Little Brook Nursing and Convalescent Home

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 monitoring behaviors and side effects for a resident using psychotropic medication for 1 of 5 residents (Resident #3) reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 3/2/26 at 09:30 AM, the surveyor observed Resident #3 during medication administration pass. The resident was alert and oriented and was able to take their medications independently. A review of Resident #3'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; [...]

Inspectors wroteBased on interviews and review of pertinent documentation provided by the facility, it was determined that the facility failed to implement the facility's abuse policy to ensure that reference checks were completed for 37 of 37 employee files reviewed. This deficient practice was evidenced by the following: The surveyor reviewed 37 employee files, which revealed the following: 1. Employee#1's date of hire (DOH) was 11/4/24, did not have a previous employee reference on file. 2. Employee#2's DOH was 11/5/24, did not have a previous employee reference on file. 3. Employee#3's DOH was 11/29/24, did not have a previous employee reference on file. 4. Employee#4's DOH was 12/4/24, did not have a previous employee reference on file. 5. Employee#5's DOH was 12/5/24, did not have a previous employee reference on file. 6. [...]

Inspectors wroteRepeat deficiencyBased on observation, interview, and record review, it was determined that the facility failed a). failed to secure one (1) of two (2) medication carts and one (1) medication room and b). properly dispose of medications for one (1) of five (5) residents (Resident #6) observed during medication administration, and c). having a medication disposal system in the facility. This deficient practice was evidenced by the following: a). On [DATE] at 11:40 AM, the surveyor called a Licensed Practical Nurse (LPN#1) into a resident's room after observing a partially consumed medication (unidentifiable tablet) on an overbed table. After the nurse acknowledged that it was a medication, she was observed bringing the medication back to the medication cart to dispose, the surveyor observed that the medication cart was unlocked. [...]

Inspectors wroteBased on facility staff interviews and review of pertinent facility documentation, it was determined that the facility failed to provide a designated qualified Infection Prevention and Control Nurse effective 11/28/26 through 03/4/26 and onward. This deficient practice was evidenced by the following: Reference: (Rev. 225; Issued: 08-08-24; Effective: 08-08-24; Implementation: 08-08-24) S483.80(b) Infection preventionist the facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must: S483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field; S483.80(b)(2) Be qualified by education, training, experience or certification; S483.80(b)(3) Work at least part-time at the facility; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 3 of12 residents reviewed for accommodation of needs (Resident #2, 5, and 28), and was evidenced by the following:1. On 2/25/26 at 10:25 AM, the surveyor observed Resident #2 in bed with his/her eyes closed. The surveyor observed the call bell cord was wrapped around the wall mounted receptacle not within the resident's reach. On 2/26/26 at 9:27 AM, in the presence of the Director of Nursing (DON), the surveyor observed the call bell cord wrapped around the wall mounted receptacle not within the resident's reach. The DON stated all call lights should be within reach of the resident. The surveyor reviewed the electronic medical record (E-mar) for resident #2. [...]

Inspectors wroteBased on observation, interview, and review of facility policy, it was determined that the facility failed to provide a homelike environment in resident rooms (Resident #16). The deficient practice was observed on 1 of 2 units during initial tour. The deficient practice was evidenced by the following: On 2/25/26 at 10:48 AM, the surveyor interviewed Resident #16 who was in his/her room, lying in bed. The surveyor observed Resident #16's call light plug taped into the wall outlet. Resident #16 stated the call light plug falls out of the outlet if it is not taped into the outlet, has been like that for over six months and the maintenance department is aware. On 2/26/26 at 9:30 AM, the surveyor and Director of Nursing (DON) entered Resident #16's room and both observed the resident's call light plug taped into the wall outlet. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan (CP) that included smoking for 1 of 12 residents reviewed for Care Plans (Resident # 22). The deficient practice was evidenced by the following:On 2/25/26 at 9:30 AM, the surveyor observed Resident #22 awake in bed. The Resident stated that he/she was a smoker and that they were supervised while smoking. On 3/4/26 at 9:15 AM, the surveyor observed Resident #22 outside on the smoking patio with a staff member. The surveyor observed that Resident #22 was wearing a smoking apron. The surveyor reviewed the Medical Record for Resident #22. The admission Record reflected that Resident #22 was admitted to the facility with diagnoses that 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.) ensure that a specialty low air loss mattress was accurately set and monitored according to the resident's weight for 3 of 7 residents (Resident #1, #2, and #5, b.) 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 3 residents reviewed for pressure ulcers (Resident #5). 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 and record review, it was determined that the facility failed to provide a privacy bag for a resident with an indwelling urinary catheter. This deficient practice was noted in 1 of 1 resident's reviewed with FC, (Resident #2). This deficient practice was evidenced by the following:On 2/25/26 at 10:25 AM, the surveyor observed Resident #2 in bed with his/her eyes closed with an indwelling urinary drainage bag hung on the bed rail visible from the resident doorway; no privacy bag observed. The surveyor reviewed the electronic medical record (E-mar) for Resident #2. A review of the admission Record (AR) an admission summary, reflected Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to label and date an enteral tube feeding container and water flush bag. This deficient practice was identified for 1 of 1 residents reviewed for enteral tube feeding, (Resident #2). This deficient practice was evidenced by the following:1. On 2/25/26 at 10:25 AM, the surveyor observed Resident #2 in bed with his/her eyes closed and an enteral feeding (a method of providing nutrition directly into the gastrointestinal tract.) machine running. The enteral feeding container and water flush (a method of providing water directly into the gastrointestinal tract.) bag both observed missing labels with resident's name, date and time the enteral feeding and water flush bag were hung and started. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain respiratory care and equipment for a resident who was receiving continuous oxygen for 1 of 1 resident (Resident #6). This deficient practice was evidenced by the following: On 2/25/26 at 10:33 AM, the surveyor observed resident #6, in bed watching television. The resident was wearing a nasal cannula (NC) that was attached to a humidification water bottle and oxygen (O2) concentrator. Neither item was properly labeled or dated. The O2 concentrator was set at 3 L/min (liters per minute). On 2/26/26 at 10:08 AM, surveyor observed the resident out of bed in a wheelchair eating breakfast. The resident was wearing a NC that was attached to a humidification water bottle and O2 concentrator. Neither item was properly labeled or dated. [...]

Inspectors wroteRepeat Deficiency Based on observations, interviews, record review, and review of facility documentation, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure that a.) to have a resident rinse their mouth after inhaling a steroid inhaler per manufacturer specification observed in one (1) of five (5) residents observed during medication administration (Resident#21) and b.) to ensure that medication is properly stored for one (1) of nine (9) residents (Resident #9) reviewed. The deficient practices were 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, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the morning medication administration observation on 2/26/26 and 3/2/26, the surveyor observed one (1) nurse administer medications to five (5) residents. There were 26 opportunities, and three (3) errors were observed which calculated to a medication administration error rate of 11.54%. The deficient practice was identified for one (1) of five (5) residents, (Resident #6), that were administered medications by one (1) of one (1) nurse that were observed. The deficient practices were evidenced by the following:1). On 2/26/26 at 9:05 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN#1) entered the room of Resident #6. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure meals were served at a safe and palatable temperature. This deficient practice was evidenced by the following:On 3/2/26 at 10:30 AM, the surveyor conducted the Resident Council meeting with four alert and oriented residents (Resident #3, #8, #16, and #27), selected by the facility to attend. During the meeting, all four residents in attendance stated that the food temperatures were not palatable: the hot foods were not hot, and the cold foods were not cold. On 3/2/26 at 12:18 PM, the surveyor calibrated a state-issued digital thermometer via the ice bath method to 32 degrees Fahrenheit (F) in the presence of the Food Service Supervisor(FSS). At 12:20 PM, the surveyor and FSS observed that the food truck arrived at the unit. [...]

Inspectors wroteBased on interview and review of the facility documentation, the Quality Assurance and Performance Improvement (QAPI) committee failed to hold quarterly meetings for 2 of four Quapi meetings conducted. This deficient practice was evidenced by the following: On 2/25/26 at 10:35 AM, during the entrance conference, the surveyor requested the sign sheets for the past four quarters of the QAPI committee meetings. On 3/3/26 at 12:17 PM, the surveyor reviewed the attendance sheets along with the QAPI book. The book was divided into 9/10/24, 3/18/25 and 7/23/25. The review revealed that there were more than 3 months between each meeting. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to follow proper infection control practices for personal protective equipment (PPE) N95 masks to prevent the potential spread of infection as per facility requirement. This deficient practice was evidenced by the following: On 2/25/26 at 09:10 AM the survey team entered the facility for a recertification survey, at that time the team was greeted and told an N95 mask was required for entrance. All surveyors complied with this request. The team coordinator asked if there were Covid positive (+) cases in the building and she was told there was not active Covid + in the building. On 2/25/26 at 09:15 AM, the surveyor observed the Licensed Nursing home administrator (LNHA) not wearing her facility required N95 respirator mask correctly. [...]

Inspectors wroteComplaint #: NJ00185571 Based on observation, interviews, and review of pertinent facility documents on 07/01/2025 and 07/02/2025, it was determined that the facility failed to implement a physician-ordered intervention to supervise and provide safety to residents from physical abuse by another resident (Resident #7,) who has a known history of aggressive behaviors towards other residents. The abuse occurred when facility staff failed to supervise, and to provide one-to-one (1:1) monitoring of Resident #7. This allowed the resident the opportunity to strike Resident #5 on the head with a metal object, causing laceration (cut) that required transfer to the hospital for treatment. This deficient practice was identified for Resident #7, 1 of 1 residents reviewed and was evidenced by the following: [...]

Inspectors wroteComplaint #: NJ183318, NJ183964 Based on interviews, medical records review, and review of other pertinent facility documentation on 3/12/25 and 3/13/25, it was determined that the facility failed to thoroughly investigate an abuse allegation that involved a Certified Nursing Assistant (CNA #1) and Resident #1. The facility also failed to ensure its policy titled Abuse Investigations was implemented during the alleged abuse allegation. On 2/4/25 at approximately 12:40 P.M., the Licensed Nursing Home Administrator (LNHA) was notified by two representatives of the Ombudsman office that CNA #1 was trying to get Resident #1 out of bed, and the resident was screaming. The LNHA went to the resident's room, and Resident #1 told her that he/she did not want CNA #1 touching him/her. Resident #1 expressed to the LNHA and the Registered Nurse (RN #1) that CNA #1 pulled and hurt his/her left arm. [...]

Inspectors wroteComplaint: NJ183318, NJ183964 Based on interviews, medical record reviews, and review of other pertinent facility documents on 3/12/25 and 3/13/25, it was determined that the facility failed to complete Section C of the Quarterly Minimum Data Set (MDS) and failed to follow its policy titled MDS for 6 of 6 sampled residents. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted to the facility in September of 2023 with diagnoses which included but were not limited to: Unspecified Dementia, Hyperlipidemia (high cholesterol), and Depression. A review of Resident #1's Quarterly Minimum Data Set (MDS), an assessment tool dated 12/22/24 under Section C0100 (Should a Brief Interview for Mental Status (BIMS) be Conducted?) revealed a code of 1 which indicated Yes. [...]

Inspectors wroteComplaint #: NJ183318, NJ183964 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 3/12/25 and 3/13/25, it was determined that the facility failed to a.) update the care plan (CP) with interventions for a resident (Resident #1) involved in a staff to resident abuse allegation and b.) for residents (Resident #3 and #4) involved in a resident-to-resident incident. This deficient practice was identified in 3 of 3 residents reviewed for care plans and was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted to the facility in September of 2023 with diagnoses which included but were not limited to: Unspecified Dementia, Hyperlipidemia (high cholesterol), and Depression. [...]

Inspectors wroteComplaint #: NJ183318, NJ183964 Based on interviews, medical record review, and review of other pertinent facility documentation on 3/12/25 and 3/13/25, it was determined that the facility failed to report an abuse allegation involving a Certified Nursing Assistant (CNA #1) and Resident #1 to the local Police Department. The facility also failed to follow its policies titled Resident Abuse Prohibition Policy and Reporting Abuse to State Agencies and Other Entities/Individuals. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted to the facility in September of 2023 with diagnoses which included but were not limited to: Unspecified Dementia, Hyperlipidemia (high cholesterol), and Depression. [...]

Inspectors wroteComplaint #: NJ1833183, NJ183964 Based on interview and review of facility documentation on 3/12/25 and 3/13/25, it was determined that the facility failed to evaluate the performance of a Certified Nursing Assistant (CNA) on an annual basis. This deficient practice was identified for 1 of 3 CNAs whose personnel files were reviewed (CNA #2). The deficient practice was evidenced by the following: On 3/12/25 at 11:13 AM, the surveyor reviewed the employee files for 3 CNAs which were provided by the facility. The surveyor identified the following: CNA #2 had a hire date of 10/23/23. According to CNA #2's personnel file, there was no documentation that an annual performance evaluation was completed. On 3/12/24 at 3:19 PM, the surveyor interviewed the Business Office Manager /Human Resources (BO/HR) who confirmed there was no annual performance evaluation completed for CNA #2. [...]

Inspectors wrotePart A Based on observation, interview, record review and review of pertinent documentation, it was determined that the facility failed to ensure a cognitively impaired resident with a PO (physician's order) for NTL (nectar thick liquid, liquid thickened with an agent for a nectar like consistency) to prevent aspiration (accidental breathing in of fluid or food into the lungs). This deficient practice was identified for 1 of 18 residents reviewed for modified liquid diet consistency. On 10/23/24 at 12:28 PM, during lunch observation, the surveyor observed Resident #19 coughing while the Licensed Practical Nurse (LPN #1) was assisting Resident#19 with their meal. LPN #1 informed the surveyor that the resident started coughing after LPN #1 fed Resident #19 whole mandarin oranges in its own thin juice. LPN #1 stated that Resident #19 was on nectar thickened liquid. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to accurately transmit the Minimum Data Set (MDS) for 20 of 32 residents reviewed, Residents #25, #3, #13, #10, #28, #1, #7, #17, #31, #231, #32, #33, #22, #27, #28 and was evidenced by the following: On 10/23/24 at 10:44 AM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The MDS is a comprehensive federal mandated process for clinical assessment of all residents that must be completed and submitted to the Quality Measure System. The facility must electronically transmit the MDS up to 14 days of the assessment being completed. After transmitting the MDS, it will generate a quality measure to enable a facility to monitor the residents decline and progress. The following residents were identified that the MDS were not transmitted timely: 1. [...]

Inspectors wroteBased on observation, interview and review of facility provided documentation, it was determined that the facility failed to ensure that the Certified Nursing Aide (CNA) received a performance review for one (1) of five (5) CNA files reviewed. This deficient practice was evidenced by the following: On 10/22/24 at 10:27 AM, the surveyor requested from the facility's Director of Nursing (DON) and Business Office Manager (the annual education, competencies, and performance reviews for five randomly selected CNAs. The facility provided a copy for each of the five CNA's records which contained their post tests for the education they received. The facility did not provide performance reviews for the five CNAs. [...]

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 10/22/24 9:07 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour: 1. The surveyor observed three dented cans (6 lb. peaches, 6 lb. potatoes, and 6 lb. shredded potatoes) stored with all intact canned goods. FSD stated those cans should have been removed and placed in the dented can area. 2. The surveyor observed the canned goods stored on the top of the storage unit were warm to the touch with a heat vent observed on ceiling next to the canned goods. 3. The surveyor observed three portable window air conditioning units (AC). [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to 1. ensure the sharps container (SC) that were filled with contaminated sharps/needles were disposed properly, 2. ensure the used COVID19 Ag test card was discarded after use, 3.ensure the clean linen room was free from soiled device and 4. ensure the Personal Protective Equipment (PPE) cart was cleaned to prevent the spread of infection. This deficient practice was evidenced by the following: 1. On 10/22/24 at 9:00 AM, two surveyors observed a used COVID19 Ag test card exposed laying on the table right by the entrance door where all the visitors and staff enter the facility. The surveyor further observed that the COVID19 Ag test card showed a one red line indicating the results was negative (-). [...]

Inspectors wroteComplaint #: NJ174200 Based on observation, interview, and record review, it was determined that the facility failed to maintain resident's dignity by, a. not providing an incontinent resident the correct size of incontinence briefs (IB) and b. standing over the resident while feeding during mealtime. This deficient practice was observed for 2 of 13 residents reviewed (Resident #21 and Resident #18) and was evidenced by the following: 1. On 10/28/24 at 9:00 AM, the surveyor observed Resident #21 in their room seated in an upward position in their bed. Resident #21 was observed eating their breakfast. The surveyor observed the Certified Nurse Aide (CNA #1) feeding Resident #21 while standing over them. The surveyor interviewed CNA #1, who stated they know they should be seated next to the resident during feeding assistance but could not provide an explanation why they were not seated. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) for 2 of 3 residents (Resident #14 and Resident #27) reviewed. This deficient practice was evidenced by: The SNF ABN provides information to beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. If the SNF provides the beneficiary with the SNF ABN, the facility has met its obligation to inform the beneficiary of his or her potential financial liability and related standard claim appeal rights. [...]

Inspectors wroteComplaint NJ#173220 Based on interview and record reviews, it was determined that the facility failed to report an allegation of Abuse/Neglect to the New Jersey Department of Health (NJ DOH) in the required timeframe for 2 of 2 sampled residents, (Residents #29 and Resident #81). This deficient practice was evidenced by the following: On 10/28/24 at 10:30 AM, the surveyor reviewed a Reportable Event Record/Report Form (RER/RF) provided by the facility. The form was dated 4/24/24 and documented an event that occurred on 4/20/24 at 3:30 PM involving Resident #81 and Resident #29. The report documented Resident #81 touched Resident #29's face and attempted to remove the resident's glasses from Resident #29's face. Resident #29 who was startled and reacted by swatting Resident #81's hand away. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to notify the resident's representative and the Office of the Ombudsman in writing for an emergency transfer to the hospital. This deficient practice was identified for 1 of 1 resident, Resident #9, reviewed for hospitalization. On 10/23/24 at 9:28 AM, the surveyor reviewed the electronic medical record for Resident #9. A review of the physician's progress note dated 4/20/24, revealed that the resident had a recent hospitalization. A review of the Discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 4/15/24, reflected that Resident #9 was discharged to the hospital with a return anticipated to the facility. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) to reflect the resident status in accordance with federal guidelines. This deficient practice was identified for 1 of 12 residents (Resident #7) reviewed. The deficient practice was evidenced by the following: The MDS is a comprehensive tool that is federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. 1. On 10/23/24 at 10:10 AM, the surveyor observed Resident #7 seated in the wheelchair inside the room, watching television. The resident was able to answer the surveyor's inquiry. On 10/24/24 at 11:15 AM, the surveyor reviewed the hybrid (paper and electronic) medical record (HMR) of Resident #7, which revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to ensure residents with significant weight changes (a weight change of 5% in 30 days and/or 10% in 180 days) were addressed by the Registered Dietitian (RD) in a timely fashion. This deficient practice was identified for 2 of 2 residents reviewed for significant weights changes (Resident #3 and #14), and was evidenced by the following: 1. On 10/22/24 at 10:30 AM, the surveyor observed Resident #3 seated in their wheelchair on the outside deck of the facility. Resident #3 stated they had weight gains and losses but was not sure of their current weight. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow acceptable standards of clinical practice for accurately administering medications according to the physician's order (PO). This deficient practice was identified in 1 (one) of 12 (twelve) residents (Resident #20) 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 wroteBased on observation, interview, and record review, it was determined that the facility failed to properly label, store, and dispose medications in one (1) of two (2) medication carts inspected. This deficient practice was evidenced by the following: On [DATE] at 11:35 AM, the surveyor inspected medication cart #1 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened vial of Fiasp insulin with an opened date of [DATE] and was expired. The surveyor also observed two opened bottles of Pro-Stat AWC (protein supplement), one bottle had an opened date of [DATE] and a second bottle with an opened date of [DATE]. Both bottles of Pro-Stat AWC were expired. At that time, the surveyor interviewed LPN#1 who acknowledged that both the Fiasp insulin vial and the two bottles of Pro-Stat AWC were expired and should have been removed from the medication cart. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined that the facility staff failed to ensure a resident received liquids in the appropriate consistency at meals in accordance with physician orders for 1 of 1 resident (Resident #1). This deficient practice was evidenced by the following: On 12/26/24 at 11:37 AM, during the kitchen inspection, the surveyor observed Resident #1's lunch tray with tray card listing the resident's diet, diet consistency and liquid consistency. [...]

Inspectors wroteBased on observation, interview, record review, it was determined that the facility failed to maintain complete and readily accessible medical records. This deficient practice was identified for (1) one of (5) five residents (Resident #28) reviewed for unnecessary medication. This deficient practice was evidenced by the following: On 10/23/24 at 10:15 AM, the surveyor observed Resident #28 in bed, awake, covered with a blanket, and unable to answer the surveyor's inquiry. On 10/23/24 at 11:23 AM, the surveyor reviewed the hybrid (paper and electronic) medical record of Resident #28, which revealed the following: A review of the admission Record (an admission summary) reflected that Resident #28 was admitted to the facility with diagnoses that included but were not limited to unspecified dementia (memory loss), unspecified severity, with other behavioral disturbances. [...]

Inspectors wroteComplaint#: NJ00171484 Based on interviews, review of electronic medical records (EMR), and other pertinent facility documentation on 03/04/24, it was determined that the facility staff failed to maintain a complete and accurate medical record by having an incomplete smoking assessment for 1 of 2 residents (Resident #1) reviewed. This deficient practice was evidenced by the following: According to the admission Record, Resident #1 was admitted to the facility with diagnoses which included but were not limited to edema (swelling caused by too much fluid trapped in the body's tissues), anxiety disorder, and Type 2 Diabetes. Review of Resident #1's 10/10/23 admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care revealed, that the resident did use tobacco. [...]

Inspectors wroteC #: NJ167461, NJ169331, and NJ169500 Based on interview, medical records (MR) review, and review of pertinent facility documents on 12/7/23, 12/11/23, and 12/12/23, it was determined that the facility failed to report four allegations of resident to resident abuse to the New Jersey Department of Health (NJDOH) and follow their facility policy on Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property Prevention for 4 of 6 sampled residents (Resident #1, Resident #2, Resident 4, and Resident #6) reviewed for incident and accident, investigation and reporting. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteC #: NJ167461, NJ169331, and NJ169500 Based on interview, medical records (MR) review, and review of pertinent facility documents on 12/7/23, 12/11/23, and 12/12/23, it was determined that the facility failed to provide documented evidence that four allegations of resident to resident abuse were thoroughly investigated according to their facility's policies on Reporting Accident and Incident and Resident Abuse Prohibition Policy for 4 of 6 sampled residents (Resident #1, Resident #2, Resident 4 and Resident #6) reviewed for incident and accident investigation and reporting. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to; Dementia and Macular Degeneration. [...]

Inspectors wroteC #: NJ167461, NJ169331, and NJ169500 Based on interview, medical records (MR) review, and review of pertinent facility documents on 12/7/23, 12/11/23, and 12/12/23, it was determined that the facility failed to revise residents care plans (CP) for 4 of 6 sampled residents (Resident #1, Resident #2, Resident #4, and Resident #6) reviewed for CP revision. The deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to: Dementia and Macular Degeneration. The Minimum Data Set (MDS), an assessment tool dated 9/27/23, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 4 which indicated cognition was severely impaired. The MDS further revealed that Resident #1 had a fall prior to the MDS assessment. [...]

Inspectors wroteComplaint #s NJ00155172, NJ00161276, NJ00160806, NJ00159306 Refer to F760K; F835L; F836L Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure 29 residents were adequately supervised when Licensed Practical Nurse (LPN) #1 worked 24 hours straight, six times in May 2023 with one Certified Nursing Assistant (CNA) #1 on the assignment during designated shifts. The failure to have adequate staff led to a lack of supervision for residents, which increased the risk of improper care, resident neglect, accidents such as falls, entrapments or elopements, and/or medication administration errors or omissions. Serious injury or death may have occurred due to staff inability to respond to an emergent situation in a timely manner. This resulted in an Immediate Jeopardy (IJ) situation. [...]

Inspectors wroteComplaint #s NJ00155172, NJ00161276, NJ00160806, NJ00159306 Refer to F689, F756, F760, F836 Based on observations, interviews, review of medical records, and review of facility documents, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure a.) staffing levels outlined in the Facility Assessment Tool were consistently met to address the population census and needs of their residents; b.) minimum State staffing requirements were met for 17 weeks of 17 weeks reviewed during which time the facility continued to admit residents; c.) safe medication administration to residents resulting in significant medication errors; d.) Consultant Pharmacist (CP) monthly medication review reports were acted upon by the Director of Nursing (DON) and the Physician in a timely manner; [...]

Inspectors wroteComplaint #s NJ00155172, NJ00161276, NJ00160806, NJ00159306 Refer to F689, F756, F760, F835 Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 118 of 119 day shifts, 54 of 119 evening shifts, and 10 of 119 overnight shifts. The failure of the facility to operate safely by following State minimum staffing requirements while continuing to admit new residents placed all residents at risk for serious harm, impairment or death. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/2021, Compliance with N.J.S.A. [...]

Inspectors wroteRefer to 760K Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the Consultant Pharmacist (CP) recommendations dated 3/7/23 were acted upon in a timely manner regarding the documentation and administration of critical medications, including anticoagulants and insulin medications to prevent serious adverse outcomes for Resident #13, #19 and #20 who required blood sugar monitoring and were dependent on insulin, and Resident #17 and #230 who had physician orders for an anticoagulant to prevent blood clotting. [...]

Inspectors wrote2. The surveyor observed Resident #25 on 5/24/23 at 10:54 AM, receiving personal care from the Certified Nursing Assistant (CNA). The surveyor again observed the resident on 5/26/23 at 11:45 AM, awake in bed watching television. The resident was alert and oriented and able to answer simple questions. A review of the hybrid medical record revealed the following: According to AR, Resident #25 was admitted to the facility with diagnoses that included but were not limited to chronic embolism and thrombosis of unspecified deep veins of the left lower extremity (also known as DVT). The resident was care planned (5/29/23) for using anticoagulant therapy related to DVT. Interventions included: Administer anticoagulant medications as ordered by the physician. Monitor for side effects and effectiveness q [every] shift. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that three (3) Licensed Practical Nurses (LPN #1, #2, #3) had competencies to assess nursing care for residents' needs. The deficient practice was evidenced by the following: On 6/01/23 at 3:25 PM, the surveyor reviewed the requested nurse competencies for LPN #1 provided by the Director of Nursing (DON). The competencies were for handwashing, covid antigen nasal swab testing, enteral nutrition feedings, and personal protective equipment donning and doffing. The competencies were done between 9/2022 and 11/2022. On 6/1/23 at 3:30 PM, the surveyor asked the DON if LPN #1 had completed other competencies. The surveyor also requested competencies for the other two (2) LPNs (LPN #2 and #3) who worked at the facility. The DON stated that no other nurse competencies were found. [...]

Inspectors wroteBased on record review and interview with the Licensed Nursing Home Administrator (LNHA), it was determined that the facility failed to complete the annual Nurse Aide performance appraisals for 4 of 4 Certified Nursing Assistants (CNA) reviewed and was evidenced by the following: On 6/5/23 at 9:36 AM, the surveyor requested the annual Nurse Aide performance appraisals for CNA #1, 2, 3, and 4. The LNHA referred the surveyor to the Director of Nursing (DON). On 6/5/23 at 12:12 PM, the DON told the surveyor that the performance appraisals were not done. The DON stated, I will begin them now. On 6/5/23 at 1 PM, the surveyor requested the facility policy regarding employee annual performance appraisals. The policy was not provided to the surveyor. NJAC 8:39-43.17(b)

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure that medications were administered and accurately signed in the electronic medication administration record (eMAR). This deficient practice was identified for 13 of 13 residents (Residents #4, #11, #13, #17, #18, #19, #20, #22, #26, #79, #179, #229, and #230) reviewed for medication management. 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 the interview and record review, it was determined that the facility failed to ensure that the Infection Preventionist (IP), Director of Nursing (DON), Medical Director (MD), or designee attended the quarterly Quality Assurance (QA) meetings. This was identified for 2 of the 3 quarterly QA meetings reviewed. This deficient practice was evidenced by the following: The surveyor reviewed the QA meeting sign-in sheets for the last three (3) quarters dated April 26, 2023, January 25, 2023, and September 30, 2022. Reviewing the sign-in sheets for those 3 quarters revealed no DON signatures to show that the DON was in attendance for September 30, 2022 and January 25, 2023 QA meetings. [...]

Inspectors wroteBased on observation, interview, and record review, 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 during lunch. This deficient practice was identified for one (1) of three (3) residents (Resident #11) who required assistance to eat and were not being assisted while the other residents at the same table were either eating or being assisted. This deficient practice was evidenced by the following: On 5/24/23 at 12:20 PM, during lunch in the dining area, the surveyor observed Resident #11 seated in a geri-chair (a chair that can fully recline with wheels to provide a portable, spacious seat) at a table with two (2) unsampled residents. All three residents had their lunch trays in front of them, and Resident #11's lunch tray remained covered. [...]

Inspectors wroteBased on the interview and review of pertinent facility documents, it was determined that the facility failed to obtain current and past-employer reference checks prior to hiring in accordance with the facility's abuse policy and procedure for screening newly hired employees. This deficient practice was identified for 3 of 5 newly hired employees and was evidenced by the following: On 6/5/23, the surveyor reviewed pre-screening for five (5) newly hired employees. Three of the 5 employees listed below had no reference checks performed before starting work at the facility. a) A Dietary Aide (DA) who began working at the facility on 5/12/22. b) A Certified Nursing Assistant (CNA) who began working on 3/13/23. c) A Registered Nurse (RN) who began working on 3/10/23. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to document the circumstances of the resident change of condition leading to emergency transfer and the resident's readmission to the facility post-hospitalization. The deficient practice was identified for 2 of 5 residents (Residents #26, #4) reviewed for hospitalization. The evidence is as follows: 1. The surveyor observed Resident #26 sitting in bed on 5/24/23 at 10:45 AM. The alert and oriented resident discussed her various medical conditions with the surveyor. A review of the resident's Electronic Medical Record (EMR) revealed the following information: The admission Record (AR) listed diagnoses of displacement of nephrostomy catheter, irritable bowel syndrome, diabetes mellitus, hypotension, kidney failure, and urinary tract infection. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, it was determined that the facility failed to: a.) assess a weight change for 1 of 1 resident reviewed for nutritional status, which did not contribute to weight loss, Resident #229, and b.) follow the physician's order (PO) for medication used to raise blood pressure for 1 of 1 resident, Resident #26. 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 maintain the necessary respiratory care and services for 1 of 1 residents (Resident #4) reviewed for respiratory care. The deficient practice was evidenced by the following: On 5/24/23 at 10:11 AM, the surveyor observed the resident in bed receiving oxygen therapy through a nasal cannula from an oxygen concentrator at two (2) liters per minute (lpm). The oxygen tubing was not labeled to indicate when the tubing had been changed. On 5/25/23 at 10:10 AM, the surveyor observed the resident in bed with eyes closed, receiving oxygen. The tubing was not dated. On 5/25/23 at 10:17 AM, the Certified Nursing Assistant (CNA) told the surveyor the resident always used oxygen, She needs it. The CNA stated nurses and CNAs encourage the resident to use oxygen. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observations on 5/25/23 and 5/26/23, the surveyors observed one (1) nurse administer medications to five (5) residents. There were twenty-seven (27) opportunities, and two (2) errors were observed, calculated to a medication administration error rate of 13.5%. This deficient practice was identified for one (1) of five (5) residents observed (Resident #18) that were administered medications by one (1) nurse. The deficient practice was evidenced by the following: 1. [...]