Palace Rehabilitation and Care Center, the

Inspectors wroteBased on observations, interviews, and review of other facility documentation, it was determined that the facility failed to maintain kitchen and equipment areas in a manner to prevent microbial growth and cross contamination. This deficient practice was evidenced by the following:On 2/17/26 at 9:30 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and the Regional Licensed Nursing Home Administrator (RLNHA) During the kitchen tour the surveyor observed the following: 1. The surveyor took a white paper town to wipe down the white plastic ice guard in the ice machine which guided the ice into the large bin. When the surveyor looked at the paper towel it was left with red and brown substance. When the surveyor visualized the white plastic guard in the ice machine, the red and brown substance was noted on the white guard. [...]

Inspectors wroteBased on observation and interview it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of debris and failed to cover 2 of the 4 dumpsters. This was evidenced by the following:On 2/17/26 at 9:30 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and the Regional Licensed Nursing Home Administrator (RLNHA). During the kitchen tour, the surveyor, in the presence of the FSD and the RLNHA, observed four outside dumpsters located behind the kitchen. Two of the four dumpsters had open lids. Surrounding the front of the four dumpsters were multiple cardboard boxes on the ground. To the right of the dumpsters there was a fence with a grassy area extending down the back of the building. [...]

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to provide immediate access to records and requested information necessary to conduct the survey. The deficient practice was evidenced by the following: On 2/17/26 at 10:10 AM, during the entrance conference, the Licensed Nursing Home Administrator (LNHA), in the presence of the Director of Nursing (DON), the Regional LNHA, and the Regional DON, was informed that the survey team required all employee personnel and medical files for staff hired or terminated since the last recertification on 10/29/24. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that all residents that maintained a Personal Needs Account (PNA) received a written notification when approaching the limit that could jeopardize a resident's eligibility for Medicaid or Supplemental Security Income (SSI). This deficient practice was identified for 11 of 11 residents (Resident #1, #8, #55, #65, #73, #108, #110, #142, #156, #159 and #171) reviewed for PNA and was evidenced by: On 2/17/26 at 12:30 PM, the Licensed Nursing Home Administrator (LNHA) provided the PNA balances as of 2/17/26. A review of the facility's PNA Quarterly Statement from 10/1/25 to 12/31/25 revealed 11 residents had balances that ranged from $1877.71 to $2316.28. [...]

Inspectors wroteBased on observation and interviews, it was determined that the facility failed to maintain the most recent State of New Jersey inspection results in a place readily accessible to the residents, families, and the public. This deficient practice was evidenced by the following: During the Resident Council Meeting on 2/18/26 at 10:30 AM, five of five alert and oriented residents (#32, #40, #86, #89, and #104), said they were not aware of the location of the State Survey results, that the facility had not spoken to them about the results, and that they were interested in reading the reports. On 2/19/26 at 11:55 AM, the surveyor toured the A-Wing Unit to locate the State Survey results, but the State Survey Book was not readily accessible. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the resident's environment, equipment, and living areas in a safe and homelike environment by providing adequate lighting. This deficient practice was identified on 1 of 3 nursing units (C-Wing) toured and was evidenced by the following: On 2/17/26 at 10:51 AM, on initial tour of the facility, the surveyor entered room [ROOM NUMBER], located on the C Wing. The surveyor observed Resident #87 sitting on the side of the bed and the resident told the surveyor that the bathroom light did not work. The surveyor entered the bathroom and there was no cover on a ceiling light. When the surveyor turned the light switch on, the light did not turn on. The resident was in a semiprivate room, and both residents used the bathroom independently. [...]

Inspectors wroteBased on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure newly hired employees were properly screened for a history of abuse, neglect, exploitation, or misappropriation and failed to implement policies and procedures related to pre-employment screening. Specifically, the facility did not complete required license verifications, reference checks, or criminal background checks prior to the start of employment. This deficient practice was identified in 10 of 55 employee files reviewed (Employees #1 through #10). [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to ensure an accurate assessment of a resident with a history of falls in the resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 1 of 5 residents (Resident #79) reviewed for accidents and was evidenced by the following:On 2/17/26 at 10:48 AM, the surveyor observed Resident #79 in bed with eyes closed. The surveyor observed a fall mat on the right side of the bed and the left side of the bed was against the wall. On 2/17/26 at 11:16 AM, the surveyor walked past Resident #79's room and observed a Certified Nursing Assistant (CNA) sitting in a chair in the doorway. The surveyor asked if the CNA was there to observe the resident because of a fall history and she stated yes. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined the facility failed to revise an Individual Comprehensive Care Plan (ICCP) for a resident no longer receiving tube feedings. This deficient practice was identified in 1 of 1 resident (Resident #164) reviewed for tube feeding and was evidenced by the following: On 2/17/26 at 10:10 AM, Resident #164 was observed in bed in his/her room. The resident was not receiving any tube feeding at the time of the observation and there was no feeding pump in the room. A review of the admission Record revealed Resident #164 had diagnoses which included, but were not limited to, bipolar disorder, gastrostomy tube (feeding tube), dementia, anxiety, and failure to thrive. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility did not ensure the daily nurse staffing report was updated and posted each day in a location accessible to the public. This deficient practice was evidenced by the following: On 2/17/26 at 8:56 AM, upon initial entrance to the facility, while the survey team was in the lobby awaiting facility administration, the surveyor observed the posted daily staffing sheet located in the lobby was dated 2/5/26. During an interview with the surveyor on 2/20/26 at 12:50 PM, the Staff Coordinator (SC) stated that staffing information was required to be updated to reflect any changes and posted daily in the facility lobby in a location accessible to the public. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate medication dispensing and administration for 1 of 6 residents (Resident #50) observed during the medication pass. This deficient practice was evidenced by the following:On 2/18/26 at 8:22 AM, the surveyor observed Licensed Practical Nurse (LPN #1) dispense five medications for Resident #50. As the LPN pulled the medications from the medication cart, she handed them to the surveyor. The LPN handed the surveyor an over-the-counter (OTC) pill bottle of calcium citrate 200 milligrams (mg) and then the LPN dispensed one pill from the bottle into the medication cup. [...]

Inspectors wroteBased on observation, interview, and pertinent facility documentation, it was determined that the facility failed to ensure that a medication was secured in a locked compartment accessible only to authorized personnel with a key. This deficient practice was identified for 1of 1 resident (Resident #143). On 2/17/26 at 11:15 AM, the surveyor observed Resident #143 seated in his/her wheelchair in their bedroom, waiting to go to therapy. A nebulizer medication vial was noted on the bedside table. The resident stated that he/she administered their own breathing treatments after the nurses leave the medication for him/her. The surveyor reviewed the medical record for Resident #143. [...]

Inspectors wroteBased on observations, interview, and review of pertinent facility documentation it was determined that the facility failed to follow the planned written menu for 2 of 2 meals observed. This deficient practice was evidenced by the following:On 2/19/26 at 11:10 AM, the surveyor entered the kitchen during lunch preparation. The menu for lunch was crispy baked chicken, macaroni and cheese, and roasted zucchini. The surveyor observed a vegetable mix cooking on the stove top which had cauliflower, carrots, and zucchini. It was simmering in a stainless-steel pan with water on the stove top. At that time, the surveyor interviewed a [NAME] who stated the lunch was chicken and the alternate lunch was glazed ham. During the observation the [NAME] was cleaning chicken thighs. [...]

Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure the Licensed Nursing Home Administrator (LNHA) and the Medical Director's (MD) licenses were visibly displayed. This deficient practice was evidenced by the following:On 2/20/26 at 12:15 PM, two surveyors toured the facility and there was no evidence that the current MD (MD #1) or the LNHA's licenses were visibly displayed. During the tour, the two surveyors observed in the facility's copier room a copy of MD #2's license on the bulletin board. On 2/20/26 at 12:30 PM, the surveyor interviewed the Director of Nursing (DON) who stated that MD #2 was the previous Medical Director and MD #1 was the current Medical Director. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility did not ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to a.) follow appropriate hand hygiene practices for 1 of 2 nurses who administered medications to 3 of 6 residents (Resident #42, Resident #50, and Resident #59) during the medication pass, and b.) properly store a nebulizer mask leaving the mask exposed to air on a bed table for 1 of 1 resident (Resident #143) reviewed for respiratory care. This deficient practice was evidenced by the following:1.) On 2/18/26 at 8:15 AM, the surveyor observed Licensed Practical Nurse (LPN) #1 exit a resident's room and return to the medication cart. [...]

Inspectors wroteComplaint #: NJ 185087 Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to maintain hot water temperatures at a safe level to protect residents from third degree burns and serious injury on 1 of 3 nursing units (C-Wing). Hot water temperatures obtained on 3/29/25, in both residents' rooms and in the resident shower room on the C-Wing nursing unit, registered between 137.1 degrees Fahrenheit (F) and 138.4 degrees F. Interviews with the Regional Licensed Nursing Home Administrator (RLNHA) and the Maintenance Director (MD) revealed that hot water temperatures should be maintained between 95 and 110 degrees F to prevent residents from being burned. The RLNHA and the MD stated that the C-Wing nursing unit had a separate boiler that provided hot water to all those residents which included cognitively impaired residents. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store food in a manner to prevent food-borne illness, b.) maintain the kitchen equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness, and c.) label all food items in the refrigerator. This deficient practice was identified in the facility kitchen and in 1 of 1 nursing unit pantry and was evidenced by the following: On 10/22/24 at 9:39 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1.) In the refrigerator identified as the walk-in cooler, a cluster of bok choy and lemongrass was noted on the shelf. Both items were dated 10/9/24. [...]

Inspectors wroteComplaint #: NJ175570 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a safe and sanitary physical environment in the central supply room. This deficient practice has the potential to affect 3 of 3 nursing units and was evidenced by the following: On 10/23/24 at 12:25 PM, the surveyor conducted a tour of the facility's basement, in the presence of the facility's Regional Licensed Nursing Home Adminstrator (RLNHA) and the staff member in charge of Central Supply. At that time, the surveyor entered the Central Supply room and observed, adhered on the wall board ceiling to the right of the doorway near the pipes, a black substance approximately 24 inches in length. [...]

Inspectors wroteCOMPLAINT #: NJ172102 Based on observations, interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to report an alleged violation of misappropriation of resident property to the New Jersey Department of Health (NJDOH). This deficient practice was identified for 2 of 7 residents (Resident #58 and Resident #365) reviewed for unneccessary medications and was evidenced by the following: 1.) On 10/22/24 at 12:14 PM, the surveyor interviewed Resident #58 who reported that pain medications were always available when requested. The resident further stated that there was never a time when he/she did not receive pain medication when the resident asked for it. A review of the admission Record, an admission summary, revealed that the resident had diagnoses which included, but were not limited to: [...]

Inspectors wroteCOMPLAINT #: NJ172102 Based on observations, interviews, records review, and review of other pertinent facility documentation, it was determined that the facility failed to thoroughly investigate an allegation of misappropriation of property for 1 of 3 residents (Resident #58) reviewed for personal property. This deficient practice was evidenced by the following: On 10/22/24 at 12:14 PM, the surveyor interviewed Resident #58 who reported that pain medications were always available when requested by the resident. The resident further stated that there was never a time when he/she did not receive pain medication when the resident asked for it. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to revise a resident's care plan with related goals and interventions each time the resident violated the facility's smoking policy. This deficient practice was identified for 1 of 5 residents (Resident #72) reviewed for smoking and was evidenced by the following: Refer to F689 During the initial tour of the facility on 10/22/24 at 11:56 AM, the surveyor observed Resident #72 as he/she self-propelled in their wheelchair in the hallway. The resident's left upper extremity was flaccid (hung loosely) and the resident's left hand was edematous (swollen), without the use of a splint or sling to aid in supporting the affected extremity. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to provide adequate supervision during resident smoking sessions and consistently follow and implement the facility smoking policy to ensure the safety of all residents at the facility for 2 of 5 residents (Resident #72 and Resident #137) reviewed for smoking. This deficient practice was evidenced by the following: During the initial tour of the facility on 10/22/24 at 11:56 AM, the surveyor observed Resident #72 as he/she self-propelled in their wheelchair in the hallway. The resident's left upper extremity was flaccid (hanging loosely) and the resident's left hand was edematous (swollen), without the use of a splint or sling to aid in supporting the affected extremity. [...]

Inspectors wroteBased on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to complete the dialysis communication book for a resident on dialysis (a treatment that replicates the kidney's function and cleans the waste from blood for individuals with kidney disease or kidney failure). This deficient practice was identified for 1 of 2 residents (Resident # 61) reviewed for dialysis and was evidenced by the following: On 10/23/24 at 9:14AM, the surveyor reviewed the medical records for Resident #61. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: dependence on renal dialysis. [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that the facility failed to administer medication in accordance with the physician's orders. This deficient practice was identified for 1 of 7 residents (Resident #110) reviewed for unnecessary medications and was evidenced by the following: According to the admission Record, an admission summary, Resident #110 had diagnoses including, but not limited to: paroxysmal atrial fibrillation (an irregular, often heart rate that commonly causes poor blood flow.) A review of the Physician's Orders (PO) revealed a physician's order dated 5/27/24 for Cardizem oral tablet 120 milligram give one tablet by mouth three times a day for atrial fibrillation related to paroxysmal atrial fibrillation, hold for systolic blood pressure less than 130, to be crushed into pudding or applesauce. [...]

Inspectors wroteCOMPLAINT#: NJ172102 Based on observations, interviews, medical records review, and review of other pertinent facility documentation, it was determined that the failed to maintain an accurate and complete medical record in accordance with acceptable standards and practice. This deficient practice was identified for 2 of 7 residents (Resident #58 and Resident #365) reviewed for unneccessary medications and was evidenced by the following: 1.) On 10/22/24 at 12:14 PM, the surveyor interviewed Resident #58 who reported that pain medications were always available when requested by the resident. The resident further stated that there was never a time when he/she did not receive pain medication when the resident asked for it. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: [...]

Inspectors wroteBased on observations, interviews, record review, and review of facility documents, it was determined that the facility failed to maintain proper infection control practices for donning (putting on) appropriate Personal Protective Equipment (PPE) prior to providing care to a resident who was on Enhanced Barrier Precautions (EBP) for 1 of 1 resident (Resident #138) reviewed for pressure ulcers. This deficient practice was evidenced by the following: On 10/24/24 at 10:26 AM, the surveyor reviewed the electronic medical record for Resident #138. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: pressure-induced deep tissue damage of right ankle and pressure-induced ulcer of left heel unstageable. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation it was determined the facility failed to: a.) ensure the facility policy for Falls Management was followed to appropriately assess a resident and determine the causal factor of a fall and implement appropriate interventions to prevent recurrent falls for a cognitively impaired resident (Resident #23), who was identified as a high fall risk, required extensive assistance with bed mobility, and had a history of falls with injury which included an unwitnessed fall on 02/15/23 at 18:40 (6:40 PM), resulting in pain, required transfer to emergency room on [DATE], with a diagnosis of an acute comminuted (a broken bone that is broken in at least two places) mildly displaced (a gap between the broken bones) fracture of the left humeral head (left shoulder and socket). [...]

Inspectors wroteThis is a repeat deficiency from the Standard Survey Date: 03/31/22 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to identify and consistently comprehensively assess, implement, and modify interventions, consistent with professional standards of practice a.) in response to an unplanned significant weight loss of 16.38% in less than 6 months for (Resident #128), and b.) in response to a significant weight loss of 8.6 pounds (lbs) in four days for (Resident #51). This deficient practice occurred for 2 of 5 residents reviewed for nutrition. The deficient practice was evidenced by the following: Reference: The Academy of Nutrition and Deititians, Position of the Academy of Nutrition and Dietitianss: Individualized Nutrition Approaches for Older Adults: [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to have a process in place to ensure that all recommendations, grievances and concerns presented by the residents during the monthly resident council meetings were consistently addressed. This deficient practice was identified for 6 of 6 residents who attended a resident council meeting and was evidenced by the following: A review of the Resident Council Meeting 02/22/23, included the following: Maintenance: Issues in some bathrooms have been fixed; asking again not to flush paper towels, Dietary: Residents are requesting banana cream pie. A review of the Resident Council Meeting minutes from 03/24/23, included the following: Repair has begun in the rooms and painting; Rooms too cluttered need to downsize; [...]

Inspectors wroteBased on observation, interview and review of other facility documentation it was determined that the facility failed to maintain the resident environment, equipment and living areas in a safe, sanitary, and homelike manner. This deficient practice was evidenced on 3 of 3 resident Wings (Wing A, B, & C) and was evidenced by the following: Observations conducted by Surveyor #1 revealed: On 05/23/23 at 12:35 PM, during a tour of the B- Wing hallway, while the lunch meal was being distributed, and in the presence of Surveyor #2. Both surveyors smelled a pervasive smell of urine permeating in the hallway outside of room [ROOM NUMBER]. Residents were observed eating meals in both room [ROOM NUMBER] and the adjacent room [ROOM NUMBER]. At that time, the Director of Nursing (DON) was in the hallway and Surveyor #1 asked the DON if she could smell anything in the hallway. [...]

Inspectors wroteBased on observation, interview and document review, it was determined that the facility failed to ensure a Registered Dietitian provided resident care per the Facility Assessment and completed nutritional assessments, implemented and updated nutrition care plans and implemented and revised interventions. The deficient practice affected residents who resided on 3 of 3 resident care units and was evidenced by the following: Refer to 692G, 693D, 800F On 05/22/23 at 12:03 PM, the surveyor received the Facility Assessment, dated October, 2022, from the Licenced Nursing Home Administrator (LNHA). The document revealed Part 1: [...]

Inspectors wroteThis is a repeat deficiency from the Standard Survey Date: 03/31/22. Based on observation, interview and document review it was determined the facility failed to maintain the kitchen environment, and all of the equipment, dishware and other items in a clean, intact and sanitary manner to limit the potential of food borne illness and potential injury. The deficient practice was evidenced by the following: On 05/22/23 from 9:49 AM through 10:47 AM, the surveyor completed an initial tour with the Food Service Director (FSD) and Regional Administrator (RA #1) and observed the following: 1. A large black floor fan was in the back area of the kitchen, facing the food preparation area. The fan was running and the grate was embedded with dust like debris throughout. The surveyor asked the FSD who was responsible for cleaning the fan and she stated, it was just brought out. 2. [...]

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure that garbage was maintianed in a manner to prevent potential contamination as evidenced by the following: On 05/22/23 at approximately 10:00 AM, the surveyor began a tour of the dietary department with the Food Service Director and observed the Dumpster area with 1/2 uncovered dumpsters. A Regional Administrator (RA #1) joined the tour. The area next to the dumpsters contained a large field of debris that included gloves, cups, papers and various other debris. There were two dumpsters observed and 1/2 dumpsters did not have a lid in place. When asked who was responsible for keeping the area clean the FSD stated she did not know and the RA #1 immediately interjected and failed to provide information pertinent to the surveyor inquiry. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility provided documentation, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure all residents received the care and services needed to enhance their quality of life related by failing to ensure: [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility Quality Assurance Performance Improvement (QAPI) failed to make good faith attempts to correct and maintain identified issues to address conditions that adversely affected the resident population and were identified during Resident Council Meeting and the condition of the facility environment. The deficient practice was evidenced as follows: Refer to F584 and F565 On 05/22/23, the survey team entered the facility. The Licensed Nursing Home Administrator (LNHA) was asked to provide the entrance documents which included the QAPI plan. During the survey ranging from 05/22/23 through 06/05/23, the survey team made multiple observations on 3 of 3 Wing (A, B, and C) which included but were not limited to, resident rooms with broken, missing, or damaged furniture; [...]

Inspectors wroteThis is a repeat deficiency from the Standard Survey Date: 03/31/22. Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to a.) maintain proper isolation procedures for a resident identified as a Person Under Investigation (PUI) for Covid-19 for 1 of 1 resident (Resident #509) reviewed for Transmission Based Precautions (TBP), b.) perform hand hygiene during the passing out of the lunch meal trays on 1 of 3 units (Unit B), and c.) ensure the cleanliness of respiratory equipment for 1 of 3 residents (Resident #83) reviewed for respiratory care. This deficient practice occurred on 2 of 3 Wings (Wing B & C) was evidenced by the following: [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide: a) a comfortable chair for each resident in his or her room for use by the resident or the resident's visitor for 66 of 157 residents, (b) a bed table with drawers for 3 of 157 residents, and c) individual closet space in the resident's bedroom with clothes racks and shelves accessible to the resident for 2 of 157 residents. This deficient practice was observed on 3 of 3 resident Wings (Wing A, B, C) and was evidenced by the following: 1. On 05/30/23 at 8:47 AM, Surveyor #3 conducted resident room rounds on Unit A and observed the following: [...]

Inspectors wroteBased on interview, observation, and record review it was determined the facility failed to develop person-centered comprehensive care plans to address the residents medical, physical, mental, and psychosocial needs. This deficient practice was identified for 4 of 31 residents reviewed (Resident #33, #49, #128, #138), for 1 of 2 closed records reviewed (Resident #157) for care plans and was evidenced by the following: 1.) On 05/22/23 at 11:00 AM, during the initial tour of the facility, the surveyor observed Resident #33 in bed and was wearing a nasal cannula (a device used to deliver supplemental oxygen). The surveyor observed that the nasal cannula was connected to an oxygen concentrator that was set to 3 liters per minute (LPM) of oxygen. The resident stated that he/she was on oxygen most of the time. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to arrange for an audiology consult when a hearing impairment was identified. This deficient practice was identified for 1 of 31 residents (Resident #8) reviewed and was evidenced by the following: On 05/26/30 at 9:30 AM, the surveyor observed the Certified Nursing Assistant(CNA), while in in Resident #8's room repeat herself several times during a conversation she had with Resident #8, the resident responded huh? to several questions/comments from the CNA. Resident #8 stated when people talk to me, I can't hear them, I cannot hear on both ears. The CNA stated to the surveyor that Resident #8 had some hearing loss, but she had not observed him/her wearing hearing aides. The surveyor reviewed Resident #8's medical record. [...]

Inspectors wroteBased on interview, observation and document review it was determined that the facility failed to ensure each resident was provided with meals that were palatable, met specific preferences related to their clinical condition and were offered alternate meal options, including options that the facility only provided to a subset of the resident population. The deficient practice occurred for 6 of 6 residents who attended a resident council meeting, for 1 of 3 residents reviewed for food (Resident #49) and was evidenced by the following: Refer to 692G On 05/23/23 at 2:23 PM, a copy of a three week menu cycle was provided by the Licensed Nursing Home Administrator LNHA and signed by [Name] Dietitian, and an unsigned two week [Asian] menu cycle. On 05/24/23 at 10:30 AM, the surveyor conducted a resident council meeting with six residents. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent documentation, it was determined that the facility failed to ensure a.) Resident Rights were not violated, and b.) promote the dignity of one resident by ensuring residents who were awake alert and ambulatory were provided with regular clothing to wear and ensure their belongings were being protected. This deficient practice was identified for 1 resident reviewed, Resident #8. The deficient practice was evidenced by the following: On 05/22/23 at 9:54 AM, the surveyor observed Resident #8 standing at the resident's room door in the hallway undressed. Resident #8 had no incontinent brief on. Resident #8 had a shirt covering his/her private area. The surveyor observed several staff ambulating back and forth in the hallway entering and exiting other resident's room. [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that the facility failed to follow the facility policy and report to the New Jersey Department of Health (NJDOH) a facility reportable event for a resident with a history of falls with injury which included an unwitnessed fall on 02/15/23 at 18:40 (6:40 PM), resulting in pain, required transfer to emergency room on [DATE], with a diagnosis of an acute comminuted (a broken bone that is broken in at least two places) mildly displaced (a gap between the broken bones) fracture of the left humeral head (left shoulder and socket). [...]

Inspectors wroteBased on observation, interview, record review, and document review, it was determined that the facility failed to conduct an investigation for an injury of unknown origin for Resident #23. This deficient practice was identified for 1 of 31 residents reviewed for incident investigations and was evidenced by the following: On 05/22/23 at 10:40 AM, the surveyor toured the B-Wing of the facility and observed Resident #23 in bed positioned on the right side, facing the wall. On 05/24/23 at 8:16 AM, the surveyor observed Resident #23 in bed and again was positioned in the same manner, facing the wall. On 05/24/23 at 1:05 PM, the surveyor returned to the room and observed Resident #23 in bed positioned on the back side. The surveyor observed a large black raised area on the right forehead. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to complete a resident assessment that accurately reflected the resident's status of weight loss. This was identified during a review of the Comprehensive Minimum Data Set (MDS), an assessment tool to facilitate the management of care, for (Resident # 128) 1 of 31 residents reviewed for MDS. This deficient practice was evidenced by the following: On 05/24/23 at 10:30 AM, the surveyor observed Resident #128 during a Resident Council Meeting. At that time, Resident #128 stated that he/she had been losing weight because of lack of edible food. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure a.) a resident dependent on staff for Activities of Daily Living (ADL) received nail care, and b.) a resident dependent on staff for ADLs received nail care and was shaved. This deficient practice was identified for 2 of 3 residents (Resident #35 and #28) reviewed for ADL care. The deficient practice was evidenced by the following: a.) On 05/24/23 at 8:31 AM, Surveyor #1 observed Resident #35 in their room sitting in a wheelchair. Resident #35 reached towards Surveyor #1 and slightly scratched the surveyors right arm. Surveyor #1 requested to see Resident #35's fingernails. The surveyor observed that all 10 nails on both hands were long, eight of the nails had jagged edges, and there was a visible black substance under the nails. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure: (a) that a resident received supplemental oxygen as prescribed by the physician, and (b) received the necessary respiratory care and services for residents who received oxygen (O2) treatment according to standards of practice for 2 of 3 residents reviewed (Resident #21 and Resident #33) for respiratory care. The deficient practice was evidenced by the following: 1.) On 05/22/23 at 11:00 AM, the surveyor observed Resident #33 in bed wearing a nasal cannula (a device used to deliver supplemental oxygen). The surveyor observed that the nasal cannula was connected to an oxygen concentrator that was set to 3 liters per minute (LPM) of oxygen. The resident stated that he/she was on oxygen most of the time. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to: a.) have a system in place to ensure that all nursing and related services were consistently provided for residents to maintain the highest practicable physical, mental, and psychosocial wellbeing for each resident, as determined by resident assessments, individual plans of care and in accordance with the facility assessment. This deficient practice was observed on 1 of 3 nursing units and for 2 of 31 residents reviewed, (Resident #28, #35) for care. This deficient practice was evidenced by the following: Refer to F677 a) On 05/22/23 at 09:49 AM, Surveyor #2 toured the B-Wing of the facility and observed Resident #28 lying in bed. Resident #28 appearred disheveled and unkempt. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to serve foods at an acceptable temperature for 1 of 6 residents interviewed during a resident council meeting and for 1 of 1 resident reviewed for Hospice Care (Resident #86). The deficient practice was evidenced by the following: On 05/24/23 at 8:37 AM, Resident #86 was observed in bed, a puree meal tray was at the bedside. Resident #86 greeted the surveyor, and the surveyor observed that the meal appeared congealed and uneaten. When the surveyor asked the resident if he/she liked the food, the resident stated, food, not so good. On 05/24/23 at 11:11 AM, during the surveyor conducted resident council interview, 1 of 6 residents stated the food was inedible, vegetables are over done, and the food is mushy. [...]

Inspectors wroteBased on observation, interview, and review of facility provided documentation, it was determined that the facility failed to ensure corridors were equipped with intact, firmly secured handrails. The deficient practice occurred on 3 of 3 units and was evidenced by the following: On 05/23/23 at 1:02 PM, on A-Wing, two surveyors were observing the facility environment. In the hallway outside of room [ROOM NUMBER] A, the surveyors observed a broken handrail with sharp edges. On 05/23/23 at 1:14 PM, during an interview with the two surveyors, the Licensed Nursing Home Administrator (LNHA) stated that she made rounds in the mornings. She stated that most of the whole floor (A Wing) does for themselves. She further stated, you do realize the whole building is behavioral. On 05/23/23 at 1:16 PM, the two surveyors escorted the LNHA to the broken handrail. The LNHA stated, I didn't see it. [...]