Troy Hills Center

Inspectors wroteREPEAT DEFICIENCYBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain kitchen sanitation practices as well as store, and label in a manner intended to prevent the spread of food borne illness. This deficient practice was evidenced by the following:On 4/2/26 at 10:09 AM, the surveyor entered the main kitchen for the initial tour. The surveyor, in the presence of the Food Service Director (FSD), observed the following:-Stand-up walk-in freezer: observed an open box of mixed vegetables and an open box of orange sherbets both undated, no date when the boxes were opened. The FSD confirmed that the boxes should have been dated when they were opened.-Drying racks: Observed pans and trays on dry racks with buildup of brownish/blackish substance; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 1 of 18 residents reviewed for accommodation of needs (Resident #4), and was evidenced by the following:On 4/2/26 at 11:25 AM, the surveyor observed Resident #4 seated in a wheelchair (w/c) in the atrium. On 4/7/26 at 11:30 AM, the surveyor observed Resident #4 seated in a w/c in their room watching television. The surveyor observed the resident's call bell (used to summon staff assistance) on the floor, behind the bed, not within the Resident's reach. The surveyor asked Resident #4 how they would call for staff assistance if needed. Resident #4 replied that they needed the call thing and would not be able to call for help without it. [...]

Inspectors wroteBased on observation, interview, and review of other pertinent record, it was determined that the facility failed to post the required prior years' State of New Jersey (State) inspection results in an area that was readily accessible to residents, families, and the public. The deficient practice was evidenced by the following: On 4/7/26 at 3:09 PM, the surveyor located the State of New Jersey inspection results binder near front entrance of the building. The surveyor reviewed the contents of the binder which revealed the following: The State of New Jersey inspection results binder contained the results for the survey dated 11/25/24, and did not contain any other results for any other surveys in the past three years. On 4/8/26 at 10:12 AM, the survey team met with the Licensed Nursing home Administrator (LNHA) and Director of Nursing (DON) to discuss the above concerns. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, the facility failed to follow the physician order with regard to monitoring side effects and behaviors in accordance with professional standards of practice for 1 of 5 residents reviewed for unnecessary medications (Resident #96). This deficient practice was evidenced by the following: On 4/7/26 at 11:43 AM, the surveyor observed Resident #96 seated in a chair in the resident's room watching television and using a smart phone. The resident did not express any concerns. A review of the admission Record or face sheet (an admission summary) revealed diagnoses which included, but were not limited to; anxiety disorder, bipolar disorder, opioid abuse, alcohol abuse, chronic obstructive pulmonary disease, and diabetes mellitus. [...]

Inspectors wroteComplaint #182228Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 2 of 5 residents (Residents #12 and #80) observed for incontinence care on 1 of 2 Nursing units (Wing 2). This deficient practice was evidenced by the following: On 4/6/26 at 7:15 AM, the surveyor conducted an incontinence tour on Wing 2 Nursing Unit and observed the following: On 4/6/26 at 7:25 AM, the surveyor, accompanied by the Certified Nursing Assistant #1 (CNA #1), observed Resident #80 in bed. CNA #1 exposed Resident #80's incontinence brief and observed a second incontinence brief in place, both were saturated with urine. CNA #1 confirmed that the two briefs were saturated and that the resident should not have had two briefs on. [...]

Inspectors wroteBased on observation, interview, review of medical records, and other pertinent documentation, it was determined that the facility failed to ensure that the resident received care consistent with professional standards of practice to prevent pressure ulcers and promote healing by failing to, a.) ensure that the pressure reducing low air loss mattress was set according to resident's body weight for 1 of 3 residents (Resident #5) and b.) administer treatment according to physician order and document for 1 of 3 residents (Resident #49). 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, record review, and review of facility documents, it was determined that the facility failed to follow the physician order with regard to medication with parameter for 1 of 5 residents (Resident #75) reviewed, and was evidenced by the following: On 4/6/26 at 11:10 AM, the surveyor interviewed Resident #75, who was seated on the bed in the resident's room, and voiced out no concern. A review of the medical record for Resident #75, revealed an admission Record or face sheet (an admission summary) indicated diagnoses which included, but were not limited to; congestive heart failure, major depressive disorder with psychotic features, dementia, diabetes mellitus, chronic kidney disease, and hypertension. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to, a.) ensure that the Consultant Pharmacist (CP) identified irregularities during the medication regimen review (MRR) recommendations were acted upon and b.) ensure that the attending physician reviewed and documented the clinical rationale when declining a CP's recommendation. This deficient was identified for 1 of 21 residents (Resident #75) reviewed. This deficient practice was evidenced by the following: On 4/6/26 at 11:10 AM, the surveyor interviewed Resident #75, who reported no concerns with care. A review of Resident #75's admission Record or face sheet (an admission summary) revealed that the resident had diagnoses which included, but were not limited to; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications (meds) were administered without error of 5% or more during medication (med) administration, 3 nurses administered meds to 4 residents. There were 28 opportunities for error, 3 errors were observed which calculated to a med administration error rate of 10.7%. This deficient practice was identified for 3 of 4 residents, (Resident #46, Resident #63, and Resident #84), that was administered meds by 2 of 3 nurses that were observed. 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 wroteCOMPLAINT NJ#381557REPEAT DEFICIENCYBased on observation, interview, and record review, it was determined that the facility failed to ensure the safe and appetizing temperatures of food were appropriately served to the residents. This deficient practice was identified for 5 of 18 residents residing on 3 of 4 Nursing Units, including during the 4/7/26 Resident Council group meeting, and confirmed during the lunchtime meal service on 4/6/26 on a test tray tested for food temperatures (common room). This deficient practice was evidenced by the following:On 4/6/26 at 11:25 AM, Surveyor #1 (S #1) observed the meal prep, tray line in the main kitchen, in the presence of the Food Service Director (FSD) and the Regional [NAME] President of Dietary Operations (RVPDO) for food temperatures. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in facility name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following:According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program:(a) Certifying compliance. [...]

Inspectors wroteBased on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to follow appropriate hand hygiene and follow appropriate infection control practices, for 1 of 3 nurses observed during the medication administration observation in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and facility's policy. The deficient practice was evidenced by the following:According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24, revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: . Immediately after glove removal. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation it was identified that the facility failed to offer a resident the pneumonia (PNA) vaccination. This deficient practice was identified for 1 of 5 residents, (Resident #68), reviewed for vaccination status and was evidenced by the following:On 4/2/26 at 12:18 PM, the surveyor observed Resident #68 walking around in their room. The resident stated no concerns and that they were admitted from hospital. A review of Resident #68's hybrid medical record (both electronic and paper chart), revealed in the admission Record or face sheet (an admission summary) the following diagnoses that included but were not limited to hypotension (low blood pressure), and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. [...]

Inspectors wroteBased on interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer a resident a COVID-19 Immunization. This deficient practice was identified for 1 of 5 residents reviewed for immunization (Resident #81). The deficient practice was evidenced by the following:On 4/2/26 at 12:28 PM, the surveyor observed Resident #81 in the common room area with a Certified Nursing Assistant (CNA) reading the chronicle to the resident. On 4/6/26 at 10:08 AM, the surveyor reviewed Resident #81's hybrid (paper and electronic) medical records which revealed the following information: A review of the resident's admission Record or face sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses which included but not limited to; unspecified dementia, severe, with other behavioral disturbance; [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined the facility failed to maintain a clean, safe, and sanitary environment in 2 of 4 Nursing units (Wing 1 and Wing 2), and was evidenced by the following: 1. On 4/2/26 at 11:40 AM, during environmental rounds on Wing 1 nursing unit, Surveyor (S #1) observed a strong malodorous urine smell in room [ROOM NUMBER]. S #1 observed that the bathroom floor and shower area were heavily soiled with a yellow-brown substance. The floor tiles by the room's entrance were stained and broken. On 4/6/26 at 7:40 AM, S #1 and the Licensed Practical Nurse/Unit Manager (LPN/UM) entered room [ROOM NUMBER]. The LPN/UM confirmed a strong malodorous urine odor upon entering. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 11/18/24 at 10:04 AM, the surveyor, in the presence of the Food Service Director (FSD), observed the following during the kitchen tour: 1. On the bottom shelf of a food prep table, next to the dry food storage area, there was a metal tray with 10 bowls of cereal resting on top of boxes of napkin and other utensil supplies. On 1 of the 10 cereals' plastic lid was a clear liquid substance. The surveyor asked the FSD about the observation. The FSD pulled out the metal tray and confirmed the observation. [...]

Inspectors wroteBased on the interview and review of facility documentation, it was determined that the facility failed to ensure that facility wide assessment included the resources required to establish policies and procedures for the management of staffing contingency plans in order to meet the requirements and needs of all residents in the facility. This failure had the potential to affect all 97 residents who currently live in the facility. This deficient practice was evidenced by the following: During the entrance conference on 11/18/24 at 10:04 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) a copy of the Facility Assessment (FA). The LNHA stated that the facility's census (the number of residents currently under the care of a specific facility) was 97. [...]

Inspectors wroteComplaint #: NJ#171636 Based on observation, interview, and review of other facility documentation, the facility failed to ensure the facility was maintained in a safe, clean, and homelike environment. This deficient practice was identified for 2 of 4 units, (Unit 1 and Unit 3), and 2 of the common areas, (lobby and Unit 3 tub room). This deficient practice was evidenced by the following: 1. During the initial tour of Unit 1 on 11/18/2024 at 11:18 AM, the surveyor observed Resident #80's room with a posted sign of EBP (Enhanced Barrier Precautions; an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes). There was a strong smell of urine in front of the resident's door. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation, it was determined that the facility failed to follow its Grievance/Concern policy and procedure by failing to a.) conduct a formal investigation of a grievance filed by a resident, (Resident #42) and followed through, b.) persisted for 4 of 4 resident council meetings regarding laundry services of the facility, and c.) conduct a formal investigation of a grievance filed by a resident to another resident to determine if abuse had occurred for 1 of 1 resident (Resident #45). This deficient practice was evidenced by the following: On 11/18/24 at 10:04 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) for an Entrance Conference. The LNHA informed the surveyor that the facility's census (total number of residents) was 97. 1. [...]

Inspectors wrote2. The surveyor reviewed the medical records of Resident #45 and revealed: The AR revealed that the resident was admitted to the facility with diagnoses that included but were not limited to, unsteadiness of the feet, need for assistance with personal care, and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) with dyskinesia ( involuntary, erratic, writhing movements of the face, arms, legs or trunk), with fluctuations. The most recent quarterly Minimum Data Set (qMDS) with an ARD of 6/07/24 revealed that Section C for cognition was not assessed or attempted. Section C was electronically signed (was done) by the RCC on 6/21/24 at 10:41 PM, 14 days after the ARD. [...]

Inspectors wroteComplaint #NJ171636 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices by failing to a.) provide meal, meal set up, and notify the physician and Resident Representative of significant weight loss for 1 of 24 residents (Resident #21), and b.) for care of 1 of 24 residents, Resident #57, with regard to medication and diagnosis for seizure for a total of three months. 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, record review, and review of other facility documentation, it was determined that the facility failed to a.) administer a medication to a resident due to unavailability of the medication, accurately account and administer a medication according to the physician's orders for one (1) of five (5) residents, Resident #53, reviewed for unnecessary medications and b.) ensure accurate documentation of the receipt of a controlled substance for 17 controlled substance medications on 3 Schedule II order forms, ordered and received by the facility for use as an emergency backup supply in accordance to pharmaceutical services and professional standards of clinical practice. 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 failed to identify the irregularity with regard to medications with parameters for 5 of 5 residents reviewed, Residents #24, #43, #53, #57, and #82 in accordance with facility's practice and policy. This deficient practice was evidenced by the following: 1. On 11/19/24 at 11:50 AM, the surveyor reviewed the paper and electronic medical record (EMR) of Resident #53. The admission Record (AR; a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to, hypertension (high blood pressure), and rheumatoid arthritis. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medication for 2 of 3 medication storage areas and 2 of 2 medication refrigerators inspected according to facility's policy and standard of clinical practice. 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 observations, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that the resident's call light was readily accessible within reach. The deficient practice was identified for 1 of 3 residents, Resident #79, reviewed for accommodation of needs and limited range of motion (ROM). This deficient practice was evidenced by the following: On 11/18/24 at 10:43 AM, the surveyor observed Resident #79 resting in bed and their right arm was elevated on the pillow. The surveyor greeted the resident, and the resident elevated their head of bed with the controller. The resident was unable to speak much at the time of observation. The surveyor observed resident's call bell wrapped around the side rails on resident's right side of bed. The resident was unable to reach it. [...]

Inspectors wroteBased on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure reference checks were completed for 2 out of 10 newly hired staff (Staff #2 and #6) prior to their start date of employment. This deficient practice was evidenced by the following: The surveyor reviewed ten randomly selected new employee files. The review for reference checks for 2 of the 10 new employees revealed the following: -Staff #2's file, a Licensed Nursing Home Administrator (LNHA) who was hired on 7/03/23, revealed no reference checks in their file. -Staff #6's file, a Nursing Assistant (NA) who was hired on 9/27/24, revealed no reference check in their file. On 11/25/24 at 12:20 PM, during an interview with the surveyor, the Staffing Coordinator (SC) stated minimum of 2 reference checks were required before the date of hire. [...]

Inspectors wroteBased on the interview, record review, and review of other facility provided documents, it was determined that the facility failed to report an allegation of Abuse/Neglect to the New Jersey Department of Health (NJDOH) in the required timeframe for 1 of 4 sampled residents, Resident #45, reviewed for abuse. This deficient practice was evidenced by the following: On 11/19/24 at 01:39 PM, the surveyor reviewed the last three months' resident council minutes that were provided by the Licensed Nursing Home Administrator (LNHA) and revealed: -8/15/24: Council Members in Attendance: 10 Compliments/Ideas/Preferences/Concerns/Suggestions: Nursing: A resident awoke another resident and tried to get into their bed. The complainant resident asked the other resident to leave and would not. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, record review, and review of other pertinent facility provided documentation, the facility failed to a.) ensure accurate documentation of treatment administration and follow wound consultant recommendations for 1 of 1 resident, Resident #15, reviewed for pressure ulcer, b.) follow a PO with regard to vital signs for 1 of 24 residents, Resident #68, and c.) clarify the physician's order with regard to pain medication for 1 of 24 residents, Resident #80, according to the standard of clinical practice. 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, record review and review of other facility documentation, it was determined that the facility failed to maintain professional standards of nursing practice by not following a.) a physician's order for the application of a splint to right wrist, and b.) document in the Treatment Administration Record for 1 of 3 residents, Resident #68, reviewed for limited range of motion (ROM). The deficient practice was evidenced by the following: On 11/18/24 at 10:30 AM, during an initial tour, the surveyor observed Resident #68 resting in their bed while watching television, with no splint in use. The surveyor observed a picture of right hand in a splint that was posted on their room wall with instructions, indicating Right hand- Apply daily with a.m. (morning) care. Remove after 8 hours. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the necessary respiratory care and services of residents that were receiving oxygen, according to the standard of clinical practice and the facility's policy and procedure, specifically a.) clarify the physician's order for as needed (PRN) oxygen and document the use of PRN oxygen therapy for 1 of 3 residents, Resident #33 and b.) that respiratory equipment was stored in accordance with facility policy and infection control measures for 1 of two 3 residents reviewed for respiratory care, Resident #80. 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, record review, and review of other pertinent documents, it was determined that the facility failed to complete post dialysis communication record assessments upon the resident's return from the dialysis center for 1 of one 1 resident, Resident #24, reviewed for dialysis services. The deficient practice was evidenced by the following: On 11/18/24 at 12:05 PM, the surveyor observed Resident #24 was not in their room. The Registered Nurse (RN) assigned to care for Resident #24 stated the resident was at dialysis. The surveyor reviewed the electronic medical record of Resident #24. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to post the accurate Nursing Home Resident Care Staffing Report daily for 2 of 7 days. This failure could affect the knowledge of the availability of staff to care for the residents, resident representative, and visitors. This deficient practice was evidenced by the following: On 11/18/24 at 9:10 AM, upon entry into the facility, Surveyor #1 (S#1) observed a posted Nursing Home Resident Care Staffing Report (NHRCSR) that was posted in the reception area of the lobby, dated 11/18/24 Day Shift, 7 AM-3 PM. The NHRCSR reflected current census of 98 that included 10 CNAs (Certified Nursing Aides) with staff to resident ratio of 1 CNA:9.8 Residents. [...]

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 medication for 1 of 5 residents (Resident #53) reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 11/18/24 at 12:10 PM, the surveyor observed Resident #53 lying in bed with their head of the bed elevated. The resident was alert, oriented, pleasant, and conversant. On 11/19/24 at 11:50 AM, the surveyor reviewed the paper and electronic medical record (EMR) of Resident #53. The admission Record (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to, hypertension (high blood pressure), depression, rheumatoid arthritis, and anxiety disorder. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to ensure meals were served at safe and appetizing temperatures for 1 of 4 nursing units (Wing 2), during the lunch meal service on 11/22/24. This deficient practice was evidenced by the following: On 11/18/24 at 12:10 PM, the surveyor observed Resident #53 resting in their room. The resident was alert, oriented and verbally responsive. The resident stated the staff were nice and helpful. The surveyor asked Resident #53 about the food served at the facility. The resident stated that sometimes the food was cold when received. A review of last three months of resident council minutes revealed: In September 2024, residents reported food was not always hot by the time it was served to their room. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to follow appropriate hand hygiene, and use of personal protective equipment (PPE) for 2 of 7 staff (Housekeeper and non-certified Nursing Aide) and follow appropriate infection control practices when performing high contact care activities in an enhanced barrier precaution (EBP) to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: [...]

Inspectors wroteBased on observations, interview, review of medical records and review of facility documents, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure: a.) that policies and procedures were developed and implemented to mitigate the spread of infections, and b.) documented on-going staff education and in-services were completed to combat breaks in infection control practices. The multiple observed breaches in infection control practices by multiple facility disciplines, were identified on 02/08/23, 02/09/23, and 02/10/23 on 4 of 4 resident care Wings. This posed a serious and immediate threat to the health, safety and well-being of all residents who resided at the facility due to the lack of infection control oversight provided by the LNHA, which resulted in an Immediate Jeopardy (IJ) that began on 02/08/23 and was identified on 02/10/23 at 4:07 PM. [...]

Inspectors wrotePart A Based on observation, interview, record review and review of pertinent documentation, it was determined that the facility, who has been in an active COVID-19 outbreak status since 10/23/22, failed to ensure: a.) a system was in place and followed to prevent the spread of multidrug resistant infections (organisms resistant to multiple antibiotic treatments including Methicillin Resistant Staph Aureus [MRSA], extended spectrum beta-lactamase [ESBL], vancomycin resistant enterococcus [VRE]) and COVID-19 (a deadly virus), and b.) facility policies and current infection control guidance was followed to limit the spread of infection. The breaches in infection control practices were observed by the survey team on 02/08/23, 02/09/23, and 02/10/23, for 4 of 4 Resident Wings and was evidenced by the following: Reference: [...]

Inspectors wroteBased on interview and document review, it was determined that the facility, who was experiencing an outbreak of COVID-19 (a potentially deadly virus) failed to take immediate action to prevent the spread of COVID-19 by failing to: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to: a.) ensure the facility policy for Falls Management and Accidents/Incidents policy was followed to determine the causal factor and interventions were updated to prevent recurrent falls, for a cognitively impaired resident (Resident #45), who was identified as high fall risk, had a history of falls with injury which included a fall on 10/08/21 that resulted in a femur fracture that required hospitalization, a subsequent unwitnessed fall on 05/29/22, and a fall requiring hospitalization on 11/06/22 after sustaining a hematoma to the head, b.) supervision was provided to prevent recurrent falls c.) implement care plan interventions for a resident (Resident #1) identified as requiring two-persons for transfer, was transferred by one staff on 06/06/22, and [...]

Inspectors wroteBased on observation, interview, record review, and document review, it was determined that the facility failed to ensure sufficient nursing staff was in place to ensure resident's highest practicable well-being was maintained by failing to ensure: a.) appropriate incontinence care was provided for 6 of 6 residents reviewed (Resident #35, #57, #88, #45, #59, #88) on 2 of 4 resident Wings (Wing 1 and Wing 3), b.) residents were provided with nail care and hygiene services for 3 of 5 residents (Resident #57, #45, #88) reviewed on 2 of 4 resident Wings (Wing 1 and Wing 3), and c.) appropriate nursing and related services required for a resident who required assistance with meals for 2 of 5 residents reviewed (Resident #35 and #88), on 2 of 4 resident Wings (Wing 1 and Wing 3) to meet the residents individual needs. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to evaluate the performance of all Certified Nursing Assistants (CNAs) on an annual basis. This deficient practice occurred with 5 of the 5 CNAs whose personnel records were reviewed and was evidenced by the following: On 02/22/2023 at 12:40 PM, the surveyor reviewed the employee files of 5 randomly selected CNAs which were provided by the facility. The surveyor identified the following: CNA #1 had a hire date of 05/04/2015. According to the CNA #1's personnel record, the last documented performance appraisal was 09/22/2020. There were no annual performance reviews conducted within the past year. CNA #2 had a hire date of 02/27/1996. According to the CNA #2's personnel record, the last documented performance appraisal was 09/18/2020. There were no annual performance reviews conducted within the past year. [...]

Inspectors wroteBased on observation, interview, and document review, it was determined that the facility failed to ensure a.) that the kitchen environment, equipment and resident meal service items were maintained in a clean and sanitary manner, b.) a walk in refrigeration unit maintained appropriate food temperatures, c.) a commercial dishwashing machine was operated within manufactures specifications, d.) food temperatures were consistently monitored, e.) hair restraints were consistently worn, and e.)food items were consistently labeled and dated with a use by date to limit the spread of infection and potential food borne illness. The deficient practice was evidenced by the following: On 02/08/23 at 8:51 AM through 9:25 AM, the surveyor conducted an initial tour of the kitchen. [...]

Inspectors wroteBased on interview, record review and review of other pertinent documentation, it was determined that the facility failed to follow facility policy and ensure the implementation of a comprehensive antibiotic stewardship program (ASP). This deficient practice was identified during a review for 3 of 3 months of the facility Infection Control Monthly Line Listing tracking forms (December 2022, January 2023, and February 2023). The deficient practice was evidenced by the following: On 02/08/23 at 11:12 AM during entrance conference, the Licensed Nursing Home Administrator (LNHA) stated that the facility was in a current outbreak of COVID-19. A review of the facility provided line list revealed the outbreak began 10/23/22. [...]

Inspectors wroteBased on observation, interview and document review, it was determined that that facility failed to ensure that contracted facility departments received training and competencies in accordance with the Facility Assessment, and to ensure facility policies and procedures for infection control standards were met. This deficient practice affected 4 of 4 Resident Wings and was evidenced by the following: On 02/08/23 at 11:12 AM, during the facility entrance conference the Licensed Nursing Home Administrator (LNHA) provided a copy of the Facility Assessment Tool (Tool), dated 03/22/22. The Tool revealed staff training/education and competencies, 3.4. Describe the staff training/education and the competencies that are necessary to provide the level and types of support and care needed for your resident population. Include staff certification requirements as applicable. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to update comprehensive patient-centered care plans for: a.) a resident with suicidal ideation, b.) a resident on a hypotensive medication, and c.) a resident with a diagnosis of pneumonia requiring antibiotics. This deficient practice was identified for 3 of 23 residents (Resident #71, #95, and #26) reviewed for Care Planning (CP) and was evidenced by the following: a.) On 02/09/23 at 8:21 AM, the surveyor observed Resident #71 sitting on the side of the bed reading the newspaper. The surveyor observed the resident's urinary catheter collection bag was not in a privacy bag. [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent documentation, it was determined that the facility failed to follow professional standards of clinical practice with respect to a.) medication administration and documentation, b. ) follow the facility's policy/protocol on discarding controlled substances, and c. ) follow standards of clinical practice and executing orders as prescribed by the physician. The deficient practice was identified for 4 of 8 residents during medication pass observation (4 unsampled residents); 1 of 6 residents (Resident #95) reviewed for medication parameters; and 3 of 3 sampled residents reviewed for care (Resident # 315, #88 and Resident #95). 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, record review, and review of pertinent facility documents, it was determined that the facility failed to provide personal hygiene and provide timely assistance for 6 of 6 residents (Resident #1, #35, #45, #66, #88 and Resident #57) reviewed who required assistance with Activities of Daily Living (ADLs). The deficient practice was evidenced by the following: On 02/08/2023 at 8:50 AM, the surveyor toured the 3rd Wing of the with staff and observed the following: 1. The surveyor entered Resident #35's room with a Certified Nurse Aide (CNA). Resident #35 was observed in bed resting. The CNA informed the resident of the task and the CNA proceeded to turn the resident over. The surveyor, along with the CNA observed that Resident #35 was soaked with urine and was wearing two incontinence briefs. [...]

Inspectors wroteBased on observation, interview and document review it was determine that the facility failed to provided meals at acceptable temperatures for 2 of 4 residents interviewed during a resident council meeting and for 4 of 4 items sampled during a test tray observation. The deficient practice was evidenced by the following: On 02/14/23 10:33 AM, a surveyor conducted a resident meeting with four residents, and 2 of 4 residents stated that the food served would sit on the meal trays too long and would then be cold because there were not enough Certified Nurse Aides to give out the meal trays. On 02/15/23 at 11:37 AM to 12:08 PM, the surveyor entered the kitchen and observed the tray line in progress for the lunch meal. The surveyor observed the tray line while next to a Dietary Staff worker (DS #1) who was opposite the Cook. [...]

Inspectors wroteBased on interview, record review and review of pertinent documents it was determined that the facility failed to complete and document a thorough investigation regarding bruises of unknown origin sustained on a cognitively impaired resident. This deficient practice occurred for 1 of 1 resident (Resident #92) reviewed for abuse and was evidenced by the following: On 02/14/23 at 8:46 AM, the surveyor observed Resident #92 seated in a chair next to the bed. Resident #92 was alert but unable to answer questions asked by the surveyor. Resident #92 was confused and unable to proceed with the interview. On 02/14/23 at 8:59 AM, the surveyor observed a Certified Nurse Aide (CNA) who was assigned to Resident #92, enter the resident's room with a meal tray. Plastic utensils were observed on the resident's meal tray and the surveyor inquired to the CNA about the plastic utensil use. [...]

Inspectors wroteBased on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure the facility policy was followed to ensure appropriate care was provided for a resident who required tracheal suctioning for a tracheostomy tube (a surgically inserted tube into the neck to help a person breathe). The deficient practice occurred for 1 of 1 resident reviewed (Resident #57) for tracheostomy care and was evidenced by the following: On 02/13/23 at 10:56 AM, the surveyor attempted to complete an observation of Resident #57. The resident was not in the room, and the staff informed the surveyor that the resident had been transferred to the hospital and was admitted with pneumonia. On 02/23/23 at 9:00 AM, the surveyor reviewed Resident #57's medical record. Record review revealed Resident #57 was readmitted from the hospital on [DATE]. [...]