Complete Care at Barn Hill

Inspectors wroteBased on observation, interview, record review, and a review of the facility policies, it was determined that the facility failed to ensure that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 2 of 27 residents (Resident #9 and Resident #29) observed during the 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 record review, it was determined that the facility failed to respond to the Consultant Pharmacist's (CP) monthly recommendations in a timely manner for 1 of 27 residents (Resident #29) reviewed. The deficient practice was evidenced by the following:On 12/29/25 at 10:45 AM, the surveyor observed Resident #29 who was seated on their bed and was watching television. The resident was alert and oriented and told the surveyor in an interview that he/she received their medications every day. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 3 of 27 residents reviewed for accommodation of needs (Resident #16, 80, and 101), and was evidenced by the following: 1. On 12/29/2025 at 10:50 AM, the surveyor observed Resident #101 in bed with their eyes open and the call bell (a device used to summon the staff for assistance) on the floor, not within the resident's reach. The surveyor reviewed the medical record for Resident #101. A review of the admission Record reflected the Resident was admitted to the facility with diagnoses that included but were not limited to; [...]

Inspectors wroteBased on observation, interview, and review of the facility policy, it was determined that the facility failed to provide a homelike environment in resident rooms. The deficient practice was observed on 1 of 5 units ([NAME] Unit). The deficient practice was evidenced by the following:On 12/31/25 at 9:30 AM, the surveyor toured the [NAME] nursing unit and observed the following: In room [ROOM NUMBER], the floor was discolored and had black smudge marks throughout. In room [ROOM NUMBER], the floor was discolored and soiled, with black smudge marks throughout. In room [ROOM NUMBER], the wall across from the door, by the bed, was cracked, exposing wallboard, and the floor was discolored. In room [ROOM NUMBER], the floor was stained and soiled with a brownish substance, with black smudge marks throughout. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer Oxygen therapy according to the physician's orders for 2 of 3 residents reviewed for Respiratory therapy, Resident #16 and #53. 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 record review, it was determined that the facility failed to maintain kitchen equipment in a clean and sanitary manner as evidenced by the following: On 08/01/24 at 10:29 AM in the presence of the Food Service Director (FSD) and the Regional FSD (RFSD) the surveyor observed the following: 1. Inspection of the Microwave unit revealed the interior to have multi-colored splattered food debris stuck to the interior upper wall. 2. During inspection of the oven the surveyor observed 3 cast iron grill plates that were visibly used, dirty with solidified grease in the oven. The FSD stated they had been used the night before. On 08/05/24 at 10:15 AM, the surveyor interviewed the FSD. who stated that the cooking equipment should have been removed from the oven and cleaned after use. [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, accurately for 1 of 28 residents reviewed (Resident # 132). The deficient practice was evidenced by the following: The surveyor reviewed Resident # 132's records. The resident was discharged from the facility and according to the Discharge Return Not Anticipated MDS, an assessment tool used to facilitate the management of care, dated 5/3/24, the resident was assessed as being discharged to the hospital. A review of Resident # 132's progress notes dated 5/3/24 revealed the resident was discharged home with family. [...]

Inspectors wroteBased on interview, and review of other facility documentation, it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and apply for a change in name to include Doing Business As in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. [...]

Inspectors wroteComplaint #NJ00174420 Based on interviews, and record reviews, it was determined that the facility failed to provide pharmaceutical services by ensuring the resident did not receive a medication not ordered by the physician. The medication, metformin, (medication used to help lower blood sugar levels in people with type two diabetes- a chronic condition that happens when you have persistently high blood sugar levels) was given to Resident #395 without a valid physician order. The deficient practice was identified for one (1) of 28 residents, (Resident #395) reviewed for medication management. The deficient practice was evidenced by the following: Resident #395 was not in the facility; the surveyor conducted interviews and investigated the closed records. [...]

Inspectors wroteComplaint # NJ172653 Based on interviews, medical record review, and review of other pertinent facility documents on 04/08/2024 and 04/09/2024, it was determined that the facility failed to develop and implement a NPO (Nothing by Mouth) Care Plan (CP) for a resident (Resident #2) with a Peg Tube (a tube inserted through the wall of the abdomen directly into the stomach, it can be used to give drugs and enteral nutrition to a patient) and failed to follow its policy titled Care Plans, Comprehensive Person-Centered. This deficient practice was identified for 1 of 3 residents reviewed for CP and was evidenced by the following: Review of the Electronic Medical Record (EMR) was as follows: [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders to ensure that the residents' current medical regimen was appropriate. This deficient practice was observed for 16 of 24 residents (Resident #81, #15, #74, #18, #70, #167, #68, #12 #57, #106, #366, #98, #7, #115, #83, and #19) reviewed and occurred over several months. This deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) for the residents listed above that revealed the resident's primary physician had not hand signed the Order Summary Reports (monthly physician's orders) located in the residents' chart. In addition, there were no electronic signatures under the physician's orders for the following residents 1. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to implement infection control procedures in a manner that would decrease the possibility of spreading infection. This was found with: 1 of 2 certified nursing assistants (CNA) during urinary drainage bag changes, 1 of 5 nurses during medication administration and 1 of 3 nurses during wound care observation. The deficient practice was evidenced by the following: 1. On 3/1/22 at 10:12 AM, the surveyor observed the CNA who was assigned to Resident #83 change their large urinary drainage bag to a urinary leg bag. The resident had a urinary catheter (A flexible tube used to empty the bladder and collect urine in a drainage bag). The CNA, with gloved hands, pulled a garbage can towards her, removed her gloves, and put on a new pair of gloves. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to provide full visual privacy and maintain confidentiality when discussing the resident's pain during medication administration and a physical assessment, for 1 of 24 residents reviewed, Resident #116. The deficient practice was evidenced by the following: On 3/3/22 at 8:40 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare to administer medication to Resident #116. The surveyor observed the LPN speaking to the resident from outside the doorway of the resident's room. The LPN entered the room of Resident #116 to administer medication and examine the resident's abdomen. The door to the room was open and the resident could be seen from the hallway lying in the bed. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to notify resident families or resdient representatives (RR), and the Ombudsman's office in writing for a facility-initiated transfer to the hospital for 6 of 6 residents (Resident #81, #15, #18, #167, #105, and #106) reviewed for hospitalization. The deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) that revealed facility-initiated hospital transfers had occurred without written notification to the families and Ombudsman's office for the following residents: 1. According to the Discharge Minimum Data Set (MDS) an assessment tool dated 11/16/21, Resident #81 was transferred to the hospital with anticipated return to the facility. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow physician's orders and failed to handle medication appropriately. This was found with 2 of 24 residents reviewed, Resident # 115 and Resident # 81. 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: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide the necessary respiratory care and services in accordance with professional standards of practice for 1 of 1 resident (Resident #15) reviewed for respiratory services. The deficient practice was evidenced by the following: On 2/25/22 at 8:22 AM, the surveyor observed Resident #15 in bed awake and alert receiving oxygen (O2) via a nasal cannula at 4 l/m (liters per minute) and a CPAP (continuous positive airway pressure to prevent the collapse of airway) mask on the nightstand not secured in a plastic bag. During the interview with resident, the resident stated that the nurses do not clean the mask. On 3/4/22 at 10:38 AM, the surveyor observed the resident in bed awake and alert with O2 via nasal cannula at 4 l/m O2 and the CPAP mask was in a plastic bag. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to properly label and date medications in 1 of 8 medication carts and 1 of 3 medication storage rooms inspected. The deficient practice was evidenced by the following: 1. On 2/28/22 at 12:26 PM, the surveyor inspected the medication cart on the [NAME] unit in the presence of the Licensed Practical Nurse (LPN) who was assigned to the cart. There was a Lispro insulin vial box with a resident's last name written with a marker on the box. The lispro insulin vial removed from inside the box, had written in marker a different resident's last name. There was a second lispro insulin vial box with a pharmacy label. The lispro insulin vial removed from inside the box, had written in marker, the resident's last name which was smeared and only partially visible. There was no pharmacy label on the vial. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to consistently provide coordination between facility staff and hospice agency staff to meet the resident's nursing needs. The deficient practice was identified for 1 of 2 residents (Resident #366) reviewed for hospice/end of life care and was evidenced by the following. On 2/24/22 at 11:18 AM, the surveyor observed Resident #366 in bed. The resident's family member was at the resident's bedside. The resident's family member said the resident was on hospice. The resident appeared weak, looked at the surveyor and mouthed words but did not speak. The resident's family member said the resident could no longer hear or see very well. The resident's family member said the hospice aide went to the facility to see the resident every day at 7 AM. [...]