Royal Suites Health Care & Rehabilitation

Inspectors wroteCOMPLAINT #2808075 Based on interview, medical record review, and review of pertinent facility documentation on 7/1/26, it was determined that the facility failed to ensure the safety of a severely cognitively impaired resident (Resident #3) who had a history of falls. Resident #3 suffered six unwitnessed falls that occurred on the following dates: 2/14/26, 2/15/26, 3/2/26, 3/17/26, 3/20/26 and 3/24/26. Two of the falls required emergency room visit for treatment due to laceration (cut) to the resident's forehead. This deficient practice was identified for 1 of 3 residents reviewed for falls (Resident #3) and was evidenced by the following: Resident #3 was not at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record revealed that Resident #3 was admitted to the facility with diagnoses that included but were not limited to: [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner designed to prevent food borne illness. This deficient practice was evidenced by the following: On 05/13/2025 from 09:39 to 10:18 AM the surveyor, accompanied by the facility Food Service Director (FSD), observed the following in the kitchen: 1. The surveyor and FSD were in the dairy kitchen. The dairy drying rack adjacent to the dairy manual wash sink had two (2) stacks of dessert plates that were cleaned and sanitized. The dessert plates were not stored in the inverted position or covered. The dessert plates were exposed to contamination. On an adjacent rack, a stack of eight (8) monkey bowls were not stored inverted or covered and were exposed to contamination. [...]

Inspectors wroteBased on observation, record review, and review of other pertinent facility documents, it was determined that the facility failed to ensure that appropriate incontinence care was provided to residents who needed assistance for toileting hygiene. This deficient practice was identified for 2 of 2 residents (Resident #23 and Resident #68) reviewed for activities of daily living (ADLs), and was evidenced by the following: 1.) On 5/19/2025 at 9:33 AM, during the incontinence tour of the memory care unit, the surveyor accompanied by Licensed Practical Nurse/ Unit Manager (LPN/UM) #2, noted a strong malodorous smell of urine from the hallway outside the room of Resident #68 and Resident #23. Upon entering the room, blackish marks were observed on the floor. The surveyor observed Resident #68 awake but not verbally engaging and lying on mattress without bed linen. [...]

Inspectors wroteComplaint # NJ183027 Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to; a.) consistently follow a physician order for treatment of facility-acquired pressure ulcer, b.) ensure pressure-relieving interventions were consistently implemented for facility-acquired pressure ulcer, and c.) weekly skin assessment was consistently completed. This deficient practice was identified for 1 of 5 residents (Resident #288) reviewed for pressure ulcers and was evidenced by the following: A review of the admission Record indicated that Resident #288 was admitted to the facility with diagnoses that included but not limited to; [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documents, it was determined that the facility failed to consistently provide urinary catheter care, as physician ordered for 1 of 5 residents (Resident #98) for urinary catheter. This deficient practice was evidenced by the following: On 05/13/2025 at 10:51 AM during the initial tour of the facility the surveyor observed Resident #98 seated in their wheelchair in their room. Resident #98 was observed to be wearing shorts and had a urinary catheter bag exposed by being attached to upper right thigh. A Privacy cover was observed on the urinary leg bag. According to the admission Record Resident #98 was admitted to the facility with the following but not limited to diagnoses: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined the facility failed to accurately document the administration of two controlled medications for 1 sampled resident (Resident #338) identified upon inspection of 1 of 4 medication carts (mid-west cart, second floor). The evidence was as follows: On 5/20/25 at 1:22 PM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the second-floor mid-west medication cart. A review of the narcotics located in the secured and locked narcotic box and reconciled to the controlled drug administration record, a declining inventory sheet, revealed Resident #338's tramadol 50 milligram (mg) tablet, a medication used to relieve pain, did not match. The blister pack contained 29 tablets, and the declining inventory sheet indicated there should be 30 tablets remaining. [...]

Inspectors wroteBased on interview, review of medical record and other pertinent facility documents, it was determined that the facility failed to: a.) ensure blood work was obtained in accordance with physician orders for the monitoring of an anticoagulant medication, Warfarin, (a medication used to prevent or treat blood clots in the heart and blood vessels) and insulin medication, Humalog and b.) ensure that high-risk medications categorized as having Narrow Therapeutic Index (NTI) (medication in which the therapeutic dose is close to the toxic dose) were administered in accordance with the physician's orders. This deficient practice was identified for 1 of 1 resident (Resident #183) reviewed for medication management and was evidenced by the following: On 5/15/2025 at 8:18 AM, the surveyor observed Resident #183 in bed awake. The resident stated that they were going to have dialysis that morning. [...]

Inspectors wroteBased on observation, interview, review of medical records, and other facility documents, it was determined that the facility failed to use appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice, specifically by a.) failing to follow appropriate disinfection of a shared resident care equipment during medication administration observation, b.) failing to wear protective gown while doing incontinence check with a resident on Enhanced Barrier Precautions (EBP), and c.) failing to place a resident with indwelling foley catheter on EBP. This deficient practice was identified for 3 out of 3 unsampled residents during medication administration observation and 2 of 3 residents reviewed for EBP (Resident #110 and Resident #122). [...]

Inspectors wroteBased on observation, interview, record review, and document review, it was determined that the facility failed to provide sufficient nursing staff to ensure resident's highest practical wellbeing by failing to: a.) provide incontinence care, b.) provide showers as scheduled, c.) assist resident with activities of daily living, d.) maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey. 1) During an interview with Surveyor #1 on 3/2/2023 at 9:51 AM, Certified Nursing Assistant (CNA #1) stated that staffing is not great now. CNA #1 stated that on average she has 15 residents in her care. CNA #1 added that if there on only 4 aides on the unit, residents will probably not get a shower. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 2/28/2023 from 9:26 AM to 9:46 AM, the surveyor, accompanied by the Food Service Director, observed the following in the kitchen: 1. On a middle rack in the dry storage room an opened bag of pasta was wrapped in plastic wrap. The plastic wrap and the original bag had no open or use by date. The FSD threw the bag of opened pasta in the trash. 2. On a multi-tiered, wheeled can storage rack in the dry storage room, a can of sauerkraut on a lower rack had a significant dent on the upper seam. When shown to the FSD they agreed that the dent was on the seam of the can. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure that a.) the residents' were transported from one area of the unit to another area in a dignified manner for 1 of 34 sampled residents (Resident # 13) and 2 unsampled residents, who were observed to be pulled backwards in the Geri chair and b.) failed to ensure that the residents' dining experience was provided in a manner to promote the dignity and respect of the residents, who were not served their meal at the same time while seated at the same table during dining observations . This deficient practice was evidenced by the following: 1. On 2/28/2023 at 12:10 PM, Surveyor #1 observed an unsampled resident to be pulled backwards in a Geri chair by Unit Manager Licensed Practical Nurse (UM/LPN #1) through the dining room out to the hallway. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to create a homelike environment during dining by not removing food from serving trays. The deficient practice was observed on the third-floor dining room and evidenced by the following: On 2/28/2023 at 11:42 AM, Surveyor #1 began a lunch meal observation in the third-floor dining room with the arrival of the first meal truck. Residents were served their meals on trays. Food was not removed from the trays and placed directly on the table during meal service. On 2/28/2023 at 12:04 PM, the second meal truck arrived to the unit dining room and the residents were served their meals on trays. Food was not removed from the tray and placed directly on the table during meal service. On 2/28/2023 at 12:21 PM, the third meal truck arrived to unit dining room and the residents were served their meals on tray. [...]

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined the facility failed to provide necessary care of respiratory equipment consistent with professional standards by a.) not replacing and properly storing a nasal cannula (tube used to deliver oxygen to a person) in accordance with facility policy and b.) not properly storing a nebulizer (small machine that turns liquid medicine into a mist that can be easily inhaled) according to facility policy. The deficient practice was identified for 2 of 3 residents (Resident #145 and #36) reviewed for Oxygen. The deficient practice was evidenced by the following: A.) On 2/28/2023 at 9:55 AM, during the initial tour of the facility, Surveyor #1 observed Resident #145 in bed in his/her room. [...]

Inspectors wroteBased on interview, and review of other facility records, it was determined that the facility Quality Assessment and Performance Improvement (QAPI) committee failed to utilize the Facility Performance Improvement Plan to follow the facility process to measure and utilize data acquired for obtaining weights as ordered and develop quantitative and measurable goals, as well as document bi-weekly meeting minutes for the performance improvement project. This deficient practice was evidenced by the following: On 3/8/2023 at 8:59 AM, the surveyors conducted an interview with the Unit Manager/Licensed Practical Nurse (UM/LPN #1) assigned to the 3rd floor of the facility. The surveyors asked UM/LPN #1 if she was familiar with the QAPI for weight discrepancies on the unit. UM/LPN #1 told the surveyors, Yes, I am aware that there is a QAPI for weights. [...]

Inspectors wroteBased on observation, interview and record review and review of other facility documentation, it was determined that the facility failed to ensure that visitors and contracted agents who provided services to residents were familiar and adhered to infection practice guidelines according to the facility's policy and Center for Disease Control (CDC). This deficient practice was identified as evidenced by the following: On 2/28/2023 at 12:01 PM, the surveyor observed a visitor dressed in street clothes, enter, and exit a resident room that was on isolation for COVID-19 without the required Personal Protective Equipment (PPE). The visitor stated she did not have physical contact with the resident. The surveyor pointed out signage posted on the door that read: STOP!! Special Droplet/Contact Precautions in addition to Standard Precautions; only essential personnel should enter this room. [...]