Careone at Madison Avenue

Inspectors wroteBased on observation, interview, record review and policy review, it was determined that the facility failed to a.) failed to ensure that the dish machine logs were completed and failed to ensure the dish machine was properly functioning and, b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 4/3/25 at 11:14 AM, in the presence of the Food Services Director (FSD) and the Culinary Director (CD), the surveyor observed the following: 1. The surveyor observed the low temperature dish machine and the FSD used a test strip to measure the Parts Per Million (PPM) for the sanitizer portion of the machine. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) follow Center for Disease Control recommendations and guidelines for Hand Hygiene for 2 of 2 Certified Nursing Assistants (CNA), b.) failed to dispose of waste appropriately in 1 of 3 residents rooms reviewed for Transmission Based Precautions (TBP) (Resident # 95) and, c.) failed to have signage for 1 of 3 residents reviewed for TBP (Resident # 95). Reference: According to the U.S. CDC guidelines for Transmission-Based Precautions dated 4/13/24, included the following recommendation details: -Contact Precaution; Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. [...]

Inspectors wroteComplaint #NJ 00174418 Based on interview and record review it was determined that the facility failed to respond to residents' requests for assistance in a timely manner for 5 of 5 residents in attendance at the resident group meeting (Resident #8, 37, 51,60, 97) and 1 of 20 Residents (Resident #254) observed during a tour of the first floor Nursing Unit. This deficient practice was evidenced by the following: The surveyor conducted the resident group meeting on 4/7/25 at 10:30 AM. All 5 of 5 residents stated that the call bell response was slow on all shifts. The residents stated they wait between 30 minutes to an hour. The surveyor interviewed resident # 254 on 4/7/25 at 12:50 PM. The resident stated that on 4/6/25, they waited from 9:00 PM to 10:30 PM for their call bell to be answered. The resident stated that they were incontinent and were dependent on staff for personal care. [...]

Inspectors wroteComplaint #NJ 00174418 Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for a.) 1 of 20 residents reviewed for Activities of Daily Living (ADL) care (Resident #254) and b.) 4 of 4 residents (Resident #17, 90, 255 and 256) observed for incontinence care on 1 of 3 Units (1st-floor Nursing Unit). This deficient practice was evidenced by the following: 1. On 4/7/25 at 12:50 PM, during a tour of the 1st floor Nursing Unit, Resident #254 stated that on 4/6/25 at 9:00 PM, the resident was incontinent of his/her bowels and used the call bell to summon staff for assistance. The Certified Nursing Assistant (CNA #1) did not respond until 10:30 PM. The Resident was in a soiled brief for 1.5 hours. [...]

Inspectors wrote2. The surveyor interviewed Resident #13 on 4/3/25 at 11:07 AM and on 4/7/25 at 10:25 AM in their room. The resident discussed their long term pain management for 3 herniated discs. The resident stated there was a time in October 2024 when a newly prescribed physician's order of oxycodone was not administered to the resident for 2 days. A review of the resident's medical record revealed the following information. The resident's admission Record included diagnoses of cervical disc degeneration, polyneuropathy, peripheral vascular disease, chronic pain, and Parkinson's disease. The 2/19/25 Annual Minimum Data Set (MDS) assessment tool indicated the resident had no cognitive deficits, utilized a manual wheelchair, experienced pain in the previous 5 days occasionally limiting day to day activities. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to clarify a physician's order for peritoneal site care and the assessment for sign and symptoms of infection for precaution. The deficient practice was identified for 1 of 1 resident reviewed for Peritoneal Dialysis (PD) and was evidenced by the following: The surveyor reviewed the closed record for Resident #26. 1. A review of the Resident admission Record (admission summary) reflected that Resident #26 was admitted , with diagnoses which included end stage renal disease, and peritonitis. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 2/27/25 reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact and on admission, the resident was received PD. [...]

Inspectors wroteBased on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure a.) disposition (destruction), reconciliation, and accountability of the returned controlled dangerous substance (narcotic; medications, with high potential for abuse, were tracked with detail) for 1 of 1 automatic dispensing system (ADS), b.) opened saline solution bottle was dated, to indicate expiration, which was identified during an observation of a resident on enhanced barrier precautions (EBP), and c.) a medication was stored in accordance with manufacturer's specifications identified in 1 of 4 medication carts inspected. [...]

Inspectors wrote2. On 4/7/25 at 12:20 PM, on the lower level (LL), the surveyor observed that in the bathroom of 2 unsampled residents in rooms #17, and #21, the emergency calling device's pull cords were wrapped around the grab bars. At 12:38 PM, the surveyor showed the concerns to the Registered Nurse (RN). The RN stated that the pull cords should not be wrapped around the grab bars and the paper product should not be placed inside the call device. The RN stated that the resident's on the LL mostly require assistance with toileting and showering and would not be in the bathroom without a staff member. 3. On 04/07/25 at 12:45 PM, on the first floor, the surveyor observed that in the bathroom of an unsampled resident's room, (room116), the emergency calling device cord above the toilet was missing. At 3:15 PM, the surveyor showed the CNA the concern. The CNA stated that the cord should be there. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to maintain the dignity of an unsampled resident on the 3rd floor. This deficient practice was found with 1 of 2 Certified Nursing Aides (CNA) observed on the 3rd floor during the survey. The deficient practice was evidenced by the following: On 4/8/25 at 12:14 PM, the surveyor observed an unsampled resident who self-propelled in their wheelchair down the hallway, the surveyor then overheard the CNA say to the unsampled resident, you can't be moving around in the hallway because people are eating in their room, and then the CNA went behind the resident's wheelchair and push their wheelchair down the hallway toward the unsampled resident's room. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure the resident's executed living will and durable power of attorney for health care was maintained in the same section of the resident's medical record readily retrievable by any facility staff, follow up on a New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) form, and determine the code status. This deficient practice was identified for 1 of 3 residents reviewed for advanced directives (Resident #52), and was evidenced by the following: On 4/3/25 at 10:18 AM, the surveyor observed Resident #52 asleep wearing a short sleeve shirt, the right upper arm had a small bandage near the arteriovenous (AV) fistula (surgically created connection between the artery and the vein primarily used for hemodialysis). [...]

Inspectors wroteBased on observation and interview, it was determined the facility failed to maintain the residents' living environment and the outside of the facility in a clean, sanitary, and homelike manner for 1 unsampled resident (room [ROOM NUMBER]) and the area on the 2nd floor outside of the elevator doors. The deficient practice was evidenced by the following: 1. On 4/3/25 at 11:10 AM, on the 2nd floor, outside of the elevator the floor, the surveyor observed 2 broken pieces in the floorboards, where double doors closed. 2. At 11:35 AM, the surveyor observed the garbage area outside of the facility and observed 1 pair of plastic gloves, a plastic knife, a few pieces of paper napkins, and a few clear pieces of plastic on the ground around the garbage dumpsters. 3. On 4/8/25 at 12:08 PM, the surveyor observed an unsampled resident inside of room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 1 of 5 residents, Resident #29, reviewed for immunization status. The deficient practice was evidenced by the following. Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 10/26/24, included the following. The CDC recommended administration of Pneumococcal conjugate vaccine (PCV20 or PCV21) at least 1 year for all adults 50 years or older who have received PCV 13 only at any age. The surveyor observed Resident #29 on 4/3/25 at 10:47 AM awake in bed. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures during wound care treatment for 1 of 2 Residents (Resident #1) reviewed for care and services for pressure ulcers. 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 and record review, it was determined that the facility failed to respond in a timely manner to the Consultant Pharmacist's (CP) monthly recommendations from February 2025 until surveyor inquiry for 1 of 5 residents (Resident #71) reviewed for medication management. The deficient practice was evidenced by the following. The surveyor observed Resident #71 on 4/03/25 at 10:43 AM laying in a low bed to the floor with cushioned mats on each side of the bed. The resident was calling out in a foreign language and appeared confused. A review of the medical record revealed the following information. The admission Record included the diagnosis of dementia with mood disturbance. The resident was receiving Hospice services. The April 2025 Medication Administration Record (MAR) included the following pain-related physician orders: Pain score every shift; 0=no pain; [...]

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 on 4/7/25 and 4/8/25, the surveyor observed five (5) nurses administer medications to five (5) residents. There were 27 opportunities, and two (2) errors were observed which resulted in a medication error rate of 7.41%. This deficient practice was identified for two (2) of five (5) residents (Resident #37 and 64), that was administered by two (2) of five (5) nurses. This deficient practice was evidenced by the following: 1. On 4/7/25 at 8:38 AM, the surveyor observed Licensed Practical Nurse (LPN #1) who was assigned to the second-floor low side medication cart, knocked on Resident #37's door. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure pneumococcal vaccination was offered according to the current Centers for Disease and Control Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommendations for Resident #29. This deficient practice was identified for 1 of 5 residents reviewed for immunization status. The deficient practice was evidenced by the following: Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 9/12/24, included the following. The CDC recommends a single dose of PCV21 (pneumococcal 21-valent conjugate vaccine; [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete and transmit Minimum Data Set (MDS) assessments in accordance with the Resident Assessment Instrument (RAI) 3.0 Manual guidelines. This deficient practice was identified for 2 of 24 residents reviewed for resident assessment (Residents #23, and #65). This deficient practice was evidenced by the following: 1. On 4/04/2023 at 1:03 PM, the surveyor reviewed the admission Record (AR) for Resident #23 which revealed that Resident #23 was admitted to the facility on [DATE] with diagnosis that included but were not limited to noninfective gastroenteritis and colitis (inflammation of the intestine). The admission MDS assessment, Assessment Reference Date (ARD) dated 3/27/23 was completed on 4/03/23 and was due for submission by 4/02/23. The MDS was not submitted until 4/06/23. 2. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care, in accordance with the federal guidelines. This deficient practice was identified for 2 of 24 residents reviewed for resident assessment (Resident #14, and Resident #68). This deficient practice was evidenced by the following: 1. During the initial facility tour on 3/30/23 at 12:25 PM, the surveyor observed Resident #14 watching tv wearing a hearing aid to her left ear. The surveyor reviewed the medical records of Resident #14 which revealed the following: The admission MDS (AMDS) dated [DATE], reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated that the resident's cognition was intact. [...]

Inspectors wroteComplaint #NJ00149914 Based on observation, interview, review of facility records, and other pertinent facility documents on 4/4/23, it was determined that the facility failed to follow a Professional Standards of Practice by not transcribing an order for medication appropriately. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to hold the prescribed medication Midodrine (a medication to treat low blood pressure) for 2 of 2 Resident's reviewed (Resident #39 & #80). 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: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) wear the appropriate personal protective equipment (PPE) inside a resident's room on Transmission Based Precautions (TBP) and, b.) conduct hand hygiene between tasks and after the removal of gloves for 1 of 6 residents (Resident #135) reviewed on TBP. This deficient practice was evidenced by the following: On 4/16/21 beginning at 10:21 AM, the surveyor conducted the Entrance Conference with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) when the Cohort Plan for the building was revealed as follows: Green Zone - Naïve, negative, recovered, and vaccinated. Staff were to wear goggles or face shield and surgical mask at minimum. [...]