Crystal Lake Healthcare and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide care and services in accordance with professional standards of practice for 2 of 6 residents reviewed (Resident # 1 and Resident #2) by implementing the practice of double diapering, which is not an accepted standard of incontinence care and has the potential to compromise skin integrity and resident dignity. According to the admission Record (AR) Resident #1 was admitted to the facility with diagnoses which included but were not limited to: dementia (a decline in mental ability-including memory, language, and reasoning), mild intellectual disabilities, and type 2 Diabetes Mellitus (a chronic metabolic disorder characterized by high blood sugar caused by insulin resistance, where body cells fail to use insulin properly, alongside relative insulin deficiency). [...]

Inspectors wroteComplaint #: 2716119 Based on observations, interviews, review of the medical record, and other pertinent facility documentation, it was determined that the facility failed to protect a resident from self-harm and provide adequate supervision for a resident (Resident #100) with a history of suicidal ideations with plans to cut their wrist prior to admission to the facility, who cut their wrist while residing in the facility. This deficient practice was identified for 1 of 6 residents reviewed for accidents (Resident #100). According to the progress notes, on 1/11/2026 at 10:30 PM, the resident was noted by facility staff with a two-inch laceration to their right wrist that was bleeding profusely. The resident stated, I thought that I was going home, but they said I was not. [...]

Inspectors wroteBased on observation, interview, review of medical records and pertinent facility documentation, it was determined that the facility failed to ensure that a cognitively impaired resident (Resident #2), who was dependent on staff for activities of daily living (ADLs) a.) received appropriate interventions to prevent the development of a facility-acquired full thickness pressure injury; b.) ongoing skin assessments were completed and documented in accordance with a physician's order; c.) hospice recommendations for pressure reducing devices were communicated to the physician; and d.) consistently follow-up documentation to monitor the progression or resolution of the skin breakdown. [...]

Inspectors wroteBased on observation, interview, and documentation review, it was determined that the facility failed to follow proper sanitation practices for dishware and kitchen equipment to prevent microbial growth in accordance with professional standards for food service safety. The deficient practice was evidenced by the following:On 1/15/26 at 10:20 AM, the surveyor toured the kitchen with the Director of Service Director (FSD) and observed that the three-compartment sink quaternary chemical sanitization solution indicated 200 parts per million (ppm) concentration. The surveyor interviewed the FSD regarding proper sanitization using sanitizer, and stated that a quaternary ammonium compound required concentration levels between 150-200 ppm. The surveyor requested that the FSD verify the sanitizer concentration level using a test strip. [...]

Inspectors wroteBased on observation, interviews, review of medical records and other pertinent facility documentation, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure that staff, as well themselves, failed to ensure the facility's policies and procedures were implemented to ensure resident safety and well-being by failing: a.) protect residents who were previously identified to be at risk for self-harm and suicidal ideations b.) properly assess, monitor and implement the provision of a wound treatment c.) secure and maintain resident specific medications at all times e.) maintain an accurate accountability for controlled medications. The deficient practice had the potential to affect all residents who resided on 3 of 5 nursing units (nursing units 5, 6 and 7) and was evidenced by the following: [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide a safe, clean, comfortable and home-like environment. This deficient practice was identified for 3 of 5 (three of five) nursing units, [the third (3rd), fifth (5th), sixth (6th)] inspected and was evidenced by the following: On 1/16/2026 at11:37 AM, during the initial tour of the facility, the surveyor observed the following on the third floor nursing unit: Room (RM) 306's rest room had a broken toilet paper holder. RM 309 C had a frayed protective mat wrapped with duct tape applied to the end of the bed. RM 313, the creases of the bathroom tiles had a brown substance on them, a broken toilet paper holder, and the toilet paper was located next to a soiled trash bin. RM 315 had a light switch box that was rusted and had flaked areas. [...]

Inspectors wroteBased on observation, interviews, record review and review of other facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards of practice to ensure: a.) accountability of controlled substance medications were consistently conducted for prompt identification of loss or potential narcotic diversion, and develop a policy and procedure for the use of an emergency electronic backup machine (electronic backup machine; EBM, b.) emergency medications were always available for administration, c.) consistent reconciliation of dispensed and administered controlled dangerous substances (narcotic medications) were accurately documented and discrepancies were immediately investigated. This deficient practice was identified for one (1) of one (1) EBMs and was evidenced as follows: [...]

Inspectors wroteBased on observation, interviews, medical record review and review of pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices a.) during medication pass observation b.) during wound care observation and c.) during dining observation specifically, performing appropriate hand hygiene during the meal service to prevent the spread of potential infectionThis deficient practice was identified for 1 of 3 nurses observed administering medications to 1 of 4 residents (Resident #88) during the medication pass observation task, and for 1 of 1 resident (Resident #2) observed for wound care and for 1 of 5 dining rooms (6th floor). This deficient practice was evidenced by the following:1.) On 1/16/26 at 9:22AM, the surveyor observed Registered Nurse (RN #1) prepare medications for Resident #88. [...]

Inspectors wroteBased on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to revise a resident's care plan with related goals and interventions each time the resident sustained a fall. This deficient practice was identified for 1 of 11 residents (Resident #135) reviewed for accidents and was evidenced by the following:On 1/16/26 at 12:52 PM, the surveyor observed Resident #135 ambulating independently in the hallway without an assistive device. At that time, the surveyor attempted to interview the resident who appeared to be confused and was unable to answer the surveyor's questions appropriately. On 1/20/26 at 11:54 AM, the surveyor reviewed the medical record for Resident #135. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: [...]

Inspectors wroteBased 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 performing treatments as ordered by the physician. This deficient practice was identified for 1 (one) of 1 resident (Resident #194) reviewed for skin alterations and was evidenced by the following:Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide urinary catheter (a tube used to drain urine), treatment and care, based upon current standards of practice specifically : a.) not documenting urinary outputs, and b.) failing to ensure the urinary catheter drainage bag was positioned off the floor and was not visible from the doorway, for 2 of 2 (two) residents (Resident #5 and Resident #8) reviewed for urinary catheter care. The deficient practice was evidenced by the following: On 1/15/26 at 12:22 PM, the surveyor observed Resident #5 lying in bed with the head of the bed elevated while being fed by staff. The surveyor observed the urinary catheter drainage bag contained within a privacy bag and positioned on the floor, visible from the hallway. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to: a.) assess a resident's oxygen setting to ensure that the resident was receiving the correct amount of oxygen as ordered by the physician and b.) properly store a Bi-level positive airway pressure (BiPAP), machine [helps breathing by delivering air through a face mask), in a bag when not in use, in accordance with professional standards of practice. This deficient practice was identified for 1 of 1 (one of one) resident (Resident #191) reviewed for respiratory care and was evidenced by the following: [...]

Inspectors wroteBased on interviews, record review, and review of facility documents, it was determined that the facility failed to act upon the recommendations made by the Consultant Pharmacist in a timely manner. This deficient practice was identified for 1 of 35 residents (Resident #135) reviewed for medications and was evidenced by the following:On 1/16/26 at 12:52 PM, the surveyor observed Resident #135 ambulating independently in the hallway without an assistive device. At that time, the surveyor attempted to interview the resident who appeared to be confused and was unable to answer the surveyor's questions appropriately. On 1/20/26 at 11:54 AM, the surveyor reviewed the medical record for Resident #135. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to properly store and secure medication left at a resident's bedside (Resident #13). This deficient practice was identified on 1 of 5 nursing units (5th Floor) and was evidenced by the following:On 1/20/26 at 10:36 AM, the surveyor in the presence of another surveyor, observed Resident #13 lying in bed, with their eyes closed, fully dressed with a blanket over their legs. On the bedside table there was a clear plastic cup containing a clear liquid and a plastic medicine cup with two round pills, one pink-colored pill, and one slightly smaller light orange pill. The resident had their privacy curtain pulled to the side of their footboard on the bed, inhibiting access to the nightstand. The resident did not respond to surveyor inquiry. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to properly dispose of garbage and refuse in one of one garbage disposal areas. This deficient practice was evidenced by:On 1/15/26 at 10:25 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the facility's garbage disposal area. The surveyor observed container tops, food waste, plastic utensils, pieces of wood and cardboard boxes, as well as used gloves and face masks discarded on the ground adjacent to the garbage disposal containers. The surveyor also observed low-lying black tubing and additional black tubing running along the ground in the garbage disposal area. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the required members were present during the quarterly Quality Assurance and Performance Improvement (QAPI) Committee Meetings. This deficient practice occurred during 2 of 4 meetings reviewed and was evidenced by the following:On 1/15/26 at 11:39 AM, the surveyor requested to view the last four quarters of the QAPI meeting sign-in sheets. On 1/20/26 at 10:13 AM, the surveyor was provided with the QAPI Committee Quarterly Meeting Sign-In Sheets that were dated 1/23/25, 4/24/25, July 2025, and October 2025. A review of the 4/24/25 Sign-In Sheet revealed that LOA (Leave of Absence) was documented in the signature panel of a mandatory participant, the Infection Control Preventionist (ICP). [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the arbitration agreement and admission agreement specifically provides for the selection of a venue that is convenient to both parties, specifically by stating in the admission Agreement a specific location where binding arbitration will be settled. This deficient practice was identified for all residents in the facility. The deficient practice was evidenced by the following: Review of a copy of the facility's undated admission Agreement revealed in section 9. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete the Comprehensive Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 23 of 59 residents (Residents #2, #108, #69, #125, #90, #57, #111, #100, #60, #21, #165, #177, #136, #134, #132, #172, #83, #104, #174, #96 ,#54, and #19) reviewed for Resident Assessment and 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 and record review, it was determined that the facility failed to complete the Quarterly Minimum Data Set (QMDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 54 of 59 residents (Residents # 129,#51, #42, #8, #2, #108, #69, #5, #1, #125, #58, #48, #111, #100, #3, #60, #21, #159, #46, #169, #75, #138, #71, #165, #107, #177, #67, #181, #176, #136, #147, #74, #134, #132, #126, #172, #18, #23, #83, #38, #104, #13, #96, #54, #78, #19, #105, #155, #116, #182, #135, #99, #39, and #52) reviewed for Resident Assessment and was evidenced by the following: Reference: [...]

Inspectors wroteBased on interview and record review, it was determined the facility failed to complete and transmit a Minimum Data Set death in facility tracking record in accordance with federal guidelines and that the facility failed to transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 5 of 59 residents reviewed for resident assessment (Resident #34, #129, #58, #26 and #48 ). This deficient practice was evidenced by: The MDS is a comprehensive federal mandated process for clinical assessment of all residents that should be completed and submitted to the Quality Measure System. The facility must electronically transmit the MDS no later than 14 days after the assessment being completed. After transmission of the MDS, it will generate a quality measure to enable a facility to monitor the residents decline and progress. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner designed to prevent food borne illness. This deficient practice was evidenced by the following: On 04/30/2025 from 09:33 to 9:58 AM the surveyor, accompanied the by the facility Registered Dietitian Nutritionist (RDN), observed the following in the kitchen: 1. In the dry storage room, a can of pear halves on 1of 4 mobile, multi-tiered storage racks had a significant dent on the bottom seam of the can. The RDN removed the dented can to the designated dented can area and told the surveyor that he noticed the dent. 2. On an upper shelf of a multi-tiered storage shelf, two (2) previously opened packages of dry pasta had no open or use by dates. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to a.) ensure the infection control practices for residents on enhanced barrier precautions (EBP) were implemented in accordance with facility policy and accepted national standards, b.) follow appropriate hand hygiene practices during wound treatment, and c.) follow appropriate hand hygiene practices during incontinence rounds to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice. [...]

Inspectors wroteF548 Based on observation, interview and review of other facility documentation, it was determined that the facility failed to ensure residents received a homelike environment during dining by removing the food from the tray and providing tablecloths. This deficient practice was identified for 1 of 6 dining rooms, the main dining room, and was evidenced by the following: 1. On 05/01/2025 at 11:50 AM during the lunch meal in the main dining room [ROOM NUMBER] residents were in attendance by surveyor count. 30 dining tables were available by surveyor count and numbered table cards. 30 tables were observed without tablecloths. The first lunch meal tray was delivered at 12:01 PM. Staff brought the meal tray into the dining room and placed the tray on the table in front of the resident. Staff removed the top pellet and then proceeded to exit the dining room. [...]

Inspectors wroteBased on observation, interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to develop and implement a baseline care plan (BCP) within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident. This deficient practice was identified for 3 of 35 sampled residents (Resident #185, Resident #187 and #293) and was evidenced by the following: 1.)1. According to the admission record, Resident #185 was admitted to the facility in January 2025 with the following but not limited to diagnoses: paranoid schizophrenia, diabetes mellitus and heart failure. A review of the [facility name] Baseline Care Plan - V 2 revealed that there were five (5) sections to the baseline care plan and were as follows: 1. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and other facility documentation, it was determined that the facility failed to ensure that a resident who was identified as having a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity or rigidity of joints) received services to prevent further decreased range of motion (ROM) after discharge from therapy. This deficient practice was identified for 1 of 2 residents reviewed for limited ROM, (Resident #33) and was evidenced by the following: On 4/30/2025 at 9:49 AM, during the initial tour of the facility, the surveyor observed Resident #33 sitting in the wheelchair in the hallway. The resident's left thumb and 4th finger were noted curled inward towards the palm. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident received appropriate care and sufficient services based upon current standards of practice for a urinary catheter. The deficient practice was identified for 1 of 2 residents (Resident # 118) investigated under the Urinary Catheter investigation. This deficient practice was evidenced by the following: On 04/30/2025 at 09:48 AM, during the initial tour of the facility, the surveyor observed Resident # 118 in bed in their room. At that time, the resident told the survey that his urinary catheter was connected to a leg bag. A review of Resident # 118's Electronic Medical Record (EMR) revealed under, Orders that there was a Physician's Order that indicated, Monitor urine output. The order was started on 01/31/2025. [...]

Inspectors wroteBased on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to a.) obtain a physician order for the use of oxygen b.) obtain a physician order for the use of a suction catheter (a flexible plastic tube used to remove fluid from the airway). This deficient practice was identified for 2 of 2 residents reviewed for respiratory care (Resident #185 and Resident #68) and was evidenced by the following: During the initial tour of the facility on 4/30/2025 at 10:45 AM, the Surveyor #1 observed Resident # 185 in the dayroom receiving oxygen via nasal cannula (a device used to deliver supplemental oxygen). On 5/1/2025 at 11:36 AM, the surveyor observed the resident in the dayroom receiving oxygen via nasal cannula. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to effectively accommodate the needs and preferences of residents during dining. This deficient practice was identified for 2 residents (Residents #14 and #85) on 1 of 6 dining rooms, who were included in the review of the dining observation and was evidenced by the following: 1. On 05/01/2025 at 12:12 PM the surveyor observed Resident #85 seated alone in the main dining room eating the lunch meal. The lunch meal consisted of baked ziti, green beans, and garlic bread. Resident #85 consumed 100%of baked ziti and garlic bread. Resident #85 did not eat the green beans received. Resident #85 stated to the surveyor that the lunch was excellent. The surveyor asked Resident #85 why he/she did not eat their green beans and Resident #85 responded that he/she did not like green beans. [...]

Inspectors wroteComplaint #: NJ185153 Based on interviews, medical record review, and review of other pertinent facility documentation on 4/10/25, it was determined that the facility failed to ensure: a) a staff member immediately reported an observed sexual encounter between a resident (Resident #1) who had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive impairment) from a resident (Resident #2) who had a BIMS score of 8 (moderate cognitive impairment) and b) both residents were immediately separated, safe, and no other residents were placed in immediate danger. The facility also failed to follow its policy titled Resident Abuse/Neglect Policy. On 4/3/25 at approximately 12:00 P.M., the Housekeeper (HK) stated she went to Resident #1 and Resident #2's room and knocked on the door. The HK entered the room and observed Resident #1 on the bed performing oral sex on Resident #2. [...]

Inspectors wroteComplaint #: NJ185153 Based on interviews and review of other pertinent facility documentation on 4/23/25, it was determined that the facility failed to maintain documentation and demonstrate evidence of its Quality Assurance and Performance Improvement (QAPI) program. On 4/23/25 at 10:47 AM, the surveyor requested the facility's QAPI plan and most recent meeting minutes from the Licensed Nursing Home Administrator (LNHA). On 4/23/25 at 11:05 AM, the surveyor interviewed the LNHA who stated she was unable to retrieve the QAPI plan and meeting minutes due to not having internet access. The LNHA stated she kept the QAPI plan and meeting minutes on her computer. She further stated she would try to email the surveyor the QAPI plan and meeting minutes. [...]

Inspectors wroteComplaint #: NJ182091 Based on interviews and review of other pertinent facility documentation on 4/10/25, it was determined that the facility failed to ensure that a staff member assigned the position of Monitor was not performing direct resident care. This deficient practice was identified for 1 of 3 monitors reviewed and was evidenced by the following: According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with an event date of 1/1/25 revealed the Physical Therapist Aide (PTA) was approached by Resident #4 who stated the aide hit Resident #3. The PTA went to the residents' room, where the aide (Monitor #1) was performing Activities of Daily Living (ADLS) with Resident #3. [...]

Inspectors wroteComplaint #: NJ181767, NJ181768, NJ181846 Based on observations, interviews, medical record review, and review of other pertinent facility documents on 12/23/2024 and 12/30/2024, it was determined that the facility failed to a.) prevent physical and verbal abuse towards a resident (Resident #1) from a staff member and b.) staff members that witnessed the abuse failed to intervene and report the incident. The facility also failed to follow its policy titled Abuse Policy and Procedure. During an interview on 12/23/2024 at 3:08 P.M., the Licensed Practical Nurse (LPN #1) stated she recorded a video on her cellphone of the Director of Nursing (DON) hitting Resident #1 with a broom. LPN #1 sent the video to a friend, and it was posted to a social media website. [...]

Inspectors wroteComplaint #: NJ181767, NJ181768, NJ181846 Based on observations, interviews, medical record review, and review of other pertinent facility documents on 12/23/2024, it was determined that the facility failed to conduct a timely and thorough investigation for an allegation of witnessed staff to resident physical abuse toward a resident (Resident #1). During an interview on 12/23/2024 at 3:08 P.M., the Licensed Practical Nurse (LPN #1) stated she recorded a video on her cellphone of the Director of Nursing (DON) hitting Resident #1 with a broom. LPN #1 sent the video to a friend, and it was posted to a social media website. The Surveyors and the Assistant Director of Nursing (ADON) reviewed a video on 12/23/2024 at 10:41 A.M. found on a social media website, that revealed a staff member hitting at a resident with a broom. [...]

Inspectors wroteComplaint #: NJ181767, NJ181768, NJ181846 Based on observations, interviews, and review of facility documentation, it was determined that the facility failed to ensure a resident's right to privacy and confidentiality were not violated when a video of a resident (Resident #1) being hit with a broom by the Director of Nursing (DON) was recorded by a staff member and sent to their friend who posted the video on a social media website. This deficient practice was identified for 1 of 1 resident (Resident #1) who was reviewed for privacy and confidentiality and was evidenced by the following: According to the admission Record (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Major Depressive Disorder, Dementia, and Epilepsy (seizures). [...]

Inspectors wroteComplaint #: NJ181767, NJ181768, NJ181846 Based on observations, interviews, medical record review, and review of other pertinent facility documents on 12/23/2024, it was determined that the facility failed to report an allegation of witnessed staff to resident physical and verbal abuse toward a resident (Resident #1) to the Department of Health and to the local Police Department when the incident occurred on 06/20/2023. This deficient practice was identified for 1 of 3 residents (Resident #1) who were reviewed for abuse and was evidenced by the following: The Surveyors and the Assistant Director of Nursing (ADON) reviewed a video on 12/23/2024 at 10:41 A.M. found on a social media website, that revealed a staff member hitting at a resident with a broom. Several other staff members observed the incident and did not intervene. The ADON identified the resident in the video as Resident #1. [...]

Inspectors wroteComplaint # NJ178530 Based on interviews, medical record review, and review of other pertinent facility documentation on 10/22/2024, 10/23/2024, 10/24/2024 and 10/29/2024, it was determined that the facility: a) failed to provide services necessary to prevent physical abuse for a resident (Resident #1), b) used a physical hold restraint for a resident (Resident #1) with a known history of physically aggressive behaviors towards others and diagnoses of Traumatic Brain Injury, Impulse Disorder, and Schizoaffective Disorder. On 10/14/2024 at approximately 11:58 AM, the Certified Nursing Assistant (CNA#1) stated she observed Resident #1 on the floor in the hallway with CNA #2 and the Smoking Monitor (SM) hitting Resident #1, at which time she ran to get the Licensed Practical Nurse (LPN#1) who was already on her way to the hallway. [...]

Inspectors wroteComplaint # NJ178530 Based on interviews, medical record review, and review of other pertinent facility documentation on 10/22/2024, 10/23/2024, 10/24/2024, and 10/29/2024, it was determined that the facility failed to conduct a timely and thorough investigation for an allegation of witnessed and reported staff to resident physical abuse toward a resident (Resident #1). On 10/14/2024 at approximately 11:58 AM, the Certified Nursing Assistant (CNA#1) stated she observed Resident #1 on the floor in the hallway with CNA #2 and the Smoking Monitor (SM) hitting Resident #1, at which time she ran to get the Licensed Practical Nurse (LPN#1) who was already on her way to the hallway. LPN #1 stated she heard a loud bang and yelling in the hallway. LPN #1 responded to the hallway and saw Resident #1 laying on the floor in the hallway yelling please stop, get them off of me. [...]

Inspectors wroteComplaint #: NJ178530 Based on interviews, medical record review, and review of other pertinent facility documentation on 10/22/2024, 10/23/2024, 10/24/2024, and 10/29/2024, it was determined that the facility failed to a.) implement care plan (CP) interventions for a resident (Resident #1) with a known history of physically aggressive behaviors towards others and diagnoses of Traumatic Brain Injury (a head injury causing damage to the brain), Impulse Disorder (an inability to control impulses and behaviors), and Schizoaffective Disorder (a chronic mental health condition that combines symptoms of psychosis with symptoms of mood disorders). [...]

Inspectors wroteComplaint # NJ178530 Based on interviews, medical record review, and review of other pertinent facility documentation on 10/22/2024, 10/23/2024, 10/24/2024, and 10/29/2024, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to: [...]

Inspectors wroteComplaint#: NJ176503, NJ178530 Based on interviews and medical record review on 10/22/2024, 10/23/2024, 10/24/2024, and 10/29/2024, it was determined that the facility failed to implement the recommendations from a resident's Pre-admission Screening and Resident Review (PASARR) level II determination. This deficient practice was identified for 1 of 2 residents reviewed for the PASARR (Resident #1), and was evidenced by the following: According to the admission Record (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Traumatic Brain Injury (a head injury causing damage to the brain), Impulse Disorder (an inability to control impulses and behaviors), and Schizoaffective Disorder (a chronic mental health condition that combines symptoms of psychosis with symptoms of mood disorders). [...]

Inspectors wroteComplaint #: NJ178766, NJ178770 Based on interviews, medical record review, and review of other pertinent facility documents on 10/22/2024, 10/23/2024, and 10/24/2024, it was determined that the facility failed to update the care plan (CP) with interventions for 2 of 7 residents (Resident #3 & #4) for making an abuse allegation about staff to the local authorities. The facility also failed to follow its policy titled Care Plan. This deficient practice was evidenced by: According to the Facility Reportable Events (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents dated 10/18/2024, with an event date of 10/17/2024 and a time of event of 12:30 P.M., pertaining to Resident #3: Local authorities came to the facility stating they were investigating an anonymous call stating, the resident was being abused by staff. [...]

Inspectors wroteComplaint #: NJ172203 Based on interviews, record review, and facility policy review, the facility failed to honor the rights to have in their possession a personal cell phone for 1 (Resident #1) of 3 sampled residents reviewed for resident rights.

Inspectors wroteNJAC 8:39-4.1(a)5 NJAC 8:39-33.2(c)12 Based on record review, interview and policy review, the facility failed to ensure residents were free from physical abuse for two of seven residents (Resident (R) 191 and R79) reviewed for resident-to-resident abuse. R79 suffered a facial fracture due to physical abuse. The facility failed to ensure residents were free from sexual abuse for one of seven (R116) residents reviewed for sexual abuse.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure allegations of physical and sexual abuse and injury of unknown origin were reported to the State Survey Agency (SSA) timely for three of seven residents (Resident (R)191, R79 and R116) reviewed for physical and sexual abuse and one of one resident (R79) reviewed for injury of unknown origin.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure resident-to- resident abuse and injury of unknown origin were investigated thoroughly for two of seven residents reviewed for resident-to-resident abuse (Resident (R)191 and R79) and for one of one injury of unknown origin (R79).

Inspectors wroteBased on interview, record review, and the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete the quarterly Minimum Data Set (MDS) assessment in a timely manner for 14 of 35 sampled residents (Resident (R) 11, R12, R24, R38, R47, R53, R76, R80, R85, R99, R116, R145, R157 and R171).

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to provide care and services in a manner that maintained and promoted dignity for two of three sampled residents (Resident (R157 and R88) reviewed for dignity in a sample of 35 residents. Specifically, staff stood while assisting residents with their meals. This failure placed residents at risk for diminished self-worth, self-esteem, and feelings of embarrassment.

Inspectors wroteBased on observation, interview, record review, document review and policy review, the facility failed to ensure one resident (Resident (R) 46) of 35 sampled residents were maintained in a manner to ensure resident privacy, in that the computer screen on the medication cart was left open revealing R46's medications. This failure placed residents at risk of loss of the right to personal privacy and confidentiality of medical information.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure that a new Preadmission Screening and Resident Review (PASARR) Level I assessment was submitted after a new mental illness diagnosis for one (Resident (R)168) out of 3 residents reviewed for PASARR.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure medical records included accurate advance directives for one (Resident (R) R88) of three residents reviewed for advance directives, of a total sample of 35 residents.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to maintain the cleanliness of the oxygen concentrators for two out of two residents (Resident (R) 38 and R12) of 35 sample residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to attempt to use appropriate alternatives prior to installing a side rail and failed to complete quarterly assessments for the continued use and safety of the side rail for one of one resident reviewed for side rails out of 35 sampled residents (Resident (R) 80).

Inspectors wroteBased on observation, interviews, record review, policy review and manufacturer's guidelines review, the facility failed to prevent the potential spread of infection and cross-contamination between residents in that the nurses did not disinfected the glucometer after completing R76's accu chek per the facility's policy prior to storage of the glucometer and the nurse failed to sanitize the top of the medication cart and residents' beside table after placing the unclean glucometer directly on the two surfaces for two residents (Resident (R) 76 and R4) of three residents in the sample of 35. In addition, one of one Certified Nursing Assistant (CNA10) staff failed to sanitize their hands between direct contact with residents, R22 and R88.