Ridgewood Center

Inspectors wroteBased on interview and review of pertinent facility documentation, it was determined that the facility failed to ensure: a.) the Antibiotic Stewardship Program (ASP) Policy and Procedure, part of the facility Infection Prevention Control Program (IPCP) included a procedure for the reporting in Quality Assurance and Performance Improvement (QAPI), b.) the standardized infection assessment tool or management algorithm (IST) was consistently utilized for prescribed antibiotics, and c.) the facility maintained evidence of an ongoing analysis of surveillance data for organisms with a documented follow-up in response to the collected data. This deficient practice was evidenced and could affect all residents in the facility by the following: [...]

Inspectors wroteBased on observation and interview on 5/20/26 and 5/21/26 in the presence of the Maintenance Director (MD) and Regional Plant Operations Director (RPOD), it was determined that the facility failed to maintain their Packaged Terminal Air Conditioner (PTAC) units in safe operating condition. This deficient practice was evidenced for 28 of 28 PTAC units observed and could affect all residents in the facility by the following: Observations while touring the facility from 9:00 AM to 12:00 PM, revealed that PTAC filters were clogged and dirty throughout the facility. In an interview the MD and the RPOD both confirmed the findings. A policy and procedure for PTAC maintenance was requested but not provided at the time of the LSC exit conference. [...]

Inspectors wroteREPEAT DEFICIENCYBased 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 as 2 of 2 units (East and West), 2 of 2 shower rooms, and 1 of 3 dining rooms, and was evidenced by the following:The deficient practice was evidenced by the following: 1. On 5/18/26 at 10:02 AM, Surveyor #1 (S #1) observed Resident #5 lying in bed during the initial interview, with no call bell was observed within the resident's reach. On 5/18/26 at 10:41 AM, S #1 conducted a second observation of Resident #5 and again observed that no call bell was present at the bedside or within reach of the resident. At that time, S #1 interviewed the assigned Registered Nurse (RN), who identified that Resident #5's call bell was located with the roommate. [...]

Inspectors wroteBased on observations, interviews, record review, and review of pertinent facility documents, the facility failed to, a.) place an indwelling catheter collection bag in a privacy bag and post signage for enhanced barrier precautions (EBP) for 2 of 3 residents (Resident #3 and #42) and b) place an indwelling catheter collection bag below the level of the bladder and develop a care plan (CP) or included interventions for EBP based on current professional standards of practice for 1 or 3 residents (Resident #3) reviewed for urinary catheter care or urinary tract infection (UTI). The deficient practice was evidenced by the following:Reference: The Healthcare Infection Control Practices Advisory Committee guidance titled GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 with an updated date of June 6, 2019, includes the following:III. [...]

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 (neb) treatments received the necessary respiratory care and services, according to the standard of clinical practice, specifically a) that neb treatment equipment was dated and stored in accordance with infection control measures for 2 of 2 residents reviewed for respiratory care (Resident #6 and #42) and b) that O2 equipment were stored in accordance with infection control measures and that cautionary and safety signs indicating the use of O2 were posted for 1 of 2 residents reviewed for respiratory care (Resident #42). The deficient practice had the potential to affect all residents receiving respiratory care and was evidenced by the following: Reference: [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure a.) timely meal delivery and provide warm food for 8 of 18 residents (Residents #4, #48, #70, Unsampled Resident (UR) #1, #2, #3, #4, and #5), b.) staff responded to call bell timely for 2 of 2 nursing units (East and [NAME] Units), and c.) staff signed off medication record and no blanks for 1 out of 18 residents ( Resident #1). This deficient practice was evidenced by the following: 1. On 5/17/26 at 10:00 AM, Surveyor #1 interviewed Certified Nursing Aide #1 (CNA #1) in the [NAME] nursing station who informed S #1 that there total of 41 residents in the unit, two nurses, and two CNAs. She further stated that she had total of 20 residents in her assignment. [...]

Inspectors wroteREPEAT DEFICIENCYBased on interview, record review, and review of facility documents, it was determined that the facility failed to ensure Certified Nurse Aides (CNAs) had an annual performance evaluations for 5 of 5 CNAs reviewed. This deficient practice was evidenced by the following:On 5/19/26 and 5/20/26, the surveyor made multiple requested numerous times to the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Human Resources Staff (HRS), and Regional Nurse for five CNA employee files containing documentation of their annual performance evaluations. On 5/21/26 at 10:00 AM, the surveyor interviewed the LNHA regarding the employee file review concerns. [...]

Inspectors wroteRefer to F881Based on interview and review of pertinent facility provided documentation, it was determined that the facility failed to ensure that the employed designated Infection Preventionist (IP) a.) worked at least part-time at the facility and b.) completed specialized training in infection prevention and control per Centers for Medicare & Medicaid Services (CMS) guidance prior to assuming the IP role. This deficient practice was identified for 3 of 4 employees reviewed for IP requirements. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, record review, and review of pertinent facility documentation it was identified that the facility failed to offer residents the influenza and pneumonia vaccinations. This deficient practice was identified for 3 out of 5 residents, (Resident #8, #9, and #10), reviewed for vaccination under unnecessary medications. The deficient practice was evidenced by the following: 1. On 5/18/26 at 11:30 AM, Surveyor #1 (S #1) reviewed Resident #8's electronic Medical Records (eMR), under the Immunization Tab, revealed there was no documentation that the influenza (Flu) vaccine was offered to Resident #8 for the 2025-2026 influenza season. On 5/18/26 at 11:47 AM, S #1 reviewed Resident #8's paper medical records on the unit revealed there was no documentation that the flu vaccine was offered to Resident #8 for the 2025-2026 flu season. 2. [...]

Inspectors wroteREPEAT DEFICIENCYBased on interview, record review, and review of facility documents, it was determined that the facility failed to maintain and provide documentation of required staff in-service education and competency records for 5 of 5 Certified Nurse Aide (CNA) employee files reviewed for staff training requirements. This deficient practice was evidenced by the following:On 5/19/26 and 5/20/26, the surveyor made multiple requests to the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Human Resources Staff (HRS), and Regional Nurse for five CNA employee files containing documentation of staff in-service education and annual competency/performance records. On 5/21/26 at 10:00 AM, the surveyor interviewed the LNHA regarding the employee file review concerns. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to treat a resident with respect and dignity. This deficient practice was identified for 1 of 18 residents (Resident #9) reviewed. On 5/17/26 at 10:14 AM, the surveyor observed Resident #9 in bed and stated their bathroom toilet was flooded, and was not able to use. Resident #9 further stated they had to go by themself in their wheelchair to another bathroom. Resident #9 stated they told the caregiver who said they would call somebody. On that same date and time, the surveyor observed that Resident #9's bathroom toilet was flooded with discolored water, filled with feces, and tissues. In addition, the surveyor observed that there were towels over the wet floor outside the bathroom. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to inform the resident's representative (RR) in advance of treatment risks and benefits, options, and alternatives to a resident receiving psychoactive medications (meds). This deficient practice was identified for 1 of 5 residents (Resident #10), reviewed for unnecessary meds. This deficient practice was evidenced by the following:On 5/17/26 at 10:23 AM, the surveyor observed Resident #10 sitting on their bed, eating breakfast, the resident could not answer any questions. On 5/17/26 at 3:45 PM, the surveyor reviewed the medical records of Resident #10, and revealed: A review of the admission Record or face sheet (an admission summary) revealed diagnoses which included but not limited to; [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure the residents' telephone and call devices were readily accessible. The deficient practice was identified for 3 of the 18 residents (Resident #7, Resident #57, and Resident #73) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: 1. On 5/18/26 at 11:10 AM, Surveyor #1 (S #1) interviewed Resident #7 inside their room. During the interview, Resident #7 stated that the resident had recently been moved to the current room within the past week. The resident further stated that there had been a telephone in the previous room, but no telephone was present in the current room. Resident #7 stated that a request had been made for a telephone in the new room; however, none had been provided. [...]

Inspectors wroteBased on interview and review of other facility documentation, it was determined that the facility failed to notify the resident in writing of the items and services that included the cost of those items and services that was required in the beneficiary notice for 1 of 1 resident reviewed for Beneficiary Protection Notification, (Resident #80). This deficient practice was evidenced by the following: On 5/21/26 at 10:15 AM, the surveyor reviewed the Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (SNF ABN) that was completed by the facility for Resident #80, and revealed: -The SNF ABN indicated Resident #80 last covered Medicare A day was 2/8/26, and Resident #80 remained in the facility. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to ensure reference checks were completed for newly hired employees in accordance with facility policy for 12 of 33 employee files reviewed for pre-employment screening. The deficient practice was evidenced by the following:On 5/19/26 at 9:20 AM, the surveyor reviewed 33 newly hired employee personnel files provided to the survey team by the Director of Human Resources and the Regional Market Director. During the review, the surveyor identified that 13 employee files lacked completed reference checks. [...]

Inspectors wroteREPEAT DEFICIENCYBased on the interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to, a.) provide the Resident or Resident Representative (RR) with a written notification of the facility's bed hold policy that included the reserve payment information and b.) send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman (LTCO) for 1 of 2 residents (Resident #77) reviewed for hospitalizations. This deficient practice was evidenced by the following:On 5/21/26 at 8:27 AM, the surveyor reviewed the medical records of Resident #77, and revealed:A review of the most recent Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, revealed in Section A-Identification Information that the resident had an unplanned discharge to the hospital. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to; a.) ensure that as needed and routine orders were not duplicative or clinically appropriate and were clarified for 1 of 21 residents (Resident #78), b.) ensure tube feeding was labeled or dated, and c.) include Candida auris (C. Auris, an emerging, multidrug-resistant fungus (a type of yeast) that causes severe, potentially fatal infections) in the resident's medical diagnosis section of the medical record for 1 of 21 residents reviewed (Resident #1), in accordance with facility's policy and standards of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to follow the recommendations of the Wound Care Consultant Physician (WCCP) for 1 of 1 resident reviewed for PU (Pressure Ulcer), (Resident #1), consistent with professional standards of practice and facility's policy. 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 wroteREPEAT DEFICIENCYBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure the Nursing Home Resident Care Staffing Report was posted and maintained with accurate and current staffing/census information for each shift. The deficient practice, identified in the facility's staffing report posting process, for 2 of 5 days of observation, as evidenced by the following: On 5/17/26 at 9:00 AM, the survey team entered the facility and observed the Nursing Home Resident Care Staffing Report (NHRCSR) located at the receptionist desk. The posted staffing report was dated 5/15/26 (Friday) for the day shift. The surveyor observed that no staffing report was available at the receptionist desk for any day or shift over the weekend. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to properly store and label medications in 1 of 2 medication rooms and 1 of 3 med carts inspected. The deficient practice was evidenced by the following:On 5/20/26 at 10:19 AM, the surveyor inspected the medication (med) cart on the [NAME] Low Unit in the presence of the Registered Nurse (RN). Upon opening a drawer of the cart, the surveyor observed Unsampled Resident #1's (UR #1) Ipratropium Bromide 0.5 milligrams (mg) and Albuterol Sulfate 3 mg Inhalation Solution box with an opened foil pouch inside that contained unit-dose vials. The opened foil pouch had no date of opening written on it. As per the storage information on the foil pouch, Unit-dose vials should remain stored in the protective foil pouch at all times. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to ensure potentially hazardous food items were maintained at safe temperatures during meal service for 1 of 2 units (West). This deficient practice was evidenced by the following:On 5/19/26 at 8:00 AM, the surveyor notified the Food Service Director (FSD) that a breakfast test tray was needed for temperature (temp) checks during the breakfast meal service. The FSD acknowledged the request and stated that room [ROOM NUMBER] (R47) would be the last room to receive breakfast on the morning meal pass. The surveyor notified the FSD that the temp would be taken when R47 received the breakfast tray. The FSD stated that it should take approximately 20 minutes for the meal tray carts to be prepared and distributed to the resident care units. [...]

Inspectors wroteBased on observation, interview, and review of other pertinent facility documentation, it was determined that the facility failed to; a.) properly handle laundry, b.) maintain a clean laundry area, c.) maintain a clean eye wash station, d.) ensure soap was available, and d.) follow appropriate hand hygiene practices for 1 of 2 nurses (1 Registered Nurse) during medication (med) pass observation, 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 the 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, it revealed .Know how to wash hands with soap and water: Wet hands with water. [...]

Inspectors wroteNJ#171811 REPEAT DEFICIENCY Based 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 2 units, and was evidenced by the following: 1. On 4/6/25 at 9:40 AM, Surveyor #1 (S#1) observed Resident #59 inside room [ROOM NUMBER], lying on bed with eyes closed. The nightstand table bottom door had no cover, and the cover piece was on the side of the table. The bottom part of the nightstand table had multiple personal items that include two bedpans, papers, and plastics. The regular chair inside the room had multiple blackish and brownish stains. The adjoining toilet room (with room [ROOM NUMBER]) vent had accumulation of grayish substances, and the tissue paper holder was broken. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 4/6/25 at 9:21 AM, the surveyor, in the presence of the Cook, observed the following during the kitchen tour: 1. In the juice refrigerator, there was an unlabeled and undated glass bottle containing an orange-colored sauce. The [NAME] stated that it was a staff member's food item and not an item for the residents. The [NAME] acknowledged it should not have been in the refrigerator and removed the bottle. 2. On a food prep countertop, there was a compact blender. The blender cup was sealed on to the machine and was observed wet inside. The [NAME] checked and confirmed the blender cup was wet inside. [...]

Inspectors wroteRefer to F584 and S0560 Based on observations, interviews, and record review, it was determined that the facility failed to ensure the staff, as well as herself, the Licensed Nursing Home Administrator (LNHA), implemented the facility's policies and procedures including the promotion of a homelike environment and sufficient staffing in order to provide the appropriate needs of residents. This failure had the potential to affect all 71 residents who currently live in the facility. The evidence was as follows: On 5/21/25 at 9:00 AM, during revisit #1, to standard of 4/10/25, the survey team entered the facility and observed the posted Nursing Home Resident Care Staffing Report (NHRCSR) dated 5/21/25-Day Shift, current census was 71, shift hours of 7:00 AM-3:00 PM (7-3), and the staff to resident ratio of 1 Certified Nurse Aide (CNA):10.1 Residents. [...]

Inspectors wroteNJ#171811 and #175736 Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure resident's highest practical wellbeing by failing to ensure that residents received timely and appropriate incontinence care. This deficient practice was identified for 7 of 20 residents, (Residents #9, #18, #30, #39, #58, #59, and #276), reviewed. This deficient practice was evidenced by the following: 1. On 4/6/25 at 9:40 AM, the surveyor observed Resident #59 inside room [ROOM NUMBER], lying on bed with eyes closed. On 4/6/25 at 9:58 AM, the surveyor asked the assigned Licensed Practical Nurse (LPN) to accompany the surveyor in Resident #59's room. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to ensure that the Certified Nursing Aide (CNA) received an annual performance review for 5 of 5 CNA files reviewed. This deficient practice was evidenced by the following: On 4/7/25 at 9:47 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the performance reviews for five randomly selected CNAs. On 4/8/25 at 1:40 PM, the Director of Nursing (DON) notified the surveyor that she could not locate the performance reviews for the five CNAs. On 4/9/25 at 1:06 PM, the surveyor notified the LNHA, DON, Clinical Lead of New Jersey (CLoNJ), and Regulatory Compliance Advisor (RCA) the concern that the performance reviews were not done. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to adequately monitor target behaviors for the use of a psychotropic (affecting the brain and nervous system, altering mood, thoughts, perception, and behavior) medications for 5 of 5 residents, (Residents #12, #21, #24, #49, and #57), reviewed for unnecessary medications. This deficient practice was evidenced by the following: 1. On 4/6/25 at 10:29 AM, Surveyor #1 (S#1) observed Resident #12 walking all around the room, alert, and well groomed. S#1 reviewed Resident #12's medical record which revealed the following: A review of the admission Record (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses which included, but not limited to; [...]

Inspectors wroteBased on observations and interviews on 4/8/2025 and 4/9/2025 in the presence of the Senior Maintenance Director (SMD), it was determined that the facility failed to ensure that all devices used to identify call bell notifications were properly functioning. This deficient practice had the potential to affect 40 residents and was evidenced by the following: An observation at 11:19 AM revealed that when testing the call bell system for resident room [ROOM NUMBER], there was no audible notification of the call bell activation at the nurse's station. In an interview at the time, there were three staff members at the nurse's station. The surveyor asked the staff members if they can hear anything. The three staff members stated no. The surveyor notified them they were testing the call bell system for resident room [ROOM NUMBER]. [...]

Inspectors wroteBased on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure licensed staff credentials were verified upon hire for 2 of 5 newly hired licensed staff reviewed (Staff Member #2 and #4). This deficient practice was evidenced by the following: On 4/7/25 at 9:47 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the employee files of six randomly selected new hire employees for which five of the selected were licensed staff. The surveyor reviewed the facility provided files for the five licensed staff. There was no license verification printout from the corresponding licensing entity to verify the staff license was active prior to or upon their date of hire (doh). However, 3 of the 5 licensed staff had a criminal background check (CBC) that contained a license verification. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman (LTCO) for 1of 1 resident reviewed for hospitalization, Resident #18. This deficient practice was evidenced by the following: On 4/6/25 at 10:43 AM, the surveyor observed the Resident #18 sitting on the wheelchair in the day room, and the resident stated that they were hospitalized before. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included, but not limited to; type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, bilateral, complete traumatic amputation of left great toe, subsequent encounter, essential (primary) hypertension. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, it was determined that the facility failed to notify the resident and/or the resident's representative in writing of the reason for transfer or discharge for 1 of 1 resident transferred to the hospital, Resident #18. This deficient practice was evidenced by the following: On 4/6/25 at 10:43 AM, the surveyor observed the Resident #18 sitting on the wheelchair in the day room. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included, but not limited to; type 2 diabetes mellitus with severe non-proliferative diabetic retinopathy with macular edema, bilateral, complete traumatic amputation of left great toe, subsequent encounter, essential (primary) hypertension. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to a.) ensure that the physician orders were followed and orders for blood work was transcribed and followed for 1 of 20 residents, (Resident #59), and b.) adhere to appropriate disposal of unused medication for 1 out of 3 residents, (Resident #65), observed during the medication pass, according to the standard of clinical practice and facility policy. 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 wroteComplaint NJ #184234 Based on interview, observation, and record review, it was determined the facility failed to; a.) update a resident's discharge goals based on the resident's representative (RR) wishes, b.) hold an interdisciplinary care plan meeting to collaborate with the RR on an updated discharge planning process, c.) and document in the electronic medical record , for 1 of 2 residents, (Resident #9), reviewed for discharge planning. This deficient practice was evidenced by the following: On 4/7/25 at 9:25 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #9. A review of the admission Record (or face sheet, an admission summary) documented that the resident had diagnoses that included but were not limited to, dementia, and adult failure to thrive (a decline in overall health and well-being in older adults). [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to, a.) maintain the necessary respiratory care and services of residents by following the physician orders and b.) verify the duplicate order for one 1 of 1 resident, (Resident #39), reviewed for respiratory care, in accordance with professional standards of practice and facility policy. 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 ensure that the 24-hour staffing report was accurately posted and in a prominent place within the facility readily accessible and visible to the residents and the visitors. This deficient practice was evidenced by the following: On 4/6/25 at 9:00 AM, the surveyor entered the facility. The surveyor observed that the Nursing Home Resident Care Staffing Report (NHRCSR) that was posted on the table across from the receptionist desk was dated 4/3/25, day shift. The NHRCSR was not up to date. On 4/8/25 at 12:31 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Clinical Lead of New Jersey(CLoNJ) the concern that the staffing report that was posted and observed on 4/6/25 was dated 4/3/25, and was not up to date. [...]

Inspectors wroteNJ#176708 Based on observation, interview, and review of facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate accountability of controlled substances, have sufficient secure procedures in place to prevent further diversion of controlled substances, and to educate all staff on accountability procedures for controlled substances. This deficient practice was identified for 1 of 2 years of controlled substances accountability reviewed. 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 interviews, record review, and a review of pertinent facility documents, it was determined that the facility's Consultant Pharmacist (CP) failed to identify irregularity for 1 of 3 residents, (Resident #62), during the medication pass observation. This deficient practice was evidenced by the following: On 4/8/25 at 9:31 AM, the surveyor observed the Licensed Practical Nurse (LPN) assigned to the medication cart (med-cart) located on the East Wing Unit, High Side, prepare and administer due medications (meds) to Resident #62. The surveyor observed the LPN prepare and administer Linzess (a medication (med) used to treat irritable bowel syndrome with constipation). The med was scheduled to be given at 9:00 AM per the physician's orders (PO) and the LPN was within the accepted time based on the order. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to a.) assure that the required staff attended the quarterly Quality Assurance (QA) meetings for 2 of 4 quarterly QA meetings and b.) ensure there was a scheduled frequency of meetings and reporting according to the regulation and facility's policy. This deficient practice was evidenced by the following: On 4/8/25 at 3:09 PM, the surveyor reviewed the QAPI (Quality Assurance Performance Improvement) Plan, dated 1/1/25, and the Center Quality Assurance Performance Improvement Process Policy that was provided by Licensed Nursing Home Administrator #1 (LNHA#1) on 4/7/25 at 8:20 AM, and revealed that the facility QAPI members will meet at least quarterly. The LNHA also provided the QAPI sign in sheets and revealed: 7/24/24=10 attendees signed and did not include their titles. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to offer a resident a pneumococcal vaccine. This deficient practice was identified for 1 of 5 residents, (Residents #57), reviewed for immunizations. This deficient practice was evidenced by the following: On 4/9/25 at 11:12 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #57 for immunizations. A review of the admission Record (or facesheet, an admission summary) documented that Resident #57 was recently admitted and had diagnoses that included but were not limited to; dementia, chronic atrial fibrillation (an irregular, rapid heart rate that commonly causes poor blood flow), and hypertension (high blood pressure). [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to offer a resident a coronavirus-19 (COVID-19) vaccine. This deficient practice was identified for 1 of 5 residents, (Residents #57), reviewed for immunizations. This deficient practice was evidenced by the following: On 4/9/25 at 11:12 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #57 for immunizations. A review of the admission Record (or facesheet, an admission summary) documented that Resident #57 was recently admitted and had diagnoses that included but were not limited to; dementia, chronic atrial fibrillation (an irregular, rapid heart rate that commonly causes poor blood flow), and hypertension (high blood pressure). [...]

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 included effective communications for 3 of 5 Certified Nurse Aides (CNAs), reviewed for mandatory education (CNA #1, #4 and #5). This deficient practice was evidenced by the following: On 4/7/25 at 9:47 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the annual education that was done for five randomly selected CNAs based on their date of hire. On 4/7/25 at 1:04 PM, the surveyor interviewed the Infection Preventionist/Educator Licensed Practical Nurse (IP/E/LPN) regarding the education process. The IP/E/LPN stated that she started in February and that the education was done in person and in an electronic system. [...]

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 included rights of the resident and the responsibilities of a facility to properly care for its residents for 2 of 5 Certified Nurse Aides (CNAs), reviewed for mandatory education (CNA #4 and #5). This deficient practice was evidenced by the following: On 4/7/25 at 9:47 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the annual education that was done for five randomly selected CNAs based on their date of hire (doh). On 4/7/25 at 1:04 PM, the surveyor interviewed the Infection Preventionist/Educator Licensed Practical Nurse (IP/E/LPN) regarding the education process. The IP/E/LPN stated that she started in February and that the education was done in person and in an electronic system. [...]

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 3 of 5 Certified Nurse Aides (CNAs), reviewed for mandatory education (CNA #1, #4 and #5). This deficient practice was evidenced by the following: On 4/7/25 at 9:47 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the annual education that was done for five randomly selected CNAs based on their date of hire (doh). On 4/7/25 at 1:04 PM, the surveyor interviewed the Infection Preventionist/Educator Licensed Practical Nurse (IP/E/LPN) regarding the education process. [...]

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to ensure that a) Certified Nurses Aides (CNA) received 12 hours of mandatory annual in-service training for 1 of 5 CNAs reviewed (CNA #4); b) CNA education included resident abuse prevention training for 1 of 5 CNAs reviewed (CNA #4); and c) dementia management training for 2 of 5 CNAs reviewed (CNA #4 and CNA #5). This deficient practice was evidenced by the following: On 4/7/25 at 9:47 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the annual education that was done for five randomly selected CNAs based on their date of hire (doh). On 4/7/25 at 1:04 PM, the surveyor interviewed the Infection Preventionist/Educator Licensed Practical Nurse (IP/E/LPN) regarding the education process. [...]

Inspectors wroteBased on interview, record review, record review, and review of other facility documentation, it was determined the facility failed to ensure accurate documentation and review of a resident's advance directives for 3 of 18 residents (Resident #49, #36, #8) reviewed. This deficient practice was evidenced by the following: 1. On 11/28/23 at 11:51 AM, the surveyor observed Resident #49 sitting in a wheelchair in their room. The resident was alert, pleasant, and verbalized no concerns. A review of Resident #49's hybrid (electronic and paper) medical records revealed the following: According to the admission Record (an admission summary) the resident was admitted with diagnoses that included but were not limited to, Dementia, Anxiety Disorder, and Schizophrenia. A physician's order, dated 11/15/2021 read, DO NOT RESUSCITATE (DNR). [...]

Inspectors wroteComplaint #: NJ00162688, NJ00161423 Based on observation, interview, and record review, it was determined that the facility failed to maintain resident's equipment and living areas in a clean and home like manner. This deficient practice was identified for 2 of 20 residents (Resident #54 and Resident # 67) and was evidenced by the following: 1. On 11/28/23 at 11:40 AM, the surveyor observed Resident #54 in the day room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor reviewed Resident #54's hybrid medical records. The admission Record (AR) reflected that Resident #54 was admitted to the facility with medical diagnoses which included but not limited to Dementia, Hypertension, Type 2 Diabetes Mellitus and Hyperlipidemia. [...]

Inspectors wroteComplaint #: NJ00162321 Based on observation, interview, and record review it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 4 of 20 residents reviewed, Resident #18, #69, #8, and #170. This deficient practice was evidenced by the following: 1. On 11/28/2023 at 11:59 AM, the surveyor observed Resident #18 in bed with eyes closed. The surveyor observed the resident with a wander guard (wander guard is an electronic device made for the purpose of keeping elderly people or people with dementia from wandering as well as alerting the caregiver whenever his or her patient breaches a perimeter or strays too far) worn on their right ankle. The surveyor reviewed Resident #18's electronic medical record (EMR). [...]

Inspectors wroteComplaint #NJ00158121 Based on observation, interview, and record review it was determined that the facility failed to develop a comprehensive, person-centered care plan for 1 of 20 residents reviewed for comprehensive care plans (Resident #270). This deficient practice was evidenced by the following: 1. The surveyor reviewed the hybrid (paper and electronic) medical record of Resident #270 which revealed the following: The admission Minimum Data Set (MDS), an assessment tool to facilitate care, dated 7/29/22, indicated the resident had diagnoses that included but were not limited to, heart failure, hypertension, Diabetes Mellitus, and End Stage Renal Disease. The facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). The resident scored an 8 out of 15 which indicated that the resident had moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan for 2 of 20 residents reviewed, Resident #54 and Resident #8. This deficient practice was identified by the following: 1. On 11/28/23 at 11:40 AM, the surveyor observed Resident #54 in the day room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor reviewed Resident #54's hybrid medical records. The admission Record (AR) reflected that Resident #54 was admitted to the facility with medical diagnoses which included but was not limited to Dementia, Hypertension, Type 2 Diabetes Mellitus and Hyperlipidemia. [...]

Inspectors wroteComplaint #: NJ00162986 Based on observation, interview, and record review it was determined the facility failed to consistently follow standards of clinical practice with regards to: accurately documenting the administration of medication for 4 out of 20 residents, Resident #24, #36, and #58 as well as transcribing a physician's order for blood work for 1 out of 20 residents reviewed, Resident #8. 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 interview, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least once every sixty days. This deficient practice was identified for 2 of 20 (Resident #8 and Resident #1) reviewed for physician visits and was evidenced by the following: 1. On 11/28/23 at 11:48 AM, the surveyor observed Resident #8 in the room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor reviewed Resident #8's hybrid medical records. The admission Record (AR) (an admission summary) reflected that Resident #8 was admitted to the facility with medical diagnoses which included but were not limited to Peripheral Vascular Disease, Absence of right leg above knee, Congestive Heart Failure and Atrial Fibrillation. [...]

Inspectors wroteComplaint #: NJ00162986 Based on observation, interview, and record review, it was determined that the, monitored, and reviewed. This deficient practice was identified for 2 of 2 units reviewed during unit inspections. This deficient practice was evidence by the following: 1. On 11/28/23 at 10:00 AM, the surveyor proceeded to perform unit inspections of the facility. While on the [NAME] Unit, the surveyor examined the declining Controlled Medication Utilization Record (CMUR) sheet for Oxycontin 10 mg belonging to Resident #2. The medication was delivered by the provider pharmacy to the facility on 8/18/23. The CMUR documented that on 9/2/23 there were no more tablets left. The CMUR then had an additional line signed with a date of 9/18/23 that there was 1 tablet left in the inventory. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices of appropriately performing hand hygiene and disinfection of a blood pressure cuff used during medication administration for 1 of 4 nursing staff members observed during medication passage on 1 of 2 units observed. This deficient practice was evidenced by the following: On 11/30/23 at 9:02 AM, the surveyor observed Registered Nurse # 1(RN#1) administer medication to Resident #41. RN#1 sanitized his hands with alcohol-based hand rub (ABHR) appropriately before entering the room to check the resident's blood pressure. RN#1 did not disinfect the blood pressure machine prior to entering the room and checking Resident #41's blood pressure. [...]