Complete Care at Cedar Grove

Inspectors wroteBased on interviews, record review, and review of pertinent facility documentations on 3/30/26 and 3/31/26, it was determined that the facility failed to provide documentation of completion of Activities of Daily Living (ADL) tasks of getting residents out of bed and providing turning and repositioning for dependent residents for the time period of of September 2025 through December 2025. This deficient practice was identified for 1 of 5 residents, Resident #1, that were reviewed for ADL documentation as follows: [...]

Inspectors wroteNJ00183439 Based on observation, record review and interview on 04/28/25, it was determined that the facility failed to provide a clean and homelike physical environment for their residents. This deficient practice was identified in 2 of 4 bedrooms observed and was evidenced by the following: During tour on 4/28/25 at 10:12 a.m., the surveyor entered room [ROOM NUMBER] and noted black dried substance behind dresser under wallpaper. During tour on 4/28/25 at 10:14 a.m., the surveyor entered room [ROOM NUMBER] and noted black dried substance behind dresser under wallpaper. During tour on 4/28/25 at 11:21 a.m. with the Director of Maintenance and the Maintenance staff, both confirmed the black dried substance on the walls behind the wallpaper behind the dressers in rooms [ROOM NUMBERS]. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) ensure respiratory tubing cannula was stored in accordance with infection control measures for 1 of 4 residents, (Resident #55) and b.) administer oxygen therapy according to the physician's order for 3 of 4 residents, Resident #28, #160 and #273). 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 maintain the call bell within reach of residents. This deficient practice was identified for 3 of 35 residents reviewed for the accommodation of needs (Resident #108, #128, and #116), and was evidenced by the following: 1. On 11/12/24 at 11:55 AM, the surveyor observed Resident #108 in bed on a specialty mattress with a contracture to their right hand. The surveyor observed the resident's call bell (a bell used to summon staff for assistance) was affixed to the right upper enabler and dangling down towards the floor, not within his/her reach. The surveyor reviewed the medical record for Resident #108. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of nursing practice for not following physician orders for medications with parameters for 1 of 1 residents reviewed (Resident # 148). 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 licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to assure that a.) intravenous bags were stored in a tamper and contaminant resistant packaging, b) accurate dispensing and administration of pain medication c.) a narcotic medication that was ordered by the physician was available for administration. The deficient practices were identified for one (1) of two (2) medication rooms and two (2) of four (4) medication carts inspected during the medication storage and observation and 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, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation conducted on 11/14/24, the surveyor observed four (4) nurses administer medications to four (4) residents. There were 27 opportunities, and two errors were observed which resulted in a medication error rate of 7.41%. This deficient practice was identified for one (1) of three (3) residents, that was administered by one (1) of three (3) nurses. and was evidenced by the following: On 11/14/23 at 9:01 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medications for Resident #64. The medications included the following: - Metformin 500 milligram (mg), give 1 tablet by mouth two times a day for type 2 diabetes mellitus. Give with food. The order was started on 3/13/23. [...]

Inspectors wroteBased on observation, interview, review of the facility's meal schedule, and facility policy review, the time span between the residents' evening meal and the following breakfast meal exceeded 14 hours and the time span between these two meals was not approved by five of five residents (Resident (R) 47, R49, R53, R61, and R118) who regularly attended the monthly resident council meetings and were interviewed regarding the facility's meal schedule. This failure had the potential to affect 164 residents who received meals from the facility's kitchen.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure coffee pitchers and the juice machine's dispenser nozzle were dry when stored, kitchen ceiling tiles were free of mold, kitchen storage racks were clean and kitchen sanitizing buckets contained adequate quaternary ammonia to sanitize kitchen equipment and food preparation surfaces. This failure had the potential to affect 164 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on interview and review of facility documentation, the Quality Assurance and Performance Improvement (QAPI) committee failed to hold quarterly meetings for one of four QAPI meetings conducted. This failure had the potential to affect all 170 residents who currently live in the facility.

Inspectors wroteBased on observation, interview, record review, review of Resident Council minutes, and facility policy review, the facility failed to serve food that was palatable to three of five residents (Resident (R) 49, R53, and R61) reviewed for food palatability. This failure had the potential to affect all 164 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of 39 sampled residents (Resident (R) 117). The facility staff failed to promote choices regarding R117 being able to stay in her room instead of going to the activity room. R117 was dissatisfied with having to go to the activity room instead of staying in her room.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to notify the Ombudsman of the transfer to the hospital for one of four residents (Resident (R) 8) reviewed for hospital transfers, out of a total sample of 39 residents.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the residents' medication status for two of two (Resident (R) 71 and R89) in a total sample of 39 residents.

Inspectors wroteBased on interview, record review and policy review, the facility failed to develop a care plan for one of five residents (Resident (R) 89) reviewed for unnecessary medications regarding the resident's daily use of an antipsychotic medication.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure staff provided the removal of facial hair for one of one dependent residents (Resident (R) 65) reviewed for Activities of Daily Living (ADLs) in a total sample of 39 residents.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to revise the care plan implement fall interventions to prevent future injuries from a fall for one resident (Resident (R) 9) out of two residents reviewed for falls from a total sample of 39 residents. The failure to update the care plan and implement revised fall interventions for a resident with a history of falls could result in serious injury.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to maintain the cleanliness of the nebulizer mouthpiece when not in use for one of 39 residents in the survey sampled (Resident (R) 30. This deficient practice increases the risk of infection for a resident requiring nebulizer therapy.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure prescribed medications were available for administration for one of eight residents (Resident (R) 49) whose drug regimen was reviewed. The facility failed to have R49's Xifaxan medication available to administer as prescribed which caused the resident to not to feel well on the days it was not administered.