Careone at Wall

Inspectors wroteBased on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to treat a resident in a dignified manner that promotes their quality of life. This deficient practice was identified for 1 of 1 residents (Resident #106) reviewed for resident rights and was evidenced by the following:On 3/19/26 at 11:15 AM, during the initial tour, the surveyor noted Resident #106 lying in bed with a tracheostomy (a hole in the neck to help breathing), a feeding tube (tubing that attaches to a pump and delivers liquid nutrition to the stomach/intestines), and a biliary drain (tubing that drains liquid from the bile duct). The resident was unable to respond to surveyor questions. On 3/20/26 at 9:43 AM, the surveyor observed Resident #106 from their open door, in bed, uncovered, with their body exposed. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure medications (meds) were administered in the allotted timeframe for 1 of 1 resident (Resident #15) reviewed for medication administration times. This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteCOMPLAINT #2720500 Based on interviews, review of medical records and other pertinent facility documentation on 1/23/26 and 1/28/26, it was determined that the facility failed to notify a resident's representative (RR) regarding a change in the resident's medical condition and or status. This deficient practice was identified for 1 of 3 residents reviewed (Resident #1) and was evidenced by the following:Resident #1 was not at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: type II diabetes, cerebral infarction, chronic obstructive pulmonary disease, and hypertension. [...]

Inspectors wroteCOMPLAINT #2715780 Based on interviews, review of medical records and other pertinent facility documentation on 1/23/26 and 1/28/26, it was determined that the facility failed to revise care plan interventions for Resident #3 after the resident pushed a bedside table into the abdomen of their roommate (Resident #1). This deficient practice was identified for 1 of 3 residents reviewed (Resident #3) and was evidenced by the following:A review of the admission Record revealed that Resident #3 was admitted to the facility with diagnoses that included but were not limited to: hemiplegia and hemiparesis following cerebral infarction, aphasia (a language disorder that affects the ability to speak and understand what others say), apraxia (a disorder of the brain and nervous system in which a person is unable to perform tasks or movements when asked), and speech disturbances. [...]

Inspectors wroteCOMPLAINT #2720500 Based on interviews, review of medical records and other pertinent facility documentation on 1/23/26 and 1/26/26, it was determined that the facility failed to maintain an accurate and complete medical record in accordance with acceptable professional standards of practice. This deficient practice was identified for 1 of 3 residents reviewed (Resident #1) and was evidenced by the following:A review of the admission Record revealed that Resident #3 was admitted to the facility with diagnoses that included but were not limited to: hemiplegia and hemiparesis following cerebral infarction, aphasia (a language disorder that affects the ability to speak and understand what others say), apraxia (a disorder of the brain and nervous system in which a person is unable to perform tasks or movements when asked), and speech disturbances. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness and b.) maintain kitchen equipment in a clean and sanitary manner. This deficient practice has the potential to affect all residents, and the evidence was as follows: On 10/11/24 at 10:11 AM, the surveyor in the presence of the Director of Culinary Management (DCM), toured the kitchen and observed the following: 1. In the walk-in freezer, a box of chocolate chip premade dough cookies, a box of beef patties, and a box of vegetable burgers. The boxes were open, there were no dates when to use by, and the the bags inside the boxes were unsealed and the products were covered in ice crystals. The DCM could not speak to when the boxes were opened. 2. [...]

Inspectors wroteBased on observation, interview, and pertinent facility documents, it was determined that the facility failed to ensure narcotic medications were secured under double lock. This deficient practice was identified in 1 of 2 medication storage rooms observed (Cove nursing unit), and was evidenced by the following: On 10/15/24 at 11:11 AM, the surveyor, in the presence of the Unit Manager/Licensed Practical Nurse (UM/LPN) observed the Cove nursing unit's medication storage room. Upon entering, the surveyor opened the unlocked medication refrigerator (med fridge), and inside was the unlocked narcotic medication lock box. The narcotic medication lock box contained 57 dronabinol 5 milligram capsules (a controlled medication used to treat weight loss). At that time, UM/LPN confirmed that the controlled medications should be stored under two secured locks. [...]

Inspectors wroteBased on interview, record review and review of facility provided documentation, it was determined that the facility failed to: a) follow their Accident/Incident Policy and complete an investigation when a resident was found with a dislodged hemodialysis [the clinical purification of blood by dialysis, a substitute for the normal function of the kidney] perma-catheter on [DATE], and required emergency transport to the hospital, and b) document and consistently implement interventions to prevent recurrence. This deficient practice occurred for 1 of 5 residents reviewed for accidents/incidents (Resident #76), when on [DATE] Resident #76 was observed by staff trying to remove the hemodialysis perma-catheter, and on [DATE] Resident #76 was found unresponsive, profusely bleeding with the hemodialysis perma-catheter dislodged and was pronounced deceased . [...]

Inspectors wroteBased on observation, interview and document review, it was determined that the facility failed to ensure: a) the dish machine was functioning properly and washing and sanitizing at appropriate temperatures, b) foods were consistently labeled with a use-by date, c) the kitchen walls and environment were maintained in a clean and sanitary manner, and d) hair restraints were appropriately worn to contain exposed facial hair to prevent the spread of potential infection and food borne illness. The deficient practice was evidenced by the following: On 10/04/23 at 8:59 AM, the surveyor conducted a tour of the kitchen with the Food Service Director (FSD) and observed the following: 1. The FSD was observed wiping down spice containers and was wearing a beard restraint that did not cover his mustache. [...]

Inspectors wroteComplaint NJ #162687 Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to: a) provide appropriate incontinence care, and personal hygiene care for 2 of 20 residents (Resident #55 and #63) on 1 of 2 resident units, and b) failed to offer nail care to a resident who was dependent assistance from staff for care (Resident #61). The deficient practice was evidenced by the following: 1. On 10/04/23 at 10:05 AM, the surveyor observed Resident #55 in bed, the head of the bed was elevated, and the resident was able to answer questions. Upon inquiry the resident stated he/she had not been provided with incontinence care since last night. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that preventive measures to prevent and promote healing of pressure ulcers were in place and consistently followed. This deficient practice was identified for (Resident #63), 1 of 4 residents reviewed for pressure ulcers and was evidenced by the following: During the initial tour on 10/04/23 at 10:45 AM, the surveyor observed Resident #63 lying in bed. Resident #63 was nonverbal, the head of the bed was elevated with the side rails in the upper position. The surveyor performed an incontinence tour with the Certified Nursing Assistant (CNA) and observed that Resident #63 was saturated with a yellow color substance. The incontinent brief was saturated, the blue pads to protect the bed along with the pull sheet was saturated. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure residents highest practical wellbeing by failing to a) provide necessary services to maintain activity of daily living (ADLs) and b) failing to provide restorative nursing services to residents. This deficient practice was identified for 3 of 5 (Residents #55, #63 and #47) and expressed by 5 unsampled residents who attended a resident council meeting. The deficient practice was evidenced as follows: Refer to F677 & F688 a) On 10/04/23 at 9:35 AM, the surveyor interviewed an unsampled resident saying there is never enough staff. The unsampled resident stated all the shifts are short staffed and especially on night shift. The unsampled resident stated aides say I don't have time to do that. I got too many people. [...]

Inspectors wroteBased on interview and document review, it was determine that the facility failed to ensure that sufficent staffing was identified by the Quality Assurance and Performance Improvement (QAPI) program, and the QAPI policy was followed to identify adequate staffing as a concern that was expressed by 5 of 5 unsampled residents who attended a resident council meeting. The deficient practice was evidenced by the following: On 10/06/23 at 10:50 AM, two surveyors conducted a resident council meeting with five unsampled residents. Five of five residents stated that call bell response was excessive and up to 1-2 hours at times, and one unsampled resident stated that he/she would take him/herself to the bathroom because staff was just not around. [...]

Inspectors wroteBased on interviews, review of electronic medical records (EMR), and review of facility provided documentation, it was determined that the facility failed to report an unexpected death to the New Jersey Department of Health (NJDOH) for 1 of 2 residents (Resident #76), reviewed for unexpected death. The deficient practice was evidenced by the following: A review of the EMR revealed that Resident #76 had diagnoses which included but was not limited to; dependence on renal dialysis [the clinical purification of blood by dialysis to substitute for the normal function of the kidney], vascular dementia with behavioral disturbances, and anxiety disorder. Resident #76 had a perma-catheter [a dialysis access site] located on the right upper chest area. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to develop a person-centered baseline Care Plan (CP) for residents within 48 hours of admission/readmission. The deficient practice was identified for 2 of 20 residents (Resident #69 and #61) reviewed for CP and was evidenced by the following: a.) On 10/04/23 at 9:33 AM, Surveyor #1 observed Resident #69 lying in bed. The surveyor observed an indwelling urinary catheter tube and collection bag present [a tube used to drain urine from the kidneys into a collection bag] and attached to the side of the bed. On 10/5/23 at 11:17 AM, Surveyor #1 observed Resident #69 in the facility therapy gym. The surveyor observed a urinary catheter tube and collection bag attached to the side of the resident's wheelchair. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to revise comprehensive person-centered Care Plans for 2 of 20 residents (Resident #76 and #63) reviewed for care planning. The deficient practice was evidenced by the following: a.) A review of the electronic medical record (EMR) revealed that Resident #76 had diagnoses which included but were not limited to; dependence on renal dialysis [the process of purifying blood when the kidneys are not functioning properly], major depressive disorder, anxiety, and vascular dementia without behavioral disturbance. The most recent Quarterly Minimum Data Set (MDS) an assessment tool used to facilitate care, dated [DATE], included but was not limited to; [...]

Inspectors wroteBased on observation, interview and review of medical records and other facility documentation, it was determined that the facility failed to follow professional standards of clinical practice with respect to: a.) the administration of medications and b.) adhering to facility policy for Medication Administration. The deficient practice was identified on 2 of 2 Units observed for medication pass administration. 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, record review and interview it was determined that the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. This deficient practice was identified for 1 of 1 resident (Resident # 47) reviewed for ROM and was evidenced by the following: On 10/04/23 at 09:30 AM, during the initial tour, the surveyor observed Resident (R #47) in bed watching television and the resident expressed some concerns with receiving restorative care to maintain physical function. During the lunch meal R #47 was observed in bed with his/her meal tray and was observed eating independently. [...]

Inspectors wroteBased on observations, interviews, record reviews, and review of facility provided documentation, it was determined that the facility failed to provide treatment and services to limit the potential of infection for 2 of 2 residents (Resident #69 and #61) reviewed for the use of indwelling urinary catheter [a tube used to drain urine from the kidneys]. The deficient practice was evidenced by the following: A.) On 10/04/23 at 9:33 AM, Surveyor #1 observed Resident #69 lying in bed. Surveyor #1 observed a urinary catheter tube draining into a urinary catheter bag with a privacy bag over it on the side of the bed. On 10/5/23 at 11:17 AM, Surveyor #1 observed Resident #69 in the therapy gym. The surveyor observed the urinary catheter with the catheter bag on the side of the resident's wheelchair. [...]

Inspectors wroteBased on observation, interview and document review, it was determined that the facility failed to ensure opened multi-use medication vials stored inside of the medication cart was labeled and dated with an open and expiration date upon opening. This deficient practice was observed during a medication storage review and was evidenced by the following: On 10/06/23 at 7:20 AM, in the presence of the Registered Nurse and the Licensed Practical Nurse (LPN), the surveyor reviewed the inventory of medications and treatment products in the Medication Administration Cart. Upon review of the medication cart contents the surveyor observed one opened and undated multi-use dose of Insulin Lantus pen for Resident #47. A review of the manufacturer's literature indicated to discard the insulin multi-dose vial and pen-injector 28 days after opening. [...]

Inspectors wroteBased on interview and document review, it was determined that the facility failed to provide education and assess staff competencies for staff who provided care for residents who received dialysis [a type of treatment used to clean the blood when kidneys do not function properly] as identified as a special care need in the Facility Assessment. The deficient practice was evidenced by the following: A review of the closed medical record for Resident #76 revealed that the resident was found with a dislodged hemodialysis [the clinical purification of blood by dialysis, a substitute for the normal function of the kidney] perma-catheter on 09/10/23, and required emergency transport to the hospital. [...]