Imperial Care Center

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to a.) keep 2 of 2 garbage disposal areas free of garbage and debris, and b.) keep the garbage contained in a closed container for one 1 of 3 (one of three) garbage containers. This deficient practice was evidenced by: On 1/07/26 at 8:55 AM, upon arrival at the facility, the surveyor observed the facility's garbage disposal area #1. The surveyor observed 3 garbage containers (GC). The first GC was uncovered and exposed to the elements. [...]

Inspectors wroteBased on observation, interview, review of medical records, and review of other pertinent facility documentation, it was determined that the facility failed to a.) implement infection control measures for the handling and storage of respiratory equipment for 1 of 3 residents reviewed for respiratory care (Resident #40) and b.) contain stored soiled linen appropriately and follow appropriate Personal Protective Equipment (PPE) practices for 1 laundry staff during handling of soiled laundry, to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice. This deficient practice was evidenced by the following: Reference: Have a separation between the soiled linen and clean linen storage areas. https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendix-d.html Reference: [...]

Inspectors wroteBased on interview, record review, and review of pertinent documents, it was determined that the facility failed to report a fracture of unknown origin to the New Jersey Department of Health (NJDOH) within 2 hours as mandated for 1 of 1 resident (Resident #43) reviewed for investigations and was evidenced by the following:On 1/7/2026 at 10:20 AM, the surveyor observed Resident #43 sitting on a wheelchair in the therapy room. The surveyor noted a yellow chair alarm hanging at the back of the resident's wheelchair. The chair alarm was attached to the resident's shirt by a clip and string at the back of the resident. A review of the electronic medical record of Resident #43 revealed the following: A review of the admission Record face sheet (an admission summary) reflected that Resident #43 was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for 1 of 18 residents (Resident # 6) reviewed. This deficient practice was evidenced by the following:A review of Resident # 6's admission Recorded revealed the resident was admitted to the facility with the following but not limited to diagnosis, dementia (a of cognitive functioning that interferes with daily life and activities). A review of Resident # 6's Electronical Medical Record (EMR) revealed physician's orders for Zoloft 100 milligrams (mg) (a medication used to treat depression and anxiety.) to be given one time a day for social anxiety. The EMR also revealed a physician's order for buspirone 7.5 mg (a medication used to treat anxiety) to be give twice a day for anxiety. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) obtain a physician's order for the use of a chair alarm; b.) identify the medical symptom that warranted the use of a chair alarm; c.) conduct ongoing evaluations for the continued use of the chair alarm; d.) document the least restrictive interventions that were utilized prior to using the chair alarms; and e.) document interventions to decrease and/or discontinue the use of the chair alarm in accordance with professional standards of clinical practice. This deficient practice was identified for 1 of 1 resident reviewed for restraints (Resident #43) 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 wroteBased on observation, interview, review of medical record and other pertinent facility documentation, it was determined that the facility failed to ensure that a resident who was identified as having a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity or rigidity of joints) received services to prevent further decreased range of motion (ROM) after discharge from therapy. This deficient practice was identified for 1 of 3 residents reviewed for limited ROM, (Resident #36) and was evidenced by the following: On 1/7/2026 at 9:37 AM, the surveyor observed Resident #36 resting in bed. The surveyor noted the resident's right fingers flexed in a fist. The fingernails of the right hand were observed to be about 4 millimeters long. The resident's right palm was noted dry with no marks nor redness. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to store of respiratory equipment in accordance with infection control standards. This deficient practice was identified for 1 of 3 (Resident #84) residents reviewed for respiratory concerns and was evidenced by the following: On 01/07/2026 at 9:59 AM, the surveyor observed Resident # 84 exiting the room. 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 a bedside table with stuffed animals. The tubing was observed positioned across the table open to air and not in a bag. [...]

Inspectors wroteBased on interview, record review and review of other facility documentation, it was determined that the facility failed to follow the recommendation identified by the Consultant Pharmacist. This deficient practice was identified for 1 of 5 Residents (Resident #57) reviewed for unnecessary medications, psychotropic medications, and medication regimen review and was evidenced by the following: On 01/08/2026 at 9:26 AM, the surveyor observed Resident #57 sitting up in bed. A review of Resident #57's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to anxiety and multiple myeloma (a blood cancer). [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a physician's order for as needed (PRN) psychotropic drug was limited to 14 days for 1 of 5 residents (Resident #57) reviewed for unnecessary medications. This deficient practice was evidenced by the following: N.J.A.C. 8:39-27.1(a) On 01/08/2026 at 9:26 AM, the surveyor observed Resident #57 sitting up in bed. A review of Resident #57's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to anxiety and multiple myeloma (a blood cancer). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to a) ensure medical supplies were stored in accordance with professional standards and b) loose, unidentified pills were found in the drawer of a medication cart, and c) remove expired drugs from the facility inventory. The deficient practice was identified in 2 of 2 medication carts reviewed under the Medication Task. The deficient practice was evidenced by the following: On 01/07/2026 at 12:08 PM, the surveyor observed the 1st Unit Low Side medication cart in the presence of the Licensed Practical Nurse (LPN) #1. At that time, the surveyor observed the following concerns: 6 safety syringes that expired on 12/31/2025. A multidose vial of insulin glargine- U-100 flex-pen (injectable medication to control blood-sugar levels) marked opened on 12/03/2025. [...]

Inspectors wroteBased on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for 1 of 20 residents reviewed (Residents #12). This deficient practice was evidenced by the following: On 08/21/2024 at 9:44 AM, the surveyor observed Resident #12 in the bed. The surveyor reviewed the admission Record for Resident #12 which reflected that the resident was admitted with diagnoses that included Chronic Obstructive Pulmonary Disease (disease of the lung). The surveyor reviewed the Physician's orders for Resident # 12. There was an order dated 07/24/2023 for Oxygen at 2 liters per minute via nasal cannula continuous every shift. The July 2024 Medication Administration Record had documentation that the Oxygen was in use. [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) assessment after a resident was newly diagnosed with a mental illness. This deficient practice was identified in 1 of 1 resident reviewed for Preadmission Screening and Resident Review PASRR (Resident #55) and was evidenced by the following: Resident #55 was a resident of the facility. The surveyor reviewed the Level I PASRR (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) for Resident #55 dated 07/04/2020 which was negative, meaning the resident did not have any mental illness diagnoses that could lead to a chronic disability. The surveyor reviewed the quarterly Minimum Data Set (MDS), an assessment tool dated 12/22/2021. [...]