Buckingham at Norwood, the

Inspectors wroteComplaint #2790946Based on observation, interview and record review it was determined that the facility failed to accurately document and administer pharmaceuticals in accordance with physicians' orders for 4 residents (#14, 67, 108, 156) of 32 reviewed. Specifically, Resident #14 received late administration of insulin, Resident #67 received late administration of pain medications, Resident #108 had documentation discrepancies regarding the administration of antianxiety medication, and Resident #156 had documentation discrepancies regarding the administration of narcotic pain medication.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to ensure call devices were positioned within reach of a resident who was at risk for falls. The deficient practice was cited for 1 resident (Resident #59) and evidenced by the following. On 3/26/26 at 11:30 am, the surveyor observed Resident #59 standing in the doorway of their room next to their bed. The resident told the surveyor that they needed help because there was spilled water in the room. The surveyor inquired whether the resident pushed the call device to summon help. The resident replied she did not know where the device was. The call device was observed on the floor under the bed near the roommate's bed. On 3/27/2026 at 10:37 am, the surveyor observed the resident lying on their bed. The surveyor observed the call device under the bed near the roommate's bed. [...]

Inspectors wroteBased on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to continue to assess a resident after a fall to ensure the resident had no adverse effects from the event in 1 of 3 residents reviewed for falls (Resident #80). This deficient practice was evidenced by the following:On 3/26/26 at 10:52 AM, the surveyor observed Resident # 80 in room seated in chair, interviewable, and stated that they are pleased with the care. A review of the Resident # 80's electronic health record (EHR) reflects the resident was admitted with diagnoses that included but were not limited to a fracture of the right femur, dementia, difficulty walking and unsteadiness on feet. A review of Resident #80's annual Minimum Data Set (MDS), dated [DATE], an assessment tool, reflected that the resident is moderately cognitively impaired. [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to monitor the nutritional status for 1 of 1 residents reviewed for nutritional status (Resident #137), by not following a physician's orders for monitoring of the resident's weight. The deficient practice was evidenced by the following:On 3/26/26 at 10:46 AM, the surveyor observed resident in bed, awake and responsive with the call bell placed within the resident's reach. A review of Resident #137's admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; type 2 diabetes, obesity, essential hypertension (high blood pressure) and urinary retention. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to clarify oxygen therapy orders to ensure a resident was provided with care, consistent with professional standards of practice, for 1 of 1 resident (Resident #16) reviewed for respiratory care. The deficient practice was evidenced by the following:On 3/26/26 at 11:11 AM, the surveyor observed Resident #16 sitting in a wheelchair, alert and sitting with other residents at a table for a recreational activity. The resident was not on any oxygen therapy and there were no observed concerns. On 4/1/26 at 9:09 AM, the surveyor reviewed the Electronic Medical Record (EMR) of Resident #16. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in facility name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following:According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program:(a) Certifying compliance. [...]

Inspectors wroteBased on interviews, and a review of pertinent facility documents, it was determined that the facility failed to ensure that a non-certified Nursing Aide (NA #1) received the required training and competencies needed prior to receiving their own assignment and rendering resident care which included but not limited to; bathing, toileting, transferring, feeding, personal hygiene, and grooming. This was identified for 1 of 9 NAs reviewed (NA#1) who provided direct care to residents on 5 of 5 nursing units. NA #1 was hired on 6/17/24, as a Hospitality Aide. NA #1 began independent resident care assignments on 7/03/24, and was enrolled in a state approved Nurse Aide in Long-Term Care Facilities Training and Competency Evaluation Program (NATCEP) that began on 7/15/24, and worked 69 shifts with no evidence of completing the required skills and competencies prior to providing resident care. [...]

Inspectors wroteBased on the interview and review of pertinent facility documentation, the facility failed to have the Infection Preventionist present for three (3) of three (3) quarterly Quality Assurance Performance Improvement (QAPI) meetings. This failure had the potential to affect all 156 residents who currently live in the facility. The deficient practice was evidenced by the following: On 10/29/24 at 11:02 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA), and the Registered Nurse/Unit Manager during an Entrance Conference meeting. The LNHA confirmed that day census (total number of residents) of 156. The LNHA stated that it was the Regional Infection Preventionist Nurse (RIPN) the facility's Infection Preventionist (IP), and the LNHA was unsure when the RIPN started to be the IP. [...]

Inspectors wroteBased on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure reference checks were completed for five (5) out of eight (8) newly hired staff prior to their start date of employment. This deficient practice was evidenced by the following: The surveyor reviewed eight randomly selected new employee files. The review for reference checks for five of the eight new employees revealed the following: -Staff #1's file, a Registered Nurse (RN) who was hired on 5/27/24, revealed only 1 reference check in their file. -Staff #2's file, a RN who was hired on 9/10/24, revealed only 1 reference check in their file. - Staff #3's file, a Certified Nursing Assistant (CNA) who was hired on 10/30/23, revealed no reference checks in their file. [...]

Inspectors wrote4. On 10/29/24 at 10:21 AM, the surveyor observed posted signs outside Resident # 140's room for oxygen (O2) in use, EBP (enhanced barrier precautions), and PPE (personal protective equipment) box hung outside the door. The resident was lying in bed with a nasal cannula (a device that delivers extra O2 through a tube and into the nose) and O2 at 2LPM (liters per minute) attached to the concentrator (a device for O2). The surveyor reviewed the hybrid medical records of Resident #140. The AR revealed that the resident was admitted to the facility that included a medical diagnosis that was not limited to essential hypertension (high blood pressure that is not due to another medical condition), chronic kidney disease, and DM. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) properly store medication (med) for one (1) of 38 residents, Resident #210, and b.) ensure that medications (meds) were stored and labeled appropriately for two (2) of four (4) med carts inspected and two (2) of four (4) med storage rooms inspected located on four (4) of five (5) nursing units according to facility's policy and standard of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to treat a resident with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of residents' quality of life specifically by not providing a.) breakfast meal in a timely manner for one (1) of nine (9) residents in 2 South dining area and b.) privacy during eye consultation and/or treatment for one (1) of eight (8) residents in 1 South dining area. The deficient practice was evidenced by the following: 1. On 10/31/24 at 8:25 AM, the surveyor observed the breakfast in the 2 South dining room. The surveyor observed nine residents inside the dining room, one Recreation Aide (RA), one Director of Recreation (DoR), and one Quality Assurance Corporate Aide (QACA). [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to electronically transmit the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within the 14th calendar day of the resident's admission (admission date plus 13 calendar days) in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for three (3) of 38 residents (Resident #125, #132, and #212) reviewed for resident assessment. The deficient practice was evidenced by the following: 1. On 11/04/24 at 9:50 AM, the surveyor observed Resident #125 lying in bed with eyes open and unable to answer the surveyor's inquiry. On 11/04/24 at 11:00 AM, the surveyor reviewed the hybrid (paper and medical) records of Resident #125 and revealed: [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to accurately reflect the resident status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care in accordance with the federal guidelines for two (2) of 38 residents (Resident #125, and #212) reviewed for the accuracy of MDS coding. This deficient practice was evidenced by the following: 1. On 11/04/24 at 9:50 AM, the surveyor observed Resident #125 lying in bed with eyes open and unable to answer the surveyor's inquiry. On 11/04/24 at 11:00 AM, the surveyor reviewed the hybrid (paper and medical) records of Resident #125 and revealed: The admission Record (AR; an admission summary) documented that Resident #125 was admitted to the facility with diagnoses that included but were not limited to encephalopathy (a disease that affects the brain). [...]

Inspectors wroteBased on observation, interview, record review, and review of facility provided documents, it was determined that the facility's interdisciplinary team (IDT) failed to ensure the facility policy was followed to ensure the person-centered care plan was revised to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and to ensure the resident was (invited to participate) involved in the care planning process. The deficient practice was identified for one (1) of 38 residents reviewed for care planning (Resident #131) and was evidenced by the following: On 10/29/24 at 10:29 AM, during initial tour, the surveyor observed Resident #131 lying in bed in their room. Resident #131 expressed concern with their discharge (d/c) plans. [...]

Inspectors wroteComplaint # NJ167164 and #167919 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and facility policies and procedures for one (1) of 38 residents, Resident #360, reviewed for quality of care. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the necessary respiratory care and services of residents that were receiving oxygen and nebulizer, according to the standard of clinical practice and the facility's policy and procedure, specifically a.) that respiratory equipment was stored in accordance with facility policy and infection control measures for two (2) of two (2) residents reviewed for respiratory care, Resident #210 and #213, b.) clarify the oxygen therapy order and ensure staff followed the appropriate hand hygiene and use of personal protective equipment (PPE) for a resident with contact precautions and oxygen posted sign for one (1) of one (1) of resident, Resident #213, reviewed for tracheostomy care. This deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure a.) sufficient nursing staff and b.) incontinence care was provided for two (2) of two (2) residents (Residents #67 and #214) in a timely manner, during the incontinence tour. This deficient practice was evidenced by the following: 1. On 10/29/24 at 9:04 AM, the survey team entered the facility and met with the Receptionist. The surveyor observed a posted Nursing Home Resident Care Staffing Report (NHRCSR) dated 10/29/24 Day Shift, 7:00 AM-3:00 PM (7-3), current Census 158, total of 13 CNAs, and staff to resident ratio of 1 CNA:12.2 Residents. On 10/29/24 at 10:21 AM, the surveyor observed Resident #140 lying on the bed with the responsible party (RP) at the bedside. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to post the accurate Nursing Home Resident Care Staffing Report daily for three (3) of seven (7) days. This failure could affect the knowledge of the availability of staff to care for the residents, resident representative, and visitors. This deficient practice was evidenced by the following: On 10/29/24 at 9:04 AM, the survey team entered the facility and met with the Receptionist who instructed surveyors to use the stand-alone thermometer and fill out the paper for COVID screening. The surveyor observed a posted Nursing Home Resident Care Staffing Report (NHRCSR) dated 10/29/24 Day Shift, 7 AM-3 PM, current census of 158 that included 13 CNAs (Certified Nursing Aides) with staff to resident ratio of 1 CNA:12.2 Residents. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to administer the medication to Resident #45 due to unavailability of the medication. The deficient practice was identified for one (1) of four (4) residents (Resident #45) observed during medication administration. The Resident did not received medication for mood disorder at the prescribed time. The deficient practice was evidenced by the following: On 11/04/24 at 7:50 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepared medication (med) of Resident #45. The LPN was unable to administer the med Seroquel 12.5 mg (milligram) to the Resident due to unavailability. The LPN acknowledged that the Seroquel 12.5 mg was not available in the med cart. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication for one (1) of five (5) residents reviewed, (Resident #73). The deficient practice was evidenced by the following: The surveyor reviewed Resident #73's electronic medical record (EMR) which revealed the following: Resident #73's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to chronic kidney disease, (when the kidneys are damaged and can't filter blood the way they should) and urinary tract infection. [...]

Inspectors wroteBased on observations, interview, and policy review, the facility failed to clean and disinfect glucometers per the manufacturer's recommendation. This facility failure to properly clean and disinfect multi-use glucometers has the potential to increase the likelihood of transmission of blood-borne pathogens for two of 30 residents (Resident (R) 351 and R 11) receiving blood sugar monitoring. On 7/13/23 at 2:59 PM, the Administrator and the Director of Nursing (DON) were notified of immediate jeopardy (IJ) in the following area: at F880-: Infection Control. The Immediate Jeopardy began on 07/13/23 when the licensed nursing staff failed to properly clean and disinfect multi-use glucometers for R351 observed on 07/12/23 and R11 observed on 07/13/23. The facility provided an acceptable plan for removal of the immediate jeopardy at F880 on 07/14/23 at 1:45 PM. [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to accurately assess one of 32 residents (Resident (R) 101) functional range of motion. Failure to code the MDS correctly can lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a care plan for one of 32 sampled residents (Resident (R) 101) with measurable goals and interventions to care for and manage the resident's right upper extremity contracture.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to accurately assess and implement interventions for the care and management of contractures for one of one resident (Resident (R) 101) reviewed for position, mobility. This failure created the potential for further preventable decline in range of motion.