The Arbor at Laurel Circle

Inspectors wroteBased on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure reference checks were completed for 18 of the 52 (Employee #1 through #18) newly hired employees reviewed since last survey of 9/13/2024. This deficient practice was evidenced by the following:1/13/2026, the surveyors reviewed the provided employee files which did not reveal reference checks for the following employees. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to change respiratory equipment in a manner to prevent contamination for infection control. This deficient practice was identified for 1 of 3 residents reviewed for respiratory care (Resident #23), and was evidenced by the following:On 1/9/26 at 11:13 AM, during the initial tour of the facility, the surveyor observed Resident #23 in their bedroom seated in their wheelchair. The surveyor observed an oxygen concentrator (device that delivers oxygen) with nasal cannula (device that delivers additional oxygen through the nose) tubing placed on the oxygen concentrator with a piece of clear tape with the date 12/5. The resident stated that they used oxygen at all times. The surveyor also observed a nebulizer machine located on the bedside table with tubing attached. [...]

Inspectors wroteComplaint # NJ 169997 Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to a.) thoroughly review the hospital discharge summary (After Visit Summary) and communicate the recommendations for an anti-anxiety (AA) medication to the physician, and b.) follow a physician's order for an AA medication (Clonazepam) ordered to be administered daily at bedtime. This resulted in Resident #152 not receiving the physician ordered AA medication for 14 days (from 12/5/23 through 12/19/23) which resulted in Resident #152 experiencing a change in behaviors which included: agitation, anxiety, insomnia and wandering at night. This deficient practice was identified for 1 of 7 residents (Resident #152), reviewed for medication administration and was evidenced by the following: Reference: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the remote healthcare food service pantry area, and adjacent storage room was maintained in a clean and sanitary manner to prevent the potential for food borne illness. The deficient practice was evidenced by the following: On 09/10/24 at 11:34 AM, the surveyor toured the healthcare food service pantry in the presence of the Food Service Supervisor (FSS). -During the meal set up, and placement into the steam table, the surveyor observed an ant crawling up the wall in the kitchen and several small flying insects in the pantry. The FSS stated there was an ant issue and the facility was notified and the pest people sprayed for ants. At that time, the surveyor observed that there was splatters in several areas on the wall and crumbs and other debris on the floor behind the equipment and in the corners. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to 1) have a system in place to ensure activities were conducted as scheduled, and 2) have a system in place to ensure residents were receiving their identified activity preferences to support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This deficient practice was identified for Resident #34, on 2 of 2 units and was evidenced as follows: A review of the facility provided policy and procedure, Community Life Services [name redacted] Policies and Procedures revised 1/2024, included but was not limited to; Monthly Program Calendars. There are 3 neighborhood calendars. Calendars are distributed for each neighborhood. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to ensure fall prevention interventions were consistently implemented, revised after each fall and supervision was provided for residents at risk for falls. This deficient practice was identified for 2 of 2 residents (Resident #9 and Resident #34) reviewed for falls and was evidenced by the following: 1.) On 09/09/24 at 7:04 PM, Surveyor #1 observed Resident #9 in bed, the bed was in a low position, the resident was non verbal and would not respond to the surveyor. Surveyor #1 observed a folded floor mat on the side of the bed in the resident's room. On 09/10/24 at 8:42 AM, Surveyor #1 observed Resident #9 sitting in a wheelchair at the bedside. Resident #9 was awake and alert and able to feed themselves after the breakfast tray was set-up. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to have an effective system in place to self- identify concerns and develop and maintain an effective data-driven Quality Assurance Performance Improvement (QAPI) program for: a) reviewing adverse events, including medication errors and falls, b) ensuring an effective pest control program was maintained, c) ensuring kitchen sanitation was maintained, and d) ensuring activity programs occurred as scheduled. The deficient practice was as evidenced by the following: Refer: 679E, 684G, 689E, 812F, 925E On 09/12/24 at 1:44 PM, the Liscensed Nursing Home Administrator (LHNA) provided the QAPI minutes for August 2024. The document revealed the following QAPIs: Admin [LHNA]-N/A [not applicable]; Community Life-N/A; EVS [environmental services]- Turnover of rooms after discharge; [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to maintain an effective pest control program for the healthcare dining room, attached meal service pantry and food storage area. The deficient practice was evidenced by the following: On 09/10/24 at 11:34 AM, the surveyor observed the meal preparation in the healthcare pantry, located on the 2nd floor, with the Food Service Supervisor (FSS) present. The trays were being assembled for distribution to the resident and for dining room service. The surveyor observed an ant crawling up the wall in the kitchen and several small flying insects in the pantry. The FSS stated there was an ant issue and the facility was notified and the pest people sprayed for ants. [...]

Inspectors wroteBased on observation and interview it was determined that the facility failed to maintain the healthcare dining room in a clean and homelike manner. The deficient practice was evidenced by the following: On 09/10/24 at 11:34 AM, the surveyor observed the meal preparation in the healthcare pantry, located on the 2nd floor, with the Food Service Supervisor (FSS) present. The trays were being assembled for distribution to the residents who eat in their rooms. At that time the surveyor observed an ant crawling up the wall in the kitchen and several small flying insects in the pantry. The FSS stated there was an ant issue and the facility was notified and the pest people sprayed for ants. At that time, the surveyor observed that there were splatters in several areas on the wall and crumbs and other debris on the floor behind the equipment and in the corners. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to revise a resident-centered on-going care plan for a resident who sustained multiple falls. This deficient practice was identified for 1 of 13 residents (Resident #34) reviewed for care plans and was evidenced by the following: A review of the facility provided policy, Care Plans, Comprehensive Person-Centered revised March 2022, included but was not limited to; Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that oxygen and respiratory related treatments were provided in a manner to prevent the spread of infection and injury for 1 of 1 resident (Resident #153) reviewed for respiratory care. The deficient practice was evidenced by the following: On 9/10/24 at 10:55AM, in the room of Resident #153, the surveyor observed an oxygen cylinder by the chair in a canvas carrier, unsupported, not in a cylinder holder. The oxygen tubing was wrapped around top of cylinder with a label dated 8/30/24. The surveyor did not observe an oxygen in use sign on the door or over the bed. The surveyor also observed a nebulizer machine on Resident #153's bedside table, with a mask wrapped in a paper towel. The surveyor did not observe a label on the nebulizer tubing/mask. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring a.) proper administration technique for an insulin pen injector as per manufacturer specifications and b.) vital parameters, (blood sugar, blood pressure, heart rate), were obtained just prior to administration of medications that had physician's orders which based the results of the parameters on whether to administer the medications for four (4) of seven (7) residents, (Resident #39, #44, #153 and #252), observed for one (1) of two (2) nurses during the medication administration observation. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review and other pertinent facility documents it was determined that the facility failed to document attempted non-drug interventions and the need for an as needed (PRN) psychoactive medication (Xanax) to be administered. The deficient practice was identified for one (1) of five (5) residents reviewed for unnecessary medications, (Resident #25) and was evidenced by the following: On 9/9/24 at 7:15 PM, the surveyor observed the Resident #25 sleeping in the room on an air mattress bed. On 9/10/24 at 8:58 AM, the surveyor observed the resident in the room sitting on a recliner. The resident stated, I've been here for five years. I'm working with therapy a couple of times a week because I try to move my legs and arms. I would like to walk again that's why I feel sad, but I really love it here and working towards that. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow appropriate infection control and hand hygiene practices to prevent the spread of infection. This deficient practice was identified for 6 of 6 resident's observed during the meal delivery. The evidence was as follows: On 9/10/24 at 8:10 AM, the surveyor observed the Certified Nursing Assistant (CNA) delivered the breakfast meals to the Unit. The surveyor followed the CNA to the rooms and observed there was no sani-wipe on the tray, The CNA delivered the tray, adjusted the bedside table, set the tray up and left the room. The CNA did not provide the residents with opportunities to cleanse their hands prior to the meals. The CNA left the room and used Alcohol Base Hand Rub (ABHR) to cleanse his hands prior to deliver the next tray. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to conduct yearly performance reviews of Certified Nursing Aides (CNA) in order to provide specific education based on the outcomes of the reviews. This deficient practice was identified for 5 of 5 CNAs whose personnel records were reviewed, and was evidenced by the following: On 7/12/23 at 2:10 PM, the surveyor requested from the Director of Nursing to provide the most recent performance evaluation for five randomly selected Certified Nursing Aides (CNA #1; #2; #3; #4; and #5). On 7/13/23 at 9:05 AM, the Licensed Nursing Home Administrator (LNHA) provided the survey team with the five selected CNAs performance evaluations. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure dietary staff had the appropriate competencies and skill sets to effectively use and maintain the facility's high temperature dish machine. This deficient practice had the potential to affect all residents, and was evidenced by the following: During a follow-up visit to kitchen on 7/13/23 10:09 AM, the surveyor conducted an inspection of the dish machine, that was not currently in use, in the presence of the Executive Chef. The Executive Chef stated the facility utilized a high temperature dish machine and the gauges should read minimum of 160 degrees Fahrenheit (F) for wash and minimum of 180 F for rinse. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a visually impaired resident who was dependent on staff for activities of daily living (ADL) was physically assisted with meals to prevent weight loss. This deficient practice was identified for 1 of 15 residents reviewed for ADL care (Resident #13), and was evidenced by the following: On 7/10/23 at 12:17 PM, the surveyor observed Resident #13 in their room eating lunch feeding themselves. The resident questioned the surveyor several times what they were eating, they stated they could not see what was on the plate. The surveyor observed that the resident was eating a whole sweet potato and grilled chicken that was cut in large pieces, and part of the chicken was not cut all the way through and still intact whole; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness and b.) maintain kitchen equipment in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 7/7/23 at 10:14 AM, the surveyor toured the kitchen with the Executive Chef and observed the following: 1. On a rack in the walk-in freezer, six baked pies, not dated or covered. The pies were exposed to air. The Executive Chef confirmed the pies should be dated and covered. 2. On a drying rack, one large white cutting board discolored yellow and deeply pitting. The Executive Chef confirmed the cutting board should be discarded because of the potential for bacterial growth. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure their infection control policies were followed and maintained for water management to minimize the risk of legionella and other opportunistic pathogens in building water systems. This deficient practice had the potential to affect all 42 residents and was evidenced by the following: On 7/13/23 at 9:47 AM, the surveyor interviewed the Director of Facilities (DOF) who stated that he was not sure how often the facility tested the water for legionella (bacteria that can cause a serious type of pneumonia), that the facility had a scheduled testing in August. The DOF stated he was not aware when legionella testing was last done in the facility and would reach out to the Licensed Nursing Home Administrator (LNHA) in order to obtain that information. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to maintain an effective tracking system to ensure that Certified Nursing Aides (CNA) received twelve hours of mandatory in-service training. This was identified for 4 of 5 CNA files reviewed for in-service education training (CNA #1, #3, #4, and #5) and was evidenced by the following: On 7/12/23 at 2:10 PM, the surveyor requested from the Director of Nursing to provide all education from 2022 for five randomly selected CNAs (CNA #1; #2; #3; #4; and #5). On 7/13/23 at 9:05 AM, the Licensed Nursing Home Administrator (LNHA) provided the survey team with education for the five selected CNAs with education dates which included both 2022 and 2023. At this time, the surveyor requested again the education provided in 2022. [...]