Wiley Mission

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed accurately for a newly admitted resident. This deficient practice was identified for 1 of 2 residents reviewed for PASRR (Resident #8), and was evidenced by the following:On 02/04/2026 at 9:57AM, during the initial tour of the facility, Resident #8 was observed out of bed in their room. A review of the admission Record face sheet (an admission summary) revealed that the resident was admitted to the facility with the following but not limited to diagnosis of psychotic disorder. A review of Resident #8's Electronic Medical Record (EMR) revealed a PASRR level 1 dated 10/21/2025. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to develop and implement a comprehensive care plan that included required monitoring for a resident receiving antibiotic therapy. The deficient practice was identified for 1 of 5 residents (Resident # 37) reviewed for Unnecessary Medications. The deficient practice was evidenced by the following: A review of Resident # 37's physician orders located under Orders in the Electronic Medical Record (EMR) revealed 3 orders to administer 4 capsules of the antibiotic Amoxicillin Oral Tablet 500 Milligram (mg) one hour prior to dental appointment. The start dates for each of the orders were 1/29/2025, 2/6/2025, and 2/12/2025. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident received appropriate care and sufficient services based upon current standards of practice for a urinary catheter. The deficient practice was identified for 1 of 1 resident (Resident # 83) reviewed for urinary catheter investigation. This deficient practice was evidenced by the following: On 02/06/2026 at 9:55 AM, the surveyor observed Resident # 83 in bed in their room. At that time, the surveyor observed the catheter drainage bag (collection bag for urine from an indwelling catheter) in contact with the floor. The catheter drainage bag plastic hook was not secured to the bed frame. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that medications were stored in a safe and sanitary manner by failing to maintain medications in their original containers and keeping medication storage drawers free of loose, unidentified tablets. The deficient practice was identified for 1 of 3 medications carts reviewed for medication storage. The deficient practice was evidenced by the following: On 02/06/2026 at 10:51 AM, in the presence of Registered Nurse (RN) # 1, the surveyor observed 8 various, loose tablets scattered within the second and third drawers from the top of the Team 2 Healthcare medication cart. At that time, the 8 tablets were observed to be of different colors, shapes, and sizes, were not in any packaging or containers, and were not labeled. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to implement its antibiotic stewardship program by failing to ensure that prophylactic antibiotic therapy for dental procedures was based on a documented clinical indication or current professional standards. This deficient practice was identified for 1 of 5 (Resident # 37) residents reviewed for Unnecessary Medications. This deficient practice was evidenced by the following:A review of the American Dental Association (ADA) clinical recommendations for antibiotic prophylaxis revealed that prophylactic antibiotics are not recommended for patients with prosthetic joint implants to prevent prosthetic joint infection during dental procedures. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 09/23/2024 from 07:57 AM to 08:27 AM the surveyor, accompanied by the Dietary Clerk (DC), observed the following in the kitchen: 1. The surveyor observed a dietary worker walking around the kitchen with a full beard and no beard guard. 2. In refrigerator #1 an unopened package of hot dogs with a use- by-date of 09/18/2024. There was also a large metal tray of raw salmon covered with plastic wrap that was not labeled or dated. The DC removed and discarded items. 3. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to a.) identify the medical symptom that warranted the use of restraints; b.) perform an assessment and evaluation for restraint use; c.) obtain a consent with disclosure of risk versus benefits for use the of a restraint; d.) conduct on-going evaluations for the continued use of the restraints; e.) monitor the residents during the use of the restraints; f.) document interventions to decrease and/or discontinue the use of the restraints and; g.) release the restraints during supervised activities. This deficient practice was identified in 1 (one) of 1 (one) residents reviewed for restraints (Residents #19) and was evidenced by the following: Review of the admission Record indicated that Resident #19 was admitted to the facility with the diagnoses which included but was not limited to: [...]

Inspectors wroteComplaint # NJ172381 and NJ173377 Based on interview, record review and document review it was determined that the facility failed to maintain documentation and ensure that a complete and thorough investigation was conducted for residents that had unwitnessed falls and sustained fractures. This deficient practice was identified for 2 (two) of 2 Residents (Resident #5 and #45) reviewed for fracture of unknown origin and was evidenced by the following: 1.) According to the quarterly Minimum Data Set, dated [DATE], an assessment that facilitates a resident's care, indicated that Resident #5 had the diagnoses that included but was not limited to cerebral vascular accident (stroke), disease (GERD) and hip fracture. The MDS also indicated that the resident was cognitively intact. [...]

Inspectors wroteComplaint # NJ00171237 Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to accurately assess the status of a resident in the Minimum Data Set (MDS). This deficient practice was identified for 1 of 22 sampled residents, (Resident #37) and was evidenced by the following: On 6/11/2021 at 9:34 AM, the surveyor observed Resident #11 in the hallway with a wander guard/elopement bracelet on his/her left ankle. On 09/23/24 at 08:53 AM, the surveyor observed Resident #37 in the room. The surveyor did not observe an elopement device. According to the admission Record, Resident #37 was admitted with diagnoses including but not limited to Parkinson's Disease (a disease effecting the central nervous system). [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to develop and implement a comprehensive interdiciplinary care plan that a.) specified a resident's preferences for care and; b.) meets the medical needs identified on the comprehensive assessment for 2 (two) of 17 residents reviewed for comprehensive interdiciplinary care plans, (Resident #40 and #48). This deficient practice was evidenced by the following: 1.) According to the admission Record (AR), Resident #40 was admitted to the facility with the diagnoses which included but was not limited to; compression fracture, fusion of the spine and osteomyelitis (infection in a bone). [...]

Inspectors wroteBased on interview, review of medical records and other facility documentation, it was determined that the facility failed to a.) follow physician's order to remove a left hand appliance during the day and b.) ensure that there was an active order for a right hand appliance for 1 of 17 residents reviewed for accuracy of physician's orders (Resident #8) c.) supervise the administration of medications for 1 of 4 residents (Resident #27) reviewed for medications and 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 ensure that an indwelling urinary catheter (tube inserted in the bladder to drain urine) drainage bag was secured in a manner to prevent contamination for 1 of 1 resident reviewed for a urinary catheter, (Resident #48). The deficient practice was evidenced by the following: During the initial tour of the unit on 09/23/2024 at 08:44 AM, Resident #48 was in bed with a urinary catheter drainage bag in contact with the floor, with no privacy bag, and visible from the hallway. It was not secured to the bed frame. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that appropriate assistive devices were provided to residents (Resident #8) to maintain and improve their ability to drink independently for 1 of 3 residents reviewed for activities of daily living. The deficient practice was evidenced by the following: On 9/23/2024 at 8:20 AM, during initial tour, the surveyor observed Resident #8 with adapted water bottle attached to the right side of resident's chair. The long flexible straw of the bottle was observed to be coiled around itself and the tip was not located near the resident's mouth, leaving the resident unable independently drink. On 9/24/2024 at 12:22 PM, the surveyor observed Resident #8 in the main dining room being assisted during lunch. The resident's water bottle was not observed attached to the resident's chair. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the pneumococcal vaccination was offered to all residents upon admission to the facility to prevent incidence of pneumonia for 2 of 5 residents (Resident #4, Resident #32) reviewed for immunization administration. This deficient practice was evidenced by the following: 1. On 9/23/2024 at 8:38 AM, during the initial tour of the facility, the surveyor observed Resident #4 sleeping in bed in their room. A review of Resident #4's admission Record revealed that the resident was admitted to the facility with diagnosis which included, but were not limited to, presence of unspecified artificial hip joint and encounter for other specified surgical aftercare. [...]

Inspectors wroteBased on observation and interview, the facility failed to promote a home-like dining atmosphere for 1 of 1 facility dining rooms. This deficient practice was evidenced by the following: 1. On 07/13/2023 at 12:21 PM, the surveyor observed the lunch meal in the facility main dining room. The surveyor observed 30 residents present at the lunch meal. All 30 residents received their meal on a tray. 2. On 07/14/2023 at 11:55 AM, the surveyor observed the lunch meal in the facility main dining room. 25 residents were observed in the dining room. 25 residents received their lunch meal served on a tray. 3. On 07/17/2023 at 12:25 PM, the surveyor observed the lunch meal in the main dining room. There were 29 resident's present in the main dining room for the lunch meal. 29 of 29 resident's received their lunch meal on a tray. 4. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to provide necessary respiratory care consistent with professional standards of practice specifically by leaving a continuous positive airway pressure (CPAP) mask exposed on top of a nightstand when not in use, failing to date nasal cannulas, and failing to appropriately store a nasal cannula when not in use and failed to update the care plan for 4 of 5 residents (Resident #1, Resident #12, Resident #21, Resident #23) investigated for Oxygen. The deficient practice was evidenced by the following: 1.) On 7/13/2023 at 10:09 AM during the initial tour of the facility, Surveyor #1 observed Resident #1 in his/her room. At that time, Resident #1 was wearing a nasal cannula (tube used to deliver supplemental oxygen to a person). [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 7/13/2023 from 9:00 to 9:42 AM, the surveyor, accompanied by the Food Service Director (FSD) and Assistant Food Service Director (AFSD), observed the following in the kitchen: 1. In the dry storage room on a middle shelf an opened bag of breadcrumbs was stored inside a plastic bin. The bin was labeled Bread Crumbs and had a date of 3/3. The AFSD stated they are good for about a week after opening. We get these regularly, but the date wasn't changed. We date the bag, but this bag isn't dated. The AFSD removed the bread crumbs to the trash. [...]

Inspectors wroteC/O # NJ 161082 Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to follow a physician order and care plan for the use of an abductor pillow (a device that will hold your hip in one position and help it heal) for 1 of 24 sampled residents, Resident #41. This deficient practice was evidenced by the following: During the initial tour of the facility on 07/13/2023 at 10:25 AM, Resident #41 said he/she had a fractured arm and also fell and fractured their hip. The Resident was out of bed sitting in a wheelchair. According to the admission Record, Resident #41 was admitted to the facility with diagnoses including but not limited to: displaced fracture of surgical neck of right humerus, Parkinson's disease, fracture left femur. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to follow their own facility policy for weights for 1 of 3 residents (Resident #28) reviewed for nutrition. This deficient practice was evidenced by the following: On 07/13/2023 at 10:29 AM, the surveyor observed Resident#28 at an activity group. Resident #28 had a soft cervical collar around their neck and appeared thin and cachectic. According to the face sheet, Resident #28 was admitted to the facility with the following but not limited to diagnoses: rhabdomyolysis (a condition in which damaged skeletal muscle breaks down rapidly), dysphagia, oropharyngeal phase (difficulty swallowing), protein-calorie malnutrition, dementia, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation it was determined that the facility failed to ensure that a resident received care and services for the provision of parenteral fluids (intravenous) consistent with professional standards of practice, specifically by failing to label and date, as appropriate, infusion fluids and lines for 1 of 1 resident (Resident #21) identified for Parenteral/IV Fluids. This deficient practice was evidenced by the following: On 7/13/2023 at 10:21 AM, during the initial tour of the facility, the surveyor observed an intravenous (IV) bag of Normal Saline Solution (NSS; fluid used for hydration) hanging from a pole in Resident #21's room. The bag had no label identifying the resident, dose, or order, and the tubing had no date on it showing when it was initiated. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of garbage and debris. This deficient practice was evidenced by the following: On 7/13/2023 from 9:00 to 9:42 AM, the surveyor observed the facility designated garbage area: The area consisted of what the Food Service Director (FSD) described as (4) comingled dumpster's for recyclables and (2) additional dumpster's that were designated for the facility garbage. The (4) co-mingled dumpster's for recyclables were observed to have their lids closed and no garbage was on the ground surrounding the co-mingled dumpster's. The surveyor them observed the garbage dumpster's. The facility had (2) red garbage dumpster's. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure staff implemented appropriate sanitary practice for resident care equipment, specifically by staff retrieving a nasal cannula from the floor and placing it onto 1 of 5 residents (Resident #1) investigated for Respiratory Care. The deficient practice was evidenced by the following: On 7/20/2023 at 10:51 AM, while inside Resident #1's room, the surveyor observed a nasal cannula (tube used to deliver supplemental oxygen to a person) on the floor behind the oxygen concentrator. Resident #1 was not in the room at this time. A review of Resident #1's Diagnosis located in the EMR revealed a diagnosis of Pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid). [...]