Peace Care St. Ann's

Inspectors wroteBased on the interview and review of facility documentation, it was determined that the facility failed to ensure that facility wide assessment included the resources required to establish policies and procedures for the management of staffing contingency plans in order to meet the requirements and needs of all residents in the facility. This failure had the potential to affect all 107 residents who currently live in the facility. This deficient practice was evidenced by the following:During the entrance conference on 3/3/26 at 10:08 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) a copy of the Facility Assessment (FA). The LNHA stated that the facility's census (the number of residents currently under the care of a specific facility) was 107. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide a safe, clean, and comfortable homelike setting. This deficient practice was identified for 2 of 3 units (2nd and 3rd floors), 2 of 3 Residents rooms (room [ROOM NUMBER] and room [ROOM NUMBER]), and common areas (3rd floor family room, 2nd and 3rd floors dining rooms, 2nd and 3rd floors Bather, 2nd and 3rd floors hallways, and 2nd floor soiled utility room) and was evidenced by the following:The deficient practice was evidenced by the following: 1. On 3/3/26 at 10:18 AM, Surveyor #1 (S#1) observed the 3rd floor Certified Nursing Assistant (CNA) charting area on the low side, the desk with peeling wood on the lower drawer. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to verify the credentials and substantiated findings for staff in the Criminal Background Screening Report and reference checks prior to date of hire in accordance with the facility's abuse policy and procedure for the screening of newly hired employees. This deficient practice was identified for 9 of 79 newly hired employees (Staff #24, #33, #42, #43, #56, #64, #69, #71, and #78) as evidenced by the following: 1. On 3/5/26 at 1:20 PM, Surveyor #1 (S #1) reviewed total of 30 new employee files and revealed: A review of Staff #24's file, a Recreation Aide, with a date of hire (DOH) of 7/9/25, revealed a criminal background screening report (CBSR) dated 7/22/25. The CBSR was completed after Staff #24's DOH. [...]

Inspectors wroteComplaint NJ#2616278Based on interviews, record review, and review of facility provided documents, it was determined that the facility failed to provide information to the resident or the Resident Representative (RR) that explains the Bed Hold and Reserve Bed Payment policy. This deficient practice was identified for 3 of 3 residents, (Resident #11, #129, and #132), reviewed for discharge process. The deficient practice was evidenced by the following: 1. A review of closed medical records revealed that Resident #132 had an acute transfer on September 2025 due to diagnoses of hypernatremia (high sodium concentration in the blood) and sepsis (serious condition in which the body responds to an infection). On 3/4/26 at 1:49 PM, Surveyor #1 (S#1) reviewed Resident #132's medical records (MR) which revealed an admission Record (AR; [...]

Inspectors wroteComplaint NJ #2616278Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that residents received care consistently with professional standards of practice, by failing to; a.) monitor, evaluate, report and document changes in the skin condition as soon as identified b.) develop a relevant care plan that includes measurable goals for management of pressure ulcer/pressure injuries (PU/PIs) with appropriate interventions c.) use clean technique for PU/PI dressing protocols, and d.) utilize a formal method of evaluating PU/PIs in accordance to facility's policies. This deficient practice was identified for 4 of 5 residents (Resident #17, #118, #131, #132) reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure that residents that received oxygen (O2), and nebulizer treatments received the necessary respiratory care and services, according to the standard of clinical practice, specifically that respiratory equipment were stored in accordance with infection control measures and develop an individualized care plan for 4 of 4 residents reviewed for respiratory care (Resident #5, #76, #119 and #130). 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 observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure 3 of 22 residents (Residents #1, #10, and #96) call bells were within reach and able to use to accommodate residents' needs. This deficient practice was evidenced by the following:On 3/3/26 at 10:09 AM, during an initial tour of the facility, the surveyor observed Resident #10, seated in a chair, with the call bell device wrapped around a siderail, and hung down past the bed between the bed and the wall. On that same day at 10:31 AM, the surveyor observed Resident #96, in bed with a breakfast tray. The surveyor observed the call bell device hung off the bed near the floor. The surveyor asked the resident how they call for help if they need it, and the resident stated that they use the button, and someone comes. [...]

Inspectors wroteBased on interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure that a Significant Change in Status Assessment (SCSA) was completed for 2 of 25 residents, (Residents #1 and #130), reviewed for Minimum Data Set (MDS). This deficient practice was evidenced by the following:According to the CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, updated October 2025 showed:An SCSA must be completed within 14 days of determining a significant change from baseline. The resident's condition is not expected to return to baseline within two weeks. Comparison with the most recent comprehensive and quarterly assessments is crucial. Criteria for SCSA include two areas of decline or improvement, or IDT (Interdisciplinary team) recommendation. [...]

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to transmit the Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, within 14 days as required, for 2 of 25 residents, (Residents #1 and #131), reviewed for MDS, in accordance with federal guidelines. This deficient practice was evidenced by the following:According to the CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, updated October 2025, revealed:The Entry tracking record, the transmission date no later than entry date + 14 calendar days. The Discharge Return Not Anticipated (DRNA), the transmission date no later than the MDS completion date + 14 calendar days.1. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, 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, for 5 of 25 residents, (Residents #1, #4, #119, #131, and #133), reviewed for MDS accuracy. This deficient practice was evidenced by the following: 1. On 3/6/26 at 8:04 AM, Surveyor #1 (S #1) reviewed the medical records of Resident #1 and revealed: A review of the admission Record (AR; an admission summary) reflected that the resident was admitted with diagnoses that included but were not limited to; type 2 diabetes mellitus without complications, other seizures, dementia in other diseases classified elsewhere, unspecified severity, and difficulty in walking, not elsewhere classified. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure expired resident-use supplies were removed from medication (med) storage areas and med storage areas were maintained in accordance with professional standards of nursing practice. This deficient practice was identified in 2 of 2 med rooms reviewed for med storage and label review. The 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 observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure residents who received enteral feeding received care in accordance to standard of practice by failing to, a.) properly label enteral feeding equipment and b.) total volume was documented and order was clarified. This deficient practice was identified for 2 of 3 residents (Residents #5 and #11) reviewed for enteral feeding. 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 interviews and review of other facility documentation, it was determined that the facility failed to ensure that the physicians must review the residents' total program of care including medications and treatments and write and sign history and physical and other succeeding visit notes. This deficient practice was identified for 1 of 25 residents, (Resident #131), reviewed for physician services. This deficient practice was evidenced by the following:On 3/5/26 at 10:23 AM, the surveyor reviewed the medical records of Resident #131 and revealed:A review of the hospital discharge medication (med) list revealed that Resident #131 to Continue taking this med and follow the directions you see here for med furosemide 40 mg (milligram) tablet (tab), take 0.5 tab (20 mg total) by mouth one time each day. [...]

Inspectors wroteBased on interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication by documenting an incorrect indication or diagnosis (Resident #4) and failure to monitor requested laboratory results (Resident #7) for 2 of 5 residents reviewed for unnecessary medications. The 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 wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store and secure medications per standards of practice. This deficient practice was identified in 1 of 6 medication carts (med cart) observed during the medication pass (med pass) observation and 1 of 6 med carts observed while touring the facility. 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 wroteBased on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene for 1 of 2 soiled utility rooms (room [ROOM NUMBER]) and b.) ensure that the eyewash stations were maintained clean and scheduled flushing was followed for 2 of 2 eyewash stations (rooms [ROOM NUMBERS]) and follow appropriate infection control practices, to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and facility's policy. This deficient practice was evidenced by the following:According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24 revealed: [...]

Inspectors wroteBased on 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 2 of 5 Certified Nursing Assistants (CNAs) reviewed for mandatory education. This deficient practice was evidenced by the following:On 3/4/26 at 12:06 PM, the surveyor requested from the License Nursing Home Administrator (LNHA) five randomly selected CNA files. On 3/5/26 at 1:55 PM, the surveyor reviewed the mandatory annual education hours for five randomly selected CNA files, which were provided by the facility. The Staff In-service Logs revealed the following: CNA #1, date of hire (DOH) of 8/1/22, Transcript Hours did not include QAPI training. [...]

Inspectors wroteComplaint #: 413630Based on interviews, medical record review, and review of other pertinent facility documentation on 8/21/2025, it was determined that the facility nursing staff failed to consistently document on the Medication Administration Record (MAR) according to the acceptable standards of nursing practice for 2 of 5 residents (Resident #3 and Resident #4) reviewed for medication administration 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 wroteBased on observation, interview, record review and policy review, the facility failed to ensure dignity was provided to one (Resident (R)165) out of one resident regarding grooming, in that nursing staff failed to remove excessive facial hair on a female resident's chin. This deficient practice could compromise the resident's dignity and comfort.

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to accurately code the Minimum Data Set (MDS) for one (Residents (R) R62) of two residents reviewed for anticoagulant medications. Inaccuracy of the MDS could lead to problems in the care area not being addressed appropriately in the care plan.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to maintain acceptable nutritional parameters by not monitoring weights for accuracy, assessing weight changes, implementing interventions, monitoring meal intake, and/or providing meal assistance for two (Residents (R)49 and R52) of three residents reviewed for nutrition in the sample of 42 residents. This had the potential to cause further weight loss without a root cause analysis and/or additional interventions put in place.

Inspectors wroteBased on observation, interviews, record review, review of facility policies, and Centers for Disease Control (CDC) and Prevention guidance, the facility failed to clean and disinfect patient equipment after use for two of five residents (Resident (R) 16 and 54) reviewed for infection control and failed to follow hand hygiene practices during medication pass for one of five residents (R7) reviewed for medication administration. These failures could promote the spread of multi drug resistant organisms (MDROs) throughout the facility.

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that: a.) the facility failed to store and serve potentially hazardous foods in a manner to prevent food borne illness in 3 of 3 Bistros, and b.) failed to maintain refrigerator temperatures and store food at the correct temperature for 1 of 3 Bistro refrigerators. This deficient practice was evidenced by the following: On 10/31/2022 at 10:46 AM, in the presence of the first floor Registered Nurse/Unit Manger (RN/UM) the surveyor observed the following: The surveyor observed on the first floor Bistro: 1.) The refrigerator had a clear, small bin that housed pre-sliced bologna deli meat wrapped in clear plastic wrap. The pre-sliced bologna was labeled and dated with an expiration date of 10/27/22. 2.) The refrigerator thermometer read 50 degrees Fahrenheit (F). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person centered care plan for an unstageable wound. This deficient practice was identified for 1 of 6 residents, (Resident # 9) reviewed for pressure ulcer injury. This deficient practice was evidenced by the following: On 11/2/22 at 11:51 AM, the surveyor observed Resident #9 out of bed seated in a wheelchair in the dayroom. The resident greeted the surveyor with a smile but was unable to answer any questions. The foot rest on the resident's wheelchair had a blue padded foot rest attached to the bottom of the wheelchair. On 11/16/22 at 10:00 AM, the surveyor in the presence of the Registered Nurse Unit Manager (RN/UM) and a Licensed Practical Nurse (LPN) observed the wound on the residents left foot. The LPN described the wound as a dry hard scab. [...]

Inspectors wroteBased on observation, interview, and record review, it was identified that the facility failed to appropriately transcribe a Physician's Order (PO) for the recommendation of a skin care treatment. This deficient practice was identified for 1 of 1 resident reviewed, (Resident #52) for general skin conditions. 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 registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards of practice to accurately administer a medication, Potassium Chloride Extended Release to 1 of 7 residents, (Resident #47) by 1 of 3 nurses observed during the medication administration observation. 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 interview and record review the facility failed to submit their Payroll Based Journal (PBJ) Report to the Centers for Medicare and Medicaid Services (CMS) within a timely manner. This deficient practice was identified for one of two PBJ Report submissions reviewed, (Fiscal Year Quarter 3 2022, April 1 - June 30) and was evidenced by the following: A review of the PBJ Staffing Data Report CASPER Report 1705D reflected a triggered area that the facility failed to submit data for the third fiscal year quarter to the CMS. The dates of the third quarter included April 1, 2022, through June 30, 2022. On 11/01/22 at 10:17 AM, the facility's Administrator stated that the PBJ Report for the third quarter was not submitted on time and rejected by CMS because it was late. [...]