The Pines at Medford

Inspectors wroteComplaint # 2794238 Based on interview, record review, and review of pertinent documentation, it was determined that the facility failed to implement their abuse policy to immediately conduct a thorough investigation to protect a resident (Resident #65) who alleged sexual abuse. This deficient practice was identified for 1 of 2 residents reviewed for abuse (Resident #65). A review of a Nurse Practitioner (NP) Progress Note dated 2/22/26 at 10:00 AM, revealed that Resident #65 alleged, I was raped. During an interview on 6/09/26, Resident #65 revealed that someone tried to force [themself on me, I thought [gender redacted] was a worker hired to care for me. On 6/10/26, the Director of Nursing (DON) stated that the NP informed the Nursing Supervisor (NS) of the allegation on 2/22/26, and the NS reported it to the Assistant Director of Nursing (ADON). [...]

Inspectors wroteBased on interviews and review of pertinent facility documents, it was determined that the facility failed to ensure a) written policies and procedures were developed and implemented to thoroughly investigate, and maintain documentation of investigation, for all types of abuse b) written procedures were in place to ensure that all residents were protected from physical and psychosocial harm during and after the investigation, and c) ensure ensure that upon receipt of an allegation of abuse, a policy and procedure was followed to ensure when an allegation of resident abuse was reported that the required notification was made within 2-hours to the Department of Health and to other agencies, including law enforcement as indicated. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to have a system in place to ensure residents who were dependent on staff to provide Activities of Daily Living (ADLs- toileting, grooming, dressing, and bathing) were provided with appropriate incontinence and nail care care in a timely manner. This deficient practice was identified for five 5 of 5 residents reviewed (Resident #2, # 21, # 53, #84 and Resident # 92) for ADL care, on 2 of 3 Resident Units (Birch and Cedar), for 5 of 5 residents who attended a resident council meeting, and had the potential to affect all residents who resided at the facility. The evidence was as follows: A review of the Resident Census List dated 6/4/26 revealed there were 48 residents who resided on Birch; [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure sufficient and competent staff were available to assure resident safety and to attain or maintain the highest practicable physical, menatal, and psychosocial well being of each resident by failing to a) provide timely and appropriate incontinence care for residents who were dependent on staff for Activities of Daily Living (ADL's) care (Residents #2, #21, #53, and Resident #92), b) provide nail care for a resident who was dependent of staff for ADL's (Resident #84) and c) ensure staff were competent upon receipt of an allegation of sexual abuse to ensure a process was followed to ensure the safety of the victim, all facility residents and immediately initiate an investigations. [...]

Inspectors wroteBased on observation, interview and document review, it was determined that the facility failed to ensure that the kitchen environment and equipment was maintained in a clean and sanitary manner to prevent potential contamination from foreign substances and limit the potential for the development a foodborne illness. This deficient practice affected all residents who resided at the facility and was evidenced by the following: On 06/04/26 at 9:47 AM, the surveyor conducted an initial tour of the kitchen with the Food Service Director (FSD) and observed the following: -Hand washing sink #1 by the dining room door in the kitchen, soiled with food debris inside sink.-Hand washing sink #2 by the dry storage food in the kitchen, soiled with food debris inside sink. [...]

Inspectors wroteBased on interview, record review, and review of pertinent documents, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure that all residents received care and to ensure the residents attained or maintained their highest practicable physical, mental and psychosocial well being by failing to ensure a) that written policies and procedures were developed and implemented to prevent and prohibit and thoroughly investigate all types of abuse, when on 2/22/26 Resident #65 alleged they were sexually assaulted and the LNHA did not become aware until 2/24/26, and b) ensure appropropriate levels of competent staff provided appropriate care and services to residents who depended on staff for care. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain the resident environment in a clean, sanitary, and homelike manner for 2 of 3 Resident Units (Birch and Cedar) observed, and the deficient practice was evidenced by the following: On 6/9/26 at 6:30 AM, Surveyor #1 observed the following on the Birch and Cedar units: Birch:-Upon approach to room [ROOM NUMBER], the surveyor observed a strong smell of urine. Upon entry, it was observed the room was a four bedded room and Resident #41 stated, it sinks and they thought it was the opposite bed (Unsampled Resident in bed 12B) that had smelled of urine because they peed the bed. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified for 1 (one) of 6 (six) residents (Resident #7) reviewed for medication administration. 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 observation, interview and record review it was determined that the facility failed to properly label, dispose of and store medications in 3 of 6 medication carts. The deficient practices were evidenced by the following:On 06/10/26 at 10:18 AM, the surveyor inspected Cedar medication cart #1 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an unopened bottle of Xalatan eye drops that was stored in the medication cart. The surveyor also observed one vial of Lantus insulin that did not contain a label with the resident's name. At that time, the surveyor interviewed LPN#1 who acknowledge that an unopened Xalatan eye drops should have been stored in the medication refrigerator. LPN#1 also stated that the Lantus Insulin vial should contained a pharmacy label with the resident's name on it. [...]

Inspectors wroteCOMPLAINT #2718861 Based on interviews and review of pertinent facility documentation on 3/13/26 and 3/24/26, it was determined that the facility failed to provide a timely follow - up management and care of a resident's indwelling catheter to address urologist's recommended procedures. This deficient practice was identified for one of two residents (Resident #2) reviewed for catheter care and was evidenced by the following:A review of the admission Record revealed that Resident #2 was admitted to the facility with diagnoses that included but were not limited to: obstructive and reflux uropathy, congenital malformation of urinary system, and severe intellectual disabilities. [...]

Inspectors wroteComplaint #2604637Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure medications were administered according to the physician's orders. This deficient practice was identified for 1 of 4 residents (Resident #2) reviewed for medication administration. 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 wroteRefer to F561 Based on observation, interview and facility assignment sheet review, the facility failed to ensure sufficient number of staff were available to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. This deficient practice had the potential to affect all 82 residents and was evidenced by the following: On 12/7/24 at 8:30 AM, the surveyor interviewed the Manager on Duty/Infection Preventionist (MOD/IP) who stated there were eight staff call-outs because staff were not paid. The surveyor reviewed the staffing assignment sheet for the 7 AM - 3 PM shift. The facility census was 82 with three nurses and four Certified Nursing Assistants (CNAs). [...]

Inspectors wroteComplaint # 181482 Based on observation and interview, the facility failed to designate a Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full time basis due to the DON resigning on 12/6/24. This deficient practice affected all 82 residents and was evidenced as follows: The facility's DON called the Department of Health Complaints' Hotline on 12/6/24 at 6:43 PM informing the Department that she resigned effective immediately. The surveyor entered the facility on 12/7/24 at 8:15 AM via a side entrance as the front door was locked and a handwritten sign was taped to the door instructing people to use the back entrance. At 8:50 AM, the surveyor spoke to the 7 AM - 3 PM shift Manager on Duty/Infection Preventionist (MOD/IP). The MOD/IP stated that the facility had eight employees call out due to not being paid. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the boiler to provide consistent hot water temperatures within 95 to 120 degrees Fahrenheit. This deficient practice had the potential to affect all 82 residents and was evidenced by the following: On 12/7/24 at 8:30 AM, the surveyor calibrated a thermometer and obtained the following hot water temperatures for the Dogwood Unit: Pantry: 122. At 9:35 AM it was rechecked and the hot water temperature was 101. Shower: 122. At 9:40 AM it was rechecked and the hot water temperature was 101. room [ROOM NUMBER]: 123. At 9:33 AM it was rechecked and the hot water temperature was 86. room [ROOM NUMBER]: 116. At 9:36 AM it was rechecked and the hot water temperature was 86. room [ROOM NUMBER]: 97. At 9:38 AM it was rechecked and the hot water temperature was 101. [...]

Inspectors wroteBased on observation, interview and relevant facility record review, the facility failed to ensure that a resident (Resident #1) was assisted out of bed timely to participate in morning activities. This deficient practice was evidenced for one of two residents sampled for self-determination. On 12/7/24 at 8:30 AM, the surveyor interviewed the Manager on Duty/Infection Preventionist who stated that there were eight staff call-outs because they were not paid. The surveyor reviewed the staffing assignment sheet for the 7 AM - 3 PM shift. The facility census was 82 with three nurses and four Certified Nursing Assistants (CNAs). At 11 AM, Resident #1 requested to speak to the surveyor. Resident #1 stated that he wanted to get out of bed, but staff told him he would have to wait because the facility is short staffed. [...]

Inspectors wroteBased on observation, interview, and review of pertinent documentation, it was determined that the facility failed to protect the residents' right to be free from neglect by not addressing residents' complaints of cold water for bathing and showering. The deficient practice was identified on 3 of 3 units (Birch, Cedar, and Dogwood). Refer to F 835L Interviews on 11/13/24, with both residents and staff, revealed the facility had no hot water for resident showering and bathing for months, and the facility was aware of the complaints. Temperatures obtained on 11/13/24, in both resident rooms and shower rooms on all the nursing units registered between 66.8 degrees Fahrenheit (F) and 82 degrees F. Interviews with the Maintenance Director (MD) confirmed water temperatures had been cold, that the water temperature should register at least 105 degrees F; [...]

Inspectors wrotePart A Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to maintain hot water temperatures at a safe level to protect residents from third degree burns and serious injury on 3 of 3 units (Birch, Cedar, and Dogwood). Refer F 835L Hot water temperatures obtained on 11/16/24, in both residents' rooms on all three nursing units and in resident shower rooms on the Cedar and Dogwood units, registered between 117 degrees Fahrenheit (F) and 131.5 degrees F. Interviews with the Maintenance Director (MD) revealed that the facility's boiler system was undersized for the facility size; provided inconsistent hot water temperatures; and the residents' water used should be between 95 degrees F through 115 degrees F. [...]

Inspectors wrotePart A Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that there was a Licensed Nursing Home Administrator (LNHA) who was physically present and actively involved by providing daily oversight to ensure all policies and procedures were implemented including consistently providing hot water for all residents' bathing and care needs. This deficient practice affected all residents who resided on 3 of 3 units (Birch, Cedar, and Dogwood). Refer to F 600L, F 689L Interviews on 11/13/24, with both residents and staff, revealed that the facility neglected residents' complaints of no hot water for showering and bathing for months, and that the LNHA had not been present at the facility in six months was aware. [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to serve meals in a dignified, home-like manner by using disposable containers to serve food and beverages for residents who resided on 3 of 3 resident units (Birch, Cedar and Dogwood). The deficient practice was evidenced by the following: On 11/17/24 at 9:06 AM, Surveyor #2 and #4 observed the breakfast meal on the Cedar unit and observed that all hot cereal was served in a 1/4 pound plastic disposable container with a lid, and all the beverages were served in Styrofoam cups. On 11/17/24 at 10:10 AM, the surveyor observed the kitchen with the Food Service Director (FSD), who was preparing a fruit cup and pudding for meal service. The fruit cups were being placed into plastic drinking type disposable cups. [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to ensure that the telephones located in resident rooms were functional and residents were provided an alternate means of communication to accommodate their needs and ensure their well-being was maintained. This deficient practice was identified for 7 of 7 residents who attended a resident council meeting and on 2 of 3 nursing units (Cedar and Birch units). The evidence was as follows: 1. On 11/14/24 at 11:06 AM, Surveyor #3 conducted the Resident Council meeting with seven resident who were alert and oriented. During the meeting, seven of seven residents informed the surveyor that the phones had not been working. On 11/20/24 at 8:33 AM, Resident #61 informed Surveyor #3 that their phone had not been working. [...]

Inspectors wroteBased on interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure a surety bond was in full force and effect to protect the residents' Personal Needs Accounts (PNA) funds (resident funds that is held by the facility in an interest bearing account). The deficient practice was evidenced as follows: On 11/13/2024 at 10:27 AM, an entrance conference was conducted with the facility administration Director of Nursing (DON). At that time the surveyor requested a copy of the current surety bond with the contact information, and a list of all residents with PNA holdings. On 11/13/2024 at 2:19 PM, the facility provided a document titled Patient Trust Fund Bond (Bond) with [name redacted] insurance company, along with four other documents. The Bond included but was not limited to; [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy by ensuring all newly hired employees were appropriately screened by conducting a criminal background checks prior to date of hire. This deficient practice was identified for 10 of 10 newly hired employees reviewed, and was evidenced by the following: A review of the facility's Freedom from Abuse, Neglect, and Exploitation policy with a reviewed date of October 2024, included .the organization will protect the resident right to be free from verbal, sexual, physical, and mental abuse. Resident must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, or volunteers .1. Screening of potential staff . [...]

Inspectors wroteBased on observation, interview, record review, and policy review, it was determined that the facility failed to; a) store food in a manner to prevent food-borne illness, b) maintain the kitchen environment and equipment in a sanitary manner, and c) ensure the water temperature was appropriate when utilizing the three-compartment sink to wash food preparation equipment to prevent potential for food borne illness. This deficient practice was evidenced by the following: 1. On 11/13/24 at 9:08 AM, the surveyor conducted an initial tour of the kitchen with the Food Service Director (FSD) and observed the following: - The door gasket and the door curtain on the walk-in refrigerator was torn. - The floor to the walk-in refrigerator was rusted and lifted. - The dish drying rack was rusted in appearance. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure garbage and recycling was managed in an appropriate manner to limit the potential for vermin and the spread of bacteria. This deficient practice had the potential to affect all residents who resided on 3 of 3 units and was evidenced by: On 11/13/24 at 9:08 AM, upon entrance to the kitchen, and in the presence of the Food Service Director (FSD), it was observed that cardboard boxes were piled up the length of a door opening by the FSD's office to the wall and were stacked in egg creates, on the floor and in a bin and the pile was at least four or more feet high. The surveyor asked the FSD why it was piled up in the kitchen and the FSD stated she did not know why because it was usually picked up 1-2 times per week. [...]

Inspectors wroteBased on interview, and review of facility documentation, it was determined that the facility failed to ensure that a facility wide assessment was reviewed and updated to identify: a) the required services and procedures necessary to protect the health, safety, and welfare of all residents; b) address staff competencies to provide resident care; c) review the facility environment to ensure safety; and d) ensure adequate facility resources to provide resident care and services. This deficient practice has the potential to affect 94 of the 94 residents at the facility during the time of survey. This deficient practice was evidenced as follows: On 11/13/24 at 10:27 AM, the survey team conducted an entrance conference with the Director of Nursing (DON). There were documents requested to complete the survey process which included but were not limited to; the Facility Assessment. [...]

Inspectors wroteBased on interview and review of pertinent documentation, it was determined that the facility failed to have in effect written transfer agreements with other Medicare and Medicaid participating facilities to ensure resident care during an emergency situation. This deficient practice had the potential to affect all residents and was evidenced by the following: On 11/13/24 at 10:27 AM, during the entrance conference with the facility administration, the facility was informed of documentation the survey team would need to review. On 11/14/24 at 12:00 PM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) to view the written transfer agreement that the facility had with one or more hospitals. The LNHA was unable to provide the surveyor a written transfer agreement. [...]

Inspectors wroteBased on interview and document review, it was determined that the facility failed to ensure that a process was in place for explaining the arbitration agreement that was included in the admission Agreement, to residents prior to having the residents sign the agreement. This deficient practice occurred for 3 of 3 residents reviewed for arbitration agreements (Resident #23, #89, and #240) and was evidenced by the following: On 11/19/24 at 10:10 AM, the Licensed Nursing Home Administrator (LNHA) provided Surveyor #9 with a list of residents who signed into a binding Arbitration Agreement (AA). The LNHA stated the admission Director (AD) was responsible for having the residents sign the agreements. On 11/19/24 at 11:00 AM, the surveyor reviewed the facility's admission Agreement. [...]

Inspectors wroteBased on observations, interview, and record review, it was determined that the facility failed to maintain a comprehensive data driven Quality Assurance and Performance Improvement (QAPI) program with demonstrated evidence of a program to improve the quality of life of all residents. This deficient practice affected all residents who resided on 3 of 3 units (Birch, Cedar and Dogwood), and was evidenced by the following: On 11/13/24 at 10:27 AM, during the entrance conference was held with the facility administration, the surveyor requested: the QAPI plan, the QAPI program, the quality assessment and assurance (QAA) committee information, and the quarterly sign-in sheets for the QAPI meetings since the last standard survey conducted on 04/21/23. [...]

Inspectors wroteBased on observation, interview, and document review, it was determined that the facility failed to implement a system to identify and initiate, a comprehensive Quality Assurance Performance Improvement (QAPI) program, that developed and monitored corrective action by failing to ensure: a) hot water was available consistently for all resident care, services and facility needs; b) water temperatures did not exceed safe standards to limit the potential for 3rd degree burns; and c) a safe smoking process was in place. The deficient practice affected residents who resided on 3 of 3 units (Birch, Cedar, and Dogwood). The evidence was as follows: Refer to F600L, F689L, F835L On 11/13/24 at 10:27 AM, during the entrance conference held with the facility administration, the surveyor requested: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure: a) a system was in place to monitor and minimize the risk of Legionella (a bacteria that causes the potentially fatal disease, Legionnaires') bacteria for the facility per the Center for Medicare and Medicaid Services (CMS) guidelines; b) staff performed hand hygiene (hh) in between assisting residents in the dining room; c) staff donned (put on) a Personal Protective Equipment (PPE) gown when assisting a resident on Enhanced Barrier Precautions (EBP) ( for 1 of 2 residents (Resident #83) reviewed who was on EBP); and d) the potential spread of infection was minimized by storing dirty meal trays away from other resident meal trays. This deficient practice was evidenced by the following: Reference: [...]

Inspectors wroteBased on observations, interviews, and pertinent facility documents it was determined that the facility failed to maintain the designated emergency supply of water needed for residents in the event of a loss of normal water supply. This deficient practice was evidenced by the following: A review of the facility's Emergency Water Management and Supply policy dated last reviewed 10/2023, included: in order to maintain daily operations and resident care services, the facility has implemented an emergency water supply plan to prepare for, respond to, and recover from a total or partial interruption of the facility's normal water supply .The organization will be prepared with emergency water . one gallon per day for the total licensed beds in the facility for a total of three days . A review of the facility's Emergency Water policy dated last reviewed 10/2023, included: [...]

Inspectors wroteBased on interview and review of pertinent facility provided documents it was determined that the facility failed to a) ensure that within 30 days of a resident's death, the resident's funds, and a final accounting of those funds were conveyed to the resident's responsible party for 1 of 1 expired unsampled resident (UR #1) Personal Needs Account (PNA) accounts; and b) notify the resident or resident's responsible party that the funds in their PNA account reached the $2,000 maximum Supplemental Security Income (SSI) or $200 less of the maximum which could jeopardize their eligibility for SSI or Medicaid. This was identified for 5 of 56 (UR #2, UR #3, Resident # 5, Resident # 24, and Resident #53) PNA accounts reviewed and was evidenced as follows: A review of the facility's Personal Needs Accounts policy last reviewed 10/2023, included; Purpose: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to properly label, dispose, and store medication in 1 of 2 medication carts reviewed. The deficient practice was evidenced by the following: On 11/15/24 at 9:15 AM, the surveyor inspected the Birch Unit Medication Cart #1 in the presence of the Licensed Practical Nurse (LPN #2). The following were observed: 1. One Lantus insulin pen (prescription medication used to treat diabetes) that was opened and not dated. At that time, the LPN stated that all insulin pens should be dated with an opened date and expiration date and then discarded after 28 days. 2. One Humalog insulin pen with an expiration date of 11/02/24. A review of the Medication Administration Record (MAR) dated November 2024, revealed that the resident received the Humalog Insulin 11/15/24. 3. [...]

Inspectors wroteBased 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 and drink served to the residents. This deficient practice was identified during the lunch time meal service on 11/18/24, on 1 of 3 nursing units (Birch) food temperatures were tested in the presence of the Food Service Director (FSD) ,and was evidenced by the following: On 11/18/24 at 12:23 PM, in the presence of the 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 to the unit at 12:10 PM. It was an open, not an enclosed cart. The surveyor tagged the bottom tray for temperature testing. [...]

Inspectors wroteComplaint # NJ173186, NJ175516 Based on interviews, medical record review, and review of other pertinent facility documents on 10/09/2024 and 10/10/2024, it was determined that the facility a.) failed to follow Care Plan (CP) interventions for a resident which resulted in the resident sustaining an injury and b.) failed to update the CP and interventions after a resident-to-resident altercation occurred. The facility also failed to follow its policy titled Care Management Policy. This deficient practice was identified for 3 of 3 residents (Resident #1, Resident #11, and Resident #12) reviewed for care plans. This deficient practice was evidenced by the following: [...]

Inspectors wroteComplaint #: NJ00175516 Based on interviews, medical record review, and review of other pertinent facility documents on 10/09/2024 and 10/10/2024, it was determined that the facility failed to ensure that an avoidable accident was prevented because care plan interventions for providing paired care were not followed for Resident #1, and resident sustained a fracture. This deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for incidents and accidents. This deficient practice was evidenced by the following: According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to, Unspecified Quadriplegia (a condition that causes paralysis that affects all a person's limbs), Chronic Pain Syndrome (persistent pain that last weeks to years), and Anxiety Disorder. [...]

Inspectors wroteComplaint#: NJ175898 Based on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to maintain acceptable standards of essential kitchen equipment in a safe and operable condition. This deficient practice was evidenced by the following: During the interview with the Surveyor on 07/30/2024 at 11:33 A.M., the Food Service Director (FSD) stated that the stove in the facility's kitchen was not working. The FSD further stated the stove caught on fire in May 2024. The FSD stated that the fire department came out to extinguish the fire and deemed the stove was unsafe and needed to be repaired or replaced. The Surveyor toured the facility's kitchen with the FSD on 07/30/2024 at 11:50 A.M. and observed the following: [...]

Inspectors wroteComplaint # NJ00158284, #NJ00156797 Refer to 677 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain the required minimum direct care staff to resident ratios as mandated by the State of New Jersey for (a) 3 of 7 day shifts, reviewed, 1 of 7 evening shifts,and 3 of 7 overnight shifts reviewed for a one week period (08/07/22 to 08/13/22), (b) 6 out of 7 day shifts reviewed during a one week period (from 09/25/2022 to 10/01/2022) (c) 14 of 14 day shifts and 2 of 14 overnight shifts during a 2 week period (03/19/2023 to 03/25/2023 and 03/26/2023 to 04/01/2023) and (d) ensure that incontinence care was provided to a dependent resident in a timely manner (Resident #77).

Inspectors wroteComplaint # NJ00157501 Based on interview, record review, and review of facility documents, it was determined that the facility failed to complete neurological evaluations (neuro checks) after unwitnessed falls for 3 of 4 residents (Resident #81, #82, and #90) reviewed for falls. This deficient practice was evidenced by the following: 1. On 04/05/23 at 11:06 AM, the surveyor observed Resident #81 lying in bed watching TV. The resident stated she had fallen while at the facility, but was unsure of the details. According to the admission Record, Resident #81 had diagnoses which included, but were not limited to: muscle weakness and difficulty in walking. [...]

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to evaluate the performance of all Nurse Aides (NAs) and Certified Nursing Assistants (CNAs) on an annual basis. This deficient practice occurred for 5 of 6 of the NAs and CNAs whose personnel records were reviewed (NA #1, CNAs #1, 6, 7, & 8). The deficient practice was evidenced by the following: On 04/18/23 at 9:24 AM, the surveyor reviewed the employee files of 6 NAs and CNAs, which were provided by the facility. The surveyor identified the following: NA #1 had a hire date of 01/05/21, to the housekeeping department, and a transfer date of 09/30/21, from the housekeeping department to the nursing department. According to NA #1's personnel record, the last documented competency evaluation was 03/08/21 as a housekeeper. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to handle potentially hazardous foods in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 04/05/23 at 11:16 AM, the surveyor, in the presence of the Assistant Director of Food Service (ADFS), observed the following during the kitchen tour: 1. In the dry storage room, a employee's personal purse was stored on a shelf alongside kitchen paper products. The surveyor also observed a walker positioned against a box that was stored on a shelf. The surveyor observed the ADFS remove the purse and walker from the dry storage room. The ADFS stated the items belong to an employee and that they should not have been stored in the dry storage room. [...]

Inspectors wroteComplaint #NJ00157742, #NJ00158284 Based on observation, interview and record review, it was determined that the facility failed to maintain complete, accurate and readily accessible medical records. This deficient practice was identified for 4 of 28 residents reviewed (Resident #24, #37, #117, and #221). This deficient practice was evidenced by the following: 1. On [DATE] at 11:26 AM, during the initial tour of the Birch Unit, the surveyor observed Resident #24 awake and alert sitting in a wheelchair with the activities aide in the activity day room. The resident stated that he/she had lost weight in the past years and now weighs 205 pounds. On [DATE] at 12:38 PM, the surveyor observed Resident #24 sitting in his/her room eating his/her lunch. The resident was observed feeding himself/herself and ate about 50% of his/her meal and drank his/her milk and apple juice. [...]

Inspectors wroteComplaint #NJ00156797, #NJ00159063, #NJ00158284 Refer to F836 Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to a.) ensure that incontinence care was provided to a dependent resident in a timely manner and b.) maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey to ensure residents received the appropriate and necessary care. This deficient practice was identified for 1 of 3 residents (Resident #77) observed for incontinence care and was evidenced by the following: On 04/13/23 at 08:25 AM, the surveyor accompanied by the Registered Nurse/Unit Manager (RN/UM #2) completed an incontinence tour on the Cedar Unit. Three random residents who were identified by RN/UM #2 as being dependent on staff for care, were checked for incontinence care. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that air mattresses were correctly inflated for residents with a history of wounds. This deficient practice was identified for 2 of 2 residents (Residents #45 and #73) reviewed for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure). The deficient practice was evidenced by the following: 1. During the initial tour on 04/05/23 at 12:00 PM, the surveyor observed Resident #45 in bed with their eyes closed. The resident did not rouse to the surveyor's greeting. The surveyor observed that the resident was on an air mattress and that the air mattress was set to 180 pounds (lbs). This would indicate that the resident weighed 180 lbs. On 04/06/23 at 9:55 AM, the surveyor observed the resident in bed. The surveyor observed that the air mattress was off. [...]

Inspectors wroteComplaint # NJ00157742, NJ00157501, NJ00156797 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) transcribe a physician's order to monitor a resident's wander guard (a device that alarms the facility if the resident attempts to leave the building) for 1 of 3 residents (Resident #98) reviewed for elopement, and b.) ensure fall risk interventions were in place for 1 of 4 residents (Resident #90) reviewed for falls. This deficient practice was evidenced by the following: 1. On 04/05/2023 at 11:42 AM, the surveyor observed Resident #98 sitting up on the edge of the bed wearing a wander guard to his/her left wrist. According to the admission Record, Resident #98 was admitted with diagnoses which included, but were not limited to, dementia. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to ensure that an indwelling urinary catheter drainage bag (drainage bag) was stored in a way to prevent the spread of infection. This deficient practice was identified for 1 of 4 residents reviewed for the use of indwelling urinary catheters (Resident #72) and was evidenced by the following: On 04/05/23 at 11:55 AM, the surveyor observed Resident #72 resting in bed with the head of bed (HOB) slightly elevated. The resident's drainage bag was observed making contact with the floor. According to the admission Record, Resident #72 had diagnoses that included, but were not limited to: [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) properly dispose of a medication, b.) administer eye drops according to the physician's order, and c.) complete and maintain copies of Federal narcotic order forms (DEA 222 forms). This deficient practice was identified for 2 of 3 nurses observed during the medication administration pass and two DEA 222 forms reviewed and was evidenced by the following: 1. On [DATE] at 8:02 AM, the surveyor observed Licensed Practical Nurse (LPN) #1 prepare medications for Resident #37. When dispensing the medication, LPN #1 dropped a tablet of levetiracetam 250 milligrams (an anti-seizure medication) on the medication cart. The LPN then picked up the tablet from the medication cart with a gloved hand and threw it away in the trash can attached to the medication cart. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide a sanitary environment for residents, staff and the public by failing to a.) keep the garbage container area free of garbage and debris and b.) have a closed cover over the opening of 2 of 2 garbage containers. This deficient practice was evidenced by the following: On 04/05/23 at 11:43 AM, the surveyor toured the kitchen with the Assistant Director of Food Service (ADFS). During the tour, the ADFS led the surveyor outside to the garbage storage area. The surveyor observed two Waste Management (WM) garbage containers which did not have a cover over the top opening. [...]