Complete Care at Holiday City

Inspectors wroteBased on interviews, review of medical records, and review of other pertinent facility documents on 5/05/2026, it was determined that the facility failed to maintain a safe environment and to provide adequate supervision to prevent the elopement of a resident (Resident #2) who was assessed to be cognitively impaired and was identified as an elopement risk. Resident #2 exited their secured unit without staff knowledge and eloped from the facility on 4/22/2026 at approximately 8:01 PM. A visitor exited the secured unit at approximately 8:00 PM on 4/22/2026 by entering a code into a keypad allowing Resident #2 to also exit the unit. Resident #2 followed the visitor to the front lobby where the receptionist enabled the front door to open which allowed Resident #2 to exit along with the visitor. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) maintain kitchen equipment in a clean and sanitary manner and b.) maintain nourishment room refrigerators in a clean and sanitary manner on 3 of 3 units and was evidenced by the following: On 4/22/25 at 9:48 AM, in the presence of the Food Service Director (FSD) and the Regional FSD, the surveyor observed the following: 1. The microwave had multi-colored dried stuck on debris on the interior ceiling of the unit. The FSD acknowledged it was not properly cleaned according to facility policy. 2. Two convection ovens were soiled with baked on brown coloring on the glass doors and interior of the unit. The FSD acknowledged and stated it was not cleaned according to facility policy. 3. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to maintain the residents' living environment in a clean, comfortable, homelike manner. This deficient practice was identified on 3 of 3 nursing units reviewed for homelike environment (Jefferson-unit, [NAME]-unit, and Applewood-unit), and was evidenced by the following: On 4/24/25 at 9:43 AM, in the presence of the Registered Nurse (RN), the surveyor observed the following in the nourishment room on the [NAME] unit: 1. The back splash and counter had black discoloration the length of the countertop joint. 2. The sink had stains and white discoloration. 3. The counters and cabinets were peeling laminate and chipped paint. 4. The interior of the far-right lower cabinet had a spill that had dried and stained the cabinet with coffee grounds stuck to it. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care for all residents, accurately. This deficient practice was identified for 3 of 27 residents reviewed for MDS (Resident #73, #99, and #101), and was evidenced by the following: 1. On 4/22/25 at 10:03 AM, the surveyor reviewed a list of smokers provided by the facility. Resident #73 was identified as a smoker. The surveyor reviewed the medical record for Resident #73. A review of the admission Record face sheet (an admission summary) revealed that Resident #73 was admitted to the facility with medical diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to provide a resident with nail care during activities of daily living (ADL) care. This deficient Practice was identified for 1 of 2 residents reviewed for ADL care (Resident #52), and was evidenced by the following: On 4/21/25 at 7:54 PM, the surveyor observed Resident #52 sitting in their wheelchair in their room. The resident's fingernails were long in length with dirt underneath, and on their left hand, the 3rd, 4th, and 5th digits (fingers) had a yellow thick discoloration of the nail. On 4/22/25 at 11:24 AM, the surveyor reviewed the medical record for Resident #52. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observation, interview, and facility document review and in the course of a complaint investigation, the facility failed to serve food at the appropriate temperatures on one of three units (Applewood Unit) in the facility. This failure had the potential for residents to experience untoward effects from eating food not served at the appropriate temperatures.

Inspectors wroteBased on observation, interview, and review of the facility policy, the facility failed to protect a resident's right to dignity while dining for one out of one resident (Resident (R)18) in a total sample of 22. The facility failed to ensure R18 was dressed and fully covered while in the dining room. This failure placed the resident at risk of a diminished quality of life and embarrassment.

Inspectors wroteBased on record review, interview, facility investigation, and in the course of a complaint investigation, the facility failed to conduct a thorough investigation in one of one resident to resident altercation (Resident (R)9 and R21) out of a total of 22 sampled residents. This failure had the potential to affect all the residents in the facility who were at risk of abuse.

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) was coded accurately for two (Residents (R)5, R10) in a total sample of 21. The facility failed to accurately code the significant change assessment for falls and the quarterly assessment for pressure ulcers for R5. In addition, the facility failed to accurately code pain on the admission assessment for R10. These failures placed the residents at risk of unmet care needs and a diminished quality of life.

Inspectors wroteBased on observations, interviews, record review, and review of the facility policy and the Resident Assessment Instrument (RAI) manual, the facility failed to develop a comprehensive Care Plan with a person-centered focus, measurable goals, and resident-specific interventions for two (Residents (R)8, and R17) in a total sample of 22. The facility failed to develop a comprehensive Care Plan related to pain for R8. In addition, the facility failed to develop a comprehensive Care Plan related to diabetes and insulin use for R17. These failures placed the residents at risk of unmet care needs and a diminished quality of life.

Inspectors wroteBased on record review, and interview, the facility failed to review and revise a care plan for insulin for one out of a total of 22 sampled residents(Resident (R)16). This failure had the potential for R16 not to receive the necessary care.

Inspectors wroteBased on record review, interview, document review the facility failed to follow professional standards in diabetic management of two of four residents (Resident (R)16 and R17) reviewed out of a 22 total sampled residents. This failure had the potential for residents that have diabetes to be mismanaged in their care.

Inspectors wroteBased on record review, and interview and in the course of a complaint investigation, the facility failed to follow physician orders for medications for two of four residents (Resident (R)7 and R22) out of a total sampled of 22 residents. This failure lead to R7 not receiving medications that were ordered by the physician to be given.

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure residents who received dialysis treatments and were on fluid restriction diets received the appropriate amount of fluids daily in accordance with their physician's orders. This deficient practice was identified for 2 of 2 residents (Resident #35 and #80) reviewed for dialysis, and the evidence was a follows: 1. On 3/20/23 at 11:34 AM, the surveyor observed Resident #80's room, and the resident was not in his/her room. Certified Nursing Aide (CNA #1) informed the surveyor that Resident #80 was currently out of the facility at their dialysis appointment. The surveyor observed on the resident's tray table two four-ounce cups of cranberry juice, one sixteen-ounce disposable cup of water with a lid and straw, and one empty eight-ounce hot beverage mug. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to a.) maintain 2 of 2 kitchen hand washing sinks with accessible paper towels; b.) maintain multi-use food-contact surface resident entree plates in a manner to prevent microbial growth; and c.) maintain potentially hazardous food temperatures above 135 degrees Fahrenheit. This deficient practice was evidenced by the following: On 3/27/23 at 7:00 AM, the surveyor conducted a follow-up survey in the kitchen. At this time, the surveyor entered the kitchen and proceeded to wash their hands in the hand washing sink. After the surveyor washed their hands, they attempted to dry their hands but observed the paper towel dispenser was empty. The surveyor asked the four kitchen staff present; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined the facility failed to accurately document the administration of controlled medication for three residents (Resident #11, Resident #14, and Resident #102). This deficient practice was identified on 1 of 3 medication carts (Applewood Low) reviewed and evidenced by the following: On 3/23/23 at 1:06 PM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the Applewood Low medication cart. The surveyor and the LPN reviewed the narcotic medication located in the secured and locked narcotic box. When the narcotic medication inventory was compared to the corresponding declining inventory sheet, the surveyor identified the following concerns: Resident #11's pregabalin 50 milligram (mg) tablets, a medication used for neuropathic pain, did not match. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow professional standards of clinical practice with respect to administering medication, in accordance with a physician's prescribed pain level parameters for Percocet (a medication to treat moderate to severe pain) for 1 of 2 residents reviewed for pain; Resident #3. 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: 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 the facility staff failed to accurately document the administration of a controlled substance medication for two residents, Resident #82 and Resident #75. This deficient practice was identified for 1 of 3 nurses and 1 of 3 carts, reviewed during the completion of the Medication Storage and Labeling task, and evidenced by the following: On 5/05/21 at 9:00 AM, the surveyor, in the Licensed Practical Nurse (LPN) presence, inspected the low side medication cart on Applewood Unit. A review of the reconciliation of the medications located in the secured and locked controlled substance box compared to the controlled substance declining inventory sheet revealed Resident #82's clonazepam 0.5 milligrams (mg) tablets, a medication used for anxiety and seizures, did not match. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility paperwork, the facility failed to follow proper infection control procedures by not cleaning reusable medical equipment by 1 of 2 nurses observed during the medication pass task. This deficient practice was evidenced by the following: On 5/5/21, beginning at 7:51 AM, the surveyor observed the medication pass on the [NAME] Unit. A Licensed Practical Nurse (LPN) took the vital signs (blood pressure (BP), heart rate, temperature, and pulse oximetry) of Resident #35. After removing the BP cuff from the resident's arm, the LPN returned the BP cuff to the basket on the rolling stand without cleaning and disinfecting it. The LPN retrieved disinfecting wipes from her medication cart and cleaned the pulse oximetry device but did not clean the BP cuff. The LPN then prepared and administered the medications to Resident #35. [...]