Chatham Hills Subacute Care Center

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication times of administration for a medication (Gabapentin) (used to treat nerve pain) to accommodate for dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) scheduled times and was not administered 41 times from June 2025 until surveyor inquiry September 2025. 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, and review of other facility documentation, it was determined that the facility failed to ensure that a Licensed Practical Nurse followed the PO to notify physician when blood sugar was less than 70 or above 250 for 1 of 1 resident's reviewed for medication administration, (Resident #15). This deficient practice was evidenced as follows: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, interviews, record review and review of pertinent facility documents, it was determined that the facility's Consultant Pharmacist's (CP) failed to identify and address irregularities for a.) a medication prescribed for neuropathy (damage, disease, or dysfunction of one or more nerves that can cause burning or shooting pain, numbness, and tingling) was not administered 41 times from 6/7/25 through 9/15/25 when the resident was consistently out of the facility to attend dialysis treatments at 1 PM. This was identified for 1 of 1 residents reviewed for dialysis (Resident #2); and b.) inadequate monitoring and documentation for the reason an as needed anti-anxiety medication (Xanax) was administered. This was identified for 1 of 5 residents, (Resident #6), reviewed for unnecessary medications. The deficient practice was evidenced as follows; REFER to F698 1. [...]

Inspectors wroteBased on observations, interviews and review of pertinent facility documents, it was determined that the facility failed to maintain proper food service sanitation practices and properly store potentially hazardous foods to prevent the development of food borne illness. This deficient practice was evidenced by the following: On 9/11/25 at 10:20 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and another surveyor and observed the following: The walk-in freezer had a solid piece of ice on the floor on the right side of a rack under the fan. The FSD stated that during the defrosting stage ice seemed to build up. An opened cardboard box labeled puff pastry was observed with ice buildup on top. The box was removed from the freezer by the FSD to further inspect. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the resident's environment, equipment, and living area in a safe, sanitary, and homelike manner. This deficient practice was identified in 1 of 2 nursing units (South Unit room [ROOM NUMBER]) observed for environment, and was evidenced by the following:On 9/11/25 at 11:50 AM, the surveyor observed in room [ROOM NUMBER], a tube feeding pump (moves the formula through the feeding tube into the stomach at a controlled rate) soiled with a yellow and brown substance. The surveyor also observed two floor mats that were heavily soiled with black and brown substances. On 9/15/25 at 12:58 PM, the surveyor observed the tube feeding pump was no longer in room [ROOM NUMBER]. [...]

Inspectors wroteRefer to F756Based on observation, interview and record review, it was determined that the facility failed to ensure a resident was free from unnecessary administration of an as needed psychotropic medication, (Xanax) (an anti-anxiety medication), by adequately documenting and monitoring non-drug interventions that were attempted and failed prior to administration and exhibited targeted behaviors identified for the need for medication use. The deficient practice was identified for one (1) of five (5) residents, (Resident #6), reviewed for unnecessary medications and was evidenced by the following:On [DATE] at 11:06 AM, the surveyor interviewed the certified Nursing Aide (CNA #1) who stated that she had been working at the facility for approximately one month and was assigned to Resident #6. [...]

Inspectors wroteComplaint #403805Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that written notice of a resident's transfer to a hospital was provided to a family member or guardian for 1 of 4 residents (Resident #102) reviewed for hospitalization. This deficient practice was evidenced by the following: A review of Resident #102's admission Record reflected the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to; post operative care of a surgical wound of the right buttock, an antibiotic-resistant infection of the surgical wound site and a history of a ruptured aneurysm (a rupture of a weakened area of a blood vessel) in the brain. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan (CP) that included the use of antipsychotic medication for a diagnosis of schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, changing how people think, feel and act ). The deficient practice was identified for 1 of 20 residents (Resident #3) reviewed for Care Plans. This deficient practice was evidenced by the following: On 9/12/25 at 11:57 AM, the surveyor observed Resident #3 in the common area, in a wheelchair, waiting for lunch. The surveyor reviewed the admission Record (or face sheet, an admission summary) which revealed that the resident had been admitted to the facility with diagnoses that included schizoaffective disorder. [...]

Inspectors wroteComplaint # NJ403814Based 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 4 of 5 residents (Resident #4, 10, 43, and 64) observed for incontinence care on 1 of 2 Nursing units (South unit). This deficient practice was evidenced by the following:On 9/16/25 at 7:40 AM, the surveyor completed an incontinence tour on the South Nursing Unit and observed the following:1.) On 9/16/25 at 7:40 AM, the surveyor, accompanied by the Certified Nursing Assistant (CNA #1), observed Resident #10 in bed. CNA #1 exposed Resident #10's incontinence brief, and the surveyor observed that it was saturated with urine and feces. [...]

Inspectors wroteBased on record review, observation, interview, and review of facility policy, the facility failed to ensure staff followed enhanced barrier precautions (EBP) while providing Activities of Daily Living (ADLs) care for one resident out of 24 facility residents (Resident (R) 1) on EBP. This failure increased the risk of the spread of infections in the facility.

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illnesses. This deficient practice was evidenced by the following: On 05/22/2024 from 10:10 AM to 10:42 AM, the surveyor, accompanied by the Food Service Director (FSD), toured the kitchen, and observed the following: In the walk-in freezer, the surveyor observed a box of hamburger patties and a box of hot dogs with no labels or dates and both boxes with the inner plastic bags open to the air. The FSD stated that there should be a received date and opened dates. She also stated that the inner bags should be closed. The surveyor also observed the fry basket with an item that resembled a french fry. [...]

Inspectors wroteNJ #167099 Based on observations, interviews, and record review it was determined that the facility failed to ensure that staff wear the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) to address the risk for infection transmission, in accordance with the facility policy and acceptable standards of infection control practice. This was observed for 2 of 3 residents (Resident #41 and #18) reviewed for Enhanced Barrier Precautions on 2 of 2 units (North and South Unit) and was evidenced by the following: 1. On 05/24/24 at 7:45 AM, during incontinence rounds with the Infection Preventionist on the South Unit, the surveyor observed an Enhanced Barrier Precautions sign outside of unsampled Resident #41's door. There was a PPE bin located under the sign. [...]

Inspectors wroteBased on observations, interview and record review, it was determined that the facility failed to ensure that residents were served their meals in a dignified manner during meal service. This deficient practice was observed for 3 of 3 meals in 1 of 2 dining rooms. The deficient practice was evidenced by the following: On 05/22/2024 at 12:24 PM, the surveyor observed in the South unit dining area during mealtime that at one table, a staff member sat and fed a resident while the other resident at the same table was not eating or being fed. A second table was observed with three residents that were served their trays and eating, while one resident at the same table did not have their meal. A third table was observed with two residents that were served their trays and eating while two other residents at the same table did not have their meals. [...]

Inspectors wroteBased on interviews it was determined that the facility failed to provide daily delivery of mail, to include Saturdays. This deficient practice was identified for 1 of 5 residents interviewed during the resident council group meeting (Resident #61), and was evidenced by the following: On 05/24/24 at 10:03 AM, the surveyor attended a resident council group meeting with Residents #38, #45, #48, #61 and #64. The surveyor interviewed the residents regarding mail delivery and Resident #61 stated that they did not received mail from November 2023 until mid-March of 2024. The resident stated that he/she was expecting a letter from Social Security and when they brought the concern to the social worker, she returned with a pile of mail including a letter that informed the resident was disqualified because the date had passed. [...]

Inspectors wroteCOMPLAINT # 157599 Based on observations, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to ensure a resident who was dependent on staff for activities of daily living (ADL) was consistently provided meal assistance as needed. This deficient practice was identified for 2 of 5 residents (Resident #10 and #32) reviewed for ADLs and was evidence by the following: 1. On 05/22/24 at 12:03 PM, during the initial tour of the South Unit, the surveyor observed Resident #32 lying in bed. The resident's eyes were closed. On 05/23/24 at 11:07 AM, the surveyor observed the resident dressed, lying in bed. There was staff in the room assisting the resident's roommate. The surveyor reviewed the electronic medical record (EMR) for Resident #32. [...]

Inspectors wroteComplaint #: NJ00167644 Based on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to a.) clarify duplicate physician's orders for an over-the-counter medication, Ferrous Sulfate and b). failed to obtain a medication for pain. This deficient practice occurred for 2 of 7 residents, (Resident #63 and #133) reviewed for medication review. 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 review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of garbage and debris. This deficient practice was evidenced by the following: On 05/22/2024 at 10:31 AM, during the initial kitchen tour with the Food Service Director (FSD), the surveyor observed debris and trash around the dumpster area, including cardboard and paper. The FSD stated that housekeeping was responsible for this area. On 05/29/2024 at 01:17 PM, the surveyor interviewed the Administrator, who stated the dumpster area was cleaned up immediately after the debris was identified by the surveyor. Review of facility provided policy Waste Management Policy, dated 01/03/24, included: #3. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to: a. ensure the infection control practices for residents on transmission-based precautions were implemented in accordance with accepted national standards, and b. perform hand hygiene while caring for facility residents and c. disinfect equipment prior to and after use, d.) follow appropriate infection control procedure during wound treatment. These deficient practices were observed on 11 of 20 residents reviewed for infection control practices, Resident #252, #253, #19, #97, #11, #6, #69, #35, #57, #35, #100. The deficiency is evidenced by the following: 1. On 3/14/21 at 11:04 AM, during the initial tour, the surveyor observed the Certified Nursing Assistant (CNA) #1 wearing a disposable gown, gloves and N-95 mask, enter Resident #252's room. [...]

Inspectors wroteBased on observation, interview, and facility documentation review, it was determined that the facility failed to document a. ordered behavioral monitoring and b. ordered urinary outputs on 2 of 20 residents whose care was reviewed for its accordance with professional standards of practice. The deficiency is evidenced by the following: Reference: New Jersey Statues, 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 properly secure an oxygen cylinder and failed to ensure that oxygen was delivered at a rate consistent with the physician orders for 2 of 3 residents reviewed for respiratory care, Resident #35 and Resident #97. The deficiency is evidenced by the following: 1. On 3/14/22 at 10:07 AM, the surveyor observed Resident #35 seated in a chair in their room with a walker in front of them. The surveyor observed an oxygen cylinder (an oxygen storage vessel) propped sideways inside the open seat of the walker which had a basket inside. The oxygen cylinder was not securely fastened to a caddy or holder. The surveyor interviewed Resident #35 who stated that this is how they, always store their oxygen because this is the way that it works best for them to walk with the oxygen cylinder. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to accurately document required information on the shift to shift narcotic accountability log and the Consultant Pharmacist failed to inform the facility of this discrepancy for 1 of 2 units inspected. This deficient practice was evidenced by the following: On 3/14/22 at 11:30 AM, the surveyor in the presence of the Licensed Practical Nurse #1 (LPN #1) assigned to the Low North Unit medication cart. reviewed the Shift to Shift Narcotic Accountability Log for February 2022 and March 2022 on the Low North Unit. Review of the North Low Unit Shift to Shift Narcotic Accountability Log dated February 2022, presented many missing signatures by nursing staff that were outgoing (ending their shift) and incoming (starting their shift). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the safe and appetizing temperatures of food and drink were appropriately served to facility residents. This deficient practice was identified during the lunch time meal service on 3/17/22 on 2 of 2 nursing units tested for food temperatures (North and South units), and was evidenced by the following: On 3/16/22 at 11:29 AM, two surveyors conducted a group meeting with six residents who were part of the facility's resident council. All six residents indicated that their breakfast and lunch meals are frequently late and the food is cold. The residents informed the surveyors that sometimes they do not get breakfast until 9 AM and lunch until 1 PM. On 3/17/22 at 9:35 AM, the surveyor calibrated the thermometer in accordance with manufacturer instructions in the presence of two other surveyors. [...]

Inspectors wroteF812 - Food Safety Requirements Based on observation, interview, and record review the facility failed to maintain proper kitchen sanitation practices. This deficient practice was identified by the following: On 3/14/22 at 10:50 AM, this surveyor conducted the kitchen inspection. Surveyor observed the following: 1. Two dietary aides without hairnets while on the tray line. Surveyor interviewed both dietary aides (DA#1 and DA#2). Surveyor asked DA#1 while in the kitchen what should be worn? DA#1 stated, While serving the tray line we wear disposable gloves and hairnets. DA#1 realized she was not wearing her hairnet and went to put one on. Surveyor interviewed DA#2. DA#2 put on a hairnet while DA#1 was being interviewed but had hair sticking out the front. Surveyor asked why she did not have her hairnet on prior. DA#2 stated, Well, I had my sweatshirt hood on. [...]