N J Eastern Star Home

Inspectors wroteBased on interview, review of the facility's policy, and other pertinent facility documents, it was determined that the facility failed to implement their abuse policy to a.) complete reference checks for 2 out of 52 employees (Employee #4, #5); b.) complete background checks for 3 out 58 employees (Employee #1, #12, #13); and c.) complete license checks for 2 out of 58 employees (Employee #3, #8). This deficient was identified for newly hired employees reviewed since last survey from 9/27/2024 and was evidenced as follows:1.) A review of the employee personnel files revealed the following:For Employee #4, a Certified Nursing Assistant (CNA) with a start date of 6/28/25, there was no evidence of a reference check prior to the start of employment. [...]

Inspectors wroteREADY TO BE REVIEWEDBased on observation, interview, and record review, it was determined that the facility failed to document the code status (medical instructions regarding resuscitation and other lifesaving measures in the event of a medical emergency) for 2 of 3 residents reviewed (Resident #30 and # 73) for advanced directives. This deficient practice was evidenced by the following:1. On 1/21/26 at 9:38 AM, during the initial tour, the surveyor observed Resident #30 in bed with their eyes closed. The resident did not respond to the surveyor. The surveyor reviewed Resident #30's electronic medical record (EMR). A review of the resident's admission Record Face Sheet (FS; an admission summary) revealed the resident was admitted to the facility with diagnoses which 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 ensure that a low air loss mattress was functioning properly and accurately setup according to the resident's weight in accordance with a physician's order for a resident who was previously identified to have had an alteration in skin integrity. This deficient practice was identified for 2 of 2 residents (Resident #15 and Resident #38) reviewed for pressure ulcers and was evidenced by the following:a.) On 1/20/26 at 10:58 AM and 12:09 PM, the surveyor observed Resident #15 lying in bed, sleeping, on an air mattress. The resident's air mattress pump was observed to be set to a weight of 250 pounds. On 1/21/26 at 9:26 AM, the surveyor observed Resident #15 lying in bed, awake, eating breakfast, the air mattress pump was noted to be set to a weight of 250 pounds. [...]

Inspectors wroteBased on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to follow physician orders (PO) for fall prevention as written on the Physician Order Summary. This deficient practice was identified for 1 of 3 residents (Resident # 2) reviewed for accidents and was evidenced by the following:On 1/21/26 at 9:56 AM, the surveyor observed Resident #2 with their eyes closed in their bed. The surveyor observed a floor mat (specialized pads placed beside a resident's bed to reduce injury severity from falls) folded up, leaning against the wall under the window. On 1/21/26 at 10:13 AM, the surveyor interviewed the Certified Nurse Aide (CNA) in the presence of the Licensed Practical Nurse (LPN#1). The surveyor inquired about the floor mat for Resident #2 and the CNA stated, it might be something new, and it is for nighttime. [...]

Inspectors wroteBased on observations, interview, and review of facility policy, it was determined that the facility failed to appropriately label medications in accordance with professional standards of practice. The deficient practice was identified for 1 of 5 medication carts (the Subacute Rehab Side 2 medication cart) inspected during the Medication Storage task. The deficient practice was evidenced by the following:On 01/22/2026 at 9:40 AM, the surveyor inspected the Subacute Rehab side 2 medication cart with the Registered Nurse (RN) on D wing. The surveyor observed five syringes of Enoxaparin 30mg/3mL (a prescription drug used to prevent and treat blood clots, especially after surgery or serious illness) were lying in the third drawer, with no resident label or date and were not in a bag. The syringes were in their original packaging. [...]

Inspectors wroteBased on interview and review of pertinent facility documentation, it was determined that the facility failed to ensure the required committee members, the Infection Preventionist (IP), was present for one of five Quality Assurance and Performance Improvement (QAPI) meetings. This deficient practice was evidenced by the following:On 01/20/2026 at 09:34 AM, during entrance conference, the surveyor requested the QAPI sign-in sheets from the last survey date of 9/27/2024 to present. On 01/23/2026 at 10:49 AM, the surveyor reviewed the QAPI Meeting Sign In Sheet dated 04/07/2025, which revealed the IP did not sign the sheet. On 01/23/2026 at 10:49 AM, during a meeting with surveyor, the Assistant Licensed Nursing Home Administrator (ALNHA) reviewed the QAPI Meeting Sign In Sheet dated 04/07/2026 and confirmed the IP did not sign the sign in sheet. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure staff: a) performed appropriate hand hygiene (HH) during meal delivery services and b) removed soiled gloves upon exiting a resident room to prevent the potential spread of infection. This deficient practice occurred on 2 of 3 units, for 1 staff observed on 1 of 3 units and was evidenced by the following: a) On 09/25/2024 at 8:13 AM, Surveyor #1 observed the breakfast meal trays being delivered to residents on the B unit. Surveyor #1 observed two Certified Nursing Aides (CNA) delivering breakfast to residents without first performing HH or offering residents the opportunity to clean their hands. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to ensure that an indwelling urinary catheter drainage bag was stored in a manner to prevent potential urinary tract infections. This deficient practice was identified for 1 of 2 residents reviewed for indwelling urinary catheter (Resident #32), and was evidenced by the following: On 09/23/24 at 6:37 PM, the surveyor observed Resident # 32 in the room. At that time, the surveyor observed a used plastic bag tied to a handrail in the resident's bathroom. Inside the plastic bag was a used indwelling urinary catheter drainage bag dated 09/23/24. The urinary catheter drainage port was not capped, and was in direct contact with the plastic bag. On 09/24/24 at at 8:48 AM, the surveyor observed the resident resting in bed. [...]

Inspectors wroteBased on observation, interview, record review and review of facility documentation, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. This deficient practice was identified during the medication administration observation for 1 of 2 nurses, 2 of 4 residents (Residents #12 and #48), and for 27 opportunities. This resulted in two observed errors which resulted in a medication administration error rate of 7.41 % and was evidenced by the following: 1. On 9/24/24 at 9:34 AM, the surveyor conducted the medication administration and observed a Licensed Practical Nurse (LPN) preparing to administer nine (9) medications which included one Aspirin chewable 81 milligram (MG) tablet to Resident #12. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to maintain the necessary respiratory care and services for residents who were receiving oxygen (O2) treatment according to standards of practice. This deficient practice was identified for three (3) of three (3) residents (Resident #10, #31, and #120) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 5/02/23 at 10:06 AM, the surveyor observed Resident #10 seated in a wheelchair in their room. The surveyor observed a nasal cannula (n/c; consisting of two hollow prongs projecting from a hollow face piece) O2 tubing attached to an O2 concentrator in Resident #10's room. The n/c O2 tubing was in a clear plastic bag and was dated 4/24/23. On that same date and time, the surveyor interviewed Resident #10. [...]

Inspectors wroteComplaint # NJ00163437 Based on observation, the interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to: a) ensure there was a physician's order and physician documentation regarding discharge for one (1) of three (3) closed medical records reviewed for discharge (Resident #117) and b) ensure a physician's order for a diet order of nectar thick consistency for one (1) of five (5) residents were followed during Medication Pass Observation of Resident#1. 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 # NJ00163437 Based on interview, review of the medical record, and review of other pertinent 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 three (3) closed records reviewed for discharge (Resident #117). This deficient practice was evidenced by the following: On 5/04/23 at 01:27 PM, the surveyor reviewed the closed medical record for Resident #117 and revealed the following: The admission Record (or face sheet; admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to provide pharmaceutical services in accordance with professional standards to ensure a) expired medications were removed from the electronic emergency (back-up) supply for 1 (one) of 1 (one) back up machine, b) prescription medication for unsampled Resident #267 was removed from active inventory after being discontinued on October 2022, c) prescription medications were labeled, dispensed, and accounted, for 1 (one) of 2 (two) medication rooms inspected and 1 (one) of 3 (three) medication carts inspected. 21 CFR 1306.24(b) If the prescription is filled at a central fill pharmacy, the central fill pharmacy shall affix to the package a label showing the retail pharmacy name and address and a unique identifier, (i.e. [...]

Inspectors wroteBased on the interview, record review, and review of the facility provided documents, it was determined that the facility failed to: a) follow up and act upon the Consultant Pharmacist's (CP's) recommendations for one (1) of 18 residents reviewed for Medication Record Review (MRR), Resident #118 and b) identify medication irregularity during the monthly MRR of the CP for one (1) of five (5) residents reviewed for unnecessary medications, Resident#120. This deficient practice was evidenced by the following: 1. On 5/02/23 at 11:08 AM, the surveyor observed Resident #118 seated in a wheelchair inside their room while watching television. The surveyor reviewed Resident #118's medical records. The admission Record (AR or face sheet; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a) properly label and date the opened bulk dry food items and b) maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a foodborne illness. This deficient practice was evidenced by the following: On 5/03/23 at 12:33 PM, during the second day tour of the kitchen, the surveyor and General Manager/Food Service (GM/FS) observed the following in the basement food storage area: 1. In the basement#1 refrigerator, the surveyor observed four (4) crates of 4oz (ounces) whole milk, one gallon of 2% milk, four boxes of individual creamers, six (6) crates of 2% 4oz milk. [...]