Health Center at Galloway, the

Inspectors wroteNJ#2643473Based on observation, interview, and record review, it was determined that the facility failed to a.) Re-implement a comprehensive care plan (CCP) for a resident (Resident #72) who had a previously identified history of inappropriate sexual behaviors b.) implement a CCP for a resident (Resident #11) who was on psychotropic medications with behaviors, c.) develop a person-centered care plan for a resident who changed the setting on the oxygen concentrator (Resident #129) d.) develop a person-centered care plan for 1 of 5 residents (Resident #130) reviewed for unnecessary medications who was prescribed an anticoagulant (a medication used to prevent blood clots). This deficient practice occurred for 4 of 29 residents surveyed (Resident #11, #72, #129, and #130) and was evidenced by the following: 1. [...]

Inspectors wroteComplaint# NJ2699824 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, by failing to ensure that critical laboratory results obtained on 12/15/25 were immediately conveyed to the physician, which resulted in a three (3) day delay in notification on 12/18/25 and immediate transfer to the hospital for evaluation and treatment. This deficient practice was identified for 1 of 1 resident (Resident #123), reviewed for quality of care. 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: [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to a.) prevent the potential for cross contamination by not initiating and implementing Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms) for a resident with a wound in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman's Office of a resident transfer to an acute care hospital in a timely manner. This deficient practice was identified for 1 of 2 residents (Resident #123) reviewed for hospitalization and was evidenced by the following: On 2/17/26 at 10:20 AM, the surveyor reviewed the closed medical record of Resident #123. A review of the admission Record, an admission summary, revealed the resident was admitted to the facility with diagnoses which included but were not limited to: [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to: a.) 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, b.) ensure that oxygen was being administered as per physician's orders, and c.) ensure that oxygen was humidified in accordance with professional standards of practice. This deficient practice was identified for 2 of 2 residents (Resident #116 and Resident # 129) reviewed for respiratory care and was evidenced by the following:1. On 2/12/26 at 10:58 AM, the surveyor observed Resident #129 sitting upright in bed. [...]

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure physician supervision and oversite of medical care for 1 of 2 residents (Resident #11) reviewed for pressure ulcer management and was evidenced by the following:The surveyor reviewed Resident #11's Electronic Medical Records (EMRs) which revealed the following information:A review of the admission Record, an admission summary, indicated that Resident #11 was admitted to the facility with diagnoses that included but were not limited to dementia: (a loss of mental functioning that affects thinking, memory, mood, and behavior) and diabetes mellitus (a condition in which the body is unable to properly regulate blood sugar due to problems with insulin production or use). [...]

Inspectors wroteBased on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to a.) develop an individualized Comprehensive Care Plan (ICCP) with specific interventions to address dementia care, and b.) follow the facility policy for dementia care. This deficient practice was identified for 1 of 2 residents (Resident #11) reviewed for dementia care and was evidenced by the following: A review of the admission Record (admission summary) indicated that Resident #11 was admitted to the facility with diagnoses that included but were not limited to dementia and diabetes mellitus. [...]

Inspectors wroteBased on interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the pharmacy consultant conducted a monthly review of each resident's medication regimen b.) to clarify a physician's order, c.) address a pharmacy consultant recommendation for one (1) of five (5) residents reviewed for unnecessary medications (Resident #113). This deficient practice was evidenced by the following:On 2/12/26 at 11:20 AM, the surveyor observed Resident #113 lying in bed. On 2/13/26 at 1:40 PM, the surveyor reviewed the electronic medical record for Resident #113. A review of the admission Record, an admission summary, revealed that the resident had diagnoses which included, but were not limited to: [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to administer medication with an error rate of less than 5%. The surveyor observed 3 nurses administer medications for 3 residents with 26 opportunities for error. There were 2 errors resulting in an error rate of 7.6% as evidenced by the following: During the medication pass observation on 2/13/2026 from 8:27 AM until 8:35 AM, the surveyor observed the following: At 8:27 AM, the surveyor observed Licensed Practical Nurse #8 (LPN #8) prepare five medications for Resident #100 including Coreg tablet 25 mg (milligram) (carvedilol); give one tablet by mouth two times a day for HTN (hypertension) take with food, and Metformin HCL tablet 1000 mg; give one tablet by mouth two times a day for DM (diabetes mellitus) with a pharmacy cautionary label indicating to take this medication with food. [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to secure a treatment cart during a wound treatment observation that was conducted on 2/17/2026. This deficient practice occurred with 1 of 1 nurse observed for the provision of a wound treatment and was evidenced by the following:On 2/17/2026 at 10:20 AM, the surveyor conducted a wound treatment observation on the third floor nursing unit with the Licensed Practical Nurse (LPN #1). LPN#1 was observed gathering treatment supplies from the treatment cart. LPN #1 then proceeded to put the treatment supplies on top of the treatment cart. She then entered a resident's room, and left the treatment cart with the treatment supplies on top of the cart unlocked, unattended and out of her line of sight. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to offer snacks to residents between meals and at bedtime. This deficient practice was identified for 2 of 4 residents (Resident #80, Resident #83,) who attended a resident's group meeting and for an additional two residents interviewed for the provision of snacks, (Resident #5, Resident #130). This deficient practice was identified on 2 of 2 nursing units (Second and Third Floor) and was evidenced by the following:On 2/13/2026 at 10:31 AM, the surveyor conducted a meeting with four alert and oriented residents. When asked about bedtime snacks, two residents stated that snacks were not passed out at night. Resident #83 stated that they did not receive snacks and worried about their blood sugars as a diabetic. [...]

Inspectors wroteBased on interview, review of medical records and other pertinent facility documents on 9/26/25, it was determined that the facility failed to maintain an accurately documented and complete an investigation in accordance with acceptable standards and practice. This deficient practice was identified for 1 of 3 residents (Resident #3) reviewed and was evidenced by the following: The surveyor reviewed a Facility Reported Event (FRE) that was submitted to the New Jersey Department of Health (NJDOH) on 9/16/25. The FRE was submitted by the Licensed Nursing Home Administrator (LNHA) and revealed that Resident #3 alleged that, someone raped me. The resident then went on to describe the person as, a short black male wearing tan, that was standing outside of the window. [...]

Inspectors wroteComplaint 2579597Based on interviews, medical record review, and other pertinent facility documentation on 08/07/25, it was determined that the facility failed to obtain a physician's order (POs) for the resident's (Resident #7) oxygen in accordance to professional standards of practice. This deficient practice was identified for 1 of 14 residents and 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 wroteComplaint # 360598Based on observations, interviews, and record reviews on [DATE], it was determined that the facility failed to ensure infection control guidelines were followed for a resident who had a sick cat visiting the facility to prevent infection. This deficient practice was identified for 1 of 14 residents reviewed for infection control (Resident #6). This deficient practice was evidence by the following:A review of the Electronic Medical Record (EMR) was as follows:According to the admission Record (AR) face sheet, Resident #6 was admitted to the facility with diagnoses which included but were not limited to Spondylosis (degenerative changes in the spine), expressive language disorder, dysphagia (difficulty swallowing), sepsis, and muscle weakness. [...]

Inspectors wroteBased on interview and review of Nurse Staffing Report sheets, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 6 days of 10 weeks reviewed. This deficient practice was evidenced by the following: A review of the Nurse Staffing Reports completed by the facility for the weeks of 11/05/2023, 12/31/2023 thru 01/06/2024 revealed the facility had no RN coverage for 8 consecutive hours for all shifts on 11/05/2023, 11/08/2023, 11/11/2023, 12/31/2023, 01/01/2024, and 01/06/2024. On 09/12/2024 at 03:15 PM, the surveyors conducted an interview with the facility Director of Nursing (DON) and the surveyor said she reviewed the facility staffing sheets which indicated that the facility had days without a Registered Nurse (RN) for at least 8 consecutive hours. [...]

Inspectors wroteBased on observation, interview, and review of other 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 09/09/2024 from 7:39 to 8:23 AM, the surveyors, accompanied by the cook and the Food Service Director (FSD), observed the following in the kitchen: 1. Prior to entering the walk-in refrigerator and freezer the surveyors reviewed the temperature logs. Review of the September 2024 Refrigerator Temperature log revealed that no AM or PM temperatures were recorded on 9/7, 9/8, and 9/9/2024. On interview the FSD stated that the aide was responsible for recording the refrigeration temperatures and that the aide had not worked on those days. 2. [...]

Inspectors wroteC/O #NJ 174603 Based on observation, interview, review of the Electronic Medical Record (EMR) it was determined that the facility nursing staff failed to document in the progress notes (PN) unusual incidents, specifically regarding a.) a fracture found on x-ray, b.) staff to resident abuse allegation and c.) a resident-to-resident altercation. This deficient practice was identified for 4 of 26 sampled residents (Resident #13, Resident #5, Resident #48 and Resident #257) and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain resident dignity when staff were observed standing while feeding residents their meals on 1 of 2 Nursing units, 2nd floor, for 1 of 1 resident reviewed for dignity (Residents #20). This deficient practice was evidenced by the following: On 09/10/2024 at 12:13 PM, the surveyor observed a facility staff on the 2nd floor dining room at the lunch meal assisting Resident #20 to eat. The staff was standing next to the table to assist the Resident #20 to eat from a standing position. Resident #20 was seated in a wheelchair at a table in the center of the dining room facing the television. The staff did not attempt to get a chair while assisting Resident #20 to eat. The staff continued to feed Resident #20 from the standing position throughout the meal. [...]

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 report an injury of unknown origin, specifically a fracture of the right distal femur, as well as an allegation of staff to resident abuse to the New Jersey Department of Health (NJDOH) in a timely manner for 2 of 26 sampled residents, (Resident #13 and Resident #257). This deficient practice was evidenced by the following: 1. During the initial tour of the unit, Resident #13 told Surveyor #1 that he/she had pain due to a fracture of the hip. Resident #13 denied having fallen and said he/she will be following up with the orthopedic physician on Thursday. A review of the EMR was conducted on 09/09/2024 at 01:05 PM and included the following: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives, timelines, and interventions to meet resident's medical and nursing needs specifically by failing to implement a care plan for an antibiotic that was infused through a Peripherally Inserted Central Catheter (PICC) used to deliver the antibiotic, and 2.) a resident diagnosed with PTSD (Post Traumatic Stress Disorder) on admission. The deficient practice was identified for 2 of 26 sampled residents, (Resident #86 and Resident #99). The deficient practice was evidenced by the following: [...]

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 follow up on a psychiatry recommendation to discontinue an antipsychotic medication, failed to monitor residents' behavior for the use of the antipsychotic, and failed to develop a care plan for the use of an antipsychotic. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications, (Resident #74) and was evidenced by the following: On 9/10/2024 at 08:58 AM, the resident was observed lying in bed with his/her eyes closed. On 9/10/2024 at 12:30 PM, the resident was observed in his/her room with a therapist eating lunch. There were no behaviors exhibited. On 9/11/2024 at 08:39 AM, the resident was observed lying in bed with his/her eyes closed. [...]

Inspectors wroteCOMPLAINT #: NJ00171580, NJ00171582 Based on interviews, medical record review, and review of other pertinent facility documents on 02/22/24, it was determined that the facility failed to develop a comprehensive person-centered care plan (CP) for a resident involved in two incidents of inappropriate sexual behavior. The deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for CP and was evidenced by the following: According to the Face Sheet, Resident #1 was admitted to the facility with diagnoses that included but were not limited to: Type 2 Diabetes, heart disease, and Schizophrenia (mental disorder that affects a person's ability to think, feel, and behave clearly). [...]

Inspectors wroteBased on observation, interviews, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to A.) administer physician prescribed insulin to diabetic residents as ordered for 8 of 24 residents (Residents #22, #24, #33, #73, #74, #81, #260, and #261) residing on 2 of 2 floors and B.) failed to follow a physician order for weekly weights on 1 of 3 residents reviewed for nutrition, (Resident # 35). Failure to administer the prescribed insulin and/or blood sugars (BS) put diabetic residents at risk for hyperglycemic reactions (high blood sugar that affects people with diabetes. Skipping doses or not taking enough insulin to lower blood sugar can lead to hyperglycemia, hospitalization, and possible death). [...]

Inspectors wroteBased on interview and review of Nurse Staffing Report sheets, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 4 of 10 weekends reviewed. This deficient practice was evidenced by the following: A review of the Nurse Staffing Reports completed by the facility for the weeks of 08/13/2023, 08/20/2023, 10/08/2023, and 10/15/2023 revealed the facility had no RN coverage for all shifts on 08/19/2023, 08/20/2023, 10/08/2023, and 10/21/2023. During an interview with the surveyor on 10/30/2023 at 12:51 PM, the Licensed Nursing Home Administrator (LNHA) confirmed yes, are we missing Registered Nurse's for 24 hours on the staffing sheets. It is all weekends. [...]

Inspectors wroteBased on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to store respiratory equipment in a manner to prevent the spread of infection for 3 of 3 resident's reviewed for respiratory care, (Resident # 2, Resident #41, and Resident #53). This deficient practice was evidenced by the following: 1. During the initial tour of the 2nd floor on 10/24/2023 at 10:26 AM, Resident #2's oxygen tubing was observed to be wrapped around the side rail uncovered. The nebulizer mask was resting on top of the nebulizer machine on the bedside table, exposed and uncovered. On 10/25/2023 at 8:48 AM, the surveyor observed Resident #2's nebulizer mask on the bed side table on top of the machine, uncovered and exposed. The oxygen tubing was wrapped around the side rail, uncovered and exposed. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to utilize facility protocols regarding feeding tube nutrition and care specifically by not labeling the nutritional formula being used on a resident. The deficient practice was identified for 1 of 1 resident (resident #54) investigated for Tube Feeding. On 10/24/2023 at 10:27 AM during the initial tour, the surveyor observed Resident #54 in bed. At that time, the surveyor observed a nutritional formula bottle hung from a pole adjacent to the resident's bed. At that time, the surveyor observed that the nutritional formula bottle did not have the resident's name, room number, date, start time, and rate of milliliters per hour as indicated by the manufacturer label. On 10/27/2023 at 10:31 AM, the surveyor observed Resident #54 in bed. [...]