Canterbury at Cedar Grove

Inspectors wroteBased on observation, interviews, and review of facility policies, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the dumpster and surrounding area free of garbage and debris. This deficient practice was observed and evidenced by the following:On 12/17/25 at 9:30 AM, the surveyor in the presence of the toured the Food Service Director (FSD) toured the kitchen and dumpster area and found the following:There was garbage debris that included shower chairs, hospital bed frames, a dresser, wooden pallets and cardboard boxes all observed on the outside of dumpster. The FSD stated the maintenance department should have cleaned the dumpster area. On 12/18/25 at 11:35 AM, the Director of Operations (DO) provided the surveyor with a facility policy titled, Dumpster/Garbage Area with a revision date of 9/2025. [...]

Inspectors wroteBased on observation, interview, and review of facility policy, it was determined that the facility failed to provide a homelike environment in resident rooms. The deficient practice was observed on 2 of 3 units during initial tour. The deficient practice was evidenced by the following: On 12/17/25 at 10:42 AM, the surveyor toured the 2nd floor nursing unit and observed the following rooms: 1. room [ROOM NUMBER], there was a hole in the wall, and the walls were stained a brownish color, and the two privacy curtains stained. 2. room [ROOM NUMBER] observed damaged flooring tile and a damaged bathroom door. 3. In the hallway leading to the low-side rooms (rooms 200-216), the water fountain had been removed, and the wall was discolored and in need of repair. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to have readily accessible physician progress notes (PPN). This deficient practice was identified for 14 of 14 residents reviewed, (Resident #3, #17, #45, #55, #74, #83, #85, #105, #116 #122, #128, 132#, #135, and #137) and was evidenced by the following: 1. On 12/19/25 at 11:01 AM, the surveyor observed Resident #3 in the 2nd floor dayroom watching television. The resident stated, they do not recall seeing their primary physician (PP#1). A review of Resident #3 Face sheet (FS) (an admission summary) was admitted to the facility with diagnoses that included but were not limited to altered mental status (a change in mental function), pneumonia (an infection in the lungs), anemia (a blood disorder that happens when you don't have enough red blood cells). [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the resident receiving enteral feedings received appropriate care and services to prevent complications of enteral feedings, specifically by having the enteral feeding pump running with the resident in a supine position (head of bed flat) not elevated to prevent aspiration ((accidentally inhaling food or liquid through the vocal cords into the lungs). This deficient practice was identified for 1 of 2 residents (Resident #9) reviewed for tube feeding and was evidenced by the following:On 12/18/25 at 10:35 AM, the surveyor knocked at the door and, with the Certified Nursing Assistant's (CNA's) permission, entered the room. [...]

Inspectors wroteBased on observation, interview, record review and review of facility policy, it was determined that the facility failed to a.) follow a Physician's Order (PO) for an Oxygen (O2) dependent resident in accordance with professional standards of practice and b.) store nebulizer tubing in a clean and sanitary manner for 2 of 4 residents, (Resident #9 and #97), reviewed for respiratory care. The deficient practice was evidenced by the following: 1. On 12/17/25 at 11:22 AM, the surveyor observed Resident #97 in bed with their eyes closed. Resident #97 was observed receiving O2 via nasal cannula (NC) (medical device to provide supplemental oxygen therapy to people who have lower O2 levels) at 3.5 liters/minute (LPM). On 12/17/25 at 11:45 AM, the surveyor reviewed Resident #97's electronic medical record (e-MAR) which revealed the following: [...]

Inspectors wroteComplaint Intake ID #: 2585781Based on interview, record review, and review of facility documents on 11/12/25 and 11/13/25, it was determined that the facility failed to notify the New Jersey Department of Health (NJDOH) and the Office of the Ombudsman immediately or within two hours of the identification of an injury of unknown origin in accordance with Federal and State laws and the facility's Abuse policy. This deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for abuse. This deficient practice was evidenced by the following:On 11/12/25 at 10:50 AM, the surveyor reviewed the closed Electronic Medical Record (EMR) of Resident #1. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to; [...]

Inspectors wroteComplaint #: NJ186030 Based on interviews, review of medical records, and review of pertinent documents, it was determined that the facility failed to a.) conduct a thorough investigation and b.) follow the facility policy Incident/Accident Investigating and Reporting Policy and Procedure, after a resident fell on facility premises on 05/02/2025. This deficient practice was identified for one of three residents (Resident 2) reviewed for accidents and was evidenced by the following: According to the admission Record, Resident #2 was admitted to the facility with diagnoses which included but were not limited to chronic diastolic (congestive) heart failure, generalized anxiety disorder, other recurrent depressive disorders, other chronic pain, opioid dependence with other opioid-induced disorder, muscle weakness (generalized), and need for assistance with personal care. [...]

Inspectors wroteComplaint#: NJ00181512, NJ00181513, NJ00181515, NJ00181438, NJ00181567 Based on observation, interview, and review of pertinent facility documents on 12/13/2024, it was determined that the facility failed to maintain a safe and comfortable room temperature levels for residents in a nursing unit [Gardenia Garden]. This deficient practice was identified in 1 of 2 nursing units in third floor and was evidenced by the following: On 12/13/2024 at 9:32 a.m. [morning], the Surveyor in the presence of the Maintenance Person (MP) checked the temperatures on the Third Floor and the following were obtained: room [ROOM NUMBER] - room temperature of 67.6 degrees Fahrenheit; occupied; radiator on with low cool air coming out; resident ambulatory; not in distress. room [ROOM NUMBER] - room temperature of 68.1 degrees Fahrenheit; occupied; resident out of room; radiator on. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure sufficient and competent staff were available to provide timely and appropriate incontinence care for Resident #5 who was dependent on staff for their Activities of Daily Living (ADLs) care. This was observed on 09/16/2024 during the surveyor's incontinence rounds on the third floor nursing unit. The deficient practice had the potential to affect all residents and was evidenced by the following: According to the facility's Transfer/Discharge Report (TDR), resident information revealed Resident #5 had diagnoses of but not limited to Cerebral Infarction, Seizures, Heart Failure, Aphasia, and Hypertension. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure residents were served their meals in a dignified manner during meal services. This deficient practice was identified on 3 of 3 nursing units on multiple dates of observation and was evidence by the following: 1. On 6/27/24 at 12:05 PM, this surveyor observed the lunch meal on the 4th floor. The main dining room had 18 residents. 18 of 18 residents were served their meal on Styrofoam plates and cups, with plastic utensils. The surveyor further observed the residents who were eating in their rooms also having Styrofoam plates and cups, with plastic utensils. The surveyor interviewed Certified Nursing Assistant (CNA #1), who stated that Styrofoam were used on most meals and it has been ongoing for the past 6 weeks. 2. [...]

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices as well as store potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 6/25/24 at 9:35 AM, the surveyor in the presence of Food Service Director (FSD) observed the following during the kitchen tour: 1. The dry storage area was noted with a temperature of 80 degrees Fahrenheit (F), the temperature was observed on two different thermometers. FSD stated recent heatwave caused dry storage room to become warmer, and maintenance was aware. 2. In the Walk in freezer, the surveyor observed boxed items being stored on the floor and stacked to ceiling. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain the prior year's state of New Jersey inspection results and post the location of those results in an area that was readily accessible to residents, families and the general public. This deficient practice was evidenced by the following: On 6/27/24 at 10:47 AM, the surveyor conducted a group meeting with seven (7) residents in attendance, Resident #5, Resident #20, Resident #43, Resident #96, Resident #118, Resident #128 and Resident #199. When asked if they were aware of the location of the previous year's survey inspection report, 7 residents said no. On 06/27/24 from 10:47 AM until 11:54 AM, the surveyor conducted the resident council meeting with seven (7) facility chosen residents who regularly attend the facility's resident council meetings that were conducted monthly. [...]

Inspectors wroteBased on the 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, in accordance with the federal guidelines for 2 of 29 residents (Resident #16, and Resident #7) reviewed for the accuracy of MDS completion. The deficient practice was evidenced by the following: 1. On 06/25/24, at 10:45 AM, the surveyor observed Resident #16 lying in bed with their eyes closed. On 06/25/24 at 12:45 PM, the surveyor reviewed Resident #16's hybrid (paper and electronic) medical record, which revealed the following information: According to the admission Record (an admission summary) (AR), Resident #16 was admitted to the facility with diagnoses that included but were not limited to Dementia with behavior. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan (CP) to include safe smoking. This deficient practice was identified for 1 of 29 residents reviewed for resident-centered care plans (Resident #350), and was evidenced by the following: The admission Record (AR) indicated that Resident #350 was admitted to the facility with the diagnoses which included but was not limited to Bipolar Disorder and Seizure Disorder. The admission Minimum Data Set (A/MDS), an assessment tool that facilitates resident care, dated 06/06/24 reflected that the resident was cognitively intact and required supervision with activities of daily living. On 06/26/24 at 10:52 AM, the surveyor interviewed Resident #350 who was outside the facility for coffee social. [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to maintain professional standards of clinical practice for 3 of 29 residents reviewed by a.) not accurately documenting in the electronic Medication Administration Record (eMAR) according to the physician's order (PO) for Resident #46 b.) not obtaining a PO for a resident's code status (the type of emergency treatment a person would or would not receive if their heart or breathing were to stop) for Resident #101, #146. This deficient practice was evidenced by: 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 ensure the primary physician (PP) addressed and evaluated the resident's significant weight changes (a weight loss or gain of 5% in 30 days and/or 10% in 180 days) in a timely manner for 2 of 6 residents (Resident #131 and #95) reviewed for nutrition. The deficient practice was evidenced by the following: 1. On 6/25/24 at 10:52 AM, the surveyor observed Resident #131 in bed. When interviewed, Resident #131 was noted alert and responsive. Resident stated they had weight loss over the past six months and was unable to recall the last time seeing PP#1. The surveyor reviewed the admission Record (AR) (one page summary of important information about a resident) for Resident #131. [...]

Inspectors wroteBased on observation, interview, record reviews, it was determined that the facility failed to 1. ensure that the responsible physician supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every 30 days and 2. ensure the physician reviewed and signed the monthly physician orders (PO). This deficient practice was identified for 3 of 32 residents (Resident #131, #7, and #77), reviewed for physician visits, and was evidenced by the following: 1. On 6/25/24 at 10:52 AM, the surveyor observed Resident #131 in bed. When interviewed, Resident #131 was noted to be alert and responsive. The resident was unable to recall the last time seeing their Physician (MD). The surveyor reviewed the admission Record (one-page summary of important information about a resident) (AR) for Resident #131. [...]

Inspectors wroteComplaint# NJ00166657 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident's food preference were honored. This deficient practice was identified for 1 of 1 resident reviewed for food preferences (Resident #4), and was evidenced by the following: On 06/26/24 at 12:26 PM, the surveyor observed Resident #4's lunch tray. The meal ticket indicated 16 ounces of skim milk and the lunch tray contained 8 ounces of whole milk. On 06/27/24 at 12:12 PM, the surveyor observed Resident #4's lunch tray. The lunch ticket indicated 16 ounces of skim milk and lunch tray contained 8 ounces of whole milk. The surveyor interviewed Certified Nursing Assistant (CNA) #1 and Unit Manager (UM) who stated that they check the contents of the trays against the meal tickets. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain complete, accurate, readily accessible medical records, and legible physician's progress notes (PN). This deficient practice was identified for 3 of 29 residents reviewed, Resident#121, #95 and #77, and was evidenced by the following: This deficient practice was evidenced by the following: 1. On 6/25/24 at 10:30 AM, during initial tour, the surveyor observed the Resident #121 in bed with their eyes closed. [...]

Inspectors wroteComplaint #: NJ159080 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) within 2 hours for an allegation of a resident-to resident physical altercation. This deficient practice was identified for 1 of 5 investigations of reportable incidents reviewed (Resident #36, #299). This deficient practice was evidenced by the following: 1. On [DATE] at 1:21 PM, the surveyor reviewed a form titled Reportable Event Record/Report Form which involved Resident #36 and Resident #299. The form was dated [DATE] and documented an event that occurred on [DATE] at 9:00 PM involving Resident #36 and Resident #299. The report documented Resident #299 was observed by the staff holding Resident #36 and was hurting the resident. [...]

Inspectors wroteBased on interviews and job description review, the facility failed to have a qualified Activities Director to oversee the activities department for all 141 current residents in the facility. This failure resulted in all residents not being provided with resident specific activities.

Inspectors wroteBased on interviews and job description review, the facility failed to have a licensed Director of Nursing to oversee the care of all 141 current residents in the facility. This failure increased the risk that all residents would not be provided with appropriate and accurate care and assessments.

Inspectors wroteBased on observation, interview and review of pertinent facility documents, it was determined that the facility failed to have a system in place to ensure that facility garbage receptacles were covered, and all garbage was contained and removed timely to prevent a buildup of refuse, and that the receptacles including a trash compactor and the surrounding areas were maintained in a clean manner to prevent the accumulation of debris, pests and foul odors. The deficient practice was evidenced as follows: On 9/14/23 at 9:20 AM, two surveyors arrived at the facility's back parking lot and observed mounds of uncontained garbage bags approximately three to six feet high and approximately 50 feet long alongside the right side of the fence leading to a dumpster and trash compactor towards the back fence. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure the timely availability of personal resident funds for one (Resident (R )21) of three residents reviewed for access to personal funds out of a total sample of 35 residents. The facility's banking hours were limited to Monday through Friday and residents did not have access to their money on weekends or on the same day if requested outside of the posted banking hours.

Inspectors wroteBased on observation and interview, the facility failed to ensure a clean and sanitary environment for five of 35 sampled residents (Resident (R) 43, R83, R95, R20, and R61) and one (Cherry Blossom) of two treatment carts located on the second floor.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to provide three residents (Resident (R)28, R88, and R36) who were unable to carry out activities of daily living (ADLs) the necessary services to maintain grooming, and personal hygiene out of a total sample of 35.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to provide a consistent program of preferred and planned activities for four (Residents (R)21, R43, R88, and R97) of seven residents reviewed for activities out of a total sample of 42 residents. Activities were not provided routinely for residents per their assessed preferences due to a lack of both nurse and activities staffing. In addition, activities posted on the activities schedule on the facility's third floor were not provided per the posted schedule.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure the use of side rails was assessed, physician's orders obtained, care plans developed, and/or informed consent obtained for the use of side rails for five (Residents (R )5, R36, R95, R20, and R43) of eleven residents who were reviewed for accidents out of a total sample of 42 residents.

Inspectors wroteBased on observations, staff and resident interviews, and record reviews, the facility failed to ensure sufficient staffing to meet the needs of the 141 residents in the facility. Five residents (Resident (R) 21, R36, R97, R17, R83, and R5) and staff members Certified Nursing Assistant (CNA 1), the facility's Medical Director, Licensed Practical Nurse (LPN anonymous), and Unit Manager (UM) 1 voiced concerns regarding sufficient staffing, and the facility exhibited multiple failures related to a lack of sufficient staffing throughout the survey.

Inspectors wroteBased on resident council interview, staff interview, and record review, the facility failed to follow the menu and provide menus for meal selection for four (Resident (R)5, R21, R36, and R46) of 35 sampled residents. This deficient practice had the potential to affect 137 out of 141 (four residents received tube feedings) residents not affording them the opportunity to choose foods from the menu but instead receive whatever was being served.

Inspectors wroteBased on observations, and interview, the facility failed to provide meals that were palatable and attractive to two residents (Resident (R)5 and R36) out of a sample of 35 residents. Specifically, the potatoes that were served to residents were burnt.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure the ice machine was functioning properly to ensure residents received ice. Three of 35 sampled residents (Resident (R)5, R36, and R21) and five residents in a group meeting (R6, R13, R97, R114 and R130) expressed frustration that the facility ice machine was down, and the facility had not supplied sufficient ice despite voiced concerns by residents.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure physical bed inspections were routinely conducted related to the use of side rails for five (Residents (R) R5, R36, R95, R20, and R43) of eleven residents who were reviewed for accidents out of a total sample of 35 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Practitioner Orders for Life-Sustaining Treatment (POLST-used as directions to emergency health personnel in the event of cardiac or respiratory failure) was complete and code status (to resuscitate or not) orders were in place for one of six residents (Resident (R) 55) reviewed for advanced directives out of a total sample of 35 residents. This failure had the potential to negatively affect the dignity, designated wishes, and physical status of the resident in case of cardiac or respiratory arrest.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to provide privacy during personal care for one (Resident (R)43) of 35 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 27) reviewed for hospitalization out of a total sample of 35 residents and their resident representative were provided with a written transfer notice that stated the reason for transfer, the place of transfer, the name and contact information of the Ombudsman, and information concerning the right to appeal the transfer if desired. This failure had the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide one of three residents (Resident (R) 27) reviewed for hospitalization out of a total sample of 35 residents and their representative written notice of the facility's bed-hold policy when the resident was transferred to the hospital. This failure created the potential for residents and/or responsible parties to not have the information needed to safeguard their return to the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate Minimum Data Set (MDS) assessments for one of 35 sampled residents (Resident (R) 119). Failure to code the MDS correctly can lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the resident.

Inspectors wroteBased on interview and record review, the facility failed to refer one (Resident (R) 57) of ten sampled residents reviewed for Preadmission Screening and Resident Review (PASRR) out of a total sample of 35 residents for a Level II resident review after the resident experienced a significant change in status assessment related to new onset mental illnesses. This had the potential to cause R57 to not receive necessary mental health services.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure two of ten residents (Resident (R) 43 and R95) reviewed for Pre-admission Screening and Resident Review (PASRR) out of a total sample of 35 residents had accurate screenings and/or were referred for a Level II review as required following a positive Level I screening. This had the potential to cause delay in receiving necessary mental health services for R43 and R95.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure notification was provided for and care plan meetings were conducted routinely for one (Residents (R ) R36) of a total sample of 35 residents.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure broken hearing aids were repaired for one of five residents (Resident (R)6) reviewed for hearing devices in a total sample of 35 residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide routine pain medications as ordered by the physician for one of 35 sampled residents (Resident (R) 61). This had the potential to cause unrelieved pain for R61.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure the appropriate nursing/physician response/follow-up to pharmacist recommendations were completed for one (Resident (R)46) of five residents reviewed for unnecessary medication in a total sample of 35 residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure one (Resident (R)46) of five residents reviewed for unnecessary medication out of a total sample of 35 residents did not receive Heparin (an injectable anticoagulant) for longer than generally recommended after a surgical procedure.