Cornell Hall Care & Rehabilitation Center

Inspectors wroteBased on observation, interview, and review of medical records, it was determined that the facility failed to ensure medication administration without significant error for a resident who received insulin on a sliding scale received their insulin as ordered on multiple dates and times. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #40), and was evidenced by the following: On 4/9/25 at 10:00 AM, the surveyor observed Resident #40 lying in bed. The resident appeared clean and dry, and the resident's head of bed was up. The surveyor was unable to interview the resident due to cognitive impairment. The surveyor reviewed the medical record for Resident #40. [...]

Inspectors wroteComplaint: #NJ183048 Based on interview, review of medical record, and other pertinent facility documentation, it was determined that the facility failed to thoroughly and accurately investigate an injury of unknown origin on 10/16/2024 and 10/22/2024. This deficient practice was identified for 1 of 4 residents reviewed for accidents (Resident #260), and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #260. A review of the admission Record face sheet (an admission summary) indicated that Resident #260 had the diagnoses which included but were not limited to; schizophrenia, depression, and mood disorder. [...]

Inspectors wroteComplaint # NJ175980 Based on observation, interview, and review of medical records, it was determined that the facility failed to provide necessary treatment services consistent with professional standards of clinical practice by not ensuring that a resident diagnosed with the shingles virus received care and services in a timely manner. This deficient practice was identified for 1 of 26 residents reviewed for quality of care (Resident #262), and was evidenced by the following: On 4/10/25 at 11:08 AM, the surveyor reviewed the closed medical record for Resident #262. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observations, interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to use appropriate infection control practices to prevent the spread or reduce the risk of infection by ensuring proper use of personal protective equipment (PPE) for a resident on contact precautions. This deficient practice was identified for 1 of 1 resident reviewed for transmission-based precautions (TBP) (Resident #90), and was evidenced by the following: On 4/9/25 at 10:45 AM, during initial tour, the surveyor observed signage on Resident #90's door which indicated that the resident was on TBP, specifically, contact precautions. The signage specified that gloves and an isolation gown were to be applied prior to entering the resident's room. The surveyor observed two bins inside of the resident's door; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that the completion of a significant change Minimum Data Set (MDS), an assessment tool, was completed in a timely manner. This deficient practice was identified for 1 of 23 residents reviewed for resident assessments (Resident # 40), and was evidenced by the following: On 4/9/25 at 10:00 AM, the surveyor observed Resident #40 lying in bed, clean, dry with the head of bed up. The surveyor was unable to interview the resident due to cognitive impairment. A review of the admission Record face sheet (an admission summary) indicated that Resident #40 was admitted to the facility with the diagnoses which included but were not limited to; [...]

Inspectors wroteComplaint #: NJ177876, NJ178837 Based on interviews, review of the medical records, and pertinent facility documents on 10/24/24 and 10/25/24, it was determined that the facility failed to follow professional standards of clinical practice with respect to nursing staff provided a service when the accepted standards of quality dictate that the service or care should not have been provided for 1 of 3 Residents (Resident #2). This deficient practice is evidence by the following: According to the admission Record Resident #2 was admitted to the facility on [DATE], with diagnosis that included but was not limited to: Polyneuropathy and Chronic Pain. The Minimum Data Set (MDS), an assessment tool dated 9/13/24, revealed that Resident #2's cognitive function was 15/15 indicating resident is cognitively intact. [...]

Inspectors wroteREPEAT DEFICIENCY C # NJ166425 Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to prevent, identify and address an unintended insidious (gradual but with harmful effects) weight loss of 9.4 pounds in less than a two-month period (4/10/23 to 6/5/23) in a timely manner for a resident who was identified as underweight, with inadequate intake and at nutritional risk on admission. The facility failed to: a.) obtain, record and monitor weekly weights for 4 weeks after admission, and b.) implement a nutritional care plan in a timely manner. This deficient practice was identified for 1 of 2 resident's reviewed for nutrition (Resident #358). The evidence was as follows: The surveyor reviewed the medical record for Resident # 358. [...]

Inspectors wroteComplaint # NJ169272 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a) maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey and b) provide sufficient nursing staff for three (3) of three (3) units of the facility according to facility policy. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio (s) were effective on 02/01/2021: [...]

Inspectors wroteBased on interview and record review it was determined that the facility failed to submit their Payroll Based Journal (PBJ) Report to the Centers for Medicare and Medicaid Services (CMS) within a timely manner. This deficient practice was identified for one of three PBJ Report submissions reviewed, (Fiscal Year Quarter 4 2023, July 1 - September 30) and was evidenced by the following: A review of the PBJ Staffing Data Report CASPER Report 1705D reflected a triggered area that the facility failed to submit data for the fourth fiscal year quarter to CMS. The dates of the fourth quarter included July 1, 2023, through September 30, 2023. On 1/12/24 at 12:01 PM, during an interview with the surveyor, the Infection Preventionist/ Regional, stated that the Regional Clinical Manager (RCM) submitted staffing to CMS on a quarterly basis. [...]

Inspectors wroteBased on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure a) licensed staff credentials were verified upon hire (Staff #7 and #8) and b) reference checks were completed (Staff #2, #3, #4, #8 and #9). This deficient practice was identified for seven (7) of nine (9) newly hired staff reviewed, and was evidenced by the following: 1.) The surveyors randomly selected nine new employee files for license verification which revealed the following: Staff #7, a Registered Nurse (RN), was transferred to the facility on 7/30/23, had a New Jersey Division Consumer Affairs (NJCA) license verification printout for license verification (used to verify the status of a RN's license status) which was dated 12/22/23, after the employee's transfer date of 7/30/23. [...]

Inspectors wroteComplaint NJ#163297, NJ#164216, and NJ#169168 Based on interviews, review of medical records (MR) and other facility documentation, it was determined that the facility failed to report an allegation of Abuse / Neglect to the New Jersey Department of Health (NJ DOH) in the required timeframe for 5 of 10 sampled residents, (Residents #35, #63, #90, #361, #362). This deficient practice was evidenced by the following: 1.) A review of the reportable event record report (FRE; Facility Reported Event) which was called in on 4/6/23 at 10:00 AM, with an event date of 4/5/23 at 7:00 PM. The FRE was reported as an allegation of resident-to-resident abuse and was described as follows: On 4/5/23 at 2:00 PM, Resident #362 was admitted to the facility screaming /yelling and cursing at the staff asking for pain medications. [...]

Inspectors wroteBased on interviews, record review, and a review of pertinent facility documents, it was determined that the facility failed to a.) provide oversight by a licensed Consultant Pharmacist (CP) in the entire month of August 2023, for 4 of 5 residents reviewed for unnecessary medications (Resident #46, #68, #80, and #87) and b.) act upon a recommendation made by a CP in a timely manner for 1 of 28 residents (Resident #92) reviewed for medication management . This deficient practice was evidenced by the following: 1. On 01/11/24 11:45 AM, the surveyor observed Resident #46 in bed. The resident was wearing a CPAP (a continuous positive airway pressure ventilation system in which the mild pressure from the system prevents the airway from collapsing or becoming blocked) mask. The resident's eyes were closed. The surveyor reviewed Resident #46's electronic medical record (eMR). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to: [...]

Inspectors wroteBased on the interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) - Discharge Assessment in accordance with federal guidelines. This deficient practice was identified for two (2) of 28 residents, (Residents #21 and #94), reviewed for resident assessments. This deficient practice was evidenced by: According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11, updated October 2023, the MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. [...]

Inspectors wroteBased on observations, interviews and record review, it was determined that the facility failed to revise comprehensive care plans for 2 of 28 residents reviewed (Resident #41 and #75). This deficient practice was identified by the following: 1. On 01/10/24 at 11:08 AM, the surveyor observed Resident #41 in bed watching television. The resident was alert and verbally responsive. The surveyor reviewed Resident #41's hybrid medical records. The admission Record (AR) (an admission summary), reflected that Resident #41 was admitted to the facility with medical diagnoses which included but was not limited to: [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documentation it was determined that the facility failed to follow the Physician's Order (PO) for a.) floor mats, b.) heel protection boots bilaterally (B/L) and c.) right arm and right leg splints. This deficient practice was identified for one (1) of twenty-eight (28) residents, (Resident #1) reviewed for quality of care. This deficient practice was evidenced by the following: On 01/12/24 at 11:12 AM, the surveyor observed resident #1 in their room, in bed, there were no floor mats on the floor. The resident presents with B/L hand contractures, right leg contracture and BL foot contractures. The resident did not have any hand gauze rolls or splints present. The resident was positioned on the right side hip with a pillow. The resident can move right lower extremity straight into the air. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to apply a left-hand roll (device that offers positioning of severely contracted hands) for the care and management of the left-hand contracture (a permanent shortening of muscle, tendon, or scar tissue, leading to deformity and rigidity of joints). This practice was observed for 1 of 5 (Resident #30) residents reviewed for limited range of motion. This deficient practice was evidenced by the following: On 01/10/24 at 11:25 AM, the surveyor observed Resident #30 in the great room sitting in the wheelchair and participating in a group activity. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to maintain the necessary respiratory care and services of residents in accordance with standard of practice for two (2) of four (4) residents, (Resident #42 and #85) reviewed for respiratory care. This deficient practice was evidenced by the following: According to the National Library of Medicine, Oxygen-induced hypercapnia: physiological mechanism and clinical implications Abstract Oxygen is probably the most commonly prescribed drug in the emergency setting and is a life-saving modality as well. However, like any other drug, oxygen therapy may also lead to various adverse effects. Patients with chronic obstructive pulmonary disease (COPD) may develop hypercapnia during supplemental oxygen therapy, particularly if uncontrolled. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to conduct yearly performance reviews of Certified Nursing Aides (CNA) in order to provide specific education based on the outcomes of the reviews. This deficient practice was identified for 5 of 5 CNAs whose personnel records were reviewed, and was evidenced by the following: On 1/23/24 at 11:22 AM PM, the surveyor requested from the Infection Preventionist/Regional (IP/R) to provide the most recent performance evaluation for five randomly selected Certified Nursing Aides (CNA #1; #2; #3; #4; and #5). On 1/24/24 at 9:31 AM, in the presence of the survey team, the IP/R confirmed that there were no performance evaluations for the two (2) of the five (5) CNAs who had completed more than a year of service. CNA#1 with a date of hire on 11/9/22, had no performance evaluation. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the 24-hour staffing report that was posted was up to date for three (3) of nine (9) days. This deficient practice was evidenced by the following: On 01/22/24 at 7:18 AM, the surveyor in the presence of the Registered Nurse Supervisor (RNS) confirmed that the Nursing Home Resident Care Staffing Report (NHRCSR) that was posted in the reception area was dated 01/19/24 and not for 01/22/24. On that same date and time, the surveyor asked the RNS why the NHRCSR posted was from Friday (01/19/24) and there were no posted staffing report for Saturday (01/20/24), Sunday (01/21/24), and Monday (01/22/24). The RNS stated that because there were no admission people during weekends that was why the NHRCSR was not updated. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to monitor target behaviors for the use of a psychotropic medication, Seroquel (used to treat certain mental/mood disorders such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder). This was identified for one of five residents, (Resident #87) reviewed for unnecessary medications. This deficient practice was identified by the following: On 01/10/24 at 11:30 AM, during the initial tour, Resident #87 was observed in bed, with eyes closed, and music on the television. The surveyor reviewed the electronic medical record (eMR) for resident #87. According to the admission Record, (an admission summary) Resident #87's was admitted to the facility with diagnoses that included but were not limited to: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of hot foods served to the residents. This deficient practice was identified for two (2) of three (3) residents interviewed during the Resident Council meeting and confirmed during the lunchtime meal service on 1/18/24 for 1 of 3 nursing units tested for food temperatures by two surveyors and was evidenced by the following: On 1/11/24 at 11:02 AM, the surveyor met with three residents for council meeting. Two out of three residents who resided on the [NAME] unit stated that hot food temperatures were unacceptable. On 1/18/24 at 11:48 AM, the surveyor calibrated a state issued digital thermometer via the ice bath method to 32 degrees Fahrenheit (F) in the presence of the survey team. [...]

Inspectors wroteBased on interview and review of pertinent facility documentation, the facility failed to have: a) the Licensed Nursing Home Administrator (LNHA) present for one (1) of three (3) Quality Assurance and Performance Improvement (QAPI) meetings and b) the Medical Director (MD) present for one (1) of three (3) quarterly QAPI meetings. The deficient practice was evidenced by the following: On 01/11/24 at 01:06 PM, the surveyor reviewed the provided last three quarters sign-in sheets for QAPI meetings that were provided by the LNHA. The QAPI committee was attended and included the required minimum members except the following who did not attend and were required to attend: 01/27/23=The MD was not in the meeting. 4/26/23=The LNHA was not in the meeting. [...]

Inspectors wroteBased on the interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the designated Infection Preventionist (IP) dedicated solely to the infection prevention and control program (IPCP), and physically worked onsite in the facility for one (1) of two (2) staff. According to the NJ Executive Directive 21-012 (revised 12/22/22) included The facility's designated individual(s) with training in infection prevention and control shall assess the facility's IPCP by establishing or revising the infection control plan, annual infection prevention and control program risk assessment, and conducting internal quality improvement audits. [...]

Inspectors wroteBased on interview and review of other facility documentation, it was determined that the facility failed to ensure 2 of 5 Certified Nursing Assistants (CNA #1 and CNA #4) received 12 hours of education annually. This deficient practice was evidenced by the following: The surveyor requested five (5) random CNA education files for the year 2023. A review of a facility form titled Individual Mandatory In-services revealed the following: CNA #1 with a date of hire on 11/9/22, had 8.5 education hours from the date of hire, to the anniversary date. CNA #4 with a date of hire on 11/17/22, had no education hours on file. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to provide written notification of the emergency transfer to the Office of the Long-Term Care Ombudsman (LTCO) for one (1) of two (2) residents (Resident #94), reviewed for hospitalizations. This deficient practice was evidenced by the following: The surveyor reviewed the hybrid (a combination of paper, scanned, and computer-generated records) medical records of Resident #94. [...]

Inspectors wroteBased on the interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to provide resident and/or their representatives with the facility's written notice of bed hold. This deficient practice was identified for one (1) of two (2) residents, (Resident #94), reviewed for hospitalization. This deficient practice was evidenced by the following: The surveyor reviewed the hybrid (a combination of paper, scanned, and computer-generated records) medical records of Resident #94. [...]

Inspectors wroteREPEAT DEFICIENCY Based on the interview, record review, and review of pertinent facility documentation it was determined that the facility failed to accurately code the Minimum Data Set (MDS) for one (1) of the 28 residents reviewed, Resident #105. This deficient practice was evidenced by the following: According to the admission Record (admission summary), Resident #105 was admitted to the facility with a diagnosis that included but was not limited to metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), Alzheimer's disease unspecified (a progressive disease that destroys memory and other important mental functions), depression, and essential hypertension (abnormally high blood pressure that's not the result of a medical condition). [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 1 of 21 residents reviewed, Resident #47 as evidenced by the following: According to the Resident Assessment Instrument Manual Version 3.0 of Centers for Medicaid and Medicare Services (CMS) guidelines, updated October 2019 a SCSA MDS is required if there is a Decline in two or more of the following: . Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days); . Emergence of a new pressure ulcer at Stage 2 or higher, a new unstageable pressure ulcer/ injury, a new deep tissue injury or worsening in pressure ulcer status; . [...]

Inspectors wrote5. On 10/25/22 at 12:10 PM, the surveyor observed Resident #47 being fed by the Certified Nursing Assistant (CNA). The surveyor reviewed the hybrid medical record for Resident #47: The admission Record revealed that Resident #47 was admitted to the facility with diagnoses that included but were not limited to Unspecified Dementia with Behavioral Disturbance, Major Depressive Disorder, and Primary Generalized Osteoarthritis (a joint disease in which the tissues in the joint break down). The 9/1/22 quarterly MDS, revealed a BIMS score of 0 out of 15, which indicated a severely impaired cognition. The MDS also indicated that Resident #47 required, supervision and setup help only with eating under Section G, which was inaccurate. The Dietary Alert Sheet dated 3/24/21 indicated, Resident needs to be fed as per ST [Speech Therapy]. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan (CP) for residents at the facility. This deficient practice was identified for 3 of 24 residents reviewed for comprehensive care plans (Resident #69, #44, and #48), and was evidenced by the following: 1. On 10/27/22 at 12:01 PM, the surveyor observed Resident #69, awake and alert, seated in a wheelchair watching T.V. in their room. The surveyor reviewed the hybrid medical record belonging to Resident #69. Review of the admission Record (an admission summary) (AR) belonging to Resident #69 documented a diagnosis that included but was not limited to Depression, Unspecified. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a resident was weighed weekly and monthly in accordance with physician's orders and facility policy. This deficient practice was identified for 1 of 7 residents (Resident #47) reviewed for weight loss. The deficient practice was evidenced by the following: On 10/21/22 at 11:47 AM, two surveyors observed Resident #47 lying in bed. The resident did not respond to the surveyors' conversation. The surveyor reviewed the hybrid medical record for Resident #47. The admission Record revealed that Resident #47 was admitted to the facility with diagnoses that included but were not limited to Unspecified Dementia with Behavioral Disturbance, Major Depressive Disorder, and Primary Generalized Osteoarthritis (a joint disease in which the tissues in the joint break down). [...]

Inspectors wroteBased on interview, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes (PN) at least once every sixty days. This deficient practice was identified for 4 of 21 residents reviewed for physician visits, Resident #4, #26, #77, #79. This deficient practice was evidenced by the following: 1.) On 10/24/22 at 10:51 AM, the surveyor observed Resident #4 in bed with eyes closed. The resident was also observed lying on a pressure relieving air mattress and was wearing bilateral heel booties. The surveyor reviewed the admission Record (AR) which indicated that Resident #4 was admitted to the facility with diagnoses that included but were not limited to, Cerebral infarction; Hemiplegia and Hemiparesis; [...]

Inspectors wroteBased on observation, interview, and policy review, it was determined that the facility failed to 1.) maintain food items in a manner to ensure they are not used past their use by date, 2.) maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and the potential for developing food borne illness, and 3.) prevent staff from handling resident's food in a non-hygienic manner. This deficient practice was evidenced by the following: 1. On 10/21/22 at 10:15 AM, two surveyors in the presence of the Food Service noted a 2.05 once (oz) container of dried Bay leaves with an expiration date of 9/16/2022 and a 16 oz container of Cumin with an expiration date of 3/25/2021 were observed in the dry storage area. The FSD could not explain why both expired items had not been thrown away. 2. [...]