Peace Care St. Joseph's

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a) maintain kitchen equipment in a clean, safe and sanitary manner for 3 of 4 kitchenettes (2nd, 3rd, 4th), and b) maintain kitchen equipment in a clean, safe and sanitary manner 4 of 4 pantries (1st, 2nd, 3rd, 4th), on the nursing floors as evidenced by the following. On 4/09/26 at 11:50 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following on the nursing units:The kitchenette microwaves had multicolored food debris on the interior ceiling of the units for 3 of 4 units, (2nd, 3rd, and 4th). The FSD acknowledged and agreed that they were not cleaned according to facility policy. The pantry microwaves had multicolored food debris on the interior ceiling of the units and food particles on the rotating tray for 3 of 4 units (2nd, 3rd, and 4th). [...]

Inspectors wroteComplaint NJ# 2593527Based on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to include a resident in the planning of care by informing them of the risks and benefits of proposed care. This was observed in 1 of 2 residents (Resident #109), reviewed for use of anticoagulant medications. The deficient practice was evidenced by the following: On 4/9/26 at 11:11 AM, the surveyor interviewed Resident # 109 The surveyor asked the resident about his concerns with a discontinued medication in August of 2025. The resident answered My Eliquis was stopped at the end of May and The doctor never talked to me about it, there was no notice, no discussion, I found out when the cariologist caught it in July. The resident added The doctor never discussed it with my sister either. [...]

Inspectors wroteBased on observation and interview it was determined the facility failed to maintain the residents' living environment in a safe and homelike manner for 1 of 25 residents (Resident #12) reviewed. The deficient practice was evidenced by the following:On 4/8/26 at 12:15 PM, the surveyor observed Resident # 12 in bed. The surveyor observed a bed controller with the cord attached to it, which was laying on the resident's bedside. The cord sheath attached to the bed controller was broken in several areas and the wires were exposed. The resident stated that the cord was like that for many months and the resident had told the facility about it a while ago but it was never fixed. At 12:41 PM, the surveyor asked the Licensed Practical nurse (LPN), who cared for Resident # 12, to come into the resident's room. The surveyor showed the LPN the broken cord sheath. [...]

Inspectors wroteComplaint NJ-2803539 Based on observation, interview, and record review it was determined that the facility failed to ensure 1 of 2 residents (Resident #14) was free from neglect. The facility failed to provide personal care and assistance from the assigned Certified Nursing Assistant (CNA) for one 8-hour shift. The deficient practice is evidenced by the following. On 4/9/26 at 10:40 AM, the surveyor observed the resident awake in bed. The resident spoke to the surveyor in Arabic and did not understand the English language. At that time, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated a translator phone number is posted in the resident's room to communicate with the resident. He stated the resident's 2 daughters visit daily during the day shift. A review of the electronic medical record (EMR) revealed the following information. [...]

Inspectors wroteBased on interview and record review it was determined that the facility failed to ensure newly hired employees underwent criminal background checks before they began employment at the facility. The deficient practice was identified for 9 of 82 employee records reviewed (Employee #12, 13, 14, 17, 34, 38, 54, 55, 67). The deficient practice is evidenced by the following. On 4/13/26 and 4/14/26, the surveyor reviewed the Human Resources records including Criminal Background Investigations (CBI) for 82 employees who were hired since the previous Department of Health Recertification Inspection. The following concerns were revealed. Employee #12, a Certified Nursing Assistant (CNA), began employment on 10/20/25. The CBI was requested by the facility on 10/27/25. Employee #13, a nurse, began employment on 10/20/25. The CBI was requested on 2/10/26. [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to complete a quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 1 (one) of 1 resident (Resident#104), system selected for resident assessment for MDS record over 120 days old. This deficient practice was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. [...]

Inspectors wroteBased on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to a) provide pharmaceutical services in accordance with professional standards to ensure signing from the reconciliation form Controlled Drug Administration Record Tablet (CDART; declining inventory log) form after the dispensed and administered a controlled dangerous substance with high potential for drug diversion medication for 1 (one) of 1 resident (Resident #107) and b) follow physician orders for 1 of 1 resident (Resident #5) reviewed for medication storage and labeling. 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 wroteComplaint #2613352Based on interview, and review of facility documentation, it was determined that the facility failed to provide services in compliance with applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles for a resident who was denied admission to the facility to provide services. This deficient practice was identified for 1 of 3 residents' referrals reviewed, Resident #138. This deficient practice was evidenced by the following:Reference: According to the Centers for Disease Control (CDC) guidelines dated 4/24/24, the Transmission-Based Precautions (TBP) and Enhanced Barrier Precautions (EBP) for Candida Auris (C. Auris; a multidrug- resistant fungus that can cause severe infections in very sick, vulnerable patients) are similar to those used for other multidrug-resistant organisms (MDROs). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow appropriate infection control measures to prevent the potential spread of infection for failing to ensure a midline intravenous (IV) connector cap was properly secured for 1 of 1 residents (Resident # 12) with a midline IV.The deficient practice was evidenced by the following: On 4/8/26 at 12:15 PM, the surveyor observed Resident # 12, in bed, with a midline IV on the resident's left arm with a date of 4/6/26 on the dressing which covered the IV site. The surveyor observed that the midline IV line was clamped but the connector was uncapped. The resident stated that the nurses gave the resident medicine in the IV yesterday. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a.) consistent maintenance of the system of record keeping of the Drug Enforcement Agency (DEA) order Form-222 (a federal narcotic requisition form), that enabled accurate reconciliation of controlled-dangerous substances (narcotic medications, that due to their high potential for abuse, are tracked with a degree of detail and attention) that was ordered and received, b) the development and implementation of policy and procedure for DEA order Form-222, c) removal and disposition of a discharged Resident's medication from the active inventory, and d.) properly label an opened blood glucose test strip. [...]

Inspectors wroteREPEAT DEFICIENCY Based on interview and record review, it was determined that the facility failed to assure that the required staff attended the quarterly Quality Assurance (QA) meetings. This was identified for 4 of 4 quarterly QA meetings reviewed. This deficient practice was evidenced by the following: On 10/31/24 at 10:00 AM, upon entrance conference, the surveyor requested to review the QA meeting sign in sheets for the last few quarters of QA meetings held. On 11/4/24 at 10:30AM, the surveyor received QA meeting sign in sheets dated, 10/17/24, 7/18/24, 4/18/24 and 1/18/24, which revealed that the Infection Preventionist (IP) was not in attendance for any of those scheduled meetings. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to a) maintain infection control standards and procedures during wound care treatments for 2 of 5 residents (Resident #181, #6) reviewed for care and services for pressure ulcers, b) provide a safe and sanitary environment to prevent the potential spread of infection and cross-contamination to both residents and staff by sharing personal care items between residents and a linen cart which contained linen for multipe residents was brought into a Resident room (room [ROOM NUMBER]) and then back out into the hallway, observed for 1 of 3 CNAs (CNA #1) on 1 of 4 nursing units, (4th-floor unit) and c) failed to practice acceptable hand hygiene as recommended by the CDC. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure pneumococcal vaccination was offered according to the current Centers for Disease and Control Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommendations for Residents #23, #36 and #83. This deficient practice was identified for three (3) of five (5) residents reviewed for immunization status. The deficient practice was evidenced by the following: Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 9/12/24, included the following. The CDC recommends a single dose of PCV21 (pneumococcal 21-valent conjugate vaccine; [...]

Inspectors wroteBased on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 3 of 6 residents (Resident #22, #109, and #87) observed for incontinence care on 1 of 3 units, the 4th floor Unit. This deficient practice was evidenced by the following: a. On 11/4/24 at 11:55 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) on the 4th floor unit. CNA #1 stated that she had 8 residents on her assignment and was also helping another aide with some of their residents. On 11/4/24 at 12:00 PM, the surveyor and CNA #1 entered Resident #22's room and observed the resident in bed. CNA #1 stated that she had not provided care to Resident #22 yet as she was very busy all morning. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician's order for 1 of 1 resident, (Resident #6). 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 registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, 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. Reference: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficient practice was evidenced by the following: Reference: NJ State requirement, CHAPTER 112. An Act concerning staffing requirements for nursing homes and supplementing Title 30 of the Revised Statutes. Be It Enacted by the Senate and General Assembly of the State of New Jersey: C.30:13-18 Minimum staffing requirements for nursing homes effective 2/1/21. 1. a. Notwithstanding any other staffing requirements as may be established by law, every nursing home as defined in section 2 of P.L.1976, c.120 (C.30:13-2) or licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall maintain the following minimum direct care staff -to-resident ratios: [...]

Inspectors wroteBased on interviews, record review, and review of pertinent facility documentations, it was determined that the facility failed to ensure medication orders for a newly admitted resident from the hospital were completely and accurately relayed to the Attending Physician (AP). On the day Resident #1 was admitted to the facility, there were six discontinued medications not clarified with the AP for continuance. This deficient practice was observed in one of three newly admitted residents (Resident #1) reviewed for admission orders as evidenced by the following: According to Resident #1's admission Record (AR), the Resident Information revealed that Resident #1 had diagnoses of which included but not limited to Type 2 Diabetes Mellitus, Anemia, Hypothyroidism, Bipolar Disorder, Depression, and Acute Pancreatitis without Necrosis or Infection. [...]

Inspectors wroteBased on interviews, record review, and review of pertinent facility documentations, it was determined that the facility failed to keep an accurate and complete list of Resident #1 discharged medical records from the hospital which entailed important medication discharge instructions for reference upon admission of the Resident to the facility. This deficient practice was evidenced in one out of three residents (Resident #1) reviewed for admission orders as follows: According to Resident #1's admission Record (AR), the Resident Information revealed that Resident #1 had diagnoses of which included but not limited to Type 2 Diabetes Mellitus, Anemia, Hypothyroidism, Bipolar Disorder, Depression, and Acute Pancreatitis without Necrosis or Infection. [...]

Inspectors wroteComplaint # NJ00161813 Based on interview and record review it was determined that the facility failed to provide effective care and services to promote healing of a pressure ulcer for 1 of 2 residents reviewed for pressure ulcers. Resident #105's right heel wound was left untreated for more than a month. During this period the wound's length doubled in size. The deficient practice was evidenced by the following: The surveyor reviewed Resident #105's closed hybrid medical record which revealed the following information. The admission Record indicated the resident was admitted to the facility from the hospital on [DATE]. The nurse documented in a 12/5/22 admission Summary Progress Note that the resident had a small skin opening on the coccyx and an Ace Wrap (an elastic bandage wrap) on the right lower extremity. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a.) assess for complications upon their return from the renal dialysis center for 2 of 2 residents (Resident #61, and #49) and b.) consistently monitor fluid restriction instructions in accordance with the physician's order for 1 of 2 resident (Resident #49) reviewed for dialysis care. The deficient practice was evidenced by the following: 1. The surveyor observed Resident #61 awake in bed on 8/14/23 at 11:41 AM. At that time, the unit Licensed Practical Nurse (LPN #1) stated the resident went to the renal dialysis (RD) clinic on Tuesdays, Thursdays, and Saturdays. The LPN stated an assessment of vital signs and the RD access site prior to leaving for the RD clinic and upon return from the RD clinic were documented in electronic nurse progress notes. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to assure that the required staff attended the quarterly Quality Assurance (QA) meetings. This was identified for 2 of 2 quarterly QA meetings reviewed. This deficient practice was evidenced by the following: On 8/09/23 at 10:25 AM , the surveyor requested to review the QA meeting sign in sheets for the last 2 quarters dated April 26, 2023 and January 25, 2023 upon entrance. On 8/10/23 at 10:00 AM, the Administrator asked the surveyor for more time to locate the QA meeting sign in sheets. On 8/14/23 at 9:40 AM, the Administrator stated that he needed more time to find the QA meeting sign in sheets, as the person who was responsible for holding those documents is away on vacation and unable to be reached. He stated that he will look one more time in that person's office to locate the sign in sheets. [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for 5 of 24 residents reviewed (Residents #34, 49, 52, 48, and #84). The deficient practice was evidenced by the following: 1. On 08/10/23 at 10:10 AM, the surveyor observed Resident #34, eyes closed, sitting in the wheelchair in front of the nurses' station, talking to the other residents. The surveyor reviewed the medical records of Resident #34, which revealed the following: The Significant MDS (SMDS), dated [DATE], reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating that the resident's cognition is severely impaired. The SMDS Section J Fall History on Admission/Entry/Reentry was coded 0 (zero) or No, which did not reflect the resident's fall incident on 7/02/23. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive, person-centered care plan addressing a resident's continence (Resident #48) and addressing a resident's hospice care (Resident #52). The deficient practice was observed for 2 of 23 residents reviewed for comprehensive care plans and is evidenced by the following: 1. The surveyor observed Resident #48 awake in bed on 8/9/23 at 12:03 PM. The surveyor interviewed the unit Licensed Practical Nurse (LPN #1) on 8/18/23 at 11:32 AM. She stated the resident was admitted with an external urinary catheter and had begun to use a urinal. Additionally, the Certified Nursing Assistant (CNA #1) stated the resident had bowel movements in the adult incontinence brief and called staff to be cleaned. A review of the hybrid medical record revealed the following information: [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to a.) accurately document the administration of medications in the electronic administration record and electronic treatment administration record, and b.) clarify duplicate physician's orders for an over-the-counter pain patch (Lidocaine) and document the removal of the Lidocaine patch. The deficient practice occurred for 5 of 9 residents, (Resident #34, #48, #49, #52 and #67) reviewed for medication management. 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 policy review, it was determined that the facility failed to sanitize and air dry steam table pans in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 8/9/23 at 11:48 AM, in the presence of the Food Service Director (FSD) and the Administrator, the surveyor observed the following: On a shelf near the wall of the kitchen, the surveyor observed eight quarter sized deep-set steam table pans stacked with water between them, 15 eighth sized steam table pans stacked with water between them, and 12 small square steam table pans stacked with water between them. The FSD stated that these should be air dried before stacking. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a.) adhere to accepted standards of infection control practices for the proper disposable of gloves, b.) implement hand hygiene between glove changes during care, and c.) perform proper hand washing to prevent the spread of infection during care and preparation of food. This deficient practice was evidenced by the following: On 8/10/23 at 12:15 PM, the surveyor observed meal service in the 3rd-floor dining room. The dietary aide (DA) doffs gloves and places them on the cart used for food preparation in front of her. The DA continued to prepare the food after removing the gloves and did not perform hand hygiene. The surveyor got the DA's attention, then went to the sink and washed her hands. The surveyor observed the DA performing hand washing. [...]