Careone at Oradell

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to maintain the kitchen exhaust hood system in good repair and free of structural defects that could compromise fire safety. This deficient practice had the potential to affect all 122 residents in the facility by increasing the risk of fire and smoke spreading behind the kitchen exhaust hood and was evidenced by the following:On 5/6/26 at 10:00 AM, the surveyor conducted a tour of the facility kitchen with the Food Services Director (FSD). During the kitchen tour, the surveyor observed the stainless steel exhaust hood located above the cooktop. Two sections of the hood had gaps measuring greater than approximately one-half inch where the panels joined. [...]

Inspectors wroteNJ #298824 Based on observation, interview, and record review it was determined that the facility failed to maintain the privacy for 4 of 4 residents (Resident #12, Resident #66, and 2 unsampled residents) during resident council meeting by 2 of 2 Recreation Aides and dignity of 1 of 4 residents (1 unsampled resident) during incontinence round and 1 of 4 residents (Resident #12) with regard to their personal care. The deficient practice was evidenced by the following. 1. On 5/6/26 at 10:10 AM, Surveyor #1 (S #1) and Surveyor #2 (S #2) met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) during an entrance conference meeting. The LNHA and DON agreed to set up the resident council meeting on 5/11/26 at 10:30 AM. [...]

Inspectors wroteREPEAT DEFICIENCYBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide a safe, clean, and comfortable homelike setting. This deficient practice was identified for 2 of 2 floors and 1 of 2 dining rooms (1st floor private dining room), and was evidenced by the following: The deficient practice was evidenced by the following: 1. On 5/7/26 at 10:28 AM, Surveyor #1 (S#1) and Surveyor #2 (S#2), conducted a facility tour. Both surveyors observed the 1st floor private dining area in the presence of the Regional Director of Environment Services (RDES), which revealed a ceiling return air vent with dust accumulation. The RDES confirmed the air vent needed to be cleaned for fire safety. [...]

Inspectors wroteNJ #2601805, #2966040, and 2734209Based on interview and review of facility documentation, it was determined that the facility failed to follow its Grievances/Complaints, Filing policy and procedure by failing to; a.) conduct a formal investigation of a grievance filed by a resident and followed through, b.) prompt efforts to resolve grievances to the satisfaction of the resident, and c.) actions on such issues responded to in writing, including rationale for the response. This deficient practice was identified for 2 of 3 months of resident council meeting minutes. This deficient practice was evidenced by the following: On 5/11/26 at 9:49 AM, the surveyor reviewed the last three months' resident council minutes (RCM) that were provided by the Licensed Nursing Home Administrator (LNHA) that included but were not limited to, and revealed: [...]

Inspectors wroteBased on observation, interviews, record review, and review of facility provided documents, it was determined that the facility failed to provide written information to the resident or the Resident Representative (RR) that explained the reserve bed payment policy. This deficient practice was identified for 3 of 4 residents, (Resident #4, #67, and #136), reviewed for discharge process. The deficient practice was evidenced by the following: 1. On 5/6/26 at 11:42 AM, Surveyor #1 (S#1) observed Resident #4 in the 2nd (second) floor main dining/activity room, sitting on a wheelchair (w/c), talking to other residents. On 5/11/26 at 9:32 AM, S #1 reviewed the medical records of Resident #4. A review of the admission Record (AR) or face sheet (an admission summary) revealed diagnoses which included but not limited to; [...]

Inspectors wroteREPEAT DEFICIENCYComplaint NJ #2601805, #2727668, #2734209, and #2966040Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure a.) residents received timely and appropriate incontinence care for 6 of 8 residents (Residents #12, #17, #66, and Unsampled Residents #1, #2, and #4) and b.) staff responded to call bell timely for 2 of 33 residents (Residents #17 and #110) observed, to achieve their highest practical wellbeing. This deficient practice was evidenced by the following: On 5/11/26 at 9:49 AM, the surveyor reviewed the last three months' resident council minutes (RCM) that were provided by the Licensed Nursing Home Administrator (LNHA) that included but were not limited to, and revealed: [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to issue the proper required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for 2 of 3 residents (Resident #4 and #11) reviewed for beneficiary notifications. The deficient practice was evidenced by the following:On 5/6/26 at 11:33 AM, the License Nursing Home Administrator (LNHA) presented the surveyor with a list of residents who were discharged (d/c'd) from the facility within the last six months and should have received Advance Beneficiary Notices (ABNs). On 5/12/26 at 12:30 PM, the surveyor provided the Director of Nursing (DON) list of three residents for beneficiary review. [...]

Inspectors wroteBased on observations, interviews, review of medical records, and facility documents, it was determined that the facility failed to develop and implement a comprehensive plan of care to meet residents' preferences and goals and address the resident's medical and psychosocial needs. This deficient practice was identified for 2 of 28 residents (Residents #2 and #22) reviewed for a care plan. This deficient practice was evidenced by the following:1. On 5/13/26 at 9:00 AM, the surveyor reviewed the electronic medical record (eMR) of Resident #2. The admission Record (AR) or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included, but were not limited to, Post-Traumatic Stress Disorder (PTSD), Chronic (a mental health disorder that may develop in people after they experience or see a traumatic event). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure physician services met professional standards of practice by failing to obtain and document a clinical evaluation addressing the risk versus benefit of continuing combined therapy with antidepressant and antipsychotic medications after the consultant pharmacist identified an increased risk for falls. This deficient practice was identified for 1 of 28 residents (Resident #7) reviewed for physician services and was evidenced by the following: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 that the facility failed to; a) ensure an air mattress was on and functioning, b) accurately document the skin observation, and c) clarify a physician' order for wound treatment for 1 of 1 resident reviewed for Pressure Ulcer (PU) (Resident #3). This deficient practice was evidenced by the following: On 5/6/26 at 10:06 AM, the surveyor observed Resident #3 lying in a low to the ground bed with an air mattress machine attached to the end of the bed which was not on and functioning. On 5/6/26 at 11:40 AM, the surveyor reviewed Resident #3's electronic medical record. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to, a.) ensure appropriate care and services for a resident receiving enteral feedings through a percutaneous endoscopic gastrostomy (PEG tube-a feeding tube inserted through the abdominal cavity directly into stomach or small intestine to provide nutrition) by securing the external tube and provide skin care to the PEG tube site and failed to b.) ensure the resident's care plan reflected care and services for the PEG tube site. This deficient practice was identified for 1 of 2 residents (Resident #11), reviewed for enteral tube feeding (TF). [...]

Inspectors wroteBased on the observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure: a.) that the Physician's Order (PO) for pain management was clarified according to the appropriate pain level for 1 of 2 residents, (Resident #37), for as needed pain medications and b.) the PO was obtained for pain medication for 1 of 2 residents, (Resident #66), reviewed for pain management according to standards of clinical practice and facility's policies. The deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure timely administration of a medication (med) for 1 of 5 (Resident #31) residents reviewed for med regimen. The deficient practice is 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 licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to properly store, and label with a date, medications in 1 of 2 medication rooms and 1 of 4 medication carts inspected. The deficient practice was evidenced by the following:1. On [DATE] at 10:50 AM, the surveyor inspected the medication (med) room on the 1st floor North, in the presence of the Licensed Practical Nurse (LPN). During the inspection, the surveyor found a safety needle that had expired on [DATE]. The LPN acknowledged the safety needle was expired. 2. On [DATE] at 1:33 PM, the surveyor inspected south med cart #3 on the second floor in the presence of the Registered Nurse (RN). [...]

Inspectors wroteBased on observation, interview, and review of other pertinent facility documentation, it was determined that the facility failed to follow appropriate hand hygiene practices for 2 of 2 staff (Recreation Assistants) during dining observation, and follow appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was evidenced by the following:According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24, revealed .Know how to wash hands with soap and water:Wet hands with water. Apply the manufacturer's recommended amount of product to your hands. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident received care consistent with professional standards of practice, to prevent pressure ulcers, and promote healing. This deficient practice was identified for 1 of 2 residents, (Resident #197) who was identified as having a pressure right hip injury on 11/13/24, with no description of a wound, which progressed to an unstageable wound to the right hip with 30% slough (necrotic tissue that needs to be removed from the wound for healing to take place) with serosanguinous drainage. The wound measured 3 centimeters (cm) x 4 cm x 0.1 cm and was identified during routine wound rounds by a consultant on 11/20/24. [...]

Inspectors wroteBased on observation, interviews, and a review of facility documentation, it was determined that the facility failed to ensure that a facility wide assessment was reviewed and updated to identify the required services and procedures necessary to protect the health, safety, and welfare of all residents to ensure adequate facility resources to provide resident care and services. These failures had the potential to affect all 109 residents who currently live in the facility during the time of the survey. This deficient practice was evidenced by the following: During the entrance conference on 12/02/24 at 10:12 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) documents to complete the survey process which included but were not limited to Facility Assessment (FA). [...]

Inspectors wroteCOMPLAINT# NJ178354 Based on observation, interview, and review of other facility documentation, the facility failed to ensure the facility was maintained in a safe, clean, and homelike environment. This deficient practice was identified for 2 of 2 units, (2 North and 2 South), and 1 of 22 residents, Resident #94. This deficient practice was evidenced by the following: 1. On 12/3/24 at 11:53 AM, during a tour of the 2nd floor nursing units, the surveyor observed a gray, dust or dirt like substance adhering to the air circulation vent covers on the 2 North Unit hallway. The surveyor observed 2 vent covers on the 2 North Unit. The surveyor proceeded to the 2 South unit nurses' station and observed a similar gray substance adhering to the vent cover in the ceiling over the desk area. [...]

Inspectors wroteREPEAT DEFICIENCY Complaint #175734 Based on observation, interview, record review and review of pertinent facility documents it was determined the facility failed to: a.) ensure a resident's medication was available and administered as scheduled for 1 of 5 residents, Resident #66, reviewed for unnecessary medications and b.) ensure residents received medications as scheduled for 2 of 22 residents (Residents #79, 87) reviewed for quality of care, in accordance with physicians' orders, and standards of 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 that promotes maintenance or enhancement of their quality of life specifically by honoring the resident's shower schedule and preferences for 1 of 2 residents, Resident #52, reviewed for activities of daily living. This deficient practice was evidenced by the following: On 12/3/24 at 9:50 AM, the surveyor observed Resident #52 sitting in a chair in their room dressed in well-fitted clothes. The resident was alert, oriented, and verbally responsive. Resident #52 stated for the last couple of weeks they only received a shower once a week. The resident stated that previously they had received a shower twice a week although they felt that was not enough. [...]

Inspectors wroteREPEAT DEFICIENCY Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to adhere to professional standards of clinical practice for failing to prevent a potential medication interaction by administering two (2) potential interacting medications at the same time for one (1) of four (4) residents (Resident #55), reviewed during the medication pass observation. The deficient practices are 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 wroteREPEAT DEFICIENCY Based 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, according to the standard of clinical practice and the facility's policy and procedure. Specifically, a.) administer oxygen therapy according to the physician's order, b.) obtain a valid order for continuous oxygen use, c.) clarify the physician's order for as needed (PRN) oxygen, and d.) document the use of PRN oxygen therapy for 1 of 3 residents, Resident #19. 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 wroteREPEAT DEFICIENCY Complaint # 175734 Based on observation, interviews, and record reviews it was determined that the facility failed to provide sufficient nursing staff to ensure resident's highest practical wellbeing by failing to: a.) provide nursing assistance care to resident in accordance with the resident care plans for 1 of 22 residents, Resident #22, reviewed and b.) maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey . This deficient practice was evidenced by the following: 1. On 12/2/24 at 11:20 AM, the Resident Representative of Resident #27 requested to talk to the surveyor, who stated, They have a huge staffing issue, on Saturday 11/30/24, they had one aide on the floor, I got from a source that it was a scheduling issue and it was a common thing, these girls are working hard. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to ensure the accurate daily report of licensed nurses, certified nursing assistant staffing, and the resident census was posted at the beginning of the current shift for 2 of 6 days during the annual re-certification survey. This deficient practice was evidenced by the following: On 12/2/24 at 9:00 AM, upon entry to the facility, the surveyor observed a Nursing Home Resident Care Staffing Report (NHRCSR) posted at the front desk by the main entrance. The NHRCSR posted was dated 11/30/24 with a census of 107, for the [7:00 AM to 3:00 PM] day shift. There was no NHRCSR for 12/2/24 posted. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medication for 1 of 2 medication storage areas and 2 of 3 medication carts inspected 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 interview, review of medical record, and review of other pertinent facility documents, it was determined that the facility failed to offer residents a pneumococcal and influenza vaccines or document the refusal and reason for ineligibility for the vaccines for 4 of 22 residents reviewed for immunizations (Resident #42, #66, #94 and #197). The deficient practice was evidenced by the following: Reference: According to the Centers for Disease Control (CDC) and Prevention, recommends pneumococcal vaccination (PCV) for many adults based on age, having certain risk conditions, and pneumococcal vaccines already received . CDC recommends PCV15, PCV20, or PCV21 for adults who never received a PCV and are Ages 65 years or older Ages 19 through 64 years with certain risk conditions. [...]

Inspectors wroteComplaint #: NJ00178451 Based on interviews, records review, and review of pertinent facility documents on 11/22/2024 and 11/25/2024, it was determined that the facility failed to ensure and provide the correct medication for a resident (Resident #1) according to the Physician's Order when the facility's providing pharmacy sent a different medication to the facility. This deficient practice was observed in 1 of 4 residents reviewed for medications and was evidenced by the following: According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but was not limited to Malignant Neoplasm of Left Breast, Cerebral Infarction, Altered Mental Status, Osteoarthritis, Muscle Weakness, and Anxiety Disorder. [...]

Inspectors wroteComplaints #: NJ00163185, NJ00166154, NJ00157351, NJ00155283 Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure resident's highest practical wellbeing by failing to: a.) maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey (NJ) and b.) ensure that 7 AM-3 PM, 3-11 PM, and 11-7 shifts were staffed to provide the ADLs (activities of daily living) for nine (9) of 17 residents, (Residents#4, #13, #22, #23, #32, #233, #235, #312, and #263) according to facility practice, required minimum direct care staff-to-shift ratios as mandated by the state of NJ, and facility assessment. This deficient practice was evidenced by the following: Reference: [...]

Inspectors wroteComplaint#00154889 Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a) ensure written grievance decisions met documentation requirements and b) maintain evidence of the result of all grievances for no less than three (3) years from the date the grievance decision was issued according to facility practice and policy. 1. The surveyor reviewed Resident #161's medical records. The admission Record (AR; or face sheet; [...]

Inspectors wroteComplaints#: NJ00160781 and NJ00157351 Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that: a) the discharge summary provides necessary information to continuing care providers pertaining to the course of treatment while the resident was in the facility and the resident's plans for care after discharge and b) the discharge summary must include an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, for four (4) of five (5) residents (Residents #108, #109, #262, and 263) reviewed for discharge home. This deficient practice was evidenced by the following: 1. The surveyor reviewed the medical records of Resident #108. The admission Record (or AR; face sheet; [...]

Inspectors wroteComplaint # NJ00160781 Based on interviews and record review and review of pertinent facility documentation, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice that meet each resident's physical, mental and psychosocial needs. This deficient practice was identified for one (1) of four (4) residents reviewed for closed record review, (Resident #262) and was evidenced by the following: Reference: NEW JERSEY ADMINISTRATIVE CODE TITLE 13 LAW AND PUBLIC SAFETY CHAPTER 37 NEW JERSEY BOARD OF NURSING 13:37-6.5 NON-DELEGABLE NURSING TASKS b) A registered professional nurse shall not delegate the physical, psychological, and social assessment of the patient, which requires professional nursing judgment, intervention, referral, or modification of care. The surveyor reviewed Resident #262's closed medical record. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation it was determined the facility failed to: a) ensure the facility policy for Accidents and Incidents was followed to thoroughly investigate each fall, appropriately assess a resident, determine the causal factor of each fall and provide conclusion and summary, implement appropriate interventions to prevent recurrent falls, and update care plan for six (6) out of six (6) investigations, b) implement policies and procedure for reporting a fall that resulted in a major injury to State Agency in accordance to current guidelines for one (1) of three (3) residents, (Resident #46) reviewed for falls; and c) complete an initial smoking assessment and initiate a care plan for smoking for one (1) of one (1) resident reviewed for smoking (Resident #93). This deficient practice was evidenced by the following: [...]

Inspectors wroteComplaint # NJ00160781 Based on observation, interview, record review, and review of pertinent facility documentation, 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, for one (1) of 24 residents, (Resident #262) reviewed for MDS accuracy, and was evidenced by the following: According to the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set 3.0 Public Reports page last modified 12/01/21, included that the MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. [...]

Inspectors wroteComplaint#NJ00157351 Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to adhere to professional standards of clinical practice for a) not initialing the Electronic Treatment Administration Record (eTAR) for one (1) of three (3) residents (Resident#110), reviewed for oxygen order and b) ensure that the Speech Therapist's recommendations were followed through for one (1) of two (2) residents (Resident #263), reviewed for nutrition. The deficient practices are 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 provide appropriate catheter care and services for one (1) of two (2) residents (Resident #72) reviewed for catheter. This deficient practice was evidenced by: On 8/24/23 at 10:39 AM, the surveyor observed Resident #72 sitting on a wheelchair, dressed and was conversant. The resident stated they were being discharged that morning. The surveyor observed the resident had a catheter drainage bag secured to the bottom of wheelchair without a privacy cover. The surveyor reviewed Resident #72's medical record. According to the admission Record (or face sheet; an admission summary), Resident #72 was admitted with diagnoses that included acute kidney failure, sepsis (body's overactive and extreme response to an infection; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a.) tracheostomy (trach) care and services were provided according to the standard of practice for one (1) of two (2) residents (Resident #28) reviewed for tracheostomy care and b.) a resident received oxygen as ordered by the physician for one (1) of two (2) residents (Resident #58) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 8/23/23 at 11:07 AM, surveyor observed Resident #28, lying in bed with their eyes closed, tracheotomy (a surgically created hole in windpipe (trachea) that provides an alternative airway for breathing) clean, dry, and intact. The surveyor reviewed the medical records for resident #28. The admission Record (AR; or face sheet; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the 24-hour staffing report that was posted was up to date and provided an accurate information. This deficient practice was evidenced by the following: On 8/23/23 at 8:56 AM, the survey team entered the facility and observed that the 24-hour staffing report that was posted was dated 8/18/23. The staffing report was not up to date. On 8/28/23 at 6:30 AM, two surveyors entered the facility and observed that the 24-hour staffing report that was posted was dated 8/25/23 and that the census listed was 118. The staffing report was not up to date. On 8/28/23 at 7:35 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) to provide a copy of Resident Census from Friday, Saturday, Sunday, and Monday. [...]

Inspectors wroteBased on interviews, record review, and review of the facility provided documents, it was determined that the facility failed to act upon the recommendations in the monthly Medication Regimen Reviews (MRR) identified irregularities of the Consultant Pharmacist's (CP's) for one (1) of three (3) residents, (Resident #110) reviewed for closed records. This deficient practice was evidenced by the following: The surveyor reviewed Resident #110's medical records. The resident's admission Record (or face sheet; admission summary) reflected that the resident was admitted to the facility and had diagnoses that were not limited to essential hypertension (elevated blood pressure), other seizures, type two diabetes mellitus without complications (is a chronic disease affecting blood glucose regulation), cerebral infarction unspecified (stroke), Alzheimer's disease unspecified. [...]

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 observation conducted on 8/28/23, the surveyor observed four nurses administer medications to sixteen residents. There were 25 opportunities, and two errors were observed which resulted in a medication error rate of 8%. This deficient practice was identified for one (1) of three (3) residents, that was administered by one (1) of three (3) nurses. This deficient practice was evidenced by the following: A review of the manufacturer's specifications for Metoprolol Tartrate (Lopressor) reflected that the medication was to be administered with or immediately following a meal. [...]

Inspectors wroteBased on observation, interview, and review of the facility provided documents, it was determined that the facility failed to ensure: a) appropriate use of personal protective equipment (PPE) for two (2) of four (4) staff observed during meal observation and b) appropriate hand hygiene practice for one (1) of two (2) staff observed during treatment observation according to facility policy and Centers for Disease Control and Prevention (CDC) guidelines. This deficient practice was evidenced by the following: [...]

Inspectors wroteBased on the interview and review of pertinent facility documents, it was determined that the facility failed to ensure: a) the designated Infection Preventionist (IP) dedicated solely to the infection prevention and control program (IPCP) for one (1) of one (1) staff and b) the IP participated in Quality Assurance Performance Improvement (QAPI) for two (2) of three (3) quarters reviewed QAPI in accordance with the facility policy and Centers for Medicare and Medicaid Services (CMS) and New Jersey (NJ) guidelines. This deficient practice was evidenced by the following: According to the NJ Executive Directive 21-012 (revised 12/22/22) included ii. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI (quality assurance and performance improvement) program for two (2) of five (5) Certified Nurse Assistants (CNAs) reviewed for mandatory education. This deficient practice was evidenced by the following: On 9/01/23 at 9:09 AM, the surveyor reviewed the annual in-service education hours for five randomly selected CNA files, which were provided by the facility. The Staff In-service Logs showed the following: CNA #1 had a hire date of 3/14/18. According to the Training Hours Transcripts, CNA #1 did not have QAPI training. CNA #2 had a hire date of 7/22/19. According to the Training Hours Transcripts, CNA #1 did not have QAPI training. [...]