Complete Care at Fair Lawn Edge

Inspectors wroteComplaint # 2693362 Based on observation, interviews and review of other pertinent facility documents on 12/22/2025,12/23/2025 and 12/29/2025, it was determined that the facility failed to develop and implement a procedure to safely acquire and receive physician ordered Methadone, (a controlled Substance) from a third party clinic; by assigning an unlicensed staff a Certified Nursing Assistant (CNA #1) to travel to an outside third party clinic to pick up Methadone (a controlled substance) for Residents #6,#7 and #8. CNA #1 would take the locked box with the key which contained the Methadone and drive to the facility in her personal car. An interview with the third-party's clinic staff and with facility's CNA #1 confirmed that CNA #1 picked up Methadone from the outside clinic and had access to the key for the box with the Methadone. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, the facility failed to ensure the facility was maintained in a safe, clean, and homelike environment. This deficient practice was identified for 2 of 2 units (3rd and 4th floors) and 2 of 2 shower rooms. This deficient practice was evidenced by the following:On 8/13/25 at 9:55 AM, the surveyor with the Housekeeping Director (HD) toured the 3rd floor and observed the following inside the shower room:-Upon entry, toward the right side of the shower room in the 1st cubicle, there was a shower chair with ripped chair cover, and across the 1st cubicle was a plastic tray. The 1st cubicle wall tiles and moldings with yellowish stain. The HD informed the surveyor that the plastic tray was part of a wheelchair that should have not on the floor. [...]

Inspectors wroteBased on the interview and review of other facility documentation, it was determined that the facility failed to issue the Notice of Medicare Non-coverage (NOMNC, which is an official document issued by Medicare-certified healthcare providers and serves as a formal notice informing beneficiaries about the termination or denial of coverage for specific health care services) or Form CMS - 10123, required notice for 1 of 3 residents (Resident #182) reviewed for beneficiary notification. This deficient practice was evidenced by the following On 8/11/25 at 10:51 AM, the surveyor reviewed the NOMNC or Form CMS -10123 review completed by the facility for Resident #182 as follows: A review of the Progress Notes (PN) dated 4/9/25 at 4:19 PM stated that the resident was transferred to another health care facility. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to consistently follow standards of clinical practice by following a physician's order for the administration of medications and clarifying a physician's order for 2 of 5 residents (Resident #19 and #21). 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 ensure that a resident receive treatment and care as specified by hospital discharge orders, in accordance with professional standards of practice and facility policies and procedures for 1 of 35 residents (Resident #169) reviewed. 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, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to ensure, a.) proper handling and storage of linen and laundry and b.) proper disposal of garbage to prevent the potential spread of infection in accordance with standards of clinical practice, and the facility's policy. This deficient practice was identified for 1 of 1 laundry area, 1 of 3 linen rooms, and 1 of 2 shower rooms observed during infection control tour. This deficient practice was evidenced by the following:On 8/13/25 at 9:38 AM, the surveyor toured the laundry area in the presence of the Laundry Staff (LS). Both the surveyor and the LS observed the following:-Upon entry to the laundry area, there was an electric fan on the floor blowing air toward the clean hung personal clothes of the residents. [...]

Inspectors wroteComplaint #NJ 165064 Complaint #NJ 166666 Based on interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to 1.) provide adequate supervision for a cognitively impaired, exit seeking resident and ensure exit doors were securely locked which resulted in Resident # 353 eloping from the facility on 06/15/2023 and 2.) follow facility elopement policy which resulted in Resident # 355 eloping from the facility on 08/17/2023. This deficient practice was identified for 2 of 3 residents (Resident # 353 and Resident # 355) reviewed for elopement. The facility failed to monitor and supervise a cognitively impaired, exit seeking resident from being able to exit the facility through an unsecured exit door. This posed a serious and immediate risk to the health, safety, and well-being of Resident #353. [...]

Inspectors wroteBased on observation, interview, record review and review of facility documents, it was determined that the facility failed to adhere to acceptable standards of nursing practice. This deficient practice was identified in 4 of 7 residents who had medication improperly prepared for administration, 1. Resident #86, #199, #73, #200, 2. facility failed to ensure a resident's medication times were adjusted to accommodate their dialysis (a clinical purification of blood as a substitute for the normal function of the kidneys) schedule for 1 of 3 Residents reviewed for accurate dialysis scheduling of medication times, Resident #84, 3. failed to ensure that the oxygen rate was administered according to Physician's Order (PO), for 1 of 1 Residents reviewed for Oxygen use, Resident #2 4. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain infection control practices to reduce the risk of infection during a pressure ulcer (PU) treatment; b.) to assess a resident for risk for pressure ulcer quarterly and c.) ensure a physician's order was administered as ordered consistently for preventative measures for skin for 1 of 2 residents (Resident #25) reviewed for PU/injury. This deficient practice was evidenced by the following: On 4/15/24 at 11:44 AM, the surveyor observed Resident #25 asleep in bed with resident's daughter at the bedside. The surveyor interviewed Resident #25's daughter who stated that the resident had a PU, and that the PU was getting better. Resident #25's daughter further stated that the staff turned and changed the resident. [...]

Inspectors wrote3. On 4/22/24 at 12:23 PM, the surveyor reviewed Resident #352's hybrid medical records. The resident was discharged from the facility on 1/31/24. The admission Record (AR) documented that Resident #352 had diagnoses that included but were not limited, Acute Respiratory Failure, Pneumonia, Type II Diabetes Mellitus and Bipolar Disorder. A review of the physician progress notes (PN), revealed there were no notes written by Physician #1 from November 2023 to January 2024. 2. On 4/18/24 at 9:45 AM, the surveyor reviewed Resident #142's hybrid medical record which revealed that the resident's physician only documented one visit which was dated 4/11/24. There was not a documented physician's visit for Resident #142's admission and subsequent monthly visit for February 2024 and March 2024. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to properly store and accurately label medications found during the initial unit inspection. This deficient practice was observed for 1 of 3 facility units examined, as evidenced by the following: On 4/15/24 at 12:50 PM, the surveyor inspected the 2nd floor low medication cart. Within the low medication cart the surveyor observed an opened 10ml bottle of Acetylcysteine 20% that was not labeled. Further examination of the bottle of Acetylcysteine revealed that the bottle did not have any documentation of a date or time the bottle was opened. Inspection of the bottle of Acetylcysteine 20% indicated on the label, Store in refrigerator after opening. and Discard opened vial after 96 hours. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide the mandatory annual dental care services. This deficient practice was observed for 1 of 31 residents reviewed for dental care services, Resident #56, as evidenced by the following: On 04/15/24 12:27 PM, the surveyor observed the resident in bed, awake and alert. A review of the admission Record for Resident #56 reflected that the resident was admitted to the facility with diagnoses that included but not limited to Depression, Post Traumatic Stress Disorder, Anorexia, Hypertension and Fracture of the left femur. A review of Resident #56's Quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 1/11/24, reflected that the Brief Interview for Mental Status score of 15 of 15 indicating that the resident had intact cognition. [...]

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices as well as store potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 4/15/24 at 09:21 AM, the surveyor in the presence of the entered the Food Service Director (FSD) observed the following during the kitchen tour: 1. During the kitchen inspection, the surveyor observed inside walk-in freezer, multiple boxed items stacked above 18 inches from ceiling. FSD stated he will do rearrange the boxes, so they are stored below the 18 inches from the ceiling. 2. On 4/16/24 at 10:38 AM, during the lunch meal preparation, the surveyor observed the Dietary Chef (DC), check the temperature of ground pork with a non-disinfected thermometer. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain proper infection control practices to mitigate the spread of infection for 2 of 3 Nurses observed during medication administration, and [NAME] statement observed during wound treatment. The deficient practice was observed on 2 (3rd and 4th floor) out of 3 nurses observed during medpass or facility floors during medication administration observation. This deficient practice was evidenced by the following: 1. On 4/18/24 at 8:39 AM, the surveyor observed medication administration (med pass) performed on the 3rd floor, performed by a Licensed Practical Nurse (LPN) #3. The State Surveyor observed LPN#3 put his soapy hands immediately under the running water without scrubbing away from the water first. [...]

Inspectors wroteOn 2/16/22 at 10:20 AM, Surveyor #4 reviewed the Behavior Monitoring Forms for Resident #89 for January 2022 which included the following: The Behavior Monitoring Form for the psychoactive medication Risperdal 3 mg twice a day (BID) had indicated that the behavioral symptoms of delusions were to have been monitored and documented daily on all three shifts. A review of the Behavioral Monitoring Form reflected that the symptom of delusions was only documented for the 7 AM to 3 PM shift and on the 3 PM to 11 PM shift each day for the month of January. The 11 PM to 7 AM shift were blank (not documented) for each day of the month of January. On 2/17/22 at 11:45 AM, Surveyor #4 reviewed Resident #89's Behavior Monitoring Form for January 2022 again and additional information was added to the forms which included the following: [...]

Inspectors wrote7. On 2/16/22 at 10:13 AM, surveyor #4 observed Resident#79 lying in bed, awake and alert, calm and soft spoken but with clear speech and was able to answer questions appropriately. A review of the admission Record reflected that the resident was admitted on [DATE] and was readmitted to the facility from the hospital on [DATE]. A review of the 1/6/22, admission MDS indicated a BIMS score of 11, which reflected that the resident's cognition was moderately impaired. A review of the POS reflected physician orders for Mirtazapine Tablet 15 MG, Give 1 tablet via G-Tube at bedtime for Depression and Escitalopram Oxalate Tablet 10 MG, Give 1 tablet via PEG-Tube one time a day for Depression. On 2/17/22 at 12:22 PM, the surveyors observed a black binder titled 3RD FLOOR-HIGH SIDE with Behavior Monitoring Form(s) in the binder and Resident #79's form could not be located in the binder. [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent documentation, it was determined that the facility failed to maintain a residents wheelchair and cushion in a clean and homelike manner. This deficient practice was identified for 1 of 3 residents reviewed for care of equipment and maintenance, Resident #63 and was evidenced by the following: The surveyor toured the 400's Unit on 2/11/2022 at 11:30 AM and observed Resident #63 siting on the bed, he/she did not acknowledged the surveyor when the surveyor entered the room. Next to the bed the surveyor observed a ripped and torn wheelchair, the cushion was torn in several places exposing the yellow foam. Some particles and food like debris were noted on the torn cushion. [...]

Inspectors wroteBased on interview, record review and review of facility provided documentation, it was determined that the facility failed to complete a Comprehensive admission 14-day Minimum Data Set (MDS) assessment or Comprehensive Annual MDS assessment as required according to the Resident Assessment Instrument (RAI) for 5 of 24 residents reviewed for MDS completion (Resident #2, #4, #5, #8 and #363). The deficient practice was evidenced by the following: Reference: The Centers For Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. [...]

Inspectors wroteBased on interview, record review and review of facility provided documents, it was determined that the facility failed to complete a Quarterly Minimum Data Set (MDS) assessment, a periodic and federally mandated, standardized assessment tool, within the required time frame, according to the Resident Assessment Instrument (RAI) for 15 of 24 residents reviewed for MDS completion (Resident #1, #3, #6, #7, #9, #10, #11, #19, #23, #25, #27, #28, #29, #30 and #50). The deficient practice was evidenced by the following: Reference: The Centers For Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide personal grooming care to a resident that was dependent on the staff for hygiene for 1 of 23 residents, Resident #63. This deficient practice was evidenced by the following: On 2/17/22 at 10:19 AM, the surveyor observed Resident #63 in the room, awake and was seated on the bed. The resident did not look at the surveyor or speak when spoken to. The resident's fingernails on both hands were long and extended beyond the fingertips. The surveyor also observed Resident #63 with a long, scattered facial hair. The surveyor reviewed the admission record that indicated Resident #63 was admitted to the facility on [DATE] with diagnoses that included but not limited to Alzheimer's Disease, Depression and Schizophrenia. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility staff failed to follow the physician orders for the administration of Ozempic (an anti-diabetic medication) for the treatment of type 2 diabetes mellitus creating a delay in treatment, and failed to assess the resident for first dose response. This deficient practice was identified for Resident #37, one of 23 residents reviewed and was evidenced by the following: Resident #37 was admitted to the facility with diagnoses which included unspecified atrial fibrillation, type 2 diabetes mellitus with hyperglycemia (elevated blood sugar), chronic kidney disease and unspecified glaucoma. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent documents provided by the facility, it was determined that the facility failed to post cautionary signage to indicate that oxygen therapy was in use and to administer oxygen therapy according to the physician's order. This deficient practice was identified for one of two residents reviewed for respiratory care (Resident #24), and was evidenced by the following: Resident #24 was admitted to the facility with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), acute kidney failure, diabetes mellitus, and mild intermittent asthma. A review of the most recent Quarterly Minimum Data Set (MDS - an assessment tool) dated 01/08/2022, revealed that Resident #24 was coded as being dependent on staff for some activities of daily living and was coded as having received Oxygen care. [...]

Inspectors wroteBased on interview, record review and review of pertinent facility documentation, it was determined that the facility failed to seek clarification of a medication order from the Medical Director (MD) when unable to reach a resident's ordering physician. This deficient practice was identified for Resident #37, one of nine residents reviewed during medication administration observation. The deficient practice was evidenced by the following: On 02/14/22 at 9:01 AM, the surveyor observed the Registered Nurse (RN) on the 4th floor, administering medications to residents including Resident #37. The RN opened a box with a pen injector of Ozempic (an anti-diabetic medication). The RN reviewed the physician order and was unsure of how to use the delivery system pen injector and asked the Unit Manager for assistance. The RN administered the Ozempic. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide appropriate pharmaceutical services, which included ensuring accurate administering of all drugs, in accordance with professional standards of practice. This deficient practice was identified for 2 of 23 residents reviewed (Resident #76 and #37) and was evidenced by the following: 1.) The surveyor reviewed the medical record for Resident #76. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included Epilepsy, Cerebral Palsy, Quadriplegia and Gastrostomy Status (G-Tube), a tube inserted into the stomach that allows nutrition to be directly administered into the stomach. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure that biological drugs and supplies were removed from the crash cart when expired. This deficient practice was identified on one of two units and was evidenced by the following: On 02/14/2022 at 10:30 a.m., the surveyor inspected the 400's Unit crash cart with the Unit Manager Registered Nnurse (UM/RN) and noted 3 bottles of normal saline solution with an expiration date of 03/2021. The Ambu bag (a self inflating, hand held device commonly used to provide ventilations to patients who are not breathing ) with a used by date of 04/2021. An interview with the nurse on 2/14/2021 at 11:30 a.m., revealed that the night supervisor was responsible to check the crash cart. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to 1) store respiratory care equipments in a manner to prevent infections, 2) adhere to infections control practices for hand hygiene according to CDC (Center for Disease Control) and the facility policy, and 3) failed to properly wear an N95 fitted respiratory mask. This deficient practice was identified for three staff members on two units. The deficient practice was evidenced by the following: 1) On 2/11/2022 at 12:04 PM, the surveyor toured the 400's Unit and observed Resident # 24 in bed. The oxygen concentrator (an oxygen delivery system) was set to deliver oxygen therapy at 3 Liters via (by way of) nasal cannula (tubing that is applied to the nose that delivers oxygen). [...]