Foothill Acres Rehabilitation & Nursing 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 5/15/26 at 10:07 AM, the surveyor entered the facility's kitchen and conducted an interview with the Food Service Director (FSD) who stated the food in the refrigerators and freezers should be sealed in an air-tight wrap and labeled with a use by date. The FSD further stated the dietary staff were responsible for maintaining the nursing unit pantry inventory to ensure there were no expired items. At 10:29 AM, the surveyor, accompanied by the FSD and the Regional Food Service Director (RFSD), observed the following in the kitchen: In the Walk-In Freezer:1. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to meet the professional standards of practice by not appropriately assessing and documenting PRN (as needed) pain medications. This deficient practice was identified for 1 of 5 residents (Resident #41) reviewed for unnecessary medications and was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey states; [...]

Inspectors wroteBased on interviews, record reviews, and a review of facility documentation, it was determined that the facility failed to consistently implement an Antibiotic Stewardship Program (ASP) (a program designed to improve clinical outcomes and reduce harm by promoting appropriate antibiotic use and monitoring prescribing practices). The facility did not utilize standardized infection surveillance criteria to determine whether antibiotic use was appropriate. This deficiency was identified in 3 of 6 residents reviewed for antibiotic use (Resident #61, #74, and #154) and was evidenced by the following: 1.) A review of the Infection Control Case List (ICCL) in the electronic medical record (EMR) for 5/2026 revealed Resident #61 had a right toe ulcer (RTU) (an open sore or wound on the toe resulting from skin breakdown), with an onset date of 5/18/2026. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to treat each resident with respect and dignity in a manner that promotes his/her quality of life. This deficient practice was identified for one 1 of 32 residents (Resident #81) reviewed for resident rights. This deficient practice was evidenced by the following:On 5/15/26 at 12:08 PM, during the initial tour, the surveyor overheard a male voice speaking in a loud, firm tone to Resident #81, stating, Are we on the same page? Do you understand what I'm saying? To which the resident replied, Yes, I understand, I'm not stupid, and the male voice responded, Well, some people would disagree with that. When the surveyor approached the room, the man left the room and was wearing a sweatshirt with the facility's name on it. [...]

Inspectors wroteBased on interviews and review of pertinent facility documents, it was determined that the facility failed to ensure that all residents that maintained a Personal Needs Account (PNA) received a written notification when approaching the limit that could jeopardize a resident's eligibility for Medicaid or Supplemental Security Income (SSI). This deficient practice was identified for 5 of 5 residents (Resident #33, #111, #122, #163 and #164) reviewed for PNA and was evidenced by: On 5/15/26 at 11:25 AM, the Director of Nursing (DON) provided the PNA balances as of 5/15/26. A review of the facility's Patient Fund Balances through 5/15/26 revealed 5 residents had balances that ranged from $1,846.70 to $2,385.22. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control practices and professional standards during a pressure ulcer treatment for 1 of 3 residents (Resident #40) reviewed for pressure ulcers. This deficient practice was evidenced by the following:On 5/20/26 at 10:34 AM, the surveyor observed Registered Nurse (RN) #1 perform a wound care treatment on Resident #40. The RN performed hand hygiene using an alcohol-based hand rub (ABHR) and then donned gloves. She wiped down the overbed table with a disinfectant wipe, removed her gloves, used ABHR, and gathered her treatment supplies onto the overbed table, which included a multi-use bottle of quarter-strength Dakin's solution (wound cleansing solution). [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure dumpster lids were kept closed and trash was not on the ground in the dumpster area. This failure had the potential to cause pest infestation or spread of infection affecting all 158 residents.

Inspectors wroteBased on policy review, record review, and staff interviews, the facility failed to develop a person-centered comprehensive plan of care for one of 34 sample residents (Resident (R) 41) regarding a continuous blood glucose monitor; or measurable goals or objectives regarding behaviors for two of seven residents (Resident (R) 60 and R138) reviewed for psychotropic medications. These failures placed the residents at risk of unmet care needs pertaining to glucose management and behavior management.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure psychotropic medication efficacy was monitored and failed to ensure PRN (as needed) antianxiety medications had a stop date including a rational for continuing the PRN medication beyond 14 days for eight of eight residents (Resident (R) 23, R28, R38, R42, R60, R61, R138, and R142) reviewed for unnecessary and/or psychotropic medications from a total survey sample of 34 residents. This failure had the potential to affect the ability for a physician to prescribe the lowest possible effective dose of medication.

Inspectors wroteBased on observation, menu review, interview, and facility policy, the facility failed to ensure residents who ate in the second-floor dining room received adequate portion sizes according to the menu. This failure had potential to cause hunger, weight loss, or malnutrition for the 28 residents, out a census of 158, who ate their meals in the second-floor dining room and had orders for regular portions with chopped or regular texture.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure nine cartons of milk were not expired. Though the milk was discarded prior to meal service, the potential receipt of expired milk by nine residents placed these residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview and review of the facility's policy, the facility failed to ensure one of four soiled utility rooms (400 Unit) was maintained in a sanitary condition. This failure placed all residents on the 400 Unit at risk for not having a safe and clean homelike environment.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure two residents (Resident (R) 51 and R306) of 36 residents observed in Initial Pool had medications unattended at the bedside only with an assessment for safety and the ability to self-administer medications. These failures placed both residents at risk for overdose, missed medication doses, or misappropriation of medication.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure the call bell was accessible for one of 36 residents (Resident (R) 32) observed in the Initial Pool. This failure placed R32 at risk of injury or distress when he could not access the call bell to alert staff of an emergency or unmet needs.

Inspectors wroteBased on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure two residents (Resident (R) 142 and R28) out of 34 sample residents had an accurately coded Minimum Data Set (MDS) assessment. This failure increased the risk of inappropriate care provision to R142 and R28.

Inspectors wroteBased on record reviews and interviews with residents and staff, the facility failed to ensure one of 34 sample residents (Resident (R) 68) was provided with the opportunity to review her care plan, medication list and express her concerns and needs during a quarterly care conference. This failure has resulted in care not being tailored to R68's needs, as the care plan was not updated accordingly.

Inspectors wroteBased on observation, interview, and review of manufacturer's instructions, the facility failed to ensure that one of one Licensed Practical Nurse (LPN) (LPN1) observed for insulin administration had primed an insulin pen prior to dialing the ordered dose for Resident (R) 41. This failure had the potential to reduce the insulin dose which could have affected R41's blood glucose.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure one of five residents (Resident (R) 68) reviewed for Activities of Daily Living (ADL) out of 34 sampled residents received timely incontinence care. This failure placed the resident at an increased risk for skin breakdown, urinary tract infections, or an undignified existence.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure one of one resident (Resident (R) 79) reviewed for pain out of 34 sampled residents was offered nonpharmacological interventions and documented and followed physician's order to administer pain medication. This failure placed the resident at risk of unmanaged pain and had the potential to negatively affect his quality of life.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure that residents were evaluated for the need and safety for use of bed rails prior to the installation/use of rails, documented alternatives to bed rails were attempted prior to the use of bed rails, failed to document reasons for failure of alternatives, and failed to advise residents and/or Resident Representatives (RR) of the risks and/or benefits of rail use with informed consent signed prior to the installation of bed rails for three of three residents (Resident (R) 28, R74, and R124) reviewed for bed rail use. This failure had the potential for the resident or the RR to be uninformed of the risks associated with bed rail use and could put the residents at risk for injury or entrapment.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure medications for return to the pharmacy were kept in a secure location. An inventory had not been completed for those medications to ensure what medications were to be returned to the pharmacy. This failure put residents at risk of accessing and taking those medications not prescribed to them by a physician.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to maintain an effective infection control and prevention program for one of four residents (Resident (R) 67) observed for pressure ulcers out of 34 sampled residents. Licensed Practical Nurse (LPN) 7 failed to don the required personal protective equipment prior to providing care to R67 who was physician ordered Enhanced Barrier Precautions (EBP). The LPN also failed to perform hand hygiene when changing gloves during wound care. This failure placed the resident at an increased risk of developing a wound infection and/or place other residents at the risk for the transmission of infections.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's use of supplemental oxygen was addressed in the comprehensive care plan for 1 (Resident #277) of 3 residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined that the facility failed to provide services to a resident who was unable to carry out activities of daily living (ADLs) necessary to maintain good grooming and personal hygiene for 1 (Resident #328) of 1 sampled resident reviewed for ADLs. Specifically, Resident #328 had facial hair approximately ½-inch long on both sides of their face, jaw, chin, and neck.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff administered oxygen at the rate ordered by the physician for 1 (Resident #277) of 3 residents reviewed for respiratory care.