New Community Extended Care Facility

Inspectors wroteBased on observations, interviews and record review, it was determined that the facility failed to ensure that hot water temperatures were maintained at safe levels to protect residents from third degree burns and/or serious injury on 2 of 2 nursing units (floors 2 and 3). Hot water temperatures obtained on 2/10/25, on all nursing units (2nd and 3rd floor units) and in resident shower rooms, registered between 125 degrees Fahrenheit (F) and 152 degrees F. Interviews with the Director of Environmental Services (DEVS) confirmed that the facility did not check hot water temperatures after repairs were made to the hot water system on 2/9/2025. The DEVS stated that the hot water temperatures should have been checked after the repair to ensure temperatures were at a safe level. [...]

Inspectors wroteComplaint NJ# 00167595 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents for 3 of 5 residents observed during incontinence rounds (Residents #59, #65, and #81) on 1 of 2 nursing units (3rd-floor unit). This deficient practice was evidenced by the following: 1. On 2/5/25 at 8:00 AM, the surveyor performed incontinence rounds with the Registered Nurse/ Unit Manager (RN/UM) on the 3rd floor Nursing Unit and observed Resident #81 in bed. The RN/UM exposed Resident #81's incontinence brief and observed a second incontinence brief wet with urine inserted inside the adult brief. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to consistently complete the Dialysis communication monitoring sheets for Residents on dialysis (a treatment that replicates the kidney's function and cleans the waste from the blood for individuals with kidney disease or failure). This deficient practice was identified for 2 of 2 residents (Resident #19 and #25) and was evidenced by the following: 1. On 2/3/25 at 12:31 PM, the surveyor observed Resident #19 seated in a wheelchair. The resident stated that she/he went to dialysis on Tuesdays, Thursdays, and Saturdays. The surveyor reviewed the medical record for Resident #19. A review of Resident #19's admission Record indicated that the resident was admitted to the facility with diagnoses that included but were not limited to; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain an infection prevention and control precautions for: a.) COVID-19 positive resident during dining and meal distribution, for one (1) of one (1) resident reviewed for transmission based precaution (Resident #56), and b.) perform proper hand hygiene for one (1) of five (5) nurses observed. This deficient practice was evidence by the following: Reference: https://www.cdc.gov/clean-hands/hcp/clinical-safety/ According to the CDC Hand Hygiene in Healthcare Settings, Hand Hygiene Guidance, last reviewed on February 27, 2024, included that Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide a dignified dining experience for 2 of 2 nursing unit dining rooms during the lunch meal. Evidence of the deficient practice is as follows. On 2/3/25 at 12:09 PM, the surveyor observed the lunch meal on the second floor in the day room/dining room. On each of thirteen tables, staff served the residents' meals on plastic trays. Additionally, the dome lids from the plates were placed upside down in the center of the tables and used as trash receptacles. On 2/3/25 at 12:15 PM, the surveyor observed the lunch meal on the third floor in the day room/dining room. On each of the six tables staff served the residents' meals on plastic trays. Additionally, the dome lids from the plates were placed upside down in the center of the tables and used as trash receptacles. [...]

Inspectors wroteComplaint NJ00166888 Based on interview and record review it was determined the facility failed to notify a resident's responsible party of a change in condition and a room change for 1 (#11) of 16 residents reviewed. The deficient practice is as follows. The surveyor reviewed Resident #11's electronic progress notes during the period of 8/23/23 through 9/4/23. The nurse documented in an 8/23/23 electronic progress note that the resident had tested positive for COVID 19 and was on isolation precautions. The resident was noted to be residing on the second floor at that time. An 8/25/23 nurse progress note indicated the resident was relocated to the third floor and continued on isolation precautions. There was no documentation in the progress notes that the responsible party had been notified of the resident's COVID 19 status or of the change to another nursing unit. [...]

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 2 of 16 residents reviewed for the accommodation of needs (Resident # 53 and # 81) and was evidenced by the following: 1. On 2/3/25 at 12:54 PM, the surveyor observed Resident # 53 in bed. The surveyor greeted the resident and Resident # 53 did not respond to the surveyor. The surveyor observed that the resident's call bell (used to summon staff for assistance) was located behind the resident's bed, on the floor and was not within his/her reach. The surveyor reviewed the medical record for Resident # 53. A review of Resident # 53's admission Record reflected that the Resident was admitted to the facility with diagnoses that included but were not limited to; [...]

Inspectors wroteBased on observation and interview it was determined the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner for 2 sampled residents (#11, #53), 2 unsampled residents (room [ROOM NUMBER] window, #220 window) and the area on the 2nd floor nursing unit hallway between rooms [ROOM NUMBERS]. The deficient practice is evidenced by the following. 1. During the 2/03/25 initial tour of the second floor nursing unit at 10:23 AM, the surveyor noted a strong odor of urine in the area between rooms [ROOM NUMBERS]. A full soiled laundry cart was located in the hallway between these two rooms. On the same day at 10:30 AM, the surveyor observed Resident #11's privacy curtain was stained with dark brown/black matter, the floor had several broken floor tiles, and the toilet was heavily stained with stool. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 2 of 16 residents reviewed for resident assessment (Resident # 11 and # 54). This deficient practice was evidenced by: The 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 up to 14 days of the assessment being completed. The following residents were reviewed for late comprehensive MDS assessments. 1. [...]

Inspectors wroteBased on resident observation, interview and record review, it was determined that the facility failed to complete a significant change in status assessment (SCSA) for Resident #25. This deficient practice was identified for 1 of 16 residents reviewed and was evidenced by the following: This deficient practice was evidenced by the following: On 2/3/25 at 11:34 AM, during the initial tour of the facility the surveyor observed Resident #25 seated on a wheelchair, awake, and conversant. At that time, the resident stated that they went to the dialysis center three times a week. The surveyor reviewed the medical record of Resident #25. According to the admission Record face sheet, an admission summary, reflected that Resident #25 was admitted to the facility with diagnoses that included, end stage renal disease, dependence on renal dialysis. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 3 of 16 residents reviewed for resident assessment (Resident # 11, # 26, and # 54). This deficient practice was evidenced by: The 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 up to 14 days of the assessment being completed. The following residents were reviewed for late quarterly MDS assessments. 1. Resident #11 - The Centers for Medicare and Medicaid Services (CMS) Internet Quality Improvement and Evaluation System report (iQIES) indicated the 10/24/24 quarterly MDS was submitted late. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure a physician order for administration was followed for a resident who was cognitively impaired (Resident #42) in accordance with professional standards of practice. The deficient practice was identified for one (1) of four (4) residents, administered by one (1) of three (3) nurses, observed during the medication administration observation, and 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, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure respiratory nasal cannula tubing was stored in accordance with infection control measures for 1 of 1 resident reviewed for Respiratory Therapy, Resident #19. 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 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 and ensure a.) documentation of a removal of a controlled dangerous substance (narcotic; with high potential for drug diversion) medication from inventory, maintain accountability, accurate reconciliation of Resident #18's Oxycodone narcotic medication, that was identified during the medication storage inspection of 1 of 2 medication carts, b.) a medication was labeled with appropriate accessory and cautionary instructions for administration that was observed during the medication pass observation of 1 of 3 resident administered by 1 of 2 nurses. The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to initiate a comprehensive care plan for 2 of 20 residents reviewed for care planning, Residents #58 and #209. The deficient practice is evidenced by the following. 1. Resident #58 was observed by the surveyor on [DATE] at 9:39 AM awake in bed watching television. The resident was conversant with encouragement by the surveyor. A review of the hybrid medical record (electronic and paper) revealed the following information: The resident's Record of admission included admission diagnoses of major depressive disorder, paranoid schizophrenia, and vascular dementia. The [DATE] Physician Orders included an order for the antipsychotic medication, Risperdal 0.25 mg. administered twice daily for paranoid schizophrenia. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to maintain current equipment for the purposes of immediate response to potential life-threatening, cardiac emergencies. This deficient practice was identified in 2 of 2 Automated External Defibrillator (AED) kits reviewed during the medication labeling and storage task and was evidenced by the following: On [DATE] at 10:16 AM, the surveyor observed an AED emergency response kit, mounted on the wall of the Third-floor nurse's station, in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM). The surveyor, with the assistance of the LPN/UM, removed the AED kit from the wall mounting, opened it, and observed two defibrillator pads enclosed in a package. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to administer a medication to the manufacturer's cautionary specifications. This deficient practice was identified for 1 of 3 nurses administering medications to 1 of 5 residents (Unsampled Resident) during the medication administration observation and was evidenced by the following. A review of the manufacturer's specifications for Lokelma (sodium zirconium cyclosilicate) under section 2.3 Reconstitution and Administration. In general, other oral medications should be administered at least 2 hours before or 2 hours after LOKELMA [see Drug Interactions (7)] . On 1/6/23 at 9:20 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN) preparing to administer medications to Unsampled Resident. [...]

Inspectors wroteBased on observation, interview, record review and policy review, it was determined that the facility failed to a.) failed to sanitize and air dry steam table pans in a manner to prevent microbial growth 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 1/4/22 at 9:55 AM, in the presence of the Food Service Director (FSD) the surveyor observed the following: 1. In the food preparation area, the surveyor observed a Food Service Worker (FSW), wearing gloves which were soiled in a red colored substance, holding a dish rag which was also soiled with a red colored substance. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to: a) provide wound care in a manner to decrease the spread of infection for 1 resident, #59, reviewed for pressure ulcer care, and b) develop a facility plan with measures to monitor for and prevent the growth of waterborne pathogens. The deficient practices are evidenced by the following. 1. The surveyor observed Resident #59 on 1/03/23 11:59 AM. The resident was awake and alert in bed with heel booties in place to right and left heels. Earlier that day, the Registered Nurse (RN) stated the resident had a hospital-acquired pressure ulcer on the right heel. The January 2023 Treatment Record contained a 12/15/22 treatment order to cleanse the right heel wound, apply medicated ointment, and cover with a dry dressing daily and as needed. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to follow a physician's order for 1 of 2 residents, Resident #5, reviewed for position/mobility. The deficient practice was evidenced by the following: On 11/04/20 at 11:22 AM, the surveyor observed Resident # 5 in bed. The resident did not respond appropriately when spoken to mumbling incoherently. The resident's left arm was tight to the side and thier hand was closed on the chest. The resident was not wearing a splint and the surveyor did n ot observe a splint in the room. On 11/05/20 at 9:27 AM, the surveyor observed the resident in bed. There was a Certified Nursing Assistant (CNA) in the room. The CNA said she was finishing up with the resident's morning/hair care. The resident was not wearing a splint and there was none seen in the room. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to appropriately identify and implement measures to reduce hazards/risks for falls. This was observed for 1 of 2 residents (Resident #6) reviewed for falls and evidenced by the following. On 11/04/20 10:48 AM, the surveyor observed Resident #6 in bed with the lights off. The resident stated that he/she was stuck in the room because of the pandemic and was not very happy about it. The resident was oberved to have contractures (muscles that stiffen and prevents normal movement) of the left arm and limited mobility of the lower left leg. The surveyor observed there were no side rails on the bed. The surveyor reviewed Resident #6's medical records that revealed the following: [...]

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; 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 11/04/20 09:32 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. In the food preparation area, the surveyor observed the following: - 10 stove top burners soiled with a thick black grease-like substance on the surface which was easily lifted with the tip of the FSD pen. - The food processor/mixer metal bowl was not covered with plastic and soiled with white particulates with a clear liquid pooling inside it. [...]