenced by:On 12/30/2025 at 12:15 PM, the surveyor, accompanied by the Director of Dining (DOD), observed the facility's outdoor trash disposal area. The surveyor observed three garbage containers (GC) situated side by side along the exterior fence. The three GCs had an open lid and contained trash that was exposed to the elements. The area surrounding the three GCs was littered with debris, including but not limited to disposable gloves, plastic bags, and cardboard boxes. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure proper infection prevention and control practices were implemented to prevent the transmission of infection, related to handling of an indwelling urinary catheter for 1 of 1 resident reviewed for Urinary Catheter. (Resident # 11)The deficient practice was evidenced by the following: During the initial tour of the unit on 12/29/2025 at 09:52 AM, Resident #11 was in bed with an indwelling catheter. The catheter drainage bag was in contact with the floor with no privacy bag. A review of Resident # 11's admissions record revealed that, Resident # 11 was admitted with but not limited to Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms (enlarged prostate), and Obstructive and reflux uropathy (a condition where urine flow is blocked. [...]

Inspectors wroteComplaint #: NJ182273 Based on observation, interview, review of the medical records, and pertinent facility documents on 4/21/25 and 4/24/25, it was determined that the facility's nursing staff failed to: a.) sign on the electronic Medication Administration Record (eMAR) that the medications were administered according to the physician's orders, and b.) administer medication according to the physician's order. The facility also failed to follow their policy titled Medication Administration. This deficient practice was identified for 4 of 5 residents (Resident #2, Resident #3, Resident #4, Resident #5) reviewed for medication administration. 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 wroteComplaint # NJ178109 Based on interviews, medical record review, and review of other pertinent facility documentation on 4/21/25 and 4/24/25, it was determined that the facility failed to submit the facility's investigation to the New Jersey Department of Health (NJDOH) in a timely manner for a resident-to-resident incident that occurred. The facility also failed to follow its policy titled Abuse Policy. The deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident # 2 was admitted to the facility in June 2020 with diagnoses which included but were not limited to: Depression, Anxiety, and Bipolar Disorder. According to the quarterly Minimum Data Set (MDS), an assessment tool dated 02/27/25, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated the resident's cognition was severely impaired. 2. [...]

Inspectors wroteComplaint NJ #: 159451; 159783 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain an environment that promoted maintenance or enhancement of the resident's quality of life. This deficient practice was identified for 1 of 1 residents reviewed for Resident Rights (Resident #60). This deficient practice was evidenced by the following: On 6/17/24 at 10:27 AM, the surveyor observed Resident #60 in their room watching television. Resident #60 stated that they did not like to spend time in their room because their roommate (Resident #71) urinated on the floor, causing the room to become smelly and unpleasant. When asked if the facility was aware of this behavior, Resident #60 confirmed. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that Justice Involved Residents (JIRs) were treated in a dignified and respectful manner by physically restraining, secluding the resident from participating in group activities, community dining, communicating with visitors, leaving the room at will, and retaining and using of personal possessions. This deficient practice was identified for 1 of 1 JIR (Resident #1). Resident #1 was admitted to the facility on [DATE], and was secluded by Corrections Officers (CO) from the Correctional Facility (CF). Resident #1 was observed being secluded to their room, guarded by two COs, and they were not permitted to participate in group activities and community dining. Resident #1 stated they were not allowed to leave their room; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to promote and facilitate resident self-determination through support of resident choice including to; participate in group activities, community dining, serving meals in a dignified manner, freely communicate with visitors, leave room at will, be free from physical restraints, and wear clothing of choice for Justice Involved Residents (JIR). This deficient practice was identified for 1 of 1 JIRs (Resident #1). Resident #1 was admitted to the facility on [DATE], and was secluded by Corrections Officers (CO) from the Correctional Facility (CF). Resident #1 was observed being secluded to their room, guarded by two COs, and they Resident #1 was not permitted to participate in group activities and community dining. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure all residents were free from abuse including the involuntary seclusion and use of physical restraints for a Justice Involved Resident (JIR). This deficient practice was identified for 1 of 1 JIR (Resident #1). Resident #1 was admitted to the facility on [DATE], and was secluded by Corrections Officers (CO) from the Correctional Facility (CF). Resident #1 was observed being secluded to their room, guarded by two COs; Resident #1 was not permitted to participate in group activities and community dining. Resident #1 stated hey were not allowed to leave their room; have visitors unless scheduled and approved by the CF; could not choose their own clothes having to wear an orange jumpsuit that made them feel embarrassed; participate in activities; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure all residents were free from abuse including the use of physical restraints imposed for the purposes of discipline or convenience for a Justice Involved Resident (JIR). This deficient practice was identified for 1 of 1 JIR (Resident #1). Resident #1 was admitted to the facility, and was secluded by Corrections Officers (CO) from the Correctional Facility (CF). Resident #1 was observed being secluded to their room, guarded by two COs, and Resident #1 was not permitted to participate in group activities and community dining. Resident #1 stated that they were not allowed to leave their room; have visitors unless scheduled and approved by the CF; participate in activities; eat all meals in their room on disposable ware; not allowed use the telephone; [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff implemented facility policies and procedures to ensure a.) residents were provided with care and services to achieve their highest practical wellbeing and b.) their Quality Assurance and Performance Improvement (QAPI) Program was being implemented to ensure sustainability with previously cited deficiencies. This deficient practice was identified on 2 of 2 nursing units, and was evidenced by the following: Refer F600, F610, F641, F725, F756, F761, F838, F865, F881, F882 A review of the Administrator's job description provided by the facility revealed the following: [...]

Inspectors wroteBased on interview and record review it was determined that the facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for 4 of 5 residents reviewed for medication management (Resident #34, Resident #80, Resident #60, and Resident #61) and was previously cited during the facility's last standard survey on 10/20/22. The evidence was as follows: Refer F865 1. On 6/19/24 at 1:27 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) the CP's recommendations for Resident #34 from March 2024 until present. According to the admission Record (AR), Resident #34 was admitted to the facility with the diagnoses which included but was not limited to unspecified dementia with behavior disturbance and bipolar disorder (a type of mental illness). [...]

Inspectors wroteBased on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the facility-wide assessment identified the required services and procedures necessary to protect the health, safety, and welfare of all residents prior to admission of registered sex offenders and residents admitted from the correctional facility. This deficient practice was previously identified and cited during the facility's last standard survey on 10/20/22, and was evidenced by the following: Refer F865 During entrance conference on 6/17/24 at 10:00 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) a copy of the facility's assessment. During initial tour on 6/17/24 at 10:29 AM, the surveyor observed Resident #26 observed in bed asleep. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure that a.) their Quality Assurance and Performance Improvement (QAPI) Program was being implemented to ensure sustainability with previously cited deficiencies and b.) sources of quantitative data was being analyzed to identify quality deficiencies and evaluate program effectiveness. The facility was cited during last standard survey on 10/20/22, and was evidenced by the following: Refer F641, F756, F761, F838, and F881 During entrance conference on 6/17/24 at 10:00 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) a copy of the facility's QAPI program plan and the last three quarterly sign-in sheets. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) implement a facility-wide system to monitor antibiotic use specifically according to the facility's antibiotic stewardship program and b.) monitor antibiotic use and conduct surveillance from January 2024 through June 2024. This deficient practice was cited during the facility's last standard survey on 10/20/22, and was evidenced by the following: Refer F865 According to the U.S. CDC Core Elements of Antibiotic Stewardship for Nursing Home, page last reviewed June 11, 2020, included, Tracking and Reporting Antibiotic Use and Outcomes Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to issue the required Advance Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) forms prior to discharge from Medicare Part A services. This deficient practice was identified for for 3 of 3 residents reviewed for beneficiary notifications (Resident #28, #55, and #82), and was evidenced by the following: On 6/25/24 at 9:18 AM, the surveyor reviewed three residents (#28, #55, #82) who were discharged from their Medicare Part A stay with benefit days remaining within the past six months and should have received Beneficiary Notices. Resident #28 had a last documented covered day of Medicare Part A service coverage date of 4/12/24, from a facility-initiated discharge when benefit days were not exhausted. [...]

Inspectors wroteBased on interview, review of facility policy, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy to a.) complete criminal background checks on employees prior to employment; b.) to complete reference checks on employees before their start date; and c.) to complete license checks on employees prior to their start date. The deficient practice was identified for 2 of 10 employees reviewed for new hires (Employee #9 and Employee #10), and was evidenced by the following: A review of facility's undated Abuse Policy included in the section titled Screening Components that it is the policy of this facility to screen employees and volunteers prior to working with residents. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accurately assess a resident's status in the Minimum Data Set (MDS), an assessment tool used to evaluate resident's care needs. This deficient practice was identified for 5 of 35 residents reviewed for accuracy of assessments (Resident #29, #60, #73, #80, and #96), and was previously cited during the facility's last standard survey on 10/20/22. The evidence was as follows: Refer F865 1. On 6/17/24 at 10:57 AM, the surveyor observed Resident #29 sitting on their bed. The surveyor attempted to interview the resident, but the resident was unable to verbally be understood. The surveyor reviewed the medical record for Resident #29. [...]

Inspectors wroteBased on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) administer multiple medications on multiple dates and times on a timely basis in November of 2022, and b.) ensure a discontinued physician's order was removed from active orders in accordance with professional standards of practices. This deficient practice was identified for 4 of 4 residents reviewed for medication administration times (Resident #32, #43, #60, and #250) and 1 of 24 residents reviewed for professional standards of practice (Resident #60). 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 review of pertinent facility documents, it was determined that the facility failed to ensure a Justice Involved Resident (JIR) was provided since admission activities of their choice designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This deficient practice was identified for 1 of 1 JIR (Resident #1) reviewed.

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide sufficient nursing staff to ensure residents were provided with care to achieve their highest practical wellbeing by failing to ensure a.) incontinence care was provided for 2 out of 7 residents observed during incontinence rounds (Resident #32 and Resident #147) and b.) medications were administered according to physician's orders for 4 of 4 residents reviewed for medication administration timing (Resident #32, #43, #60, and #250). This deficient practice was evidenced by the following: Refer F658 and F677 1. According to the admission Record (AR), Resident #147 was admitted to the facility with the diagnoses which included but not limited to chronic respiratory failure and tracheostomy (hole in the windpipe to facilitate breathing). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring a.) the accurate documentation of medication administration during the 6/18/24 medication administration observation for ten residents by 1 of 2 nurses; b.) accurate documentation of the administration of a medication (Depakote) according to physician's orders from 6/11/24 until surveyor inquiry; c.) accurate inventory documentation of a controlled medication (methadone) administered on 6/17/24; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the morning medication administration observation on 6/18/24, the surveyor observed two (2) nurses administer medications to three (3) residents. There were 29 opportunities, and three (3) errors were observed which calculated to a medication administration error rate of 10.3%. The deficient practices were identified for 2 of 3 residents, (Resident #51 and #5), that were administered medications by 2 of 2 nurses that were observed. The facility was previously cited for this during their last standard survey. The deficient practices were evidenced by the following: 1. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) properly store medications, b.) maintain clean and sanitary medication storage areas, and c.) properly label opened multidose medications. This was observed in 2 of 2 observed medication carts on 2 of 2 nursing units and was previously cited during the facility's last standard survey on [DATE]. The evidence was as follows: Refer F865 On [DATE] at 10:44 AM, during initial tour of the facility, the surveyor observed in Resident room [ROOM NUMBER], which was occupied by four residents, a box of sodium chloride (NaCl) inhalation solution individual vials (medication used to treat lung disease) stored unsecured and in the open, on top of a table next to the room door. [...]

Inspectors wroteBased on observations, interviews, 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 5 of 7 residents during the Resident Council meeting (Resident #23, #55, #61, #74, and #79), and was evidenced by the following: On 6/19/24 at 9:15 AM, the surveyor in the presence of the District Operations (Regional Food Service Director; Regional FSD) observed labeled snacks in the reach-in refrigerator in the kitchen. The Regional FSD stated that the facility supplied approximately seventy-five snacks in total for three snack times a day for residents. The Regional FSD continued that not all residents received snacks; [...]

Inspectors wroteBased on observation, interview, review of pertinent facility documents, it was determined that the facility failed to: a) change respiratory equipment tubing in a manner to prevent the spread of infection for 1 of 1 resident reviewed for respiratory care (Resident #80); b.) ensure that infection control standards were followed during medication pass for 1 of 2 nurses observed during medication administration; and c.) ensure staff maintained appropriate nail length to prevent the spread of infection for 1 of 2 unit managers. This deficient practice was identified on 2 of 2 nursing units, and was evidenced by the following: 1. During the initial tour of the Second Floor nursing unit on 6/17/24 at 10:52 AM, the surveyor observed Resident #80 lying in bed. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to hire a designated Infection Preventionist (IP) who worked at least part-time and had completed specialized training in infection control and prevention. The deficient practice was identified and evidenced by the following: Refer F880; F881; and F883 During entrance conference on 6/17/24 at 10:00 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) who the facility's Infection Preventionist (IP) was, and the DON stated the facility's previous IP left about two or three months ago and the position was vacant. The DON stated herself, the Assistant Director of Nursing (ADON), and the two unit managers reviewed immunizations, antibiotic stewardship, and infection control issues. [...]

Inspectors wroteComplaint NJ #159783 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to to maintain the residents' environment, equipment, and living areas in a safe, sanitary, and homelike manner that included clean linens and privacy curtains. This deficient practice was identified for 2 of 2 nursing units observed for the facility environment task. This deficient practice was evidenced by the following: 1. During entrance conference on 6/17/24 at 10:00 AM, the surveyor asked what the resident census in the facility was, and the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON) stated 94 residents. On 6/17/24 at 10:42 AM, during initial tour of the Second Floor nursing unit, the surveyor observed that the clean linen cart located near Resident room [ROOM NUMBER] did not contain any towels. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to develop and implement an individualized comprehensive care plan (ICCP) consistent with the resident's history of sex offenses. This deficient practice was identified for 1 of 35 residents reviewed for care planning (Resident #73), and was evidenced by the following: On 6/19/24 at 10:01 AM, the surveyor observed Resident #73 in their room. On 6/20/24 at 11:23 AM, the surveyor interviewed the Registered Nurse (RN) who stated an ICCP was a picture of the resident and explained what needed to be done or expected for the resident. The RN confirmed that a resident's behavior or ongoing behavior patterns should be identified on the ICCP. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to revise an individualized comprehensive care plan (ICCP) in a timely manner for a resident whose orthotic was discontinued. This deficient practice was identified for 1 of 35 residents reviewed for comprehensive care plans (Resident #60), and was evidenced by the following: On 6/17/24 at 10:27 AM, the surveyor observed Resident #60 in their room watching television. The resident was not observed wearing any orthotics to lower extremities. The surveyor reviewed the medical record for Resident #60. [...]

Inspectors wroteComplaint #: NJ 159451 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) incontinence care was provided for 2 out of 7 residents observed during incontinence rounds (Resident #32 and Resident #147) and b.) nail care was provided during activities of daily living (ADLs) for residents 2 of 4 residents reviewed for ADLs (Resident #60 and Resident #73). This deficient practice was evidenced by the following: Refer F725 1. According to the admission Record (AR), Resident #147 was admitted to the facility with the diagnoses which included but not limited to chronic respiratory failure and tracheostomy (hole in the windpipe to facilitate breathing). [...]

Inspectors wroteBased on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) obtain a physician's order for pressure reducing devices and b.) implement the individualized comprehensive care plan (ICCP) intervention to use a pressure reducing device on a resident's bed. This deficient practice was identified for 1 of 1 resident reviewed for pressure ulcer/injury(Resident #9), and was evidenced by the following: On 6/17/24 at 10:54 AM, during initial tour of the facility, the surveyor observed Resident #9 lying in bed. The resident was on a regular mattress which was placed atop a deflated low air loss mattress/pressure reducing mattress, which was connected to an air pump that was not plugged into the power outlet or turned on. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to monitor an enteral tube feeding administration pump to ensure the total volume administered was in accordance with physician's orders. This deficient practice was identified for 1 of 1 residents reviewed for tube feeding (Resident #32), and was evidenced by the following: On 6/17/24 at 10:54 AM, the surveyor observed Resident #32 lying in bed awake with a tube feeding pump (TF; a tube feeding surgically inserted into the stomach) was located on a pole near their bed. There was no nutritional formula being administered at this time. When asked by the surveyor if they received tube feedings daily, Resident #32 shook their head indicating yes. [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documents, it was determined that the facility failed to provide adequate monitoring for the use of psychoactive medications. This deficient practice was identified for 4 of 5 residents reviewed for unneccessray medications (Resident #34, #60, #61, and #80), and was evidenced by the following: 1. According to the admission Record (AR), Resident #34 was admitted to the facility with the diagnoses which included unspecified dementia with behavior disturbance and bipolar disorder (a type of mental illness). The quarterly Minimum Data Set (MDS), an assessment tool dated 3/30/24, reflected that the resident had severe cognitive deficits and had behaviors directed toward others. The MDS also reflected that the resident was dependent for activities of daily living (ADLs) and was on psychoactive medications. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to a.) maintain multiuse food-contact surface cutting board in a manner to prevent microbial growth; and b.) maintain storage and preparation areas in a sanitary manner. This deficient practice was evidenced by the following: On 6/19/24 at 9:15 AM, the surveyor conducted a kitchen tour with the Regional District Operations (RDO) and observed the following: 1. In the walk-in freezer, the vinyl strip curtains located in the entrance to the freezer, there were only two curtain strips. These curtains protect the inside of the freezer from outside dust particles as well as keep the cold air from escaping the freezer when the door was opened. There was also ice accumulation around the door frame. The RDO acknowledged the freezer needed vinyl curtains and there should not be ice around the door frame. [...]

Inspectors wroteBased on interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to implement their policy to a.) ensure all eligible residents were educated on the benefits and potential side effects of the pneumococcal immunization and b.) document in the medical record the residents' education and refusal of the pneumococcal immunization. The deficient practice was identified for 2 of 8 residents reviewed for immunizations (Resident #76 and Resident #87), and was evidenced by the following: 1. [...]

Inspectors wroteComplaint NJ #159451; 159539; 159783; 162168 Based on observation, interview, and review of other facility documentation it was determined that the facility failed to maintain resident environment, equipment, and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified for 2 of 2 nursing units (First and Second Floor) and was evidenced by the following: On 6/19/24 at 9:09 AM, the surveyor observed in the hallway by Resident room [ROOM NUMBER] a wheelchair with brown matter that resembled fecal matter, smeared across the seat cushion and down the leg of the wheelchair onto the wheels. On 6/20/24 at 10:52 AM, the surveyor observed on the Second Floor nursing unit a strong urine odor while approaching Resident room [ROOM NUMBER]. The surveyor entered the room to discover the floor by Bed B was wet and sticky. [...]

Inspectors wroteNJ Complaint #166562 Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure a resident who was on one-to-one (1:1) monitoring by staff was constantly monitored by staff to ensure the resident was free from neglect when they sustained bruising to both ears and a lower spine fracture from an unwitnessed fall. The deficient practice was identified for 1 of 7 residents reviewed for abuse (Resident #254), and was evidenced by the following: [...]

Inspectors wroteNJ Complaint #166769 Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure a resident who received daily pain management a.) received their pain medications as order and b.) ensure the resident's pain was being assessed and monitored every shift. This deficient practice was identified for 1 of 1 residents reviewed for pain management (Resident #97), and was evidenced by the following: On 6/20/24 at 9:23 AM, the surveyor reviewed the closed medical record for Resident #97. A review of the Resident Face Sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included malignant neoplasm of unspecified site of left and right [male/female] breast (breast cancer); [...]

Inspectors wroteNJ Complaint #168809 Based on interviews and review of pertinent facility documents, it was determined that the facility failed to provide a discharged resident with a copy of their medical records within a timely manner of the written request. This deficient practice was identified for 1 of 1 resident reviewed for medical records (Resident #252), and was evidenced by the following: According to the Resident Face Sheet (an admission summary), Resident #252 was admitted to the facility in 2022 with diagnoses kidney failure. The face sheet did not include the resident's discharge date . A review of the electronic Admissions record revealed Resident #252 was discharged from the facility in July of 2022. On 6/19/24 at 12:09 PM, the surveyor interviewed the Medical Records personnel who stated residents and authorized personnel can request medical records. [...]

Inspectors wroteComplaint NJ #162168 Based on interviews, review of the closed medical records, and pertinent facility documents, it was determined that the facility failed to notify a resident's family after a change of condition. This deficient practice was identified for 1 of 35 sampled residents (Resident #247), and was evidenced by the following: A review of the closed medical record for Resident #247 revealed the resident was admitted to the facility in 2019 and discharged from the facility in 2023. A review of the Minimum Data Set (MDS), an assessment tool dated 2/3/23, indicated that the resident had unclear speech and usually understood with diagnoses which included hypertension, depression, bipolar, and schizophrenia. A review of the Progress Notes included a Nurses Note (NN) dated 11/13/22, that the resident was noted sitting on the floor in their bathroom with no injuries. [...]

Inspectors wroteNJ Complaint #166562 Based on interview and review of pertinent facility documents, it was determined that the facility failed to a.) initiate an investigation at the time of an injury of unknown origin was discovered on 8/13/23; and b.) complete a thorough investigation of how a resident on one-to-one (1:1) monitoring by staff had an unwitnessed fall. The deficient practice was identified for 1 of 7 residents reviewed for abuse (Resident #254), and was evidenced by the following: [...]

Inspectors wroteComplaint NJ #163249; 168809 Based on observation, interview, review of the medical record, and other pertinent facility documents, it was determined that the facility failed to maintain an accurate, complete, and easily accessible medical record. This deficient practice was identified for 3 of 35 residents' medical records reviewed (Resident #97, #248, and #252), and was evidenced by the following: 1. On 6/17/24 at 1:00 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) a copy of the investigation for the reportable event to the New Jersey Department of Health (NJDOH) for Resident #248 reported on 4/3/23. On 6/18/24, the surveyor was provided with a copy of the form submitted to the NJDOH, but was not provided with the investigation. The surveyor requested a copy of the investigation. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to a.) complete and submit to Centers for Medicare and Medicaid Services (CMS) a Quarterly Minimum Data Set (MDS), a resident assessment tool used to facilitate the management of care, in a timely manner for 16 of 27 residents (Resident #1, #3, #4, #5, #6, #7, #8, #14, #16, #17, #21, #27, #31, #35, #36, and #37) reviewed for system selected MDS over 120 days for late submissions b.) complete a Quarterly MDS in a timely manner for three (3) of 19 residents reviewed (Resident #45, #57, and #63). This deficient practice was evidenced by: a.) On 10/14/22 at 10:36 AM, surveyor #1 interviewed the Regional Minimum Data Set Coordinator (MDS/RMC) regarding late, non-completed MDS assessments. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to electronically submit the Minimum Data Set (MDS), a resident assessment tool, within 14 days after completion as required. This deficient practice was identified for 22 of 27 residents (Residents #1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #14, #16, #17, #21, #23, #27, #30, #31, #33, #35, #36, and #37) reviewed for MDS record over 120 days . This was evidenced by the following: On 10/14/22 at 10:36 AM, the surveyor interviewed the Regional Minimum Data Set Coordinator (MDS/RMC) regarding late, non-completed MDS assessments. The surveyor provided the MDS/RMC with a list of resident MDS assessments that were late or not submitted and the MDS/RMC stated that she would email the surveyor information regarding the late assessments and why the assessments were not completed or transmitted timely. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that residents were free from physical restraints which included the use of full side rails to both sides of a cognitively impaired, dependent resident's bed. This deficient practice was identified for one (1) of one (1) resident reviewed for Restraints, (Resident #63) and was evidenced by the following: On 10/06/22 at 11:06 AM, during the initial tour of the facility the surveyor observed Resident #63 lying in bed asleep with full metal side rails in place on both sides of the resident's bed. On 10/07/22 at 9:48 AM, the surveyor observed Resident #63 lying in bed asleep. The right side of the resident's bed was positioned tightly up against the wall. The left full side rail was pulled up and a full-sized bumper pad covered the entire length of the side rail. [...]

Inspectors wroteBased on interviews, review of medical records and other facility documentation, it was determined that the facility failed to a.) complete the Comprehensive Minimum Data Set (an assessment tool that accurately reflected the resident's status) in a timely manner for six (6) of 27 residents (Residents #9, #10, #11, #23, #30, and #33) reviewed for system selected MDS over 120 days for late submissions to CMS (Center for Medicare/Medicaid Services) and b.) complete the Comprehensive MDS in a timely manner for four (4) of 19 residents (Resident #22, #216, #217 and #266) reviewed. This deficient practice was identified by the following: a.) On 10/14/22 at 10:36 AM, surveyor #1 interviewed the Regional Minimum Data Set Coordinator (MDS/RMC) regarding late, non-completed MDS assessments. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to accurately complete and update a Preadmission Screening and Resident Review (PASARR) to include all psychiatric diagnoses to ensure the resident was referred to the appropriate state-designated authority for level II PASARR evaluation and determination. This deficient practice was identified for one (1) of five (5) residents (Resident #35) reviewed for level II PASARR and was evidenced by the following: According to the Resident Face Sheet, Resident #35 was admitted to the facility with the diagnoses that included but were not limited to: Schizophrenia, generalized anxiety disorder, and bipolar disorder. [...]

Inspectors wroteBased on observation, interview and review of other pertinent facility documents, it was determined that the facility failed to provide a hand splint for a resident with decreased range of motion related to a right hand contracture (shortening and hardening of muscles and tendons that often leads to deformity and rigidity of joints) in accordance with therapy recommendations and physician's orders. This deficient practice was identified for one (1) of two (2) residents reviewed for limited range of motion, (resident #63) and was evidenced by the following: On 10/06/22 at 11:06 AM, during the initial tour of the facility the surveyor observed Resident #63 lying in bed asleep. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to a.) identify and monitor the dialysis access site, b.) consistently maintain ongoing complete communication notes between the facility and the dialysis center and, c.) follow physician ordered fluid restriction, and d.) update the care plan to include the dialysis access site and fluid restriction for one (1) of one (1) resident (Resident #116) reviewed for dialysis and was evidenced by the following: On 10/06/22 at 10:27 AM during tour, Resident # 116 was observed in bed. The resident stated that he/she goes to dialysis and his/her access site was in the chest area. The resident could not explain to surveyor what days he/she went to dialysis, what time he/she went or what the name of the dialysis center was. [...]

Inspectors wroteBased on record review, and review of other pertinent facility documentation, it was determined that the facility to respond to comments and recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for one (1) of five (5) residents reviewed for unnecessary medications, (Resident #57) and was evidenced by the following: On 10/07/22 at 11:30 AM, the surveyor reviewed the Electronic Health Record (EHR) of Resident #57 which failed to contain specific CP recommendations. The surveyor requested to view the CP reviews and recommendations that were provided to the facility. [...]

Inspectors wroteBased on observation, interviews and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On 10/06/22 from 09:49 AM until 10:47 AM, the surveyor toured the kitchen in the presence of the Certified Dietary Manager (CDM) and observed the following: 1. In the walk-in freezer, there were five sealed ten pound frozen logs of ground beef with manufacturer marked best before or freeze by [DATE] with no received or use by date. [...]

Inspectors wroteBased on interview and review of facility documents, it was determined that the facility failed to ensure that the facility-wide assessment identified the required services and procedures necessary to protect the health, safety, and welfare of all residents prior to the admission of registered sex offenders and residents admitted from the correctional facility. On 10/06/22 from 10:07 AM to 10:43 AM, the surveyor conducted the entrance conference with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and Regional Nurse #1 and requested a copy of the Facility Assessment. On 10/13/22 at 01:03 PM, after multiple requests the LNHA provided the Facility Assessment to the surveyor. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that their Quality Assurance and Performance Improvement (QAPI) Program was being implemented, and sources of quantitative data was being analyzed to identify quality deficiencies and evaluate program effectiveness. This deficient practice was identified during the standard survey, and was evidenced by the following: On 10/14/22 at 09:45 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with only one (1) quarterly Quality Assurance (QA) meeting from 08/29/22, which reflected the following: -QAPI Meeting Minutes: The COVID-19 (a contagious respiratory infection) outbreak in the month of August. It further reflected they discussed infection control precautions related to COVID-19. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to: a.) perform proper hand hygiene and perform a wound treatment in a safe and sanitary manner for one (1) of one (1) nurse observed providing a wound care treatment to one (1) of one (1) resident (Resident #57); b.) maintain and store Personal Protective Equipment (PPE) and non-sterile resident care equipment in a safe and sanitary manner; and, c.) follow appropriate hand hygiene practices for one (1) of two (2) nurses who administered medications to two (2) of six (6) residents (Resident #4, and #5) during the medication pass. This deficient practice was evidenced by the following: 1. [...]

Inspectors wroteBased on interview, medical record review, and review of other facility documentation, it was determined that the facility failed to accurately document and clarify a resident's life-sustaining treatment preferences on physician's orders for one (1) of two (2) residents (Resident #47) reviewed for advanced directives. This deficient practice was evidenced by the following: According to Resident #47's Resident Face Sheet the resident was admitted to the facility with the diagnoses that included but were not limited to; depression, diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and convulsions. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to complete a significant change in status (SCSA) Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care. This deficient practice was identified for one (1) of one (1) resident (Resident #266) reviewed, and was evidenced by the following: According to the Resident Assessment Instrument (RAI) Manual Version 3.0 Chapter 2 Assessment for the RAI pages 2-23 of CMS (Center for Medicare/Medicaid Services) guidelines, updated October 2019 included, An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for one (1) of one (1) resident (Resident #266) reviewed for hospice and for one (1) of one (1) resident reviewed for restraints (Resident #63). This deficient practice was evidenced by the following: On 10/06/22 at 10:50 AM, during the initial tour of the facility the surveyor interviewed Agency Licensed Practical Nurse (ALPN #1) who stated Resident #266 was the only resident on hospice at the facility. On 10/06/22 at 11:06 AM, during the initial tour, the surveyor observed Resident #266 lying in bed. Resident #266 was non-verbal but acknowledged the surveyor by nodding his/her head. The surveyor reviewed the medical record for Resident #266. [...]

Inspectors wroteBased on observations, interview, and review of pertinent facility documentation, it was determined that the facility failed to update and revise the resident Care Plan (CP) to include goals and interventions for one (1) of one (1) resident (Resident #266) reviewed for hospice care. This deficient practice was evidenced by the following: On 10/06/22 at 10:50 AM, during the initial tour of the facility the surveyor interviewed Agency Licensed Practical Nurse (ALPN #1) who stated Resident #266 was the only resident on hospice at the facility. On 10/06/22 at 11:06 AM, during the initial tour, the surveyor observed Resident #266 lying in bed. Resident #266 was non-verbal but acknowledged the surveyor by nodding his/her head. The surveyor reviewed the medical record for Resident #266. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to follow professional standards of practice by ensuring a.) that staff did not utilize personal equipment, a personal blood pressure (BP) monitor for resident care and b.) that staff obtained vital signs prior to administering a medication and hold a medication used to treat hypotension (low BP) in accordance with the physician's order (PO). This deficient practice was identified for one (1) of two (2) Licensed Practical Nurses (LPN) observed during medication administration. 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 ensure that all medications were administered without error of 5% or more. During the medication administration observation performed on 10/13/22 and 10/14/22, the surveyor observed two (2) nurses administer medication to six (6) residents. There were 28 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.14%. This deficient practice was identified for one (1) of six (6) residents, (Resident #268), that were administered medications by one (1) of two (2) nurses. The deficient practice was evidenced by the following: On 10/13/22 at 08:22 AM, the surveyor conducted the medication administration task and observed the Licensed Practical Nurse (LPN #1) reviewing the electronic medication administration record (EMAR) for Resident #268. [...]

Inspectors wroteBased on observation, interview, and review of other facility documents, it was determined that the facility failed to ensure medications were appropriately dated when opened and implement a comprehensive policy to address dating medication after opening. This was observed for one (1) of two (2) medication carts reviewed during the medication storage and labeling task. This deficient practice was evidenced by the following: On [DATE] from 09:11 AM to 09:25 AM, the surveyor, in the presence of the Licensed Practical Nurse (LPN#1), observed the following within the first-floor on medication cart one (1): -One (1) opened and undated box of insulin Humalog 100 unit/milliliter (ml) was located inside a plastic bag for unsampled Resident #1. LPN #1 confirmed that the insulin was opened and that it did not have an opened date written on the plastic bag, the box, or the bottle. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure the Licensed Nursing Home Administrator (LNHA) attended the quarterly Quality Assurance (QA) meetings. This was identified for one (1) of two (2) QA meetings reviewed. This deficient practice was evidenced by the following: On 10/12/22 at 12:30 PM, the LNHA provided a list of the QA committee which revealed that the Medical Director (MD), the LNHA, the Director of Nursing (DON), and the Director of Social Worker (DSW) attendance was mandatory at the quarterly meetings. On 10/14/22 at 09:45 AM, the LNHA provided the surveyor with only one (1) quarterly QA meeting sign-in sheet for 08/29/22 which reflected the following: [...]

Inspectors wroteBased on interview and review of other pertinent facility documentation, it was determined that the facility failed to ensure full implementation of the antibiotic stewardship program including ongoing monitoring and use of a nationally recognized surveillance criteria prior to consulting the prescriber. This deficient practice was identified for One (1) of one (1) resident reviewed for antibiotic stewardship, (Resident #11) and was evidenced by the following: On 10/11/22 at 11:34 AM, the surveyor interviewed the Licensed Practical Nurse/Infection Preventionist (LPN/IP) who stated that she had worked in the role since May of 2022 and did not have previous IP experience. [...]

Inspectors wroteBased on observations, interviews, and review of other facility documentation, it was determined that the facility failed to ensure that mitigation measures were followed to prevent the potential spread of COVID-19, a contagious respiratory infection. This deficient practice was identified for two (2) of three (3) unvaccinated staff, and was evidenced by the following: On 10/06/22 at 09:07 AM, the survey team was greeted by the Licensed Nursing Home Administrator (LNHA) who stated that there were three COVID-19 positive residents at the facility. He clarified that two of the residents were positive upon admission and one resident tested positive at the facility. [...]