Harbour View Senior Living Corp

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a resident who did not have a Pressure Ulcer (PU) upon admission and who was identified at risk of developing a PU, received care and services in accordance with professional standards of practice to prevent PUs. Resident #7 developed a facility acquired unstageable sacral wound identified by the Certified Nursing Aide and deep tissue injuries to bilateral heels identified during wound consultation (both four days after admission). In addition, the facility failed to ensure treatments were ordered at the time of identification. The resident's wounds worsened, developed a wound in another site, and had undergone a surgical debridement (a medical procedure that involves removing dead or infected tissue from a wound). [...]

Inspectors wroteBased on interview and review of facility provided documentation, it was determined that the facility failed to ensure that the Certified Nursing Aides (CNAs) received a performance review for 5 of 5 CNA files reviewed. This deficient practice was evidenced by the following:On 8/18/25 at 11:53 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) the annual education, competencies and performance reviews for five randomly selected CNAs. The facility provided a copy for each of the five CNAs which contained Nursing Assistant Clinical Skills Checklist and Competency forms and in-service education sign in sheets for education topics. The facility did not provide performance reviews for the five CNAs. On 8/19/25 at 1:59 PM, the surveyor asked the DON if the CNA performance evaluations were available. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to assure that the required staff attended the quarterly Quality Assurance (QA) meetings for 4 of 6 (Medical Director) and 2 of 6 (Infection Preventionist) quarterly QA meetings according to the regulation and facility's practice. This deficient practice was evidenced by the following:On 8/18/25 at 1:56 PM, Surveyor #1 (S#1) reviewed the provided Quality Assurance Performance Improvement (QAPI) binder and revealed: On 3/28/24 QAPI meeting, the facility management signed the attendance sheet that included the Medical Director (MD), Licensed Nursing Home Administrator #1 (LNHA#1), Director of Nursing #1 (DON#1), and Infection Preventionist #1 (IP#1). On 6/24/24 QAPI meeting, the MD, LNHA#1 and IP#2 signed the attendance sheet. [...]

Inspectors wroteBased on interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to follow appropriate COVID testing according to standards of clinical practice, facility's policy and procedure, and Centers for Disease Control and Prevention (CDC) guidelines. This deficient practice was identified for 10 of 16 facility staff (6 Certified Nursing Aides, 1 Registered Nurse, and 3 Licensed Practical Nurse) reviewed for COVID-19 testing. This deficient practice was evidenced by the following:According to the CDC guidelines, Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, March 18, 2024,.For this guidance an exposure of 15 minutes or more is considered prolonged. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to offer and administer resident a pneumococcal vaccine. This deficient practice was identified for 4 of 5 residents (Residents #5, #7, #52, and #62) reviewed for immunizations. This deficient practice was evidenced by the following: 1. On 8/19/2025 at 12:00 PM, Surveyor #1 (S#1) reviewed Resident #5's hybrid medical record. A review of Resident #5's admission Record or face sheet (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to ensure that Certified Nurse Aides (CNA) received at least twelve hours of mandatory in-service training for 5 of 5 CNAs education reviewed. This deficient practice was evidenced by the following: On 8/18/25 at 11:53 AM, the surveyor requested, from the Director of Nursing (DON), employee files consisting of but not limited to staffing, competencies, and educational in-services for five randomly selected CNAs. The DON stated that the Infection Preventionist/Licensed Practical Nurse (IP/LPN) was responsible for all the staff education. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, the facility failed to ensure the facility was maintained in a safe, clean, and homelike environment. This deficient practice was identified for 3 of 4 Resident Rooms (Rooms 7,11, and 29) and 1 of 2 shower rooms. This deficient practice was evidenced by the following: 1. On 8/18/25 at 10:38 AM, Surveyor #1 (S#1) with the Housekeeping Director (HD) toured the [NAME] unit and did random tour of the unit rooms. Both S#1 and the HD went inside Resident room [ROOM NUMBER] (RR#11). Upon entry, on the right side the closet was unable to fully closed, and the HD moved the clothes inside the closet and stated that there were too much residents' clothes inside the closet that was why it was not closing well. Both S#1 and the HD observed the toilet room with no paper towel. [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to complete the comprehensive Minimum Data Set (MDS) assessment in accordance with the Resident Assessment Instrument (RAI) manual and facility policy for 2 of 17 (Residents #57 and #62) residents reviewed for comprehensive resident assessments. This deficient practice was evidenced by the following:Reference: Centers For Medicare and Medicaid Services (CMS), RAI manual, Version 3.0, last revised in October 2024, indicated in Chapter 2, pages 2-8 revealed: .admission refers to the date a person enters the facility and is admitted as a resident. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to transmit a Minimum Data Set (MDS) assessment, an assessment tool used to facilitate the management of care, within the appropriate timeframe and in accordance with federal guidelines for 3 of 17 residents (Residents #4, #5, and #19), reviewed for resident assessments. This deficient practice was evidenced by the following:Reference: Centers For Medicare and Medicaid Services (CMS), RAI manual, Version 3.0, last revised in October 2024, indicated in Chapter 2, Section 2.6-Required OBRA [Omnibus Budget Reconciliation Act] Assessments for the MDS revealed: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to; a.) ensure the care plan was updated and monitored the behavior episodes for 1 of 5 residents (Resident #5), b.) ensure rationale for the discontinuation of medication was documented for 1 of 5 residents (Resident #62), reviewed for unnecessary medications, and c.) follow a physician's order for 3 of 17 residents (Residents #5, #24, and #31) reviewed, in accordance with standards of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a resident receive treatment and care in accordance with professional standards of practice and facility policies and procedures with regard to tube feeding for 1 of 3 residents (Resident #8) reviewed. 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, interview, and review of facility documents, it was determined that the facility failed to a.) provide pharmaceutical services in accordance with professional standards to ensure accurate accountability of controlled substances, have sufficient secure procedures in place to prevent diversion of controlled substances for 1 of 4 residents observed during the medication administration observation and b.) ensure an accurate ordering and receiving of narcotic medications specifically failing to complete the required U.S Official Order Forms Schedules I & II (DEA 222 forms) with sufficient detail to enable accurate reconciliation for 2 of 2 executed forms reviewed and the unexecuted DEA 222 forms were signed by the Medical Director prior to being filled out for 4 of 4 unexecuted forms reviewed. The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store an ointment and biologicals according to clinical standards of practice. This deficient practice was identified in 1 of 4 Resident Room (Resident room [ROOM NUMBER]) observed during tour of the facility. 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; [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to properly contain trash in a closed dumpster resulting in trash overflowing the dumpster area, spilling onto the ground of 59 census residents.

Inspectors wroteBased on observations and staff interviews, the facility failed to prominently post daily nurse staffing information readily accessible to residents and visitors of 59 census residents.