Country Arch Care Center

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 3/31/26 at 10:36 AM, the surveyor conducted an interview with the Regional Food Service Director (RFSD) and Registered Dietician (RD) prior to the initial tour of the kitchen. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that the residents' dining experience was provided in a manner to promote dignity and respect of the residents. This deficient practice was identified in 1 of 2 dining areas observed, (100 Unit) and was evidenced by the following: On 4/1/26 at 11:58 AM, the surveyor observed lunch in the 100 Unit dining area. The surveyor observed one (1) unsampled resident and Resident #30 sitting at the same table. A staff member was seated and feeding the unsampled resident their lunch. Resident #30 had not received their lunch tray. Resident #30 asked the surveyor, Miss, am I going to eat my noon meal? Resident #30's was not served their lunch until 12:09 PM. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to have a cover over the opening of 2 of 3 garbage dumpsters. This deficient practice was evidenced by the following: On 3/31/26 at 11:30 AM, the surveyor, accompanied by the Regional Food Service Director (RFSD) and Registered Dietician (RD), observed the facility's designated garbage disposal area. There were three garbage dumpsters that each had two lids. Two of the garbage dumpsters each had one lid open, exposing the trash bags inside. At that time the RFSD stated the garbage dumpster lids should be closed to prevent pests. [...]

Inspectors wroteComplaint# NJ00172367 Based on interviews, record review, and review of other pertinent facility documentation on 06/12/24, it was determined that the facility failed to maintain a complete Medical Record (MR) which contained the New Jersey Universal Transfer Form (NJUTF) for a resident who was sent out to the Hospital. This deficient practice was identified for one resident (Resident #3), and was evidenced by the following: According to the admission Record, Resident #3 was admitted to the facility with diagnoses which included but were not limited to: Dementia, Transient Cerebral Ischemic Attack, Muscle Weakness A review of the Resident #3's Progress Notes (PN) revealed that on 03/21/2024 at 12:53 A.M, Registered Nurse (RN) documented that Resident #3 needed to be sent out to the hospital for an injury near the right eye area. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a.) store foods in a manner intended to prevent the spread of food borne illness and b.) maintain a clean storage for food and cooking utensils as evidenced by the following: On 10/06/23 at 9:44 AM, the surveyor toured the kitchen with the Food Service Director (FSD), observed the following: 1. In the freezer the surveyor found; one opened box of carrots without an open and a use by date. The interior bag holding the carrots was opened and unlabeled. The FSD stated, that the exterior of the box should be labeled with the open and used by date. He also stated, the interior bag once opened should be labeled and dated. 2. In the freezer the surveyor found; one opened box of chopped celery. The exterior of the box was unlabeled. [...]

Inspectors wroteBased on observations, interviews, review of medical records, and review of facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure: a) accurate documentation of the needed information in the Nurse Staffing Report, b) minimum State staffing requirements were met for 14 of 14 day shifts and on 3 of 14 overnight shifts reviewed, c) physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes (PN) at least once every sixty days in a timely manner, d) that nurse aides received the minimum required number of in-service hours, and e) LNHA and Medical Director attended the QAPI (Quality Assurance and Performance Improvement) meeting routinely necessary to provide for the needs of residents. [...]

Inspectors wroteBased on the interview, record review, and review of other pertinent facility documentation it was determined that the facility Medical Director (MD) failed to provide clinical oversight and guidance regarding resident care policies and procedures that affect resident care, medical care, and resident quality of life related to a) required physician visits and notes, b) attends mandatory quarterly QAPI (Quality Assurance and Performance Improvement) meetings, and c) minimum State staffing requirements were met. This failure had the potential to affect all 105 residents who currently live in the facility. This deficient practice was evidenced by the following: 1. A review of Resident #1's Progress Notes (PN) showed that the Physician Note's most recent documentation was a late entry on 7/23/23 for a date of service of 6/30/23. The following were other Physician Notes documented in the PN: [...]

Inspectors wroteBased on interview and review of pertinent facility documentation, the facility failed to have: a) the Medical Director (MD) present for two out of three Quality Assurance and Performance Improvement (QAPI) meetings, b) the Licensed Nursing Home Administrator (LNHA) present for three out of three QAPI meetings, and c) set QAPI meeting schedule. This failure had the potential to affect all 105 residents who currently live in the facility. The deficient practice was evidenced by the following: On [DATE] at 8:57 AM, the survey team entered the facility and met with the Receptionist who instructed the surveyors to use the touchless thermometer attached to a wall to check the surveyors' temperature, log in the binder temperature, and answer the COVID-19 screening questions. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an incident/accident: a) on 6/23/23 that resulted in a nose fracture for Resident #27 and b) Resident 208. This deficient practice was identified for two (2) of six (6) residents reviewed for accident and was evidenced by the following: 1. On 10/10/23 at 11:44 AM, the surveyor observed Resident #27 sitting in their room and could not be interviewed as the resident spoke in [dialect redacted]. At that time, the activities/translator was at the activities area, attending to other [dialect redacted] speaking residents. On 10/10/23 at 12:47 PM, the surveyor observed the resident was not in the room and found the Certified Nursing Assistant (CNA) in the room instead. [...]

Inspectors wroteBased on interviews, 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 in a timely manner. This deficient practice was identified for three (3) of six (6) residents reviewed for physician visits, Residents #1, #8, and #18. This deficient practice was evidenced by the following: 1. On 10/17/23 at 8:51 AM, the surveyor and the Licensed Practical Nurse both observed Resident #1 lying on the bed. The surveyor reviewed Resident #1's medical records. The admission Record (AR; or face sheet; an admission summary) showed that the resident was admitted to the facility with diagnoses that included but were not limited to multiple sclerosis (or MS; [...]

Inspectors wroteBased on interviews, record review, and review of other pertinent provided facility documents, it was determined that the facility failed to: a) identify residents in need of, offer a Pneumococcal vaccine for four (4) of six (6) residents, (Residents #13, #82, #84, and 95), and offer the subsequent Pneumococcal vaccine for two (2) of six (6) residents, (Residents #28 and #30) and b) follow the facility Pneumococcal vaccine policy in accordance with the Advisory Committee on Immunization Practices and the CDC (Centers for Disease Control and Prevention) guidelines. This deficient practice was evidenced by the following: Reference: A review of the CDC guidelines for Pneumococcal vaccination included: Age 65 years or older who have: -Not previously received a dose of PCV13, PCV15, or PCV20 or whose previous vaccination history is unknown: 1 dose PCV15 OR 1 dose PCV20. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility provided documents it was determined that the facility failed to provide a physically impaired resident a specialized call bell according to the resident's limitation and preference. This deficient practice was identified for Resident #1, one (1) of two (2) residents reviewed for the limited range of motion, and was evidenced by the following: On 10/13/23 at 11:47 AM, during the courtesy meeting with the facility's Volunteer Advocate (VA), the VA informed the survey team that she was the one who recommended to the facility for the resident to have a specialized call bell due to the resident's limitations to upper extremities as per resident's preference. The surveyor reviewed Resident #1's medical records. The admission Record (or face sheet; [...]

Inspectors wroteBased on interview, record review, and other pertinent facility documentation, it was determined that the facility failed to a) notify in advance and in writing of a resident's new roommate change for a cognitively impaired resident in accordance with federal and state regulations. This deficient practice was identified for one (1) of three (3) residents reviewed for room change (Resident #81) and was evidenced by the following: On 10/17/23 at 10:07 AM, the surveyor interviewed the Director of Social Services (DSS) who stated the process for a resident's room change were discussed during the morning clinical meeting with the Interdisciplinary team. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation it was identified that the facility failed to provide residents with a clean, safe, comfortable, and home like environment. This deficient practice was identified in one (1) of two (2) dining areas where morning activities for the English-speaking residents were also held. A review of the Material Safe Data Sheet for [brand name redacted] under Section 7: Handling and Storage included the following: Provide good ventilation. Do not use in confined spaces without adequate ventilation and/or respirator. Avoid contact with skin and eyes. Do not eat, drink, or smoke when using the product. Methods of Clean-up: Small spillages: Absorb with sand or other inert absorbent. Large spillages: Dam and absorb. Collect spillage in containers, seal securely and deliver for disposal according to local regulations. [...]

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 licensed staff credentials were verified upon hire. This deficient practice was identified for three (3) of nine (9) newly hired staff reviewed, (Staff #1, #4, and #6) and was evidenced by the following: On 10/18/23 at 9:16 AM, the surveyor reviewed nine randomly selected new employee files for license verification which revealed the following: Staff #1, a Certified Nursing Assistant (CNA), hired 7/06/23, had a New Jersey Department of Health (NJDOH) online Public Registry license verification printout (used to verify the status of a CNA's license and to check the nurse aide registry) which did not include the date that the verification was done. [...]

Inspectors wroteComplaints # NJ00158985, NJ00156816 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for three (3) of 21 residents, (Resident #26, Resident #208, Resident #209) reviewed for MDS accuracy, and was evidenced by the following: According to the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set 3.0 Public Reports page last modified October.20.2023, included that the MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. [...]

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; and b.) ensure an individualized comprehensive care plan interventions were developed and implemented to a Stage 1 pressure injury wound; and c.) ensure an individualized comprehensive care plan with interventions were developed and implemented in a timely manner after a skin impairment occurred for one (1) of three (3) residents reviewed for PU (Resident #81). This deficient practice was evidenced by the following: On 10/16/23 at 10:00 AM, the surveyor observed Resident #81's assigned Licensed Practical Nurse (LPN #1) perform a wound treatment. [...]

Inspectors wroteBased on observation, interviews, record review and review of other pertinent facility provided documentation, the facility failed to implement and document in the resident's care plan a new intervention after each fall in order to prevent any additional falls for one (1) of five (5) residents reviewed for falls (Resident #22). This deficient practice was evidenced by the following: On 10/10/23 at 12:12 PM, the surveyor observed resident #22 in their room, seated in a wheelchair eating lunch. Resident #22 did not want to be bothered at this time. The surveyor reviewed Resident #22's medical records. The admission Record (or face sheet; [...]

Inspectors wroteBased on observation, interview, and review of other pertinent provided facility documents, it was determined that the facility failed to ensure that tracheostomy (trach) care and services were provided according to the standard of clinical practice for one (1) of one (1) resident (Resident #18) reviewed for respiratory care. This deficient practice was evidenced by the following: On 10/06/23 at 10:37 AM, the surveyor observed Resident #18 seated in a geri chair (a specialized seating solution designed specifically for seniors and individuals with limited mobility) in their room eyes open, nonverbal, with trach (an incision in the windpipe made to relieve an obstruction to breathing) and oxygen (O2) in use. The surveyor reviewed the medical records of Resident #18. The resident's admission Record (or face sheet; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a) consistently monitor the resident's vital signs (VS) and dialysis access site and b) complete the Hemodialysis Communication Record (HCR) according to the facility's policy and standard of clinical practice. This deficient practice was observed for one (1) of one (1) resident reviewed. The deficient practice was evidenced by the following: On 10/06/23 at 9:48 AM, the surveyor observed that Resident #60 was not in their room. The Unit Clerk stated that the resident was at the dialysis center. On 10/10/23 11:48 AM, the surveyor observed the resident in bed asleep. The surveyor reviewed the hybrid medical records (a combination of paper, scanned, and computer generated record) of Resident #60. The admission Record (or face sheet; [...]

Inspectors wroteBased on interviews and review of pertinent facility documentation, it was determined that the facility allowed one (1) of one (1) Non-Certified Nursing Aides (NA) to continue working as an NA after the specified 120 days. This deficient practice was identified during new hire employee review. This deficient practice was evidenced by the following: On 10/18/23 at 9:16 AM, the surveyor reviewed the facility provided new hire employee files. The review included the following: The NA had a date of hire (doh) 5/11/23. The NA completed a Certified Nurses Aide (CNA) Program on 4/14/23. The NA passed the Skills Evaluation on 4/17/23. There was no documented evidence that the NA was licensed as a Certified Nursing Assistant. On 10/18/23 at 11:13 AM, the surveyor interviewed the Human Resources Director (HRD) and the Director of Nursing (DON) regarding the NA. [...]

Inspectors wroteBased on observation, interview, record review it was determined that the facility failed to provide the mandatory annual dental care services. This deficient practice was observed for two (2) of 21 residents, (Resident #26, Resident #209) reviewed for dental care services, and was evidenced by the following: 1. On 10/18/23 at 12:17, PM the surveyor observed the resident had jagged teeth and brown discoloration when Resident #26 smiled. The resident stated that there was not any pain at this time. The surveyor asked the resident if he/she had seen a dentist or had been offered since the resident was admitted . The resident stated no, neither. On 10/16/23 at 11:46 AM, surveyor interviewed the Certified Nursing assistant (CNA). The CNA informed the surveyor that Resident #26 was a set-up for morning (AM) care including care for resident's teeth. [...]

Inspectors wroteBased on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently identified and implemented for one (1) of six (6) residents (Resident #8) reviewed for dietary preferences. This deficient practice was evidenced as follows: On 10/06/23 at 11:04 AM, the surveyor observed Resident #8 inside their room with a Certified Nursing Assistant providing care. On 10/11/23 at 9:04 AM, the surveyor observed the resident seated on a specialized air mattress, covered with a blanket, and with water on top of a tray table in front of the resident. The resident stated that the resident had a concern with food because the resident was not being provided with a menu in advance to choose what the resident likes to eat. [...]

Inspectors wroteBased on observation, interview, and review of the facility provided documents, it was determined that the facility failed to ensure: a) appropriate use of personal protective equipment (PPE) for two (2) of three (3) staff observed during meal observation and b) linen carts were maintained and cleaned for proper storage of clean supplies for four (4) out of five (5) linen carts according to facility policy and Centers for Disease Control and Prevention (CDC) guidelines. This deficient practice was evidenced by the following: According to the CDC, Appendix D - Linen and laundry management, last reviewed May 4, 2023, Best practices for management of clean linen: Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items. [...]

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) for three (3) of three (3) staff in accordance with the facility policy and Centers for Medicare and Medicaid Services (CMS) and New Jersey (NJ) guidelines. This deficient practice was evidenced by the following: According to the NJ Executive Directive 21-012 (revised [DATE]) included ii. 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 facility provided documents, it was determined that the facility failed to ensure that all Certified Nursing Assistant (CNA) received the mandated 12-hours annual competency training as required. This deficient practice was identified in five (5) of five (5) CNAs reviewed and was evidenced by the following: On 10/17/23 at 02:25 PM, the surveyor asked the Director of Nursing (DON) for the mandated education and annual competency training of five (5) randomly chosen CNA. On 10/18/23 at 9:16 AM, the Human Resource Director provided the requested mandatory education and annual competency training documents that included the following: CNA #1 was hired 01/02/1999; total of eight hours of education CNA #2 was hired 09/24/2021; total of eight hours of education CNA #3 was hired 04/01/2007; total of eight hours of education CNA #4 was hired 03/24/2016; [...]

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide written notification of the emergency transfer to the resident representative and the Office of the Long-Term Care Ombudsman (LTCO) for one (1) of two (2) residents (Resident #46), reviewed for hospitalizations. This deficient practice was evidenced by the following: On 10/06/23 at 10:58 AM, the surveyor observed Resident #46 inside their room seated on a bed. The resident stated that there was no concern with care. The surveyor reviewed the hybrid (a combination of paper, scanned, and computer-generated records) medical records of Resident #46. [...]