Mohawk Meadows

Inspectors wroteC39051/IQBased on interviews, medical record reviews, and review of other pertinent facility documentation on 08/14/25, 08/15/25, and 08/18/25, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) allegations involving resident abuse for : a.) on 8/15/24 when facility was notified of an allegation of misappropriation of resident's funds by the Social Worker (SW) b.) an allegation of resident-to-resident verbal abuse involving Resident #11 and Resident #13; and C.) an allegation of resident-to-resident verbal abuse involving Resident #11 and Resident #14. [...]

Inspectors wroteComplaint #: 390051Based on interviews, medical record review, and review of other pertinent facility documentation on 8/18/2025, it was determined that the facility failed to consistently document on the Treatment Administration Record (TAR) according to the acceptable standards of nursing practice for 1 of 3 residents (Resident #11) reviewed for documentation. 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: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteC39051/IQBased on interviews, medical record review, and other pertinent facility documentation on 08/14/25, 08/15/25, and 08/18/25 it was determined that the facility failed to obtain a physician's order (PO) for the resident's (Resident #11) bilevel positive airway pressure (BiPAP) machine (a non-invasive ventilation therapy that uses a machine to deliver pressurized air to a patient through a mask). This deficient practice was identified for 1 of 14 residents reviewed (Resident #11). The deficient practice was evidenced by the following:A review of the Electronic Medical Record (EMR) was as follows:According to the admission Record (AR) face sheet, Resident #11 was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to a. ensure reference checks (RC) were completed to seven (7) out of ten (10) newly hired staff (NHS) b. ensure criminal background checks (CBC) were completed to four (4) out of ten (10) NHS and c. ensure a physical examination (PE) was performed to 2 (two) out of ten (10) NHS prior to their start date of employment. This deficient practice was evidenced by the following: The surveyor reviewed ten randomly selected new employee files. The review for reference checks for five of the eight new employees revealed the following: -Staff #1's file, a Business Office Manager who was hired on 9/23/24, revealed no RC in their file. -Staff #2's file, a Maintenance Director (MD) who was hired on 5/28/24, revealed no RC in their file. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 1 (one) of 25 residents (Resident #46) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: On 11/12/24, at 9:30 AM and 1:32 PM, the same day, the surveyor observed Resident #46 lying in bed, awake and alert. The surveyor observed that the call bell was behind the resident's headboard, between the wall and the bed. On 11/12/24, at 1:35 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) and the LPN/Supervisor, who stated that the call bell should be within the residents' reach. The LPN placed the call bell next to the resident's right hand. [...]

Inspectors wroteBased on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that residents' bathing choice of a day shower was provided for 1 of 1 resident (Resident #83) reviewed for choices. This deficient practice was evidenced as follows: On 11/12/24 at 10:38 AM, the surveyor interviewed Resident #83 in their room. The resident stated, I am supposed to and want to get two showers per week, but I have not received a shower in weeks. A review of Resident #83's admission Record reflected that the resident had diagnoses that included but were not limited to; major depression (persist depressed mood), type 2 diabetes mellitus(elevated blood sugar), and bipolar disorder(mood disorder with mood swings). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a resident was free from a physical restraint (means of limiting or obstructing the freedom of a person's bodily movement). This deficient practice was identified in 1 of 2 residents reviewed for restraints, (Residents #99) and was evidenced by the following: On 11/12/24 at 10:20 AM, the surveyor observed Resident #99 awake and was seated in their wheelchair that had a seatbelt device around the resident's waist. The resident was unable to respond to the surveyors' inquiry. The surveyor further observed that Resident #99 had contractions (abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching) to bilateral arms. The surveyor in the presence of the Licensed Practical Nurse #1 (LPN #1) assessed Resident #99. [...]

Inspectors wroteBased on observation, interview, record review, it was determined that the facility failed to ensure a resident received a medication according to the physician's order (PO) that was indicated for breast cancer (CA) (a disease in which body cells grow uncontrollably and spread to other parts of the body) in accordance with professional standards of practice and facility policies and procedures for one (1) of 25 residents, (Resident #131), reviewed for medication administration. This deficient practice was evidenced by the following: On 11/14/24 at 8:45 AM, during the medication administration observation with Licensed Practical Nurse (LPN #2), the surveyor observed Resident #131 in their room seated in a wheelchair. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to record and document the urinary output of resident's with an indwelling urinary catheters per Physician Orders (PO). This deficient practice was noted in 1 of 2 resident's reviewed with an indwelling urinary catheter (Resident #68). This deficient practice was evidenced by the following: On 11/12/24 at 10:18 AM, the surveyor observed Resident #68 awake in their bed. Resident stated they have a catheter for urinary problems. The resident had a urinary privacy bag on side of their bed. The surveyor reviewed Resident #68's hybrid (combination of paper and electronic) medical records. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain complete and readily accessible medical records. This deficient practice was identified for 1 of 28 residents reviewed (Resident # 86). This deficient practice was evidenced by the following: The surveyor reviewed the hybrid (paper and electronic) medical records of Resident #86. According to the admission Record (a summary of important information about the resident), Resident #86 had diagnoses that included but were not limited to: dementia, schizoaffective disorder (a mental health condition with symptoms of schizophrenia and mood disorders that causes a person to experience dramatic changes in their thoughts, moods, and behaviors), and major depressive disorder. [...]

Inspectors wrotePART A. Refer to F684 Based on observations, interviews, review of medical records and review of facility documents on 11/16/23, 11/17/23, 11/20/23, and 11/21/23, it was determined that the Administrator failed to ensure that the facility policies on Medication Shortages/Unavailable Medications and Outbreak Response Plan was initiated and implemented to ensure all residents received the care and service needed to maintain their quality of life. The facility's LNHA and administrative staff were notified of the IJ for 835 s/s L on 11/20/23 at 5:02 p.m. The facility provided and acceptable removal plan on 11/20/23. The survey team accepted the removal plan and verified the removal plan onsite on 11/21/23 during the survey. The non-compliance remained on 11/21/23 for F835, with no actual harm with the potential for more than minimum harm that is not immediate jeopardy. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent documentation on 11/16/23, 11/17/23, 11/20/23, and 11/21/23, it was determined that the facility failed to ensure that Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) guidance was implemented to limit the spread of infectious disease. The facility failed to initiate contact tracing for the following: a.) A Certified Nursing Assistant (CNA #1), who provided care to 7 residents on 9/11/23 and 9/12/2023 and then tested positive on 9/13/2023; CNA #2, who came to work and was symptomatic and provided care to 2 residents on 9/20/23 and tested positive for COVID-19 on the same day. [...]

Inspectors wroteBased on interview, record review, and review of facility documentation, it was determined that the facility failed to clarify a physician's order for Paxlovid (an antiviral medication used to treat COVID-19, a deadly virus) for a vaccinated resident (Resident #4), for it to be administered within 24 hours for one of 14 residents reviewed for COVID-19 care. The original order was for Paxlovid to be administered for five days was faxed to the pharmacy on 10/22/23 but failed to include a dosage amount. This caused the pharmacy to contact the facility three additional times for clarification of the Paxlovid order. Resident #4 was provided a different antiviral medication on 10/25/23 (3 days later) and expired at the facility on 10/28/23. COVID-19 is known to be a highly infectious communicable disease which can lead to hospitalization and death. [...]

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 5 residents (Resident # 268, #36, and #116) reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 6/30/23 at 12:02 PM, the surveyor observed Resident #268 in the dayroom on the A2 unit, sitting in a wheelchair with a seatbelt and shoulder harness that was connected to the back of the wheelchair. Visually, the surveyor noted that Resident #268 could not reach the buckle to release the seatbelt as well as the Velcro straps to release the shoulder harness both connected behind the resident's wheelchair. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policies it was determined that the facility failed to review and revise care plans to reflect changes of resident's care for 3 of 6 residents (Resident # 20, #55, and #36) reviewed. The deficient practice was evidenced by the following: 1. On 6/30/23 at 11:23 AM, the surveyor observed Resident #20 in their room sitting on their bed. The resident informed the surveyor that they had lost 30 lb. over the past year and were currently taking a nutritional supplement twice a day. On 7/6/23 at 9:32 AM, the surveyor reviewed the Face Sheet (FS), (a one-page summary of important information about the patient) belonging to Resident #20 that reflected admission to the facility on 6/22/22 with diagnoses that included but not limited to Anxiety Disorder, Type 2 Diabetes mellitus without complications and bipolar disorder. [...]

Inspectors wroteBased on observation, interview, review of the medical records and other facility documentation, it was determined that the attending physician failed to document a discharge summary which included a recapitulation (recap) of the resident's stay and a final summary of the resident's status for 2 of 3 closed records reviewed for discharge to community, expiration, and discharge to the hospital (Resident #114 and Resident #115). This deficient practice was evidenced by the following: 1. On [DATE] at 10:51 AM, the surveyor reviewed the closed hybrid medical record for Resident #115. The Face Sheet (a one-page summary of important information about the patient) reflected that the resident was admitted to the facility on [DATE] and was discharged home on [DATE]. Further review of the hybrid medical record revealed that the Physician Discharge Summary was blank. 2. [...]

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 a) a routine medication was timely ordered, b) received, c) a physician's order was obtained prior to administration, and d) administration of medication was documented for Resident #18, identified during the medication administration observation for one of three nurses. This deficient practice was evidenced by the following: On 7/7/23 at 9:11 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medication for Resident #18. At that time, the LPN stated that Resident #18 had a routine order for 5 milligrams (mg) of Haldol (Haloperidol; an antipsychotic medication used to treat mental/mood disorders such as schizophrenia, schizoaffective disorder) which was not available. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure an antibiotic was administered to effectively treat a resident with diagnosis of Urinary Tract Infection (UTI). This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #1) and was evidenced by the following: On 7/3/23 at 12:25 PM, the surveyor observed Resident #1 sitting in the dining room. The surveyor also observed that the resident had an indwelling catheter draining via gravity to a urinary bag covered in a privacy bag. A review of the Resident #1's face sheet (an admission summary) indicated that Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Acute Cystitis, Dementia and Acute Renal Failure. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that oxygen therapy was administered to a resident in accordance with physician's orders. This was found with 1 of 1 residents reviewed, Resident # 46. The deficient practice was evidenced by the following: On 11/22/21 at 10:34 AM, the surveyor observed Resident #46 in bed, alert, and oriented. The resident was receiving oxygen via a nasal cannula (nc-plastic prongs that are attached to a tube, inserted into the nostrils that oxygen flows through) that was attached to an oxygen concentrator (an oxygen delivery system). The oxygen concentrator was set at 3.5 lpm (liters per minute). The resident stated I have COPD (Chronic Obstructive Pulmonary Disease) and the oxygen should be set at 3 lpm. The surveyor asked the resident who set the oxygen rate on the oxygen concentrator. [...]

Inspectors wroteBased on observation, interview, record review and policy review, it was determined that the facility failed to observe, monitor, assess and document the care of a hemodialysis resident's access site for 1 of 3 residents (Resident # 121) reviewed for dialysis care. This deficient practice was evidenced by the following: On 11/23/21 at 9:02 AM, the surveyor interviewed Resident #121 who was in bed and stated was receiving hemodialysis. The surveyor reviewed Resident #121's medical record which showed that the resident was admitted with diagnoses that included End Stage Renal Disease (ESRD). The resident was assessed as cognitively intact according to the admission MDS, an assessment tool used to facilitate the management of care, dated 11/5/21. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain controlled medications in a manner that would decrease the possibility of loss or diversion. This was found in 1 of 4 medication carts inspected. The deficient practice was evidenced by the following: 1. On 11/23/21 at 10:01 AM, the surveyor inspected the B 1 unit medication cart with the Registered Nurse (RN) who was assigned to the cart. The surveyor pulled up on the locked compartment for controlled medications(narcotics) and found that it lifted right up, it was not locked. The surveyor and the RN went through the process of the narcotic count (the physical counting of all controlled medications and comparing the numbers of medications counted with the number of medications accounted for on the declining inventory sheets (DIS)). [...]