Premier Cadbury of Cherry Hill

Inspectors wroteComplaint Intake # 2740465Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of food served to the residents. This deficient practice was identified during the lunchtime meal service on 3/13/26, on 1 of 2 nursing units ([NAME] 600) and was evidenced by the following:On 3/13/26 at 12:25 PM, in the presence of the Food Service Director (FSD), the surveyor conducted a test tray with a calibrated (calibration ensures that the thermometer is accurate and precise for the measurement of food temperatures) thermometer. The meal tray cart arrived on the unit at 12:20 PM. It was an open, not enclosed, cart. The surveyor tagged the bottom tray for temperature testing. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to a.) maintain clean kitchen equipment and b.) store foods in a manner intended to prevent the spread of food borne illness in resident pantries. This deficient practice was evidenced by the following:On 3/11/26 at 09:20 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the following: 1. On a large open stainless-steel shelf, the surveyor observed stacks of stainless-steel pans. The surveyor observed eight stainless steel pans. When the surveyor separated the eight pains there was wet nesting within each pan. One of the pans had a dried yellow substance on the inside. The surveyor asked the FSD if they were clean pans and he stated yes, but he would rewash the pans. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to follow a consultant physician's recommendations in a timely manner. This deficient practice was identified for 1 of 1 resident (Resident #47) reviewed for accommodation of needs and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on interview and review of facility documents, it was determined that the facility failed to consistently provide residents with mail delivery between December 2025 and late February 2026. This deficient practice was identified for 1 of 5 residents (Resident #49) during a resident council group meeting and was evidenced by the following: On 3/12/26 at 10:15 AM, the surveyor conducted a resident council group meeting with five alert and oriented residents (Resident #11, # 22, #49, #65, and #95). The surveyor interviewed the residents regarding mail delivery. All residents stated that the Activities Director (ACD) coordinated mail delivery, but that the facility had no ACD between December 2025 and late February 2026. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to a.) maintain the most recent State of New Jersey inspection results in a place readily accessible to the residents, and b.) post notice of the availability of the inspection results in prominent areas. This deficient practice was identified on 2 of 2 units ([NAME] 5 and [NAME] 6) and was evidenced by the following: On 3/12/26 at 10:15 AM, the surveyor conducted a resident council meeting with five alert and oriented residents. All five residents stated they were not aware of the location of the State Survey results. On 3/13/26 at 11:50 AM, the surveyor toured the [NAME] 5 unit but was unable to locate the most recent State Survey results. There was no signage on the unit to indicate where to find the State Survey results. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain a homelike environment that was clean, safe, and sanitary. This deficient practice was identified for 1of 2 units ([NAME] 6 Unit). This deficient practice was evidenced by the following: On 3/11/26 at 10:10 AM, in room [ROOM NUMBER]B on the [NAME] 6 Unit, the surveyor observed a personal refrigerator. Inside the refrigerator door, there was an unlabeled, open container of food. [NAME] and red debris were identified on the bottom of the refrigerator, along with a loose piece of a blue paper label. The freezer compartment did not contain a thermometer, and the floor of the freezer was covered in ice. [NAME] and red debris were also visible on the bedroom floor. The wall had areas of missing white paint, exposing the paper layer of the drywall. [...]

Inspectors wroteBased on interview, record review and review of pertinent facility documents, it was determined that the facility failed to a.) notify the representative of the Office of the State of Long-Term Care Ombudsman about a resident's emergency discharge to the hospital and b.) provide the bed hold policy for 1 of 1 resident (Resident #99) reviewed for hospitalization. This deficient practice was evidenced by:On 3/12/26 at 12:16 PM, the surveyor reviewed the hybrid medical records (combination of electronic and paper medical records) for Resident #99. The resident had a facility-initiated discharge (d/c) and was no longer in the facility. A review of the admission Record (an admission summary) reflected that the resident had diagnoses that included influenza, dysphagia (difficulty swallowing), seizures, heart disease, and dementia. [...]

Inspectors wroteBased on observation, interviews, review of medical records, and other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 3 of 20 residents reviewed (Residents #1, #5, and #61).1.) On 3/11/26 at 9:54 AM, the surveyor observed Resident #1 awake and alert sitting in a wheelchair in his/her room. The resident stated that he/she did not speak English. The surveyor reviewed the medical record for Resident #1. A review of the admission Record, an admission summary, revealed that the resident had diagnoses which included, but were not limited to: osteomyelitis (an infection in the bone). [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to notify the physician of the resident's change in condition for 1 of 23 sampled residents (Resident #99). This deficient practice was evidenced by the following:On 3/12/26 at 12:16 PM, the surveyor reviewed the hybrid medical records (combination of electronic and paper medical records) for Resident #99. The resident had a facility-initiated discharge (d/c) and was no longer in the facility. A review of the admission Record (an admission summary) reflected that the resident had diagnoses that included, influenza, dysphagia (difficulty swallowing), seizures, heart disease, and dementia. A review of the individual comprehensive care plan (ICCP) included a focus, dated 1/2/26, that the resident had influenza. Interventions included: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that therapy services and treatment for range of motion limitations were provided for 1 of 2 residents (Resident #9) reviewed for range of motion concerns. This deficient practice was evidenced by the following: On 3/11/26 at 9:45 AM, the surveyor observed Resident #9 in his/her bedroom, seated in a wheelchair next to the bed. The resident stated that he/she had difficulty using the right side of his/her body. The resident's right hand was contracted, and no orthosis or hand splint was in place. On 3/12/26 at 9:14 AM, the surveyor observed Resident #9 in the hallway on the [NAME] 6 Unit, self-propelling in his/her wheelchair. He/she stated to the surveyor that he/she was going outside to smoke. [...]

Inspectors wroteBased on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to provide a nutritional supplement as prescribed by the physician for 1 of 5 residents (Resident #5) reviewed for nutrition. This deficient practice was evidenced by the following: On 3/12/26 at 12:30 PM, the surveyor observed Resident #5 sitting in bed with the lunch tray on the overbed table. The surveyor observed the lunch meal ticket included a [name redacted] nutritional supplement (a fortified protein and calorie dense nutritional frozen dessert designed to fight malnutrition supplement) with the meal. The surveyor observed that the nutritional supplement was not on the lunch tray. At that time, the surveyor interviewed Licensed Practical Nurse (LPN # 1) who confirmed the nutritional supplement was not on the lunch tray. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) administer oxygen at the prescribed flow rate, and b.) provide the resident with an appropriate oxygen delivery system while ensuring oxygen was handled and dispensed safely for 1 of 1 resident (Resident #14) reviewed for respiratory care. This deficient practice was evidenced by the following: On 3/11/26 at 10:03 AM, the surveyor observed Resident #14 in his/her bedroom lying in a lateral position with the head of the bed flat. The resident was receiving oxygen via a nasal cannula (NC) (a device used to deliver oxygen), connected to a portable oxygen cylinder in a cart. [...]

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 #52) observed during the medication pass. This deficient practice was evidenced by the following: On 3/12/26 at 8:10 AM, the surveyor observed License Practical Nurse (LPN) #2 dispense six medications for Resident #52. As the LPN pulled 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 carbonate 600 milligrams (mg) - vitamin D 10 micrograms (mcg) and then the LPN dispensed one pill from the bottle into the medicine cup. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to ensure recommendations made by the pharmacy consultant were acted upon in a timely manner for 2 of 5 residents (Resident #3 and #61) reviewed for unnecessary medications. This deficient practice was evidenced by: 1.) On 3/12/26 at 12:59 PM, the surveyor interviewed Resident #61 in their room. Resident #61 was alert and oriented and conversed with the surveyor regarding his/her care. The surveyor reviewed the electronic medical record (EMR) for Resident #61. A review of the admission Record, an admission summary, reflected that the resident had diagnoses which included, but were not limited to, acute pulmonary edema, anxiety, and depression. A review of the pharmacy consultant's recommendations for February 2026 revealed the following recommendations: [...]

Inspectors wroteBased on observation, interview, and review of facility documentation 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 1 of 1 dumpsters. This was evidenced by the following: On 3/11/26 during the initial tour of the kitchen with the Food Service Director (FSD), the surveyor observed the dumpster area. The large green dumpster did not have a lid. The FSD told the surveyor it was delivered with no lid. Just past the dumpster in the same enclosed area the surveyor observed two mattresses, four wood pallets, and a reclining chair on the ground. The surveyor asked the FSD who was responsible for the maintenance of the trash surrounding the dumpster and he stated it was the responsibility of the housekeeping department. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to maintain medical records that were accurately documented by not signing off medications immediately after administration for 3 of 6 residents (Resident #24, #52, and #77) observed during the medication pass. This deficient practice was evidenced by the following: On 3/12/26 at 8:13 AM, the surveyor observed Licensed Practical Nurse (LPN) #2 dispense and administer six medications to Resident #52. The nurse did not sign off the medications as administered when she returned to the medication cart, and instead moved on to the next resident. At 8:22 AM, the surveyor observed LPN #2 dispense and administer five medications to Resident #77. [...]

Inspectors wroteBased on observation, interview, 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 properly store the oxygen nasal cannula (NC) (a device used to deliver oxygen tubing) for 1 of 1 resident (Resident #14) reviewed for respiratory care, leaving the device exposed on a bare mattress. This deficient practice was evidenced by the following: On 3/12/26 at 9:20 AM, the surveyor observed that Resident #14's oxygen NC tubing was exposed to air, lying directly on the resident's bare mattress. The surveyor reviewed the electronic medical record for Resident #14. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide a safe environment for facility staff. This deficient practice was identified throughout the kitchen and was evidenced by the following:On 3/11/26 at 09:20 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD). During the tour of the kitchen the surveyor observed that the floor was made up of four inch by four inch tiles throughout the kitchen. Tile size was confirmed with the FSD. During the observation of the three basin sink the surveyor noticed that 18 of the ceramic tiles were missing from the floor creating an uneven floor surface. The FSD acknowledged the missing tiles and told the surveyor, Sometimes they place mats over the area to make it safer. The surveyor then observed the steam table area. [...]

Inspectors wroteBased on interviews, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to activate their emergency response system including calling emergency services/911 for a resident (Resident #103) who was found unresponsive and was a full-code status (all resuscitation procedures will be provided when a person stops breathing or their heart stops beating) in accordance with the Basic Life Support (BLS) for Healthcare Providers. This deficient practice was identified for 1 of 4 residents (Resident #103) reviewed for a death in the facility. [...]

Inspectors wroteComplaint # NJ 00173863 Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure a treatment that was ordered for a right shin tear was implemented without a 23-day delay which resulted in the wound worsening with a necrotic (death of cells in your body tissues) wound infection that required a seven-day antibiotic treatment. This deficient practice was identified for 1 of 4 residents (Resident #305) reviewed for pressure ulcer and was evidenced by the following: On 11/6/24 at 12:30 PM, the surveyor reviewed the closed medical record for Resident #305. A review of the admission Record face sheet (an admission summary) revealed that the resident had diagnoses which included but were not limited to; Alzheimer's disease, dementia, heart failure, diabetes mellitus, and muscle weakness. [...]

Inspectors wroteComplaint NJ #'s: 170567 and 171267 Based on 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: 1.) Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio (s) were effective on 02/01/2021: One (1) Certified Nurse Aide (CNA) to every eight (8) residents for the day shift. [...]

Inspectors wroteThis is a repeat deficiency Based on observations, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On 11/6/24 from 9:46 AM to 10:50 AM, the surveyor observed the following in the kitchen in the presence of the Dining Director (DD): 1. The DD demonstrated use of the high temperature dish machine. The DD stated that the facility used a booster for the dish machine to reach the required rinse temperature of 180 degrees Fahrenheit (F) but sometimes the booster does not work so we always use a chemical sanitizer. The surveyor requested to see the dish machine temperature/sanitizer log. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff implemented facility policies and procedures to ensure a.) residents were provided with care and services to achieve their highest practical wellbeing and, b.) the minimum State staffing requirements were met. This deficient practice was identified for and 2 out of 2 nursing units, and was evidenced by the following: Refer to F678, F684, F688, F698, F725, F804, F809, and F812 A review of the Administrator's job description provided by the facility revealed the following: [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to a.) clarify and transcribe a Physician's Order (PO) for carrot hand splints (a type of splint that provides a barrier between the fingers and the palm to prevent injury to the palm from finger contracture) to the both hands, and b.) follow a physician's order for the application of a carrot hand splints to both hands, and c.) document in the Treatment Administration Record (TAR). This deficient practice was identified for 1 of 1 resident (Resident #91) reviewed for positioning and mobility and was evidenced by the following: [...]

Inspectors wrote2. On 11/7/24 at 12:51 PM, the surveyor reviewed the closed medical record of Resident #306. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: acute osteomyelitis (bone infection), right ankle and foot, anemia (a low number of red blood cells) in chronic kidney disease, dependence on renal dialysis (a procedure to remove waste products and excess fluid when the kidneys stop working properly). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, dated 5/27/24, included that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. Further review of the MDS revealed the resident received dialysis while a resident at the facility. [...]

Inspectors wroteComplaint #NJ174562 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure palatable temperature of food for 1 of 1 lunch meal served on 1 of 2 units ([NAME] 600). This deficient practice was evidenced by the following: On 11/7/24 at 10:52 AM, the surveyor conducted a meeting with the Resident Council which included five residents (Residents #9, #3, #48, #64, and #81). Four of the five residents informed the surveyor that the food was not served hot and was described as cool on both nursing units. On 11/12/24 at 11:10 AM, the surveyor observed the [NAME] who calibrated (process to make sure the instrument is taking an accurate temperature reading) a thermometer to 32 degrees Fahrenheit (F) before he proceeded to obtain food temperatures from the steam table. [...]

Inspectors wroteThis is a repeat deficiency Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to serve residents a nourishing snack when there was more than a 14-hour span of time between the dinner and breakfast meal times. This deficient practice was identified for 5 of 5 residents (Residents #9, #33, #48, #64, and #81) interviewed during a meeting with the Resident Council and was evidenced by the following: On 11/7/24 at 10:30 AM, the surveyor conducted a resident council meeting with five (5) awake, alert, and oriented residents. During the meeting, 5 out of 5 residents stated that snacks were kept in the pantry and were not accessible during the evening shift to the residents. One resident stated, If we don't like our dinner, then we are hungry and need a snack at night. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that residents were served their meals in a manner that promotes respect and dignity during lunch. This deficient practice was identified for 6 out of 10 unsampled residents who were not served their meals at the same time and for 1 of 1 resident (Resident #40) who also experienced a significant delay in meal service delivery in the [NAME] 500 Dining Room. This deficient practice was evidenced by the following: On 11/6/24 at 12:03 PM, the surveyor observed residents who were seated in the [NAME] 500 Dining Room who awaited meal service. On 11/6/24 at 12:09 PM, the surveyor observed that the food cart was delivered to the nursing unit and staff had begun to pass out trays to residents in their rooms. [...]

Inspectors wroteBased on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to implement their new hire policy to ensure reference checks were completed. This deficient practice was identified for 4 of 10 employee files reviewed (Employee #1, #6, #8, and #10) and was evidenced by the following: A review of the employee files for reference check reflected the following: Employee #1, a Licensed Practical Nurse (LPN), with a date of hire of 8/6/24, did not have a reference check on file. Employee #6 a Certified Nurse Aide (CNA), with a date of hire of 1/24/24, did not have a reference check on file. Employee #8, a CNA, with a date of hire of 10/30/24, did not have a reference check on file. Employee #10, a Registered Nurse (RN) with the hire date of 7/29/24, did not have a reference check on file. [...]

Inspectors wroteComplaint #: NJ172932 Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) a resident-to resident altercation for 1 of 4 residents (Resident #310) reviewed for abuse. This deficient practice was evidenced by the following: On 11/8/24 at 11:46 AM, the surveyor reviewed Resident #310's closed medical record. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: Alzheimer's Disease, dementia, major depressive disorder, unspecified mood [affective] disorder, persistent mood [affective] disorder, post-traumatic stress disorder (PTSD), insomnia, cognitive communication deficit, and generalized anxiety disorder. [...]

Inspectors wroteComplaint #: NJ172932; NJ172314 Based on interview, record review, and review of facility documents, it was determined that the facility failed to conduct a thorough investigation for a.) a resident-to-resident altercation, and b.) an injury of unknown origin. This deficient practice was identified for 2 of 4 residents (Resident #6 and #310) reviewed for abuse, and was evidenced by the following: 1.) On 11/8/24 at 11:46 AM, the surveyor reviewed Resident #310's closed medical record. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: Alzheimer's Disease, dementia, major depressive disorder, unspecified mood [affective] disorder, persistent mood [affective] disorder, post-traumatic stress disorder (PTSD), insomnia, cognitive communication deficit, and generalized anxiety disorder. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a resident hospitalization. This deficient practice was identified for 1 of 1 resident (Resident #2) reviewed for hospitalization and was evidenced by the following: On 11/6/24 at 10:01 AM, the surveyor observed that Resident #2 was not in their room. On 11/7/24 at 12:00 PM, the surveyor reviewed the medical record for Resident #2. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: chronic obstructive pulmonary disease (COPD, a condition that makes it difficult to breathe), acute respiratory failure, and tobacco use. [...]

Inspectors wrote2.) On 11/8/24 at 12:25 PM, the surveyor reviewed the closed electronic medical record (EMR) for Resident #309. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: muscle wasting and atrophy, other abnormalities of gait (a person's manner of walking) and mobility and vascular dementia. A review of the admission Minimum Data Set (MDS), an assessment tool, dated 1/24/24, included the resident had a Brief Interview Mental Status score of 3 out of 15 which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident has one (1) fall with injury since admission. A review of the individualized comprehensive care plan (ICCP) included a focus area, dated 1/23/24, that the resident was a high risk for falls related to confusion, gait/balance problems, and unaware of safety needs. [...]

Inspectors wroteComplaint #: NJ172314 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to complete an incident report and thoroughly investigate a resident's fall for 1 of 3 residents (Resident #87) reviewed for accidents. This deficient practice was evidenced by the following: On 11/6/24 at 9:51 AM, the surveyor observed staff providing care to Resident #87 in their room. On 11/6/24 at 12:34 PM, the surveyor reviewed the medical record for Resident #87. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: vascular dementia, muscle wasting and atrophy, and other abnormalities of gait and mobility. [...]

Inspectors wroteComplaint #NJ176585 Based on interview, record review, and review of facility documents, it was determined that the facility failed to follow standard operational procedures in accordance with the facility policy for a resident with weight loss of five pounds or more for 1 of 5 residents (Resident #304) reviewed for nutritional status and was evidenced by the following: A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: anemia (a lack of healthy, red blood cells), dysphagia (difficulty swallowing) unspecified, major depressive disorder, recurrent without psychotic features, generalized anxiety disorder, muscle wasting and atrophy (to waste away), not elsewhere classified, muscle weakness, and tobacco use. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure an as needed (PRN) psychotropic medication was prescribed with a 14-day duration and re-evaluated for continued use for 1 of 5 residents (Resident #39) reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 11/6/24 at 10:20 AM, the surveyor observed Resident # 39, awake and alert, lying in bed with a family member at the bedside. The resident's spouse stated that the resident has been depressed and had started on Zoloft (anti-depressant) medications and has been getting seen by psychiatry doctor. On 11/7/24 at 8:50 AM, the surveyor observed Resident # 39 lying in bed awake and alert with their breakfast tray on the over bed table. No behaviors observed at that time. [...]

Inspectors wroteComplaint# NJ166308 Based on observation, interview, and review of facility documentation on 1/5/24, it was determined that the facility failed to consistently serve hot foods at acceptable temperatures to the residents. This deficient practice was observed for 2 of 2 test trays on two different units ([NAME] 5 and [NAME] 6) and evidenced by the following: On 1/5/24 at 11:57 AM, the surveyor, in the presence of the Dietary Director (DD), observed the server at the steam table calibrate the digital thermometer before taking the temperatures of the prepared foods. The surveyor recorded the temperatures of the prepared foods on the steam table prior to service at 12:00 PM and the temperatures were as follows: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain multi-use food-contact surfaces in a manner to prevent bacterial growth; b.) store potentially hazardous foods to prevent food-borne illness; c.) cool potentially hazardous foods in a manner to prevent food-borne illness; d.) maintain kitchen equipment in a sanitary manner; and e.) maintain cold food items to prevent food-borne illness. This deficient practice was evidenced by the following: 1. On 7/18/23 at 11:03 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and observed along the tour, the meat walk-in refrigerator's door was left ajar. The surveyor and FSD proceeded into the walk-in refrigerator and observed the ambient temperature to be 55 degrees Fahrenheit (F). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed a.) to clarify a physician's order from 10/2/21 until 7/26/23 for dentures; b.) to apply and remove ace wraps (compression bandage) as ordered by the physician; c.) administer vitamin D3 in accordance to a physician's order; and d.) document on the Medication Administration Record and Treatment Administration Record for residents in accordance with professional standards of practice. This deficient practice was identified for 4 of 25 residents reviewed for professional standards of practice (Resident #62, #65, #66, and #79). 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 documents, it was determined that the facility failed to a.) properly dispose of a medication that fell on a contaminated surface and was previously cited during last standard survey and b.) ensure mediation was not left unattended at a resident's bedside. This deficient practice was identified for 1 of 4 residents reviewed during medication pass observation (Resident #13), and was evidenced by the following: On 7/21/23 at 8:39 AM, the surveyor during medication pass observation observed the Licensed practical Nurse (LPN) on [NAME]-5 nursing unit prepare medication for administration for Resident #13 which included two (2) 1000 milligram (mg) capsules of fish oil (a supplement) and one ampule (vial) of ipratropium-albuterol inhalation solution 0.5-2.5 mg (a medication used to treat symptoms of lung disease). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to serve residents a nourishing snack when there was more than a fourteen-hour span of time between the dinner and breakfast mealtimes. This deficient practice was identified for 10 of 10 residents sampled for bedtime snacks (Resident #2, #21, #43, #45, #47, #66, #100, #103, #104, and #564), and was evidenced by the following: During initial tour of the facility on 7/18/23 at 11:58 AM, Resident #45 informed the surveyor that he/she felt there was a long-time span between dinner and breakfast meals. The resident continued that he/she should receive breakfast around 8:00 AM, but usually received breakfast around 8:30 AM or 9:00 AM. [...]

Inspectors wroteBased on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) follow appropriate infection control practices and perform hand hygiene as indicated during dining observation, b.) ensure respiratory equipment was kept in a clean and sanitary condition and stored properly to reduce the risk of infection, and c.) follow appropriate infection control practices and perform hand hygiene as indicated during a medication pass. This deficient practice was identified on 1 of 2 nursing units ([NAME]-6) for 1 of 3 residents reviewed for respiratory care (Resident #62) and for 2 of 4 residents reviewed for medication pass (Residents #13 and #78.) This deficient practice was evidenced by the following: 1. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to protect the confidentiality of a resident's health related information. This deficient practice was identified for 1 of 4 residents observed during medication pass (Resident #78), and was evidenced by the following: On 7/21/23 at 9:00 AM, during the medication pass observation on [NAME]-5 nursing unit, the surveyor observed the Licensed Practical Nurse (LPN) walk away from the medication cart leaving the Medication Administration Record (MAR) for Resident #78 opened to full view. The MAR was displayed on a fixed laptop attached to the top of the medication cart located in the hallway. The medication cart was locked, but the LPN was not near the cart. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) implement care plan interventions of bilateral floor mats for a resident with a history of falls and b.) develop a care plan for a resident who received nebulizer treatments. This deficient practice was identified for 2 of 25 residents reviewed for comprehensive care plans (Resident #62 and #85), and the evidence was as follows: 1. On 7/24/23 at 10:05 AM, the surveyor observed Resident #85 receiving morning (AM) care. At that time, the surveyor did not observe any floor mats in the room. The surveyor reviewed the medical record for Resident #85. [...]

Inspectors wroteComplaint # NJ165640 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to revise comprehensive care plans in a timely manner for a.) two residents (Resident #59 and #67) with significant weight loss and b.) a resident (Resident #45) with a change in bowel and bladder status. This deficient practice was identified for 3 of 25 resident reviewed for revision of comprehensive care plans (Resident #45, #59, and #67), and the evidence was as follows: 1. On 7/18/23 at 12:14 PM, the surveyor observed Resident #59 seated in their wheelchair watching television. Resident #59 reported that they had an unintentional weight loss due their dislike of the facility's food. The surveyor reviewed the medical record for Resident #59. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) perform complete and accurate skin assessments for visible facial injuries and b.) develop and implement an individualized comprehensive care plan with interventions for a resident's behavior of excoriating their skin. This deficient practice was identified for 1 of 3 residents reviewed for mood and behavior (Resident #80) and was evidenced by the following: On 7/18/23 at 11:02 AM, the surveyor observed Resident #80 in bed wearing a hospital gown. The surveyor observed a wound on the jaw on the left side of the resident's face. The resident stated to the surveyor he/she liked to pick at the scabs on their skin; that the nurse did not treat or bandage the area, but that would be a good idea. The surveyor reviewed the medical record for Resident #80. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure all medications were administered without an error of 5% or more. During the medication observation on 7/21/23, the surveyor observed three (3) nurses administer medications to four (4) residents. There were 35 opportunities, and three (3) errors were observed which calculated a medication administration error rate of 8.5%. This deficient practice was identified for 1 of 4 residents (Resident #65) that were administered medications by 1 of 3 nurses. The deficient practice was evidenced as follows: On 7/21/23 at 9:13 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medications for Resident #65 which included, Bactrim [DS] (double strength; an antibiotic), Depakote [DR] (delayed release; a mood stabilizer). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) properly label opened multi-dose medications, b.) ensure that out of date medications were removed from the medication carts where other current in use medications were stored, and c.) maintain proper temperature ranges for the medication refrigerators. This deficient practice was identified for 2 of 4 medication carts and 2 of 2 medication refrigerators on 2 of 2 nursing units ([NAME]-5 and [NAME]-6) and was evidenced by the following: 1. On 7/25/23 at 11:47 AM, the surveyor inspected the [NAME]-5 nursing unit medication cart identified as Cart 3 & 4, in the presence of Licensed Practical Nurse (LPN #1). There was an opened multi-dose insulin lispro pen that was not labeled with an opened date. The date on the bag for the insulin lispro pen was 6/1/23. [...]

Inspectors wroteComplaint NJ#: 164425 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure safe and appetizing temperatures of food for 4 of 4 entree meals observed during 1 of 1 meal observations (breakfast). This deficient practice was evidenced by the following: On 7/21/23 at 10:35 AM, the surveyor conducted a Resident Council meeting which included nine residents (Resident #2, #21, #43, #47, #66, #100, #103, #104, and #564). All nine residents informed the surveyor during the meeting that all meals served at the facility were cold, and that the facility did not offer to warm up cold food. Resident #21 stated if you asked staff to warm up your food, staff gave you an attitude. The residents stated that food will sit on the floor for at least ten minutes before staff will start to pass out meal trays. [...]