Clover Meadows Healthcare and Rehabilitation Cente

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 kitchen sanitation in a safe consistent manner in order to prevent food borne illness. The deficient practice was evidenced by the following: On 6/23/26 at 8:28 AM, the surveyor entered the kitchen and observed the FSD preparing and handling food at the kitchen counter without a hairnet on. At that time, the surveyor interviewed the FSD and he acknowledged that he was not wearing a hairnet. The FSD then left from preparing and handling the food at the kitchen counter, walked to and opened the kitchen door to exit the kitchen to retrieve a hairnet, then opened the kitchen door to re-enter the kitchen, walked back to the kitchen counter and continued to prepare and handle the food in the kitchen without washing his hands. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide the necessary services to maintain adequate grooming for a resident who was dependent on the staff for Activities of Daily Living (ADL). This deficient practice was observed for 1 of 1 resident (Resident #47) reviewed for ADL care. The deficient practice was evidenced by the following:On 6/22/26 at 10:55 AM, during an initial tour, the surveyor observed Resident #47 watching TV in their bed. The surveyor observed the resident's chin with grey colored, curled facial hair and both hands with long, jagged fingernails with sharp edges. The resident stated, that needs to be done while pointing towards their facial hair. The resident stated they (the nails) need to be cut short, and I cannot do it by myself. [...]

Inspectors wroteComplaint # 2581082Based on observation, interview, medical record review and review of other pertinent facility documentation it was determined that the facility failed to update and revise a resident's Comprehensive Interdisciplinary Care Plan (CICP) after facility identification of a skin condition. This deficient practice was identified for 1 of 3 residents (Resident #1) and was evidenced by the following:A review of the resident admission Record (admission summary) indicated that Resident #1 was admitted to the facility with the diagnoses which included but was not limited to dementia, depression, and malignant neoplasm of the breast. A review of the annual Minimum Date Set (MDS-an assessment the facilitates a resident's care) dated 9/27/25, indicated that Resident #1 had severe cognitive deficits and was dependent on staff for activities of daily living. [...]

Inspectors wroteBased on observations, interviews, record review, and review of pertinent facility documents, it was determined the facility failed to ensure a.) a physician's order (PO) was in place for a resident who used a machine that helps you breathe for sleep apnea (a sleep disorder in which breathing repeatedly stops and starts), which the resident brought from home, b.) a PO was in place for the proper settings, c.) a PO was in place to maintain the cleanliness of the machine and it's parts in accordance to the manufacturer's instructions. This deficient practice was identified for 1 of 3 residents (Resident #9) reviewed for respiratory care; and d.) respiratory masks were stored properly after use to prevent contamination. This was identified for 2 of 3 residents (Resident #9 and #238) that were reviewed for respiratory care. This deficient practice was evidenced by the follows: 1. [...]

Inspectors wroteCOMPLAINT# NJ00179885 Based on observation, interview and record review, it was determined that the facility failed to submit a report to the New Jersey Department of Health (NJDOH) within the two-hour timeframe for an allegation of abuse made by a resident, (Resident #82). The deficient practice was identified for one (1) of four (4) residents reviewed for abuse investigations and was evidenced by the following: On 1/12/25 at 11:00 AM, the surveyor observed Resident #82 in bed. The surveyor interviewed the resident, and the resident had no concerns. On 1/14/24 at 11:15 AM, the surveyor observed the resident in their room in bed. The surveyor interviewed the resident regarding an incident in November but the resident had not wanted to speak about any incident regarding staff. The surveyor reviewed the medical record for Resident #82. [...]

Inspectors wroteBased on observation, interviews, record review, and facility documents it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication administration times to accommodate a resident's dialysis (a clinical purification of blood as a substitute for the normal function of the kidneys) schedule for 1 of 1 resident, Resident #62, reviewed for dialysis. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to post the nurse staffing report daily. This deficient practice was identified on 1/12/25, and was evidenced by the following: On Sunday, 1/12/25, at 09:00 AM, the surveyor observed the nursing staffing report posted at the front reception desk. The receptionist was present. The nursing staffing report was dated Friday 1/10/2025, which reflected all shifts for that day. On 1/13/25 at 8:04 AM, the surveyor observed the nursing staffing report posted at the front reception desk had not been updated from 1/10/2025. The receptionist was present. On 1/13/25 at 10:46 AM, the surveyor observed the nursing staffing report posted at the front reception desk had not been updated from 1/10/2025. The receptionist was present. [...]

Inspectors wroteBased on observation, interview, and pertinent record review, it was determined that the facility failed to ensure the accountability of the Narcotic Shift Count logs were completed in accordance with facility policy. This deficient practice was identified on 2 of 2 medication carts reviewed for medication storage and labeling and was evidenced by the following: On 10/26/23 at 10:27 AM, the surveyor, in the presence of the Licensed Practical Nurse #3 (LPN #3), reviewed the narcotic logbook for the North Wing Back Hall medication cart. The Controlled Drugs Accountability/Count Sheet for August, September, and October 2023 shift logs revealed the following incomplete or blank sections: 8/5/23 - 11 PM -7 AM total incoming count section containing counts for Bingo, Boxes, Bottle, and Sheet. 8/6/23 - 11 PM -7 AM total incoming counts for Bingo, Boxes, Bottle, and Sheet. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to properly store medications and properly label opened multidose medications. This deficient practice was observed in 1 of 1 medication storage rooms and 2 of 2 medication carts reviewed for medication storage and labeling and was evidenced by the following: On [DATE] at 10:27 AM, the surveyor, in the presence of the Licensed Practical Nurse #3 (LPN #3), reviewed the North Wing Back Hall medication cart. The following was observed: One (1) opened aluminum envelope of dorzolamide hydrochloride and timolol maleate ophthalmic solution, usp 2%/0.5% preservative free (a prescription eye drop medication used to treat glaucoma) labeled from the manufacturer to contain 15 single use containers, opened and contained 18 single use containers. [...]

Inspectors wroteBased on observations, interviews, and review of other facility documentation, it was determined that the facility failed to provide privacy and promote dignity during resident assessment and medication administration. This deficient practice was identified for 2 of 2 residents (#20 and #52) reviewed for dignity and was evidenced by the following: 1. During the initial tour of the facility on 10/24/23 at 10:45 AM, the surveyor observed Resident #20 seated in the wheelchair in the hallway outside of their room. When interviewed, the resident reported a positive cough last evening. Review of Resident #20's admission Record revealed that the resident was readmitted to the facility in October of 2023 with diagnosis which included but were not limited to: [...]

Inspectors wroteBased on record review and interview, it was determined that the facility failed to transfer discharged or expired resident's personal needs account (PNA) funds back to the appropriate jurisdiction within 30 days of death or discharge and ensure that the total amount in the PNA account did not exceed the Supplemental Security Income (SSI) resource limit. This deficient practice was identified for 7 of 7 residents reviewed for PNA accounting (Resident #7, #9, #298, #299, #300, #301, and #302). This deficient practice was evidenced by the following: The surveyor reviewed the Clover Meadows Healthcare and Rehabilitation Center Funds Balance Report - Resident Trust Liability (RTL) dated [DATE]. The RTL indicated the following balances: [...]

Inspectors wroteComplaint # NJ00167863 Based on observation, interviews, review of medical records, and other facility documentation, it was determined that the facility failed to thoroughly investigate an allegation of resident to resident abuse for 2 of 2 residents (Residents #52 and #64) reviewed for resident to resident abuse. This deficient practice was evidenced by the following: The surveyor reviewed Resident #64's electronic health record (EHR) and noted a Behavior Note within the Progress Notes (PN) that was documented on 09/23/23 at 6:38 PM, that was written by the Registered Nurse (RN) and revealed that the resident was observed taking food off of the food cart. Certified Nursing Assistant (CNA) covered the food cart and the resident became argumentative, cursed at another resident and a confrontation occurred with the same resident. No injuries were noted. [...]

Inspectors wroteComplaint #NJ00151166 Based on interviews, medical records review, and review of other pertinent facility documentation on 10/30/23, it was determined that the facility failed to follow their policies and procedures for a facility-initiated discharge. A resident (Resident #243) left the facility against medical advice (AMA) and ended up at the hospital. The hospital reached out to the facility when the resident was ready for discharge from the hospital and the facility would not permit Resident #243 to return back to the facility. The deficient practice was identified for Resident #243, 1 of 1 residents reviewed for transfer/discharge and was evidenced by the following: [...]

Inspectors wrote2. According to the Face Sheet, Resident #143 was admitted to the facility with diagnoses including but not limited to: acute kidney failure and kidney transplant status. A review of the Minimum Data Set (MDS) admission Assessment for Resident #143 revealed an ARD of 10/15/23 with a completion date of 10/26/23. A review of the medical record on 10/31/23 reflected that the MDS for Resident #143 had not been completed in accordance with RAI manual. During an interview on 10/31/23 at 10:17 AM, the Registered Nurse/MDS Coordinator (RN/MDS) confirmed the admission assessment had not been completed by 10/24/23 as required. She confirmed that the admission assessment was completed on 10/26/23 two days past due. [...]

Inspectors wroteBased on observations, interviews, and review of medical records and other facility documention, it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) using the Resident Assessment Instrument (RAI) process on a resident who elected hospice benefits. This deficient practice was identified for 1 of 1 resident reviewed for hospice (Resident #9). This deficient practice was evidenced by the following: During the initial tour of the facility on 10/24/23 at 10:31 AM, the surveyor observed Resdient #9 lying in bed with the bed positioned up against the wall and a fall mat was placed on the left side of the resident's bed. The resident smiled but did not respond when spoken to. [...]

Inspectors wroteBased on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 2 of 19 residents reviewed (Resident #40 and #56). This deficient practice was evidenced by the following: 1. On 10/24/23 at 12:21 PM, the surveyor observed Resident #40 in the room sitting on the bedside. Resident #40 stated he/she had been at the facility for five years and had no concerns. Resident #40 told the surveyor they were pleased that they could smoke at the facility. Resident # 40 was admitted to the facility in 2019. Medical diagnoses included but were not limited to acute kidney failure, alcohol dependence, hyperlipidemia (high cholesterol), and hypertension (high blood pressure). [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to conduct a new Preadmission Screening and Resident Review (PASARR) level one assessment after a resident was newly diagnosed with a mental illness. This deficient practice was identified in 1 of 1 resident reviewed for PASARRs (Resident #56) and was evidenced by the following: On 10/24/23 at 10:33 AM, during the initial tour of the facility the resident was out of bed in a wheelchair. The resident told the surveyor they were going outside to Take care of things. The surveyor asked if the resident was a smoker and Resident #56 replied, Yes. On 10/24/23 at 12:18 PM, during resident record review the surveyor reviewed Resident #56 Pre-admission Screening and Resident Review (PASARR) one which was completed prior to admission to the facility on [DATE]. [...]

Inspectors wroteNJ Complaint #NJ00165907 Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to ensure that the job description of a Certified Nursing Assistant (CNA) was followed by allowing the cutting of a residents hair. This was indentified in 1 of 1 resident reviewed (Resident #40) and 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 state: [...]

Inspectors wroteBased on observations, interviews, medical record review and review of other pertinent facility documentation, it was determined that the facility failed to properly assess and monitor a resident that was previously identified as a high risk for falls after a fall occurred in accordance with professional standards and the facility policy for 1 of 1 resident (Resident #9) reviewed for falls. 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 state: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to properly document the correct amount of Oxygen administered in the progress notes. This deficient practice was identified for 1 of 1 resident (Resident #2) reviewed for respiratory care, and was evidenced by the following: On 10/26/23 at 11:50 AM, the surveyor observed Resident #2 receiving Oxygen via nasal cannula with a setting of 2 liters/minute. A review of the face sheet revealed that Resident #2 was admitted to the facility with diagnoses including, but not limited to, chronic obstructive pulmonary disease ( a respiratory disease), and congestive heart failure (a disease where the heart does not pump blood as well as it should), and pneumonia (an infection of the lungs) with a history of home Oxygen use. [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documents, it was determined that the facility failed to a.) properly label, date, and store potentially hazardous foods in a manner that was intended to prevent the spread of food borne illnesses, and b.) maintain equipment and dishware in a manner to prevent microbial growth and cross contamination and c.) discarding food items. This deficient practice was observed and evidenced by the following: On 10/24/2023 at 09:43 AM, the surveyor toured the kitchen in the presence of the Director of Culinary Services (DCS) and observed there were no hair nets available at the entrance of the kitchen. The DCS stated no hair nets were kept at the entrance because it was the only way to deter staff from entering the kitchen, staff must ask for a hair net first. The surveyor asked if this was the policy and the DCS confirmed it was. [...]

Inspectors wroteBased on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to: 1) maintain proper infection control practices identified during the: a) medication administration observation and 2) follow their policy for Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that may cause serious illnesses and injuries) usage and hand hygiene to prevent the possible spread of infection. This deficient practice was identified during the: [...]