Deptford Center for Rehabilitation and Healthcare

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that a resident's physician ordered medication was signed as administrated at the time of administration in accordance with professional standard of practice. This deficient practice was identified for 1 of 9 residents reviewed for standards of practice (Resident #7). The evidenced was as followed: Reference: The practice of nursing as a Licensed Practical Nurse is defined as performing tasks, and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a Registered Nurse, or otherwise legally authorized Physician or Dentist. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain kitchen equipment in a clean and sanitary manner as evidenced by the following: On 8/8/25 at 9:58 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. The microwave had multicolored dried stuck on debris on the interior ceiling of the unit. The FSD acknowledge it was not properly cleaned according to facility policy. 2. The convection ovens were soiled with baked on brown coloring on the glass doors making them opaque and not transparent. There were baked on debris on the interior corners of the units. The FSD acknowledged and stated, it was not cleaned according to facility policy. 3. The six-burner stove top and oven were not clean. The interior of the oven had food sediment and build up on the interior door. [...]

Inspectors wroteBased on interview and document review, it was determined that the facility failed to ensure that all residents that maintained a Personal Needs Account (PNA) a.) received a written notification when approaching the limit that could jeopardize a resident's eligibility for Medicaid or Supplemental Security Income (SSI) and b.) funds and final accounting of those funds were conveyed within 30 days of the resident's discharge or death to the proper jurisdiction. This deficient practice was identified for 12 of 13 residents (Resident #6, #39, #80, #159, #173, #186, #239, #241, #243, #245, #248 and #249) reviewed for PNA and was evidenced by: 1.) On [DATE] at 12:00 PM, the Licensed Nursing Home Administrator (LNHA) provided the PNA balances as of [DATE]. A review of the facility's Trial Balance revealed 12 residents had balances that ranged from $1,964.18 to $39,870.91. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure a low-air-loss mattress was operating and set according to the resident's weight, as per a physician's order for a resident previously identified as being at risk for impaired skin integrity. This deficient practice was identified for 1 of 4 residents (Resident #7) reviewed for positioning and mobility, and was evidenced by the following:On 8/8/2025 at 10:46 AM, the surveyor observed Resident #7 lying in bed awake. The mattress was noted to be inflated; however, the air loss mattress (a mattress used to prevent and treat pressure ulcers) was not on at that time. There was a piece of tape on the machine, with weight 235 pounds (lbs), written on it. On 8/13/2025 at 11:08 AM, the surveyor conducted a follow-up visit to the resident's room. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure an accurate account of the administration and documentation of controlled medications. This deficient practice was identified for 1 of 3 nurses on 1 of 8 nursing units (2 D) reviewed during the medication administration and storage observation and was evidenced by the following: On 8/12/25 at 8:57 AM, the surveyor observed Licensed Practical Nurse (LPN) #1 administer six (6) medications to Resident #128 during the medication administration observation. When finished, the surveyor requested to review the Shift Count narcotic inventory log. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to respond to comments/recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for 1 of 5 residents (Resident #185) reviewed for Unnecessary Medications and was evidenced by the following:A review of Resident #185's Order Summary Report (OSR) revealed a Physician's Order (PO) dated 4/9/25, for Fludrocortisone Acetate (used to treat certain conditions in which the adrenal glands (a gland) cannot make enough hormones such as Addison's Disease) Oral Tablet 0.1 milligrams (mg) (Fludrocortisone Acetate) Give one (1) tablet by mouth one time a day for Syndromes. The surveyor reviewed the diagnoses listed on the resident's OSR which failed to include a medical diagnosis of syndromes. [...]

Inspectors wroteBased on interview, record review, document review, and policy review, the facility failed to provide quality care in accordance with physician orders for one Resident (R) 9) of three residents reviewed for outside appointments out of a total sample of 22 residents. Specifically, the facility failed to ensure R9 had a gastric emptying scan as ordered. This had the potential for R9 and other residents to have medical issues related to missed procedures.

Inspectors wroteC# NJ166810 C# NJ167847 C# NJ168096 Based on interview, document review, and review of facility policy, the facility failed to ensure four residents (Resident (R) 6, R9, R25, and R30) of 31 sampled residents reviewed for abuse were free from resident-to-resident abuse perpetrated by R5. This had the potential to affect resident safety at the facility.

Inspectors wroteC# NJ165261 C#NJ165932 C#NJ166156 C#NJ166810 C#NJ167718 C#167847 C#NJ168096 C#NJ168350 C#NJ168593 C#NJ171428 Based on interview, document review, and review of facility policy, the facility failed to ensure the facility reported the results of their abuse/neglect investigations to the State Survey Agency (SSA) within five working days for 10 out of 13 residents (Resident (R) 3, R4, R5, R6, R9, R2, R11, R7, R31, R14) reviewed for abuse of 31 sampled residents. This failure had the potential to delay corrective measures and appropriate response to abuse allegations ensuring the safety of the residents.

Inspectors wroteC/O # NJ171057 Based on interview and review of the Nurse Staffing Report and Payroll Based Journal (PBJ) Staffing Data Report, it was determined that the facility failed to ensure to have sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. This deficient practice was evidenced by following: On 02/28/2024 at 10:30 AM surveyor #2 held a resident council meeting with 10 to 11 residents. Regarding the call bells, all in the group said the wait time was from 2 hours to 4.5 hours waiting for call bell to be answered, especially on evenings and night shift. They further stated, weekends horrible. 5 of 5 residents stated the delay in call bell response time caused a fall or incontinence episode. On 02/28/2024 at 12:05 PM surveyor #2 met with Resident #171 who stated that he/she constantly hears people calling for help. [...]

Inspectors wroteBased on observation, interview, and pertinent record review, it was determined that the facility failed to ensure the accountability of the narcotic Shift Count logs were completed in accordance with facility policy and accurately account for and document the administration of controlled medications. This deficient practice was identified on 4 of 4 medication carts observed on 4 of 4 nursing units and was evidenced by the following: Repeat deficiency from recertification survey of 09/20/2022 On 2/28/2024 at 11:00 AM, the surveyor, in the presence of a second state surveyor and a federal surveyor, interviewed Licensed Practical Nurse (LPN #4), who stated nurses coming on duty along with the nurse going off duty are to count the narcotics in the medication cart together and sign the Shift Count log together to confirm the count is accurate and narcotics are accounted for. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) properly store and secure medications and properly label opened multidose medications and b.) properly secure wound treatment carts when not attended. This deficient practice was observed in a.) 2 of 2 medication storage rooms and 4 of 4 medication carts on 4 of 4 nursing units reviewed for medication storage and labeling and in b.) 1 of 1 treatment carts observed during wound observation. This was evidenced by the following: Repeat deficiency from recertification survey of 09/20/2022 a.) On 02/28/2024 at 9:39 AM, the surveyor, in the presence of a second state surveyor and a federal surveyor, interviewed Registered Nurse/Unit Manager (RN/UM #1), who stated all nurses are responsible to maintain the medication storage room's organization and cleanliness. [...]

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 to prevent food borne illness. This deficient practice was evidenced by the following: Repeat deficiency from recertification survey of 09/20/2022 On 02/27/2024 from 9:32 AM to 10:21 AM, the surveyors, accompanied the Director of Food Services (DOFS), observed the following in the kitchen: The surveyors observed a dietary aide (DA) in the kitchen. The DA had lengthy braids to mid shoulder and was observed wearing a baseball style hat. The braids extended past the shoulders and were exposed. The DA did not have a hair net in place and the hair was exposed. [...]

Inspectors wroteComplaint #NJ169732 Complaint #NJ170765 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a) provide a homelike dining experience on 1 of 2 units, (2nd floor), and b) maintain the facility and equipment in clean and sanitary environment. This deficient practice was identified for 2 of 2 units, (1st and 2nd floor) and was evidenced by the following: Repeat deficiency from recertification survey of 09/20/2022 a.) During the initial tour of the 2nd floor on 02/27/2024 12:22 PM, Surveyor #1observed the nurse pass the first tray and no placemats observed on the trays. There were no tablecloths on the tables. All food and drinks were left on the tray for all residents and not placed directly on the tables. On 02/28/2024 at 12:05 PM, the 1st meal truck arrived at the dining room/patient lounge on the 2nd floor. [...]

Inspectors wroteBased on interviews and review of other facility documentation, it was determined that the facility allowed Non-Certified Nursing Aides (NAs) to continue working as an NA after the specified 120 days from date of hire. This deficient practice was identified for 7 NAs, (NA1, NA2, NA3, NA4, NA5, NA6, NA7) during the NA review. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health memo dated [DATE], sent to Nursing Homes included the following: Facilities are advised as follows: II. Nurse Aides Nurse Aides (not TNAs) who are enrolled in a NATCEP program must finish training and pass the nurse-aide written or oral exam and the State approved clinical skills competency exam within the usual 120 days, pursuant to N.J.A.C. 8:39-43.10. [...]

Inspectors wroteRepeat deficiency from recertification survey of 09/20/2022 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide all the items that were on the corporate menu. This deficient practice occurred during one breakfast meal that was observed on the first floor and was evidenced by the following: Repeat deficiency from recertification survey of 09/22/2022 1. On 02/28/2024 at 09:24 AM, Resident #146 had not received their breakfast tray at that time. Resident #146 stated that they usually receive breakfast between 9-9:15 AM. The meal cart arrived on the unit at (9:30 AM and Resident #146 received his/her tray at 9:34 AM.) Resident #146 received scrambled eggs, bagel (whole) with cream cheese, an 8-ounce (oz) skim milk, 6 oz coffee, cold cereal portion control, a small muffin, and 4 oz orange juice. [...]

Inspectors wroteComplaint # NJ00171057 Repeat deficiency from recertification survey of 09/20/2022 Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to consistently serve foods at a safe and appetizing temperature. This deficient practice was evidenced by the following: On 02/27/2024 at 12:14 PM, during the initial tour of the facility Resident #146 stated that the food has improved but we need more variety, and the portions are small. Resident stated that meal trays arrive between 12:15 and 12:45, you never know. Sometimes food is cold, not what menu says is received. On 2/28/2024 at 10:30 AM, during the resident council meeting 8 of 8 residents attending the resident council meeting complained of cold food to the surveyor. [...]

Inspectors wroteBased on observation, interviews, record review, and review of other facility documentation, it was determined that the facility failed to: 1.) donn (put on) the appropriate personal protective equipment (PPE) prior to entering an isolation room to prevent the transmission of infection 2.) maintain proper infection control practices while performing wound care and 3.) maintain proper infection control practices during the dining observation. This deficient practice was identified for: 1.) 1 of 3 residents (Resident #645) on transmission-based precautions, 2.) 1 of 2 residents observed for wound care (Resident #126), and 3.) 1 of 3 dining rooms observed for meals (first floor dining room). This deficient practice was evidenced by the following: 1. On 02/28/2024 at 12:33 PM, Surveyor #1 observed a Contact Precautions sign at Resident #645's doorway. [...]

Inspectors wroteBased on observation, interview, and review of the medical record, it was determined that the facility failed to ensure a resident was dressed appropriately while in common areas of the unit and did not expose him/herself to other residents as well as failed to transport a resident from one area of the facility to another in a dignified manner. This deficient practice was identified for 1 of 48 sampled residents reviewed for dignity, (Resident # 89) and was evidenced by the following: During the initial tour of the 2nd floor on 02/27/2024 at 10:35 AM, the surveyor observed Resident #89 in Activity room/patient lounge on the 2nd floor in a reclining Geri chair. Resident #89 was dressed in a hospital gown, pulled up and his/her brief exposed to room. 10 other residents were in the room along with activity staff. [...]

Inspectors wroteBased on observations and interviews it was determined that the facility failed to maintain the most recent State of New Jersey inspection results in a place readily accessible to the residents, families, and the public. This deficient practice was evidenced by the following: On 02/27/2024 at 09:00 AM, during initial entrance to the facility the surveyor observed the State Results Binder on a small table next to the reception desk. There was a set of double doors between the lobby and a hallway which led to the nursing units. The doors were locked and required a four-digit code to open the doors to enter the nursing units or to exit back to the entrance lobby, where the binder was located. On 02/28/2024 at 10:30 AM, the surveyor held a Resident Council meeting with 10 residents. During the meeting the surveyor asked the residents if they were aware of the survey results and the location. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to protect the confidentiality of a resident's health related information. This deficient practice was identified at 1 of 2 nursing stations and was evidenced by the following: On 03/01/2024 at 12:26 PM, at the 2nd floor nursing station, the surveyor observed a medication cart unattended with the Medication Administration Record (MAR) opened to full view, exposing a resident's personal identification which include the following information: The resident's name, photo, date of birth , medical diagnoses, allergies, diet, and medications. The MAR was displayed on a fixed laptop attached to the top of the medication cart located at the nursing station across from hallway C. The medication cart was locked. On 03/01/24 at 12:29 PM, the Licensed Practical Nurse (LPN #5) returned to her cart. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide information and educate residents on the grievance process. This was deficient practice was identified for 10 of 10 residents interviewed (Resident #9, 26, 46, 75, 82, 86, 125, 166, 172, and 446)) on the grievance process during a Resident Council meeting conducted on 02/28/2024 at 10:30 AM and was evidenced by the following: On 02/28/2024 at 10:30 AM, during the resident council meeting with ten alert and oriented residents, the surveyor asked the residents if they were aware of what a grievance was and how to file a grievance with the facility if necessary. Ten of the ten residents present during the meeting told the surveyor they did not know the definition of a grievance or how to file a grievance or formal complaint in writing. [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed ensure a Preadmission Screening and Resident Review (PASARR) one was completed accurately for a newly admitted resident. This deficient practice was identified in 1 of 3 residents reviewed for PASARR (Resident #150) and was evidenced by the following: On 02/27/2024 at 10:09 AM, during the initial tour of the facility, the resident was sitting in the bed with eyes opened. A review of the admission Record indicated Resident #150 had medical diagnoses which included but were not limited to :dementia, psychotic disorder (a mental illness), aphasia (inability to express self verbally). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical needs and failed to implement focus and interventions that are specific to the resident's catheter care and respiratory diagnosis. The deficient practice was identified for 1 of 2 Residents (Resident # 48) for catheter care and of 2 Residents (Resident #170) for respiratory diagnosis, investigated for care plans. The deficient practice was evidenced by the following: 1. On 02/27/2024 at 10:43 AM during the initial tour of the facility the surveyor observed Resident # 48 sitting in the dining room. Resident # 48 was observed to have a indwelling catheter (a medical device that helps drain urine from your bladder) in a blue privacy bag. [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to update a care plan for a resident following a hospitalization and change in condition. This deficient practice was identified in 1 of 48 residents reviewed for care plans (Resident #80) and was evidenced by the following: On 02/27/2024 at 09:22 AM, during the initial tour of the facility Resident #80 was observed in bed with eyes open. The surveyor did not observe a feeding pump or feeding tube supplies in the resident's room. Resident #80 told the surveyor that he/she used to have a feeding tube when they were admitted to the facility, but no longer had a feeding tube and tolerated a regular diet. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure care and services are provided according to accepted standards of clinical practice, specifically by not providing a resident a medication that was available in the automated medication dispenser and failing to follow a physician's order for oxygen administration. The deficient practice was identified for 2 of 2 residents (Resident # 124 & # 170) investigated for Services Provided to Meet Professional Standards. The deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: [...]

Inspectors wroteBased on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure that residents with decreased range of motion and mobility received prescribed treatments to prevent contractures for 1 of 4 residents (Resident #112) reviewed for limited range of motion. This deficient practice was evidenced by the following: During the initial tour of the facility on 02/27/2024 at 10:36 AM, the surveyor observed Resident #112 lying in bed awake. The resident's left hand was contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity or rigidity of joints) and a right hand deformity was noted. When interviewed the resident stated that he/she had a brace somewhere that staff put on once in a while. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined the facility failed to maintain a urinary catheter and provide services in a manner consistent with standards of practice for 1 of 2 residents reviewed for urinary catheter care (Resident #80). This deficient practice was evidenced by the following: On 02/27/2024 at 09:22 AM, during the initial tour of the facility, Resident #80 was observed in bed with eyes open. The surveyor observed a urinary drainage bag hanging on the left side of the bed facing towards the doorway of the residents' room. The drainage bag was not in a privacy bag, meaning the bag did not have a cover to conceal the contents. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to follow their own policy for storage of respiratory equipment. This deficient practice was identified for 1 of 2 (Resident #154) residents reviewed for respiratory concerns and was evidenced by the following: During a tour of the facility on 02/27/2024 at 09:58 AM, Resident #154 was observed in bed. On 02/29/2024 at 03:19 PM, the surveyor observed the nebulizer machine (a nebulizer machine delivers aerosol medication to the person via a mouthpiece and chamber/cup that holds the medication, via tubing that is attached to the machine. It is used to treat respiratory conditions such as COPD, bronchitis, and asthma.) on an overbed table. The surveyor observed the tubing and mouthpiece of the nebulizer machine exposed to air and uncovered. [...]

Inspectors wroteBased on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure that the resident's prescribed dietary supplement and preferences were accurately identified and implemented for 1 of 3 residents (Resident #25) reviewed for dining services. This deficient practice was evidenced by the following: On 02/27/24 from 11:59 AM to 12:49 PM, the surveyor observed dining services in the first floor main dining room. At 12:19 PM, The surveyor observed a Dietary Aide (DA) as she called out for a condiment cart after the resident's meals had already been served and the residents had begun to eat their meals. The surveyor observed Resident #25's meal ticket and noted that the resident had not received creamer for his/her coffee, salt, pepper and a health shake (dietary supplement). [...]

Inspectors wroteComplaint #: NJ00165456 Based on interview, medical record review, and review of other pertinent facility documentation on 10/20/23, 10/24/23, and 10/26/23, it was determined that the facility failed to develop a baseline care plan for a newly admitted resident who experienced pain. This deficient practice was identified for Resident #2, 1 of 2 residents reviewed for baseline care plans and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #2: [...]

Inspectors wroteComplaint #: NJ00168282, NJ00168313 Based on observation, interview, review of medical records, and review of other pertinent facility documentation on [DATE], [DATE], and [DATE], it was determined that the facility failed to update a comprehensive care plan for a resident who had a life-threatening event. The deficient practice was identified for Resident #3, 1 of 4 residents reviewed for comprehensive care plans and was evidenced by the following: During an interview with the surveyor on [DATE] at 12:23 PM, Resident #3 stated that they overdosed on fentanyl (a synthetic opioid) twice at the facility within the last few months. The resident stated that facility staff used Narcan (opioid overdose treatment) on him/her and that they were sent out to the hospital after each overdose. [...]

Inspectors wroteComplaint #: NJ00165456 Based on interview, medical record review, and review of other pertinent facility documentation on 10/20/23, 10/24/23, and 10/26/23, it was determined that the facility failed to provide treatment for a resident with a pressure ulcer. The deficient practice was identified for Resident #2, 1 of 2 residents reviewed for pressure ulcers and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #2: [...]

Inspectors wroteComplaint # NJ00164862, NJ00165456, NJ00168282, NJ00168313, NJ00168836 Based on observation, interview, medical record review, and review of other pertinent facility documentation on 10/20/23, 10/24/23, 10/26/23, and 11/09/23 it was determined that facility staff failed to consistently document on the Documentation Survey Report, the Activities of Daily Living (ADL) status and care provided to the residents. In addition, the facility staff failed to follow the facility's policy titled Charting and Documentation-CNA for Resident #1, #2, #3, and #5, 4 of 5 residents reviewed for documentation. The deficient practice was evidenced by the following: 1. [...]

Inspectors wroteBased on observation and interview it was determined that the facility had insufficient staffing in the kitchen to carry out the duties of the food service operations competently. This deficient practice was evidenced by the following: Cross-reference: F 760, F803, F804, F809 and F812 On 08/30/22 at approximately 10:00 AM, during the initial brief tour of the kitchen, the surveyor questioned the Director of Food Services (DOFS) why the kitchen staff were still assembling breakfast trays at 10:00 AM. The DOFS explained, We are normally done breakfast tray line by 9 AM. I had to call in (2) staff and borrow a cook from a sister facility. Staffing has been an issue for the month I've been here. It is slowing and affecting our production. On 08/30/22 at 11:24 AM, the surveyor observed CNA #3 assisting resident #92 with the breakfast meal at 11:24 AM. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a) ensure that staff were following the menu over multiple meal observations which affected all residents of the facility and b) failed to obtain approval of menu substitutions in accordance with facility policy. This deficient practice was evidenced by the following: 1. On 08/30/22 at 11:24 AM, Surveyor #1 observed a Certified Nursing Assistant (CNA #3) assisting resident #92 with the breakfast meal. The surveyor asked CNA #3 if that was the breakfast or lunch meal. CNA #3 stated, It's breakfast. They didn't send a puree tray and we had to wait for another. According to the admission Record, Resident #92 was admitted to the facility with diagnosis including but not limited to: [...]

Inspectors wroteBased on observation, interviews, and record review and review of other facility documentation, it was determined that the facility failed to serve meals at regular times in a manner that meets the residents needs for 2 of 2 residents (Resident #92 and Resident #74) observed during mealtime. This deficient practice was evidenced by the following: Cross reference F760, F802 1. On 08/30/22 at 11:24 AM, while on the initial tour of the facility on the 2nd floor, the surveyor observed a Certified Nursing Assistant (CNA #3) assisting Resident #92 with eating his/her meal at 11:24 AM. The surveyor asked CNA #3 if that was the breakfast or lunch meal. CNA #3 responded, It's breakfast. They didn't send a puree tray and we had to wait for another. We get the trays based on how many people show up to work in the kitchen. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 08/30/22 from 09:18 AM to 10:08 AM the surveyor, accompanied by the Director of Food Service (DOFS), observed the following in the kitchen: 1. On a middle shelf of a multi-tiered rack in the dry storage room a Styrofoam cup without a lid contained an unidentified liquid. The cup had not been labeled or dated. The DOFS stated, That doesn't belong there. 2. On a middle shelf (2) gallon containers of Fresh Kosher Chips had a received date of 6/24/21. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to consistently revise and/or update resident care plans for 2 of 38 residents (Resident #6 and Resident #62) reviewed for comprehensive care plans. This deficient practice was evidenced by the following: 1. According to the admission Record, Resident #6 was admitted with diagnoses that included, but were not limited to, senile degeneration of brain, hemiplegia (paralysis of one side of the body) and muscle weakness. [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that the facility failed to consistently complete neurological evaluations (neuro checks) after unwitnessed falls for 1 of 6 residents (Resident #189) reviewed for accidents. This deficient practice was evidenced by the following: On 08/31/22 at 11:46 AM, the surveyor observed Resident #189 resting comfortably in bed with the head of bed (HOB) slightly elevated. The surveyor observed floor mats positioned on both sides of the resident's bed. According to the admission Record, Resident #39 was admitted with diagnoses which included, but were not limited to, acute respiratory failure with hypoxia (low levels of oxygen in your body tissue) and dementia. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to follow a physician's order for the application of a palm protector (a type of splinting that provides a barrier between the fingers and the palm to prevent injury to the palm from finger contracture) for 2 of 3 residents (Resident #6 and Resident #62) reviewed for positioning and mobility. The deficient practice was evidenced by the following: 1. During tour of the 2B unit on 08/30/22 at 11:14 AM, the surveyor observed Resident #6 in bed with the head of bed (HOB) elevated. The surveyor observed that Resident #6 had limitation to the left hand and did not have on a palm protector. When interviewed, Resident #6 was unable to provide any information about his/her care. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to: a.) follow professional standards of nursing practice by administering expired insulin medication and b.) ensure that insulin medication was administered to residents within an appropriate time frame according to physician's order and manufacturer specifications. This deficient practice was identified for 4 of 35 sampled residents, (Residents #12, #93, #182 and #168) reviewed for the administration of insulin (a medication used for Diabetes) during medication administration and was evidenced by the following: 1. [...]

Inspectors wroteBased on observation, interview, and review of other pertinent facility documentation, it was determined the facility failed to maintain an orderly and sanitary environment by leaving garbage bags, a spill, gowns, linens, and unpackaged incontinence briefs in the hallway of B unit. The deficient practice was identified for 1 of 4 wings (B Wing) on the first floor and was evidenced by the following: On 8/31/22 at 10:26 AM, in the B Wing, the surveyor observed two trash bags filled with garbage unattended on the floor. The surveyor also observed linen with unpackaged incontinence briefs left on top of a plastic supply bin in the hallway. Further, the surveyor observed another opened bag of incontinence briefs on a chair in the hallway. [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) a.) an allegation of physical and verbal abuse for 1 of 1 resident (Resident #134) reviewed for abuse and b.) an unwitnessed event resulting in major injury for 1 of 3 residents (Resident #41) reviewed for falls. This deficient practice was evidenced by the following: 1. On 09/01/22, the surveyor requested the personnel files for five employees hired within the last four months. Review of Certified Nursing Assistant (CNA) #8's personnel file revealed an Employee Warning Record (EWR), dated 08/02/22, that included a conduct violation with a violation date of 07/31/22 at 11:00 AM in Resident #134's room. Further review of the EWR revealed [Resident #134] stated that [CNA #8] was mean and degrading. [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that the facility failed to thoroughly investigate an allegation of physical and verbal abuse for 1 of 1 resident (Resident #134) reviewed for abuse. This deficient practice was evidenced by the following: On 09/01/22, the surveyor requested the personnel files for five employees hired within the last four months. Review of Certified Nursing Assistant (CNA) #8's personnel file revealed an Employee Warning Record (EWR), dated 08/02/22, that included a conduct violation with a violation date of 07/31/22 at 11:00 AM in Resident #134's room. Further review of the EWR revealed [Resident #134] stated that [CNA #8] was mean and degrading. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to complete a significant change in status (SCSA) Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care. This deficient practice was identified for 1 of 1 resident (Resident #208) reviewed for expired resident and was evidenced by the following: Within 14 days after the facility determines or should have determined that there has been a significant change in the resident's physical or mental condition, a SCSA/MDS must be completed. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a.) follow a physician's order for bilateral side rail pads for one resident, 1 of 6 residents (Resident #6) reviewed for accidents. The deficient practice was evidenced by the following: During tour of the 2B unit on 08/30/22 at 11:14 AM, the surveyor observed Resident #6 in bed with the head of bed (HOB) and bilateral half side rails elevated. The surveyor observed that Resident #6 was leaning to the right side and there was no padding to either side rail. When interviewed, Resident #6 was unable to provide any information about his/her care. According to the admission Record, Resident #6 was admitted with diagnoses that included, but were not limited to, senile degeneration of brain, hemiplegia (paralysis of one side of the body) and muscle weakness. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to ensure that a resident with an indwelling urinary catheter (tube inserted into the bladder to facilitate the flow of urine) had physician orders for the care of the catheter. The deficient practice was identified for 1 of 2 residents (Resident #136) reviewed for catheters. This deficient practice was evidenced by the following: On 08/30/22 at 10:27 AM, during the initial tour of the 1st floor, the surveyor observed Resident #136 in bed. At that time, the surveyor observed a urinary catheter drainage bag attached to the bed frame. The catheter drainage bag was also observed on 08/31/22 and 09/01/22. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to implement infection control measures for the handling and storage of respiratory equipment for 2 of 4 residents reviewed for respiratory care, (Resident # 10 and Resident # 180). This deficient practice was evidenced by the following: 1. On 09/06/22 at 12:29 PM, Surveyor #1 observed the mouthpiece, chamber, and tubing of Resident #10's nebulizer propped in an upright position by the machine. The mouthpiece, chamber, and tubing was not contained in a bag and was exposed to the surrounding environment. A nebulizer machine delivers aerosol medication to the person via a mouthpiece and chamber/cup that holds the medication, via tubing that is attached to the machine. It is used to treat respiratory conditions such as COPD, bronchitis, asthma etc. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to obtain a physician order to monitor the dialysis access site and failed to ensure the dialysis transfer forms of ongoing records of communication between the facility and dialysis center were consistently completed for 1 of 1 resident reviewed for dialysis care, (Resident #119). This deficient practice was evidenced by the following: During an interview with the surveyor on 09/06/22 at 9:21 AM, Resident #119 said he/she goes to dialysis on Monday-Wednesday-Friday (MWF). Resident #199 went on to say that he/she gets dialysis through a catheter in right chest as the shunt is not ready for use. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to supervise the administration of medication for 1 of 10 residents (Resident #19) reviewed for medications. This deficient practice was evidenced by the following: On 09/06/22 at 9:50 AM, the surveyor observed Resident #19 lying in bed. There was a medicine cup with pills in it on the resident's over-the-bed table. When asked about the medicine cup, the resident stated the nurse left the medication at the bedside because the resident was waiting for his/her breakfast tray before taking the medications. During an interview with the surveyor on 09/06/22 at 9:51 AM, Licensed Practical Nurse (LPN) #3 stated she completed the morning medication pass for her assignment. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure expired and discontinued medications were removed from active inventory and medications were appropriately labeled and dated when opened in 1 of 4 medication carts reviewed. This deficient practice was evidenced by the following: On [DATE] at 11:40 AM, the surveyor, in the presence of the Licensed Practical Nurse (LPN #2), observed the following within the 2C Wing medication cart: -One opened box of Insulin Lispro (Humalog) 100 unit/milliliter (ml) located inside a plastic bag for Resident #12. The box was labeled with an opened date of [DATE]. At that time LPN #2 stated that Resident #12 only received insulin when needed because he/she was on a sliding scale (received insulin depending on the blood sugar level) and that insulin had an expiration date of 30 days once opened. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to consistently serve foods at a safe and appetizing temperature. This deficient practice was evidenced by the following: Cross Reference F 802 On 08/30/22 at approximately 10:05 AM, the surveyor conducted the initial tour of the kitchen. The surveyor questioned the Director of Food Services (DOFS) why the kitchen staff were still assembling breakfast trays at 10:00 AM. The DOFS explained, We are normally done breakfast tray line by 9 AM. I had to call in (2) staff who were scheduled off today and borrow a cook from our sister facility. Staffing has been an issue for the month I've been here. It is slowing and affecting our production. [...]

Inspectors wroteBased on observation, interview, and other pertinent facility documents, it was determined that the facility failed to ensure personal protective equipment (PPE) (equipment such as, but not limited to gowns, gloves, and eye protection worn to protect the wearer from the spread of infection or illness) was used appropriately and failed to ensure handwashing was performed before and after exiting and entering resident rooms that were on isolation and between changing gloves. The deficient practice was observed on 1 of 4 units on the first floor. The deficient practice was evidenced by the following: [...]