Dwelling Place at St. Clares

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain and document respiratory care and equipment for a resident who was receiving humidified, oxygen-enriched air via a medical ventilator (a machine that mechanically supports or entirely replaces a patient's breathing) for 12 of 12 residents reviewed (Residents #1, #2, #3, #4, #5, #6, #7, #8, #11, #17, #23, #25). This deficient practice was evidenced by the following: 1.) On [DATE] at 10:40 AM, the surveyor observed resident #1 in bed with a ventilator in place. The ventilator did not have a dated label or a written date on the circuit tubing or filters. On [DATE] at 10:00 AM, the surveyor reviewed the medical records for resident # 1, which revealed the following: [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide a resident with a pressure ulcer, the necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcer development for 1 of 2 residents reviewed for pressure ulcers (Resident #7). According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers (HCP) for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included that the HCP should perform hand hygiene before and after direct contact with the residents and immediately after glove removal. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the appropriate management of gastrostomy enteral feeding formula. This deficient practice was identified for 1 of 3 residents (Resident #11) reviewed for tube feeding and was evidenced by the following:On 7/6/26 at 11:50 AM, the surveyor observed Resident #11 in bed with a gastrostomy enteral feeding tube (FT; a tube surgically inserted into the stomach to provide food and nutrients) pump administering an unidentified formula at a rate of 70 milliliters (mL) per hour. The surveyor observed that the 1000 milliliter (mL) bag was unlabeled and did not include the Resident's name, formula type, date, or rate of infusion (mL per hour). On 7/6/26 at 12:00 PM, the surveyor reviewed the medical record for Resident #11. [...]

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 4/6/25 at 9:36 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour: 1. In the Nourishment supply standing two door refrigerator, the surveyor observed a 46 ounce (oz) Thickened Orange Juice bottle and a 16 oz bottle water, both bottles had been opened and were missing open and use by labels. The FSD stated all items should have a open and use by label once opened, both items were discarded. 2. In the walk-in freezer, the surveyor observed fans with a greyish dust-like debris, one opened package of frozen pizza and one opened package of gluten free bread. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow appropriate infection control practices for a.) storing linens observed in the laundry room, b.) tracheostomy (an opening to the neck into the trachea (windpipe) to facilitate breathing) care for 1 (one) of 12 residents (Resident #23), and c.) when performing a wound care treatment for 1 of 1 resident (Resident #17) performed by 1 nurse observed providing a wound care treatment. This deficient practice was evidenced by the following: a). On 4/8/25 at 10:45 AM, the surveyor and the Housekeeping Director (HD) observed the laundry room; the surveyor observed that there were 2 bins of clean linen in the hallway that were not covered. The HD stated that the housekeeping staff should be working on those clean linens, which is why they are not covered. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 1 (one) of 5 (five) residents (Resident #19) observed during the medication observation pass. 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 wrote4. On 11/16/23 at 1:16 PM, the surveyor observed Resident #5 in bed with eyes closed. The surveyor noted that Resident #5 was in the process of receiving their feed of Jevity at a rate of 40 ml/hr. via feeding pump. On 11/20/23 at 10:22 AM, the surveyor observed Resident #5 in bed with eyes closed. The surveyor noted that Resident #5 was in the process of receiving their feed of Jevity running at 40 ml/hr. (set on the pump). The surveyor reviewed the electronic medical record for Resident #5 and found the following: Review of the AR, Resident #5 was admitted to the facility with diagnoses that included but were not limited to Chronic Respiratory Failure with Hypoxia, Unspecified Protein-Calorie Malnutrition, Tracheostomy, Essential Hypertension, Heart Failure, Anoxic Brain Damage, Chronic Kidney Disease, and Dementia. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow a physician's order (PO) for the application of a device for 1 of 4 residents reviewed for the use of devices, Resident #24. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; 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 licensed or otherwise legally authorized physician or dentist. On 11/15/23 at 10:07 AM, the surveyor interviewed Resident #24 in their room. [...]