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Inspectors wroteComplaint #: 3008061 Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a staff member, Unidentified Person (UP #1), who was providing resident direct care as a Certified Nursing Aide (CNA) was a.) certified as an nursing aide and b.) had the appropriate competencies and skills sets to provide resident care in a manner to assure resident safety and ensure each resident attained or maintained their highest practicable physical, mental, and psychosocial wellbeing. This deficient practice had the potential to affect all residents who resided on 2 of 3 nursing units. On 4/29/2026 at 6:36 PM, the Staffing Coordinator called Agency CNA #1 with the phone number listed on the online staffing agency platform seeking CNA coverage for 4/30/2026. [...]

Inspectors wroteRepeat deficiency Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 1/27/25 at 9:55 AM, while on the 4th floor in the kitchenette the surveyor observed the following: in refrigerator #1 had an individual cheesecake without a cover and missing a use by date, an open jar of molasses without an open/use by label, and in freezer #2 a paper cup with a brown frozen substance not dated and without a use by label. On 1/27/25 at 10:15 AM, while on the 2nd floor in the kitchenette the surveyor observed the following in refrigerator #1: a zip lock bag of sliced pickles and red cup with oatmeal-like substance both missing labels and use by dates. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to revise the comprehensive care plans (CP) for 2 of 15 residents reviewed (Resident #35 and #13). This deficient practice was evidenced by the following: 1. On 1/27/25 at 11:00 AM, the surveyor observed Resident #35 sitting in the wheelchair inside the recreation room, unable to answer the surveyor's inquiry. On 1/27/25 at 1:25 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #35, which revealed the following: A review of the Face Sheet (FS; an admission summary) reflected that Resident #35 was admitted with diagnoses that included but were not limited to unspecified dementia (loss of memory), unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to consistently monitor, document, and evaluate the ongoing benefits of continued use of psychoactive medications for 3 of 5 residents reviewed for unnecessary medications (Resident #3, #4, and #35). This deficient practice was evidenced by the following: 1. On 1/27/25 at 10:43 AM, the surveyor observed Resident #3 out of bed to the wheelchair inside the activity room, able to answer the surveyor's inquiry. On 1/29/25 at 11:33 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #3, which revealed the following: [...]

Inspectors wroteBased on observation, interview, review of medical records and review of other pertinent documentation, it was determined that the facility failed to treat all residents in a dignified manner by failing to provide a resident with respect and dignity during wound care. This deficient practice was identified 1 of 16 residents reviewed (Resident #231). The deficient practice was evidenced by the following: On 1/27/25 at 11:12 AM, the surveyor observed Resident #213 in their room. The resident was observed with a gauze (gauze wrap is a sterile material used to wrap or cover wounds) wrapped around their right elbow. During the interview the resident stated they had a skin tear prior to coming into the facility. Resident #231 was agreeable to allow the surveyor to observe the wound care treatment. [...]

Inspectors wroteRepeat deficiency Based on observation, interview, and record review of other facility documentation, it was determined that the facility failed secure medications within the medication cart. This deficient practice was observed during wound care observation and was evidenced by the following: On 1/28/25 at 11:51 AM, the surveyor observed Registered Nurse (RN#1) provide wound care on Resident #213. RN#1 was observed gathering medication from the medication cart outside of Residents #213's room. Once RN#1 gathered all medications and supplies from the medication cart, the surveyor observed RN#1 close the drawer to the medication cart and walk away. Surveyor asked RN#1 if they had locked the medication cart. RN#1 went back to the medication cart and stated, I forgot to lock the cart. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) for 2 of 3 residents (Resident #8 and Resident #41) reviewed. The SNF ABN provides information to beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. If the SNF provides the beneficiary with the SNF ABN, the facility has met its obligation to inform the beneficiary of his or her potential financial liability and related standard claim appeal rights. On 1/27/25 at 10:51 AM, the facility provided the surveyor with a list of residents who were discharged from the facility within the last 6 months and should have received the SNF ABN form. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to store potentially hazardous foods in a manner to prevent food borne illness as evidenced by the following: On 10/30/2023 at 9:59 AM, in the presence of the Food Service Manager (FSM) the surveyor observed the following: 1. In the tray line freezer, room service the surveyor observed a pack of vegetable burgers undated and opened, and six (6) trays of pastries prepared by the baker, the FSM was unable to state when the package was received, opened, or expiration date. 2. In the room service storage, cold prep, [soda brand] refrigerator the surveyor observed shredded mozzarella cheese that was opened and undated. The FSM was unable to state when the package was received, opened, or expiration date. 3. [...]

Inspectors wroteBased on interviews, record review, and review of the facility provided documents, it was determined that the facility failed to a) identify irregularity for a total of twelve months and b) act upon the recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for one (1) of five (5) residents reviewed for unnecessary medications (Resident #17). This deficient practice was evidenced by the following: On 10/30/23 at 11:51 AM, the surveyor observed Resident #17 in bed asleep. The surveyor reviewed Resident #17's medical records. The resident's admission Record (or face sheet; [...]

Inspectors wroteBased on observation, interview, and record review of other facility documentation, it was determined that the facility failed to provide appropriate Pharmaceutical Services and ensure a) a biological was properly labeled with an expiration date, b) removal of a discontinued biological from active inventory for a discharged resident (Resident # 23), c) medications were secured within the medication cart, and d) a narcotic medication for Resident #38 was properly labeled with an expiration date. This deficient practice was observed in two (2) of two (2) refrigerators located in the medication storage room, and one (1) of two (2) medication carts inspected and was evidenced as follows. A review of the manufacturer's specifications for Daptomycin (an antibiotics that can treat infections) under section 2.7 titled, Preparation and Administration of Daptomycin for Injection. [...]

Inspectors wroteBased on the interview and review of pertinent documentation, it was determined that the facility failed to ensure that the a) employed designated Infection Preventionist (IP) had at least part time position for one (1) of three (3) IP and b) had completed specialized training in infection prevention and control per Centers for Medicare & Medicaid Services (CMS) guidance prior to assuming the IP role for three (3) of three (3) employees reviewed for IP. This deficient practice was evidenced by the following: A review of CMS QSO-19-10-NH, dated 3/11/19, included but was not limited to Background: Effective November 28, 2019, the final requirement includes specialized training in infection prevention and control for the individual(s) responsible for the facility's IPCP (infection prevention and control program). Specialized Training for Infection Prevention and Control: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI (quality assurance and performance improvement) program for five (5) of five (5) Certified Nurse Assistants (CNAs) reviewed for mandatory education. This deficient practice was evidenced by the following: The surveyor reviewed the annual in-service education hours for five randomly selected CNA files, which were provided by the facility. The Training Hours Transcripts showed the following: CNA #1 had a hire date of 8/09/10. The facility could not provide a Training Hours Transcripts. CNA #1 did not have QAPI training. CNA #2 had a hire date of 8/09/10. According to the Training Hours Transcripts, CNA #2 did not have QAPI training. [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent documentation, it was determined that the facility failed to ensure a medication was administered to the manufacturer's cautionary specifications and in accordance with professional standards of clinical practice. The deficient practice was identified for one (1) of three (3) nurses administering medications to one (1) of four (4) residents during the medication administration observation and was evidence by the following. A review of the manufacturer's specifications for Lopressor (Metoprolol Tartrate) under section 2.1 titled Hypertension. Individualize the dosage of Lopressor tablets. Lopressor tablets should be taken with or immediately following meals. [...]

Inspectors wroteBased on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to a) ensure a root cause analysis conclusion was included in a resident's fall investigation/incident report and b) implement and document in the resident's care plan a new intervention after a resident's fall in order to prevent any additional falls for one (1) of two (2) residents reviewed for falls (Resident #35). This deficient practice was evidenced by the following: On 10/31/23 at 11:54 AM, the surveyor observed Resident #35 seated in a wheelchair at the end of the hall looking out the window. The surveyor reviewed Resident #2's medical record. 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 wroteNJ00168293 Based on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility staff failed to: a) properly assess bed rails (side rail/enabler) safety to prevent harm to a cognitively impaired resident by not screening the resident properly during admission, ensuring correct installation, usage, and maintenance, b) obtain a physician order, c) educate and obtain consents from the resident/responsible party regarding risk/benefit of using bed rails, and evaluating alternatives before using bed rails prior to installation, d) monitor, inspect, and supervise the usage of bed rails, and e) follow facility policy and procedures. This deficient practice was identified for one (1) of one (1) resident reviewed for bed rails and was evidenced by the following: A review of the reportable event record/report (FRE; [...]

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 two (2) residents reviewed for hospice care, (Resident #17). This deficient practice was evidenced by the following: On 10/30/23 at 11:30 AM, during the tour, Licensed Practical Nurse#1 (LPN#1) informed the surveyor that Resident #17 was cognitively impaired and on hospice care. On 10/30/23 at 11:51 AM, the surveyor observed Resident #17 in bed asleep. The surveyor reviewed Resident #17's medical records. The resident's admission Record (or face sheet; [...]

Inspectors wroteBased on observation, interview and review of facility documentation, it was determined that the facility failed to ensure that Certified Nursing Assistants (CNAs) received 12 hours of mandatory annual in-service training/education that included specific topics for one (1) of five (5) CNA files reviewed (CNA #1). The deficient practice was evidenced by the following: The surveyor reviewed the in-service education hours for five randomly selected CNA files, which were provided by the facility which included the following: The facility provided Training Hours transcripts (record of inservices that were done through a computer education program) for four (4) of the five (5) requested CNAs. The facility could not provide any documented evidence that CNA #1, with a date of hire of 8/09/10 received any in-service training from 8/09/22 to 8/09/23. [...]

Inspectors wroteBased on observation, interviews, record review and review of other pertinent documents, it was determined that the facility failed to follow standards of professional practice with respect to following physicians orders. This deficient practice was identified for 1 of 15 sampled residents, (Resident # 18), and was evidenced by the following: Reference: New Jersey Statutes, 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 documentation it was determined that the facility failed to: a.) document the non-pharmacological interventions (interventions to calm the resident that were not medicinal) for a resident with behaviors prior to the administration of an as needed anti-anxiety medication, b.) routinely document the behaviors associated with the administration of the as needed medication, c.) initiate a Care Plan with interventions to manage the residents behaviors, and d.) follow their facility's Behavior Management Policy and Procedure for residents presenting with behaviors. This deficient practice was identified for 1 of 5 residents reviewed (Resident #41) for unnecessary medications and was evidenced by the following: [...]

Inspectors wroteBased on interview and document review it was determined that the facility failed to hold quarterly Quality Assessment and Assurance (QAA) meetings with the required members for the last four quarters. On 07/22/21 at 9:45 AM the surveyor interviewed the temporary facility Administrator (LHNA) and the Director of Nursing (DON). The DON stated the prior Administrator left the position in January. The DON stated the prior Administrator did not conduct formal QAA meetings. The DON provided the surveyor with two QAPI (Quality Assurance and Performance Improvement Plan) sign in sheets for meetings held on 04/27/21 and 07/21/21 and stated the meeting resumed on 04/27/21. The surveyor inquired to the DON as to why the medical director was not in attendance for the last two meetings. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide a resident with individualized continence care for a resident who had episodes of incontinence. The deficient practice occurred for 1 of 1 residents reviewed for bowel and bladder (Resident #158) and was evidenced by the following: On [DATE] at 12:53 PM, the surveyor conducted a resident meeting with four residents in attendance. During the meeting Resident #158, stated he/she was now in a diaper because he/she was not taken to the toilet in time. On [DATE] at 8:52 AM, the surveyor interviewed Resident #158, while the resident was seated in a wheelchair inside the resident's room and during the breakfast meal. The surveyor inquired as to the resident's preferences regarding using the toilet. [...]

Inspectors wroteBased on observation, interview, record review and document review, it was determined, that the facility failed to administer the correct amount of oxygen (O2) to residents per the physician's order. This deficient practice was identified for two of two residents reviewed (Resident #50 and Resident #53) for respiratory care and was evidenced by the following: 1.) On 07/13/21 at 10:12 AM, the surveyor observed Resident #53 sitting upright in his/her bed wearing O2 via nasal cannula (a device used to deliver supplemental oxygen, which consists of a lightweight tube on one end and another end that splits into two prongs that is placed in an individual's nostrils). The surveyor observed that the O2 tubing was connected to a water bottle on the O2 concentrator located next to the resident's bed and the oxygen flow rate was set at 4.5 Liters (L) per minute. [...]

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to evaluate the performance of all Certified Nursing Aides (CNA) on an annual basis, and failed to provide regular in-service education based off of the performance reviews. This deficient practice was identified for 3 of 5 CNA personnel records reviewed (CNA #1, #2 & #3) and was evidenced by the following: On 7/19/21 at 11:39 AM, the surveyor reviewed the personnel records of 5 randomly selected CNA's which were provided by the facility. The surveyor identified the following: CNA #1 had a hire date of 12/06/1999. According to CNA #1's personnel record, there were no annual performance reviews conducted within the past year. The most recent performance review was completed March 1, 2018. CNA #2 had a hire date of 08/12/2013. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to honor a resident's meal preferences. This deficient practice occurred for 1 of 4 residents who attended a resident council meeting (Resident #158) and was evidenced by the following: On 07/15/21 at 10:24 AM, during a surveyor conducted resident council meeting, Resident #158 stated he/she received too much food and it was stamped directly on the menu to receive small portions. On 07/15/21 at 11:44 AM, the surveyor observed the kitchen tray line in progress during the lunch meal preparation. The surveyor observed the dietary staff place Resident #158's tray ticket on a tray and the surveyor observed Small Portions was stamped on the tray ticket twice. The tray ticket had 1 portion of minced penne pasta/meat sauce listed. [...]