Livingston Post Acute Care

Inspectors wroteBased on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure licensed staff credentials were verified upon hire for 56 of newly hired licensed staff reviewed. The deficient practice was evidenced by the following. 1. On 12/29/25 at 9:49 AM, during entrance conference of Surveyor #1 (S #1) with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Assistant DON (ADON), S #1 asked the LNHA a list of new employees who were hired since the last recertification survey that included their title and date of hire. S #1 also notified the LNHA that all new hired employee files and medical records must be provided to the survey team as soon as possible. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to evaluate the need for the continued use of an indwelling catheter for a resident who were admitted to the facility with an indwelling catheter, failed to include catheter care in the comprehensive care plan and provide appropriate and sufficient care specifically by having the catheter tubing in contact with the floor. This deficient practice was identified for 2 of 2 residents (Resident #8, Resident #171), reviewed for indwelling catheter use and was evidenced by the following:1. On 12/29/25 at 10:56 AM, Surveyor #1 (S #1) observed Resident #8 lying in bed asleep, and an indwelling catheter (Foley) bag hung from the left side of the bed with a privacy bag. On 12/30/25 at 12:19 PM, S #1 reviewed the medical records of Resident #8 and revealed: A review of the admission Record (AR; [...]

Inspectors wroteBased on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure; a.) disposition of a narcotic medications for 2 Unsampled Residents (Unsampled Residents #1 and 2), b.) the backup controlled medications cycle count was routinely done, and c.) backup controlled medications discrepancies were resolved in a timely manner, for 3 Unsampled Residents (Unsampled Residents #3, 4, and 5), in accordance with the regulation for accurate reconciliation and accountability. The deficient practices were identified on 2 of the 4 medication carts inspected in 2 of 2 nursing units, and 1 of 1 backup up machine observed, and was evidenced by the following:Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to inform the resident's representative in advance of treatment risks and benefits, options, and alternatives to a resident receiving psychoactive medications. This deficient practice was identified for 1 of 5 residents (Resident #8), reviewed for unnecessary meds. This deficient practice was evidenced by the following:On 12/29/25 at 10:56 AM, the surveyor observed Resident #8 lying in bed asleep. On 12/30/25 at 12:19 PM, the surveyor reviewed the medical records Resident #8, and revealed:A review of Resident's #8 admission Record (an admission summary) reflected diagnoses which included but not limited to; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure 3 of 26 residents (Residents #2, #15, and #171) call bells were within reach and able to use to accommodate residents' needs. This deficient practice was evidenced by the following: 1. On 12/29/25 10:34 AM, during the initial tour of the facility, Surveyor #1 (S #1) observed Resident #2, sleeping in bed, with the call bell hung off side of the bed with the cord wrapped around the side rail. S #1 observed that the call bell was not within reach of the resident. S #1 reviewed the electronic medical record (eMR) of Resident #2, which revealed the following: A review of the admission Record (AR; an admission summary) that reflected that the resident had diagnoses of but not limited to; [...]

Inspectors wroteBased on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to adequately monitor target behavior for the use of a psychotropic medication specifically an antipsychotic medication for 2 of 5 residents (Resident #4 and #9), reviewed for unnecessary medications. This deficient practice was evidenced by the following:1. On 12/29/25 at 10:35 AM, the surveyor observed Resident #4 seated on a couch in their room. A review of Resident #4's admission Record (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses which included, but not limited to; [...]

Inspectors wroteREPEAT DEFICIENCYBased on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of nursing practice for not following physician orders for 2 of 29 residents reviewed, Resident #1 and Resident #4. 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: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident receive treatment and care in accordance with professional standards of practice, by failing to ensure; a.) a physician's order (PO) was transcribed for acute transfer to hospital, b.) the PO for supplement was followed, and c.) the provider's assessment and plan was followed through and clarified for 1 of 29 residents (Resident #166) reviewed. 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 wroteRepeat Deficiency Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the necessary respiratory care and services of residents that were receiving oxygen, according to the standard of clinical practice and the facility's policy and procedure, specifically, having a valid physicians' order and by documenting the date and time the oxygen tubing was changed for 1 of 1 resident, Resident #74. 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 interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication by excessive dose for 1 of 5 residents reviewed for unnecessary medications, (Resident #7). The deficient practice was evidenced by the following: The surveyor reviewed Resident #7's electronic medical record (EMR) which revealed the following. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included, essential hypertension (high blood pressure), pain due to internal orthopedic implants, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications (meds) were administered without error of 5% or more during medication (med) administration, 3 nurses administered meds to 3 residents. There were 25 opportunities for error, 6 errors were observed which calculated to a med administration error rate of 24%. This deficient practice was identified for 2 of 3 residents, (Resident #139, and Resident #83), that was administered meds by 2 of 3 nurses that were observed. 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 a.) provide pharmaceutical services by ensuring the accurate administration of a medication (med) Midodrine, with a parameter according to the physician's order to meet the needs of the resident for 1 of 2 residents, (Resident #1) reviewed for med management and b.) ensure that residents were free from any significant med errors for 1 of 3 residents (Resident #83) during the med pass observation, in accordance with professional standards clinical practice. 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 ensure a.) medication was removed from active inventory when resident was discharged from the facility for 1 of 4 medication carts inspected and b.) emergency cart (ecart) supplies were not expired for 1 of 1 ecart inspected. The deficient practices were evidenced by the following:1. On [DATE] at 10:55 AM, the surveyor inspected the second floor medication cart #2 (medcart #2), in the presence of the Licensed Practical Nurse (LPN), and both observed Unsampled Resident #1's (UR #1's) Cosopt Ophthalmic Solution 2-0.5 % bottle was inside medcart #2. The surveyor asked the LPN if the resident was still at the facility, and he responded no, the resident was discharged (d/c'd) to home probably two days ago. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to perform testing of close contacts to resident that tested positive for COVID-19 to prevent further spread for 2 of 3 identified COVID positive incidents. This deficient practice was evidenced by the following:Reference: A review of the Centers for Disease Control (CDC) Infection Control Guidance: SARS-CoV-2, dated June 24, 2024, reflected the following but was not limited to:This guidance applies to all U.S. (United States) settings where healthcare is delivered, including nursing homes and home health. The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency. Under Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic. [...]

Inspectors wroteComplaint#: 437202Based on facility policy review, record review, and staff interview, the facility failed to ensure one Resident (R) R3 out of a total of 17 residents reviewed in the sample was provided with appropriate quality of care (QOC) related to intravenous (IV) antibiotic medication administration. This failure created the potential for the residents to experience a negative change in physical status related to medication not being provided timely. Review of the facility's policy titled, Unavailable Medication Policy dated adopted 06/2021 revealed, In conjunction with the contracted pharmacy, the facility will make every effort to ensure a medication ordered for the resident is available to meet their needs; and In the event that a medication ordered for a resident is noted to be unavailable near or at the time it is to be dispensed, nursing staff shall: a. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain kitchen sanitation in a manner intended to prevent the spread of food borne illness and in accordance with professional standards for food service safety. The deficient practice was evidenced by the following: On 9/16/24 at 7:55 AM, the surveyor toured the facility kitchen with Dietary Aid (DA#1). DA#1 stated that the Food Service Director (FSD) was not at the facility. The surveyor observed the following concerns: 1. The surveyor observed a refrigerator next to the stove. [...]

Inspectors wroteBased on the interview and review of facility documentation, it was determined that the facility failed to a.) ensure that facility wide assessment included the resources required to establish policies and procedures for the management of staffing contingency plan to meet the requirements and needs of all residents in the facility and b.) meet the staffing plan as reflected in the Facility Assessment. These failures had the potential to affect all 126 residents who currently live in the facility. This deficient practice was evidenced by the following: During the entrance conference on 9/16/24 at 7:54 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) a copy of the Facility Assessment (FA). Both the LNHA and DON stated that the facility's census (the number of residents currently under the care of a specific facility) was 126. [...]

Inspectors wroteBased on observation, interviews, record review, and review of other pertinent provided facility documents, it was determined that the facility failed to ensure that residents provided one or more rooms designated for residents dining and dining activities according to the federal regulation, approved floor plan, and facility policy. This failure had the potential to affect all 126 residents who currently live in the facility. This deficient practice was evidenced by the following: On 9/16/24 at 9:26 AM, Surveyor #1 (S#1) and Surveyor #2 (S#2) met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) for an Entrance Conference. The LNHA informed the surveyors that the facility census (the current total number of residents in the facility) was 126. [...]

Inspectors wroteREPEAT DEFICIENCY Complaint #NJ175244 Refer to F883 Based on interview and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for three (3) of 28 residents, (Residents #62, #148, and #209), reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: According to the CMS (Centers for Medicare & Medicaid Services) MDS 3.0 RAI (Resident Assessment Instrument) Manual of October 2023, for definitions of the types of therapies listed in this section, please refer to the Glossary in Appendix A. O-23 Coding Instructions: Coding Instructions for Respiratory, Psychological, and Recreational Therapies. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) administer oxygen therapy according to the physician's order for one (1) of five (5) residents, Resident #67, b.) followed and clarified the plan for respiratory care of one (1) of five (5) residents, Resident #148), c.) ensure respiratory tubing, cannula, and masks were stored in accordance with infection control measures for four (4) of five (5) residents, Residents #11, #103, #124, and #148, and d.) obtain a physician order for oxygen therapy for one (1) of five (5) residents, Resident #124, reviewed for respiratory care according to the standard of clinical practice, and the facility's policy and procedure. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. [...]

Inspectors wroteComplaint#: NJ175260 and NJ176352 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined the facility failed to ensure sufficient nursing staff and ensure call bells were answered timely without waiting a long period of time for seven (7) of 28 residents (Residents # 36, 60, 83, 84, 100, 102, and 153). This deficient practice was evidenced by the following: 1. On 9/16/24 at 7:45 AM, the surveyor observed the posted Nursing Home Resident Care Staffing Report (NHRCSR) dated 9/15/24 -Day shift 7:00 AM- 3:00 PM, which displayed Current Resident Census: 120 and the CNA (Certified Nursing Aide) to Resident ratio of 1:8.6. On 9/17/24 at 8:45 AM, the surveyor observed the posted NHRCSR dated 9/16/24 - Day shift 7:00 AM-3:00 PM, Current Resident Census: 126 and the CNA to Resident ratio of 1:9. [...]

Inspectors wroteBased on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for four (4) of nine (9) staff (two Recreation Staff, one Certified Nursing Aide, and one Hospice Aide), b.) follow appropriate infection control practice during the medication pass observation when administering an eye drops for one (1) of three (3) nurses, c.) maintain infection control standards and procedures during wound care treatment for one (1) of one (1) nurse observed for wound treatment, and d.) follow appropriate infection control practices prevent the potential spread of infection for one (1) of two (2) linen carts observed during environmental tour in accordance with the Center for Disease Control and Prevention (CDC) guidelines and [...]

Inspectors wroteComplaint NJ#175244 Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to notify the resident's representative and physician of a change in condition in a timely manner for one (1) of three (3) residents, (Resident #209), reviewed for accidents. This deficient practice was evidenced by the following: A review of the closed medical record for Resident #209 revealed the resident was admitted to the facility in 2023 and discharged from the facility in 2024. A review of the admission Record (an admission summary) revealed that Resident #209 was admitted to the facility with diagnoses which included but were not limited to: lower back pain, hypertension (high blood pressure), and metabolic encephalopathy (change in how your brain works due to an underlying condition). [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure that staff monitor and document resident's condition status post (s/p) fall and clarify the neurocheck documentation according to standards of clinical practice for one (1) of three (3) residents, Resident #148, reviewed for accidents, b.) follow the physician's written order and appropriately document urinary catheter output for one (1) of two (2) residents, Resident #358, reviewed for urinary catheters. c.) ensure staff follow the physician's order for one (1) of three (3) nurses, (Registered Nurse), observed during medication administration according to the facility's policies and standards of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. [...]

Inspectors wroteComplaint #NJ 174669 Based on interview, record review and review of other documents provided by the facility, it was determined that the facility failed to obtain a physician's order for discharge and document the response of an approval or acceptance for the referral of home care/visiting nurse services post discharge to ensure a safe discharge for one (1) of two (2) residents reviewed for discharge (Resident #308). The deficient practice was evidenced by the following: On 9/17/24 at 12:55 PM, the surveyor reviewed the closed hybrid (paper and electronic) medical record for Resident #308 which revealed the following: Resident #308's admission Record (or face sheet; [...]

Inspectors wroteComplaint # NJ174669 Based on the interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to document a discharge summary which included a recapitulation of the resident's stay and a final summary of the resident's status for one (1) of two (2) residents reviewed for discharge (Resident #308). This deficient practice was evidenced by the following: On 9/17/24 at 12:55 PM, the surveyor reviewed the closed hybrid (paper and electronic) medical record for Resident #308 which revealed the following: Resident #308's admission Record (or face sheet; [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to provide care and services consistent with professional standards of practice for a resident with pressure ulcers. This deficient practice was identified in one (1) of two (2) residents (Resident #36), reviewed for pressure ulcer care and prevention. The deficient practice was evidenced by the following: On 9/16/24 at 9:36 AM, the surveyor observed Resident #36 lying in their bed with the head of the bed elevated. The resident was alert and verbally responsive. Resident #36 stated they had a right heel wound which they were receiving treatment (tx) for. The resident added the wound was new, and they did not have it prior to being admitted to the facility. On 9/18/24 at 11:17 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) any skin investigations for Resident #36. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and other facility documentation, it was determined that the facility failed to ensure that residents admitted with decreased range of motion and mobility received appropriate treatment, device, appropriate services, and assistance to maintain and prevent further decline. This deficient practice was identified for one (1) of two (2) residents, Resident #67, reviewed for a limited range of motion (ROM). This deficient practice was evidenced by the following: On 9/16/24 at 10:25 AM, the surveyor observed Resident #67's room closed. Licensed Practical Nurse #1 (LPN#1) came out from the resident's room and informed the surveyor that the surveyor had to come back later. The LPN further stated that there were two aides providing care. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed to ensure that a.) the monthly weight and re-weighs were done, documented, and monitored for two (2) of two (2) residents, Residents #2 and #67, b.) the physician was notified the significant weight loss for one (1) of two (2) residents, Resident #2, reviewed for nutrition, and c.) the duplicate physician orders for gastrostomy tube flushes were clarified for one (1) of one (1) resident, Resident #67, reviewed for hydration. This deficient practice was evidenced by the following: 1. On 9/16/24 at 10:40 AM, the surveyor observed Resident #2 seated on the bed with a breakfast tray in front of the resident with the Certified Nursing Aide (CNA) at the bedside. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #2 and revealed: [...]

Inspectors wroteComplaint NJ#175244 Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a moderately impaired resident received care and services with regard to pain management for one (1) of one (1) resident, Resident #209, reviewed for pain according to standards of clinical practice and facility's policy. 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 wroteComplaint #NJ167713 Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to: a) maintain the dialysis communication record between the facility and the dialysis center for one (1) of two (2) residents (Resident #458) and b.) provide care and services in accordance with professional standards clinical practice and facility policy for two (2) of two (2) residents (Resident #98, 458), reviewed for dialysis services. 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 review of pertinent facility documents it was determined that the facility failed to ensure the daily posting of licensed nurses, certified nursing aide staffing, and the resident census on two (2) of five (5) days during the survey. This deficient practice was evidenced by the following: On Monday, 9/16/24 at 7:45 AM, upon entry into the facility, the surveyor observed a Nursing Home Resident Care Staffing Report (NHRCSR) which was posted in the reception area of the lobby. The NHRCSR posted for day shift was dated 9/15/24. There was no NHRSCR posted for 9/16/24 day shift. On Tuesday, 9/17/24 at 8:45 AM, the surveyor observed the NHRCSR posted in the lobby. The NHRCSR posted for day shift was dated 9/16/24. There was no NHRSCR posted for the 9/17/24 day shift. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for one (1) of five (5) residents (Resident #62) reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 9/16/24 at 9:06 AM, the surveyor observed Resident #62 in their room, lying in bed with the head of the bed elevated. The resident was alert, verbally responsive, and could not recall how long the resident was at the facility. Resident #62 verbalized no concerns with their care. The surveyor reviewed the hybrid (paper and electronic) medical record of Resident #62. [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to ensure that medications were stored securely and appropriately. This deficient practice was identified in one (1) of two (2) medication carts observed on the third floor during the surveyor's initial tour of the facility. This deficient practice was evidenced by the following: On 9/16/24 at 11:49 AM, the surveyor observed the medication (med) cart located on the 3rd floor, side three. The surveyor observed two vials of med located on the top of the med cart. The vials were observed to be opened for use and had a manufacturer label that reflected they contained the drug Acetylcysteine (a med used to decrease mucous in some lung conditions). The surveyor did not observe a nurse or other authorized person at the med cart. [...]

Inspectors wroteBased on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain a complete, available, accurate, and readily accessible medical records. This deficient practice was identified for two (2) of the 28 residents reviewed (Residents #62 and #148). This deficient practice was evidenced by the following: 1. On 9/16/24 at 9:06 AM, the surveyor observed Resident #62 in their room, lying in bed with the head of the bed elevated. The resident was alert, verbally responsive, and could not recall how long they were at the facility. Resident #62 verbalized no concerns with their care. The surveyor reviewed the hybrid (paper and electronic) medical record of Resident #62. The admission Record (AR; [...]

Inspectors wroteBased on interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer residents a pneumococcal vaccine or document the reason for ineligibility for the pneumococcal vaccine for three (3) of five (5) residents reviewed for immunizations (Resident #43, #62 and #148). The deficient practice was evidenced by the following: Reference: Centers for Disease Control (CDC) recommends pneumococcal vaccination (PCV) for many adults based on age, having certain risk conditions, and pneumococcal vaccines already received . CDC recommends PCV15, PCV20, or PCV21 for adults who never received a PCV and are Ages 65 years or older Ages 19 through 64 years with certain risk conditions. Chronic conditions and other factors that increase someone's risk for pneumococcal disease include: [...]

Inspectors wroteC# NJ00169866 Based on interview, medical records (MR) review, and review of pertinent facility documents on 02/08/24 and 02/12/24, it was determined that the facility failed to complete the residents care plan (CP) that was initiated on 11/22/23 for a Resident who was at risk for falls for 1 of 4 residents (Resident #2). The deficient practice was evidenced by the following: According to the admission Record (AR), Resident #2 was admitted with diagnoses which included but were not limited to: Metabolic Encephalopathy, Alzheimer's Disease, Adult Failure to Thrive, Difficulty in Walking, and Muscle Weakness. The Minimum Data Set (MDS), an assessment tool dated 11/28/23, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 6 which indicated cognition was severely impaired and the resident needed help in Activities of Daily Living (ADLs). [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) - Entry Reporting Assessment in accordance with federal guidelines. This deficient practice was identified for 2 of 38 residents reviewed for resident assessment (Resident #90, #133). This deficient practice was evidenced by: On 8/10/23 at 10:26 AM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. A MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. 1. Resident #90 was observed to have an Entry MDS of 6/19/23 and was due to be transmitted no later than 7/3/23. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 3 of 22 residents (Resident # 138, #140, and #86) reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On [DATE] at 12:13 PM the surveyor reviewed the closed medical chart for Resident #138 who was MDS coded for hospitalization. The surveyor reviewed the Progress Notes (PN) created on [DATE] by the Social Worker (SW) for Resident #138. The PN documented that Resident #138 was discharged home per their family's request. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to properly administer a medication used to treat hypotension in accordance with the physician's order (PO) in accordance with professional standards of nursing practice, for 1 of 22 residents, Resident #97. The deficient practice is 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, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to obtain weekly weights for a resident according to the physician's order (PO) and facility policy for 1 of 5 residents, Resident #97 reviewed for nutrition. This deficient practice was evidenced by the following: On 8/7/23 at 9:10 AM, the surveyor reviewed Resident #97's electronic medical record (EMR) which revealed the following: [...]

Inspectors wroteBased on observation, interview, and record, it was determined that the facility failed to monitor an enteral tube feeding administration pump to assure the total volume administered was in accordance with physician's orders. This deficient practice was identified for 1 of 3 residents reviewed for enteral tube feeding, (Resident #391), and was evidenced by the following: On 8/2/23 at 10:24 AM, the surveyor observed Resident #391 in bed awake, alert, and verbal. Communication board on table at bed side. observed with an enteral tube feeding pump (TF; a tube feeding surgically inserted to the stomach) administering Glucerna 1.2 (nutritional formula) at a rate of 65 milliliters (ml) an hour. On 8/3/23 at 9:13 AM, the surveyor observed the resident in bed on specialized mattress awake, alert, and responded appropriately to surveyor. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to act upon recommendations reported to the facility by the Pharmacy Consultant (PC) within an acceptable timeframe. This deficient practice was observed for 1 of 38 residents (Resident #105) reviewed. On 8/7/23 at 12:24 PM, the surveyor observed Resident #105 lying in bed, awake and alert. The resident was placed under contact isolation due to diagnosis of Clostridium Difficile (Infection of the large intestine (colon) caused by the bacteria Clostridium difficile). A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care Brief Interview for Mental Status (BIMS) section, dated 6/21/23 reflected that Resident #105 was cognitively intact. [...]