Cedar Grove Respiratory and Nursing Center

Inspectors wroteDuring rounds on 05/15/2025 at 09:39 AM survey #2 observed the wardrobe door in room [ROOM NUMBER]-unit B peeling off with sharp edges. During an interview on 05/20/2025 at 09:25 AM with surveyor #2, the Acting Maintenance Director (AMD) said they inspect random rooms weekly. The AMD said that when they see furniture in need of repair, they order replacement furniture it can sometimes take two weeks to a month to be replaced. When asked if there should be peeling furniture in residents' rooms, the AMD said no it can be a dignity and safety issue. During an interview with surveyor #2 Licensed Nursing Home Administrator (LHNA) said that there should not be any broken or peeling furniture in residents' rooms and that they are working on replacing all furniture that is not in good repair to provide a homelike environment. [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to administer Tube Feedings per Physician's order (PO). This deficient practice was identified for 1 of 5 residents (Resident #82) reviewed for receiving nutrition via Tube Feeding (TF) and was evidenced by the following: On 05/14/2025 09:08 AM, the surveyor entered Resident # 82's room and observed the resident in bed. The surveyor observed that the resident had a TF (nutrition received through a flexible tube surgically inserted into the stomach) formula hanging on a pole, attached to a TF pump, and infusing at a rate of 55 ml/hr (milliliters per hour). On 05/14/2025 at 1:04 PM, the surveyor observed Resident #82 in the bed. The surveyor further observed a TF connected to a TF pump and infusing at a rate of 55 ml/hr. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to administer medication with an error rate of less than 5%. The surveyor observed 2 nurses administer medications for 6 residents with 33 opportunities for error. There were 3 errors resulting in an error rate of 9% as evidenced by the following: During the medication pass on 05/14/2025 from 8:00 AM until 8:55 AM, the surveyor observed the following: At 8:43 AM, the surveyor observed the Licensed Practical Nurse (LPN) administer a Cholecalciferol (Vitamin D3) 1000 unit capsule to Resident #72. The LPN stated she is giving a capsule not a tablet. The Physician Order (PO) dated 08/31/2023 indicated to give a Cholecalciferol 1000 unit tablet; not a capsule. [...]

Inspectors wroteBased on observation, interview, and pertinent facility documentation, it was determined that the facility failed to ensure that a medication was secured in a locked compartment accessible only to authorized personnel with a key. This deficient practice was identified for 1 of 4 units (C unit). This deficient practice was evidenced by the following: On 05/14/2025 at 12:40 PM, the surveyor observed an opened 4% Lidocaine patch (pain-relief patch) on top of the dresser in room [ROOM NUMBER]A. During an interview with the surveyor on 05/19/2025 at 12:45 PM, the Director of Nursing said that the patch should not have been left on the resident's dresser and stored in a locked medication cart for safety reasons. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents it was determined that the facility A.) failed to use appropriate infection control practices, specifically hand hygiene when providing wound care and B.) failed to implement infection control measures for the handling and storage of respiratory equipment. The deficient practice was identified for 1 of 3 residents (Resident # 110) reviewed for Pressure Ulcer/Injury and 1 of 3 residents (Residents #9) reviewed for respiratory care. The deficient practice was evidenced by the following: A review of Resident # 110's Minimum Data Set (an assessment tool) revealed under section M that he/she had a pressure ulcer. A review of Resident # 110's Electronic Medical Record (EMR) under Orders revealed an order that revealed, Acetic Acid Irrigation Solution 0.25 % (Acetic Acid): [...]

Inspectors wroteBased on observation, interview, and pertinent facility documentation, it was determined that the facility failed to ensure that the resident call system was maintained in an operable condition. This deficient practice was identified on 1 of 4 units (C unit). This deficient practice was evidenced by the following: On 05/13/2025 at 10:01 AM, the surveyor observed that in bedroom [ROOM NUMBER]B, the call bell device cord was detached from the wall system. On 05/14/2025 at 12:26 PM, the surveyor observed that in bedroom [ROOM NUMBER]B, the call bell device cord was detached from the wall system. On 05/15/2025 at 9:36 AM, the surveyor observed that in bedroom [ROOM NUMBER]B, the call bell device cord was detached from the wall system. [...]

Inspectors wroteNJ 167523 Based on interview, record review, and policy review, the facility failed to protect the resident's right to be free from physicial abuse by another resident for one (Resident (R) 19) of nine residents reviewed for abuse. R23 approached R19, while the resident was in her bathroom and hit R19's back, neck, and shoulders. R19 sustained pain and fear during the altercation.

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 05/03/2023 from 08:32 to 09:04 AM, the surveyor, accompanied by the Dietary Director (DD), observed the following in the kitchen: 1. On an upper shelf under the refrigeration unit of the walk-in refrigerator, an opened box contained individual packets of [NAME] Sour Cream. The packets had a use by date of [DATE]. The DD removed the box of individual sour cream packets to the trash. 2. On a lower shelf of the walk-in refrigerator, a sheet pan contained a package of ground beef pulled from the freezer to defrost. [...]

Inspectors wroteBased on observation and interview it was determined that the facility failed to create a homelike environment during dining by not removing food from serving trays. The deficient practice was observed in the facility's main dining room and was evidenced by the following: 1. On 05/03/2023 at 12:06 PM, the surveyor observed the main dining room at the lunch meal. 8 residents were present at various tables. 8 of 8 residents were observed to be eating their lunch meal from a plastic tray. 2. On 05/08/2023 at 12:06 PM, the surveyor observed the main dining room at the lunch meal. 11 of 11 residents present in the dining room were observed eating their lunch meal from a plastic tray. The facility did not provide a policy or procedure for dining pertaining to not serving residents on trays in the dining room. N.J.A.C. 8:39-4.1(a)(12)

Inspectors wroteBased on observation, interview, medical record review and review of other facility documentation, it was determined that the facility failed to contain oxygen/nebulizer delivery systems in a manner to prevent the spread of infection for 1 of 6 residents (Resident #120) reviewed for respiratory care. This deficient practice was evidenced by the following: On 05/03/2023 at 09:59 AM, during the initial tour of the facility, the surveyor observed Resident #120 lying in bed while receiving oxygen via nasal cannula. Resident #120 stated that he/she wore received oxygen continuously. On 05/09/2023 at 08:40 AM, Resident #120 was observed sitting up in bed eating breakfast. The nebulizer mask was in the top drawer of the opened bedside table. The mask was uncovered and exposed. Portable oxygen was observed to be in a back pocket of the resident's wheelchair. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) to maintain a detailed record of receipts and accurate reconciliation of controlled medications for 7 of 7 Drug Enforcement Administration (DEA) 222 forms (a form used for ordering controlled substances)and b.) failed to ensure that controlled drugs are reconciled in accordance with facility policy and professional nursing standards on 1 of 5 SHIFT to SHIFT CONTROLLED MEDICATION COUNT LOG (B Unit, Cart #1). This deficient practice was evidenced by the following: A.) On 05/11/2023 at 09:22 AM, Surveyor #1 requested all of the DEA 222 forms for the last six (6) months from the Assistant Director of Nursing (ADON). The ADON provided Surveyor #1 with seven (7) DEA 222 forms. [...]

Inspectors wroteNJ Complaint: #NJ00160866 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow the prescriber's orders and accepted professional standards and principles by administering medications past the required time frame. The deficient practice was identified for 1 of 1 resident reviewed for being free of significant med errors. The deficient practice was evidenced by the following: A review of Resident #108's quarterly Minimum Data Set (an assessment tool) dated 02/27/2023, revealed that Resident #108 had a brief interview of mental status score of 15 which indicated he/she was cognitively intact. [...]

Inspectors wroteBased on observation, interview, and document review, it was determined that the facility failed to store a biological (Tubersol INJ [injection], used to aid in the diagnosis of tuberculosis infection [TB]) in accordance with the manufacturer's instructions. This deficient practice was identified in 1 of 5 medication carts inspected. On 05/11/2023 at 10:11 AM, the B-Wing Medication Cart #1 was inspected, by the surveyor, in the presence of Licensed Practical Nurse (LPN #1). Upon opening the bottom right-hand drawer, the surveyor observed an unopened box of house stock Tubersol INJ (Injectable) 5/0.1 ML (Milliters) manufactured by [company name]. A label affixed to the outside of the box indicated Refrigerate, Do Not Freeze, as well as an image of a refrigerator and the word REFRIGERATE written in bold letters next to the image. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide all the items that were on the menu. This deficient practice occurred during one lunch meal that was observed in the main dining room and was evidenced by the following: 1. On 05/09/2023 at 11:48 AM, during the lunch meal in the main dining room, the surveyor observed 12 residents were present in the dining room. According to the menu, residents were to receive a slice of apple pie at the lunch meal on 05/09/2023. The surveyor observed 12/12 residents in the main dining room receive strawberry ice cream for dessert at the lunch meal instead of apple pie. The surveyor interviewed resident #39 during the lunch meal observation. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide access to the call system while a resident was in bed. The deficient practice was identified for 1 of 1 resident (Resident #423) investigated under the Environment Task. On 05/03/2023 at 09:40 AM, during the initial tour of the facility, the surveyor observed Resident #423 asleep in bed. At that time, the surveyor observed the handheld call system on the floor adjacent to the bed. On 05/11/2023 at 09:56 AM, the surveyor observed Resident #423 awake in bed. At that time, the surveyor observed the handheld call system on the floor adjacent to the bed. On the same date at 10:00 AM, during an interview with the surveyor, Resident #423 said the handheld call system is on the floor sometimes and makes it difficult to get care. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to develop a person-centered comprehensive care plan (CP) or develop a person-centered comprehensive care plan in a timely manner a) addressing the placement and care of hand mitts on left/right hands (Resident #23), b) addressing the use, care, cleaning and storage of a nebulizer (a machine that delivers aerosol medication into the lungs) (Resident #126), and c) failure to develop a hospice care plan in a timely manner for a resident enrolled and disenrolled in hospice services (Resident #69) . This deficient practice was observed for 3 of 33 residents reviewed and was evidenced by the following: a) On 2/11/2022 at 11:14 AM, the surveyor observed Resident #23 in bed, on a ventilator with a tracheostomy in place. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to A) develop and implement a policy to track facility staff vaccination status to ensure all eligible staff were vaccinated by the required dates and B) follow their own policy for contingency plans by not ensuring unvaccinated staff wore an N 95 mask to mitigate the potential spread of COVID-19. This deficient practice was evidenced by the following: On 2/11/22 during entrance conference, the facility was asked to provide a matrix of the vaccination status of all their staff. The facility provided a sheet of paper, separated by department, and listed the number of total vaccinated and unvaccinated staff. The paper did not identify or specify which facility staff were vaccinated or unvaccinated. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to refer Resident #14 to the appropriate state-designated authority for level II Preadmission Screening and Resident Review (PASARR) evaluation and determination. This deficient practice was identified for 1 of 4 residents reviewed for Level II PASARR. On 2/11/2022 at 2:21 PM the surveyor reviewed Resident #14's electronic and paper record. According to the admission record Resident #14 was admitted to the facility with the following diagnoses: injury of cauda equina (a sack of nerve roots at the lower end of the spinal cord), suicidal ideations, schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder), schizophrenia, major depressive disorder, and anxiety disorder. [...]

Inspectors wroteBased on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to revise a care plan when there was a change in the medication regime for 1 of 33 sampled residents, (Resident # 58). This deficient practice was evidenced by the following: During the initial tour of the ventilatory unit on 2/11/22 at 10:40 AM, Resident #58 was observed lying in bed with their tracheostomy connected to a mechanical ventilator with their eyes closed. A review of the admission Record revealed Resident #58 was admitted to the facility with diagnoses including but not limited to; acute and chronic respiratory failure, and anoxic brain damage (lack of oxygen to the brain). A review of an Order Summary Report dated active orders as of 2/16/22, did not include an order for anticoagulant medication (a blood thinning medication). [...]

Inspectors wroteBased on observation, interview, review of the medical record, and other facility documentation it was determined that the facility failed to follow acceptable standards of clinical practice in accordance with the New Jersey Board of Nursing Statutes by not maintaining medication records that were complete with staff signatures for 2 of 33 residents reviewed (Resident # 9 and Resident #75). 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 other pertinent facility documentation, the facility failed to ensure residents who are unable to carry out activities of daily living (ADL) received the necessary nail care to maintain proper grooming and personal hygiene. The deficient practice was observed for 2 out of 3 residents reviewed for Activities of Daily Living, (Resident #99 and Resident #92). The deficient practice was evidenced by the following: A) During the initial tour of the facility on 2/11/22 at 10:13 AM, surveyor #6 observed Resident #99 in their room. At that time, the surveyor observed Resident #99's fingernails on his/her right hand. The nails were chipped, long, and had unidentified matter underneath the nails. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure a resident had physician's orders for ongoing care and protocols for a Foley catheter (tube inserted into the bladder to drain urine) for 1 of 3 residents reviewed for a Foley, (Resident #477). The deficient practice was evidenced by the following: During the initial tour of the facility on 2/11/22 at 10:34 AM, the surveyor observed Resident #477 in bed. A Foley catheter drainage bag was on the floor with a tube ascending towards the resident. A review of Resident #477's Electronic Medical Record (EMR) revealed under, Medical Diagnosis that he/she had a diagnosis of but not limited to, Focal Traumatic Brain Injury (localized damage to the brain from direct mechanical forces), and a Pressure Ulcer of Sacral Region. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to accurately and consistently monitor an enteral tube feeding administration pump free water flush in accordance with physician's orders. This deficient practice was observed for 1 of 3 residents (Resident #149) reviewed for tube feeding and was evidenced by the following: On 2/11/2022 at 10:50 AM, during the initial tour of the facility, the surveyor observed Resident #149 lying in bed with the head of bed elevated. The surveyor observed the following from the enteral pump screen: Resident #149 was actively receiving a tube feed of Jevity 1.5 (a type of nutritional formula) infusing at 60 milliliters per hour (ml/hr). In addition, Resident #149 was receiving an autoflush (water flush) at 60 ml q (every) hour. [...]

Inspectors wroteBased on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure respiratory equipment was stored properly when not in use, to reduce the risk of infection for 1 of 2 residents reviewed for respiratory equipment, (Resident #126). The deficient practice was evidenced as follows: On 2/11/2022 at 11:20 AM, during the initial tour of the B Unit, the surveyor observed a nebulizer machine on top of Resident #126's four drawered dresser. The dry nebulizer mask was exposed, connected to the dry medication cup, and the tubing was connected to the nebulizer machine. The mask was resting on top of a TV remote control, and a tan rolled bandage. The equipment was unlabeled and undated. During an interview at that time, the resident stated the nebulizer was for her to use when she got winded. [...]

Inspectors wroteBased on interview, record review and review of other facility documentation, it was determined that the facility failed to document that topical pain medication was administered as ordered by the physician. This deficient practice was identified for 1 of 3 residents reviewed for pain management, (Resident #75) and was evidenced by the following: According to the admission Record, Resident #75 was admitted to the facility with diagnoses that included arthritis. A review of review the Order Summary Report revealed a physician's order dated 12/9/2021 for the resident to receive Voltaren Gel 1% (a topical pain medication) Apply to B/L (bilateral) knees topically two times a day for pain. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to consistently communicate with a contracted dialysis facility according to facility policy and procedure. This deficient practice was observed for 1 of 1 residents (Resident #50) reviewed for dialysis. This deficient practice was evidenced by the following: A review of an admission Minimum Data Set (MDS), an assessment tool dated 12/1/21, revealed Resident #50 had a Brief Interview for Mental Status score of 13/15, indicating that he/she was cognitively intact. According to section I of the MDS, Resident #50 had an active diagnosis of end stage renal disease and section O revealed that Resident #50 received dialysis while a resident. According to the Order Summary Report, Active Orders As Of: 2/22/2022, Resident #50 had an order, dated 11/26/2021 for: [...]

Inspectors wroteBased on interview and review of other facility documentation, it was determined that the facility failed to ensure that all Certified Nursing Assistants (CNA) received 12 hours of mandatory education training, annually as required. This deficient practice was identified for 1 of 5 CNA files reviewed and was evidenced by the following: On 02/17/22 at 10:09 AM, the surveyor obtained and reviewed the performance evaluations and continuing education (CE) records of five randomly selected CNA staff members from the Assistant Director of Nursing (ADON). Upon review of the records, the surveyor noted the following: 1 of 5 Certified Nursing Assistants had no annual education for 2021. On 02/17/22 at 12:30 PM, the Infection Prevention Nurse (IPN) stated they did not have the required annual education for 1 of the 5 CNA's the surveyor requested for 2021. [...]

Inspectors wroteBased on interview, record review and review of other facility documentation, it was determined that the facility failed to follow the recommendation identified by the Consultant Pharmacist. This deficient practice was identified for 1 of 5 Residents (Resident #75) reviewed for unnecessary medications, psychotropic medications, and medication regimen review and was evidenced by the following: According to the admission Record, Resident #75 was admitted to the facility with diagnoses that included arthritis. A review of the Order Summary Report with active orders as of 2/17/2022, revealed a physician's order dated 12/9/2021 for the resident to receive Voltaren Gel 1% (a topical pain medication) Apply to B/L (bilateral) knees topically two times a day for pain. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documents, it was determined the facility failed to A.) ensure a used syringe left in a plastic cup on a bedside table was placed into a puncture proof container, B.) ensure a peripheral venous catheter (PVC) (medical tube placed into a peripheral vein for venous access to administer intravenous medications) had a protective sterile cap (an antimicrobial impregnated plastic device) applied when it was not in use to prevent exposing the access device to the environment and C.) failed to maintain contact isolation for 3 of 6 residents reviewed for Infection Control (Resident #477, Resident #169 and Resident # 103). The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to A.) implement a system to review antibiotic (medicine used against bacteria) use with the consultant pharmacist by failing to obtain monthly reports documenting potential areas of improvement, irregularities, and recommendations and B.) failed to implement ongoing education on the Antibiotic Stewardship Program (program to improve clinical outcomes and minimize harms by improving antibiotic prescribing). The deficient practice was evidenced by the following: During an interview with the surveyor on 2/16/22 at 10:21 AM, the Licensed Practical Nurse Unit Manager (LPNUM #2) revealed she is not sure what Antibiotic Stewardship is. LPNUM #2 revealed that when the facility obtains a new order for an antibiotic, there is nothing specific to do. [...]

Inspectors wroteBased on interview and review of other facility documentation, it was determined that the facility failed to provide residents with the required beneficiary notices for 2 of 3 residents reviewed for Beneficiary Protection Notification (Resident #41 and Resident #160). This deficient practice was evidenced by the following: On 2/17/22 at 8:30 AM, the surveyor reviewed the SNF Beneficiary Protection Notification Review (SNFBPNR) completed by the facility for Resident #41. The SNFBPNR indicated that Resident #41 last covered Medicare day was 4/10/22 and the resident remained in the building. The SNFBPNR further revealed that a Notice of Medicare Non-Coverage-Form CMS 10123 (NOMNC) was not provided to Resident #41. On 2/17/22 at 8:38 AM, the surveyor reviewed the SNFBPNR completed by the facility for Resident #160. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete a Significant Change in Status Assessment Minimum Data Set (SCSA-MDS) using the Resident Assessment Instrument (RAI), an assessment tool, process on a resident who elected hospice benefits. This deficient practice was identified for 1 of 2 residents (Resident #69) reviewed for hospice and end of life. This deficient practice was evidenced by the following: According to the most recent admission Record, Resident #69 was admitted to the facility with diagnoses that included: encounter for palliative care, polymyalgia rheumatica, fibromyalgia, and unspecified dementia with behavioral disturbance. On [DATE] at 11:19 AM during the initial tour of the facility the surveyor observed Resident #69 lying in bed. [...]