McAuley Hall Health Care Cente

Inspectors wroteBased on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness and, b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following:On 8/5/25 at 11:00 AM, in the presence of the Food Services Director (FSD), the surveyor observed the following:1. In the food preparation area, the surveyor observed a handwashing sink, which was attached to a stainless-steel food preparation area and there was no partition between the sink and food preparation surface.2. In the walk in refrigerator, the surveyor observed an opened half full apple juice with an open date of 7/23/25. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a high blood pressure medication with parameters (a defined set of conditions) was administered without significant medication error, the physician's order was followed, and adhered to the professional standards of practice. The deficient practice was identified for 1 of 4 residents (Resident #39) observed during the medication administration and was evidenced by the following: On 8/6/25 at 8:35 AM, the surveyor observed the Registered Nurse (RN) prepare 9 medications (meds) for Resident #39, which included a physician's order (PO) for metoprolol succinate ER oral tablet extended release 24 hour 25 milligrams (mg) give 0.5 tablet by mouth in the morning related to hypertension. Hold if systolic blood pressure (bp) less than 100; hold if heart rate (hr) less than 60. [...]

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 three (3) of the three (3) quarterly QA meetings reviewed. This failure had the potential to affect all 68 residents who currently live in the facility. The deficient practice was evidenced by the following: The surveyor reviewed the QA meeting sign-in sheets for the last three (3) quarters dated June 30,2023, September 30, 2023, and January 12, 2024. The sign-in sheets for those three (3) quarters revealed no DON signatures to show that the DON was in attendance for June 30, 2023, and January 12, 2024, QA meetings. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) maintain infection control practices to reduce the risk of infection during a pressure ulcer (PU) treatment; b.) follow a physicians order during a PU treatment; c.) follow the recommendations of the wound care center physician; and d.) assess and document the measurements of the PU one (1) of two (2) residents reviewed for PU (Resident #39). This deficient practice was evidenced by the following: On 3/06/24 at 11:13 AM, the surveyor observed that Resident #39's door had a stop sign that indicated the resident was on enhanced barrier precautions. After donning the appropriate personal protective equipment required, the surveyor entered Resident #39's room and interviewed the resident. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to: a.) maintain a system of record keeping of DEA (Drug Enforcement Administration) Form-222 (a federal narcotic requisition form used for ordering controlled substances), that ensured drug records were in order, and controlled dangerous substance (narcotics medications), with high potential for abuse were tracked with detail to enable prompt identification of loss or potential diversion of controlled substance; and b.) develop a policy and procedure for narcotic medications which included record keeping of DEA Form-222. This deficient practice was evidenced by the following: On 3/11/24 at 8:45 AM, in the presence of the Director of Nursing (DON), the surveyor reviewed the facility provided binder that contained the DEA 222 forms. [...]

Inspectors wroteComplaint# NJ154270 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain: a) the residents' patio in a safe and homelike condition for one (1) of two (2) patios, b) the laundry area in a safe and sanitary condition, and c) a safe and sanitary environment in one (1) of three (3) kitchenettes in accordance with the facility procedures and federal regulations, and were identified during the environment tour of the facility. This deficient practice was evidenced by the following: 1. A review of the 4/22/22 at 9:37 AM phone interview of another surveyor with the anonymous resident's Responsible Party (RP) revealed that according to the RP (also known as the caller), the following was the physical environment outside of the facility's building: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's Quality Assurance and Performance Improvement (QAPI) program for five (5) of five (5) Certified Nurse Assistants (CNAs) reviewed for mandatory education. The deficient practice was evidenced by the following: The surveyor requested five (5) random CNA education files for the year 2023. A review of the facility form, Employee Official Inservice Transcript for [facility name redacted] for the 2022 to 2023 revealed the log did not include the mandated QAPI education training. [...]

Inspectors wroteBased on interview and review of other facility documentation, it was determined that the facility failed to ensure the facility staff had the mandatory behavioral health training for five (5) of the five (5) Certified Nursing Assistants (CNAs) reviewed for mandatory education. The deficient practice was evidenced by the following: The surveyor requested five (5) random CNA education files for the year 2023. A review of the facility form, Employee Official Inservice Transcript for [facility name redacted] for 2022 to 2023 revealed the log did not include the mandated behavioral health education training. On 3/11/24 at 11:51 AM, during a meeting with the surveyors, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concern regarding the missing in-services for the CNAs. [...]

Inspectors wroteBased on interview 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 a) licensed staff credentials were verified upon hire (Staff #1 and #4) This deficient practice was identified for two (2) of four (4) newly hired staff reviewed, and was evidenced by the following: The surveyors randomly selected five new employee files for license verification which revealed the following: Staff #1, a Licensed Practical Nurse (LPN), with a date of hire of 4/27/22, had a New Jersey Division Consumer Affairs (NJCA) license verification printout for license verification (used to verify the license status of a nurse) which was dated 3/07/24, Staff #4, a Registered Nurse (RN), with a date of hire of 12/08/22, had a NJCA verification print out for license verification which was dated 03/07/24. [...]

Inspectors wroteComplaint# NJ169416 Based on interviews, review of medical records and other facility documentation, it was determined that the facility failed to report an allegation of Abuse/Neglect to the New Jersey Department of Health (NJDOH) in the required timeframe for one (1) of three (3) residents, reviewed for incident/event (Residents #57). This deficient practice was evidenced by the following: On 3/07/24 at 10:16 AM, Resident #57 was not in the room, the room was observed to be clean, the bed was positioned against the wall with the floor mat on the right-hand side of the bed. At 10:16 AM, the surveyor observed the resident in the main dining room where at that time activities were being conducted. The resident was observed sitting at a round table with three (3) other residents. At 01:15 PM, the resident was observed in the main dining room having lunch with two (2) other residents. [...]

Inspectors wroteBased on interviews, record review, and review of pertinent facility documentation it was determined that the facility failed to accurately complete and update a Preadmission Screening and Resident Review (PASaRR) to include all psychiatric diagnoses to ensure the resident was referred to the appropriate state-designated authority for level II PASARR evaluation and determination. This deficient practice was identified for one (1) of one (1) resident (Resident #19) reviewed for level II PASARR and was evidenced by the following: On 3/06/24 at 10:36 AM, the surveyor observed the Registered Nurse (RN) administer medications to Resident #19 inside the resident's room while the resident was seated in a recliner chair. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #19 as follows: [...]

Inspectors wroteBased on observations, interviews, record review, and review of other pertinent facility provided documentation, the facility failed to: a) obtain a physician's order for droplet precaution and b) ensure that the required posted sign was followed according to the facility's practice and policy, and standard of clinical practice, for one (1) of five (5) residents reviewed for infection control (Resident #10). 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 review of facility documentation, it was determined that the facility failed to ensure: a) that appropriate care was provided for the hemodialysis (the filtration of waste when the kidneys are no longer able to do so) access site and b) care plan was developed with regard to the care of the hemodialysis access site. This deficient practice was identified for one (1) of one (1) resident (Resident #20) reviewed for hemodialysis and was evidenced by the following: On 3/06/24 at 10:41 AM, the surveyor observed Resident #20 was seated in a wheelchair wearing dark eyeglasses, with a call bell within reach, and with a left lower leg prosthetic in use. The resident stated that the dialysis was every Tuesday, Thursday, and Saturday at around 01:30 PM pick up. The resident showed their right upper chest dialysis access site covered with a clean dressing. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the posted Resident Care Staffing Report (24-hour staffing report) was up to date and provided accurate information. This deficient practice was evidenced by the following: On 3/06/24 at 8:55 AM, the surveyors entered the facility and observed the posted 24-hour staffing report which was dated 3/06/24. The resident census was not included. The staffing report did not indicate if a Registered Nurse, was on duty. The posting indicated the number of licensed nursing staff and certified nursing staff on a shift. The shift did not specify the total number and actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain complete and readily accessible medical records. This deficient practice was identified for one (1) of seventeen (17) residents reviewed (Resident #16). This deficient practice was evidenced by the following: On 3/11/24 at 10:41 AM, the surveyor reviewed Resident #16's closed electronic medical record. Resident #16'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 asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe), hypertension (elevated blood pressure), and heart failure. [...]

Inspectors wroteBased on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to ensure the consistent coordination/communication was provided between facility staff and hospice staff to meet the resident's needs (Resident #26). This deficient practice was identified for one (1) of two (2) residents reviewed for hospice and end of life care. This deficient practice was evidenced by the following: On 3/06/24 at 10:12 AM, during the initial tour, the surveyor observed Resident #26 sleeping on a low positioned bed with knees bent. The surveyor reviewed the hybrid (combination of both paper and electronic) medical record for Resident #26. [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to issue the required Medicare Beneficiary Protection Notification. This deficient practice was identified for two (2) out of three (3) residents reviewed, Resident #10 and #170. The deficient practice was evidenced by the following: According to the Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS (Centers for Medicare & Medicaid Services)-10123, When to Deliver the NOMNC, A Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. [...]

Inspectors wroteBased on interview, record review and review of other pertinent facility documents, it was determined that the facility failed to provide the resident and the resident's representation written notification of the reason for transfer to the hospital and also send a copy to a representative of the Office of the State Long-Term Care Ombudsman (LTCO) for two (2) of two (2) resident's (Resident #10 and #16) reviewed for hospitalization. This deficient practice was evidenced by the following: 1. A review of Resident #10's electronic medical record included the following: Resident #10's discharge return anticipated Minimum Data Set's (DRAMDS), an assessment tool used to facilitate the management of care, for the two DRAMDS, reflected that the resident was transferred to the hospital. [...]

Inspectors wroteBased on interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to provide the resident or resident representative written notification of the facility's bed hold policy prior to transfer to the hospital for two (2) of two (2) resident's (Resident #10 and #16) reviewed for hospitalizations. This deficient practice is evidenced by the following: 1. A review of Resident #10's electronic medical record included the following: Resident #10's discharge return anticipated Minimum Data Set's (DRAMDS), an assessment tool used to facilitate the management of care, for two DRAMDS, reflected that the resident was transferred to the hospital. [...]

Inspectors wroteBased on the interviews, record review, and review of pertinent facility documentation it was determined that the facility failed to accurately code the Minimum Data Set (MDS) for one (1) of the 19 residents reviewed, Resident #19. This deficient practice was evidenced by the following: On 3/06/24 at 10:36 AM, the surveyor observed the Registered Nurse (RN) administer medications to Resident #19 inside the resident's room while the resident was seated in a recliner chair. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #19 as follows: [...]