Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Peace Care St Ann's during CMS and state inspections, most recent first.
The facility failed to include staffing contingency planning and a staffing grid in its facility assessment. Review of the assessment showed it did not address contingency planning for staffing, while NSRs showed CNA staffing shortages on multiple day shifts across several weeks. The LNHA acknowledged the assessment should have included the NJ mandated staffing law and contingency plan and stated the facility did not meet minimum staffing requirements 100% of the time.
Unsafe and Unclean Resident Areas: Surveyors observed peeling wood on CNA charting station drawers used by residents, stained rugs in family rooms, a broken floor tile, stained ceiling tiles, and dust or blackish buildup on vents, window sills, baseboards, and hallway lights in resident rooms, bathing areas, dining areas, hallways, and a soiled utility room. Staff, including an LPN, CNA, RN/UM, housekeeping, and maintenance, acknowledged several of the conditions and were unsure how long some had been present or who was responsible for cleaning certain areas.
The facility failed to complete required pre-employment screening before hire for multiple new employees. Surveyors found that several staff files contained criminal background screening reports dated after the date of hire, and two files had no reference checks at all. The facility’s abuse policy required job reference checks, licensure verification, and criminal conviction record checks for all applicants, and HR stated these checks were expected for all new hires.
Respiratory care was not provided consistently for several residents receiving O2 and nebulizer treatments. One resident’s O2 was set above the physician-ordered flow rate, the nasal cannula was not properly positioned, and the tubing and humidifier were undated. Another resident’s nasal cannula was left attached to the concentrator and not stored in a bag on repeated observations, and a third resident’s nebulizer mask was found in an open drawer instead of being stored in a bag. A fourth resident’s record lacked orders for changing O2 cannula and neb tubing, and the care plan did not address respiratory equipment care.
The facility failed to provide written bed-hold and reserve bed payment information to resident representatives after hospital transfers for three residents. One resident had severe cognitive impairment and was transferred for hypernatremia and sepsis, while two others with moderate to severe cognitive impairment were transferred for G-tube dislodgement and shortness of breath. Records showed transfer notices were sent, but no written bed-hold policy notifications were documented, and the AD stated the facility did not have an official bed-hold letter.
Pressure ulcer care, assessment, documentation, and wound treatment failures: Surveyors found that multiple residents had pressure injuries or skin breakdown with missing or conflicting nursing notes, no formal skin risk assessment, incomplete or absent care plans for actual wounds, and no incident reports or investigations. One resident’s wound care was also observed to be performed with poor infection control, including reuse of gloves during treatment, failure to disinfect supplies and surfaces, and lack of hand hygiene/ABHS when leaving the room.
A facility failed to keep call bells within reach for 3 residents. Surveyors observed call lights hanging off siderails, near the floor, or off the back of the bed, and one CNA had to place a resident’s call bell onto the bed so it was reachable. An RN/UM later adjusted the call bells and stated one resident may not be alert enough to use it; records showed severe or moderate cognitive impairment and other medical issues including osteomyelitis, epilepsy, HTN, difficulty walking, and CKD stage 4.
The facility failed to complete required SCSA documentation for two residents with significant changes in status. One resident had severe cognitive impairment, major weight loss, and a facility-acquired stage 3 pressure injury, but no SCSA was documented to reflect the decline. Another resident was admitted to hospice, but the SCSA did not indicate hospice status in the MDS. The RN/MDSC acknowledged the hospice coding should have been checked and said the MDS was later modified after the surveyor’s inquiry.
Late Transmission of MDS Assessments: The facility failed to transmit MDS assessments within the required timeframe for two residents. An RN/MDSC stated she sometimes delayed transmission for Medicare residents, and she confirmed the two MDSs were late when the surveyor reviewed them. The facility policy addressed timely completion of assessments but did not include transmission timing.
A facility failed to accurately code MDS assessments for several residents after surveyors compared the MDS with transfer forms, PN, treatment orders, consults, and eTAR/eMAR records. The errors involved skin conditions, including pressure ulcers and MASD, as well as Foley catheter status, insulin administration, and O2 services. The RN/MDSC acknowledged some of the coding concerns and stated that certain assessments were done wrong or relied on notes that did not match other records.
Expired resident-use supplies were found in two med rooms during a surveyor review. In the 2nd floor med room, three urinary leg drainage bags with a past use-before date were observed, and an LPN/UM confirmed they were for resident use. In the 1st floor med room, seven tubes of toothpaste with a past expiration date were also observed, and the Unit Manager confirmed they were for resident use.
Unlabeled enteral feeding equipment and an unclear TF order were identified for two residents. A resident’s feeding bag/container was observed without required labeling, and staff confirmed it should have been labeled. For another resident, the tube feeding order stated to run Jevity 1.5 cal at 50 ml/hr for 20 hours or until 1000 ml was infused, but there was no shift documentation of total volume infused and no clarification of when the feeding should stop; staff interviews showed confusion about whether the feeding ended by time or by volume.
A resident with DM, COPD, and chronic ischemic heart disease had a hospital discharge med list that included furosemide, but the facility’s orders and eMAR did not show the med and there was no documentation explaining the omission. The record also lacked evidence that the physician reviewed the resident’s hospital records, completed the H&P, or signed the required orders and follow-up notes; an LPN/UM confirmed the med had been missed and that the expected physician documentation was not found.
A resident received risperidone for Bipolar even though the chart did not support that diagnosis; the record instead reflected dementia, and psychiatry documentation did not list Bipolar. In a separate case, a resident had a psychiatry request for a Depakote level with the next lab draw, but the chart showed no current order or result for that level despite subsequent blood draws.
A facility failed to properly secure medication carts when unattended. Surveyors observed one med cart on the 1st floor left open and unattended with the lock not engaged, and an LPN on the 3rd floor leave another med cart open and unattended on two occasions during med pass. The UM, CP, and DON all stated med carts should be locked when unattended, and the facility policy required medications to be stored in locked cabinets, carts, or medication rooms accessible only to authorized personnel.
In two soiled utility rooms, staff failed to maintain eyewash stations and hand hygiene supplies as observed by the surveyor. One room had no soap in the dispenser, uncovered and damaged eyewash nozzles, and a dirty eyewash cover, while both rooms had eyewash flush logs with missing signatures and no current entries. The DON, LNHA, DM, and RN/IP acknowledged the issues, and the facility policy required clean, intact eyewash covers, proper maintenance, and soap availability.
Missing Mandatory QAPI Training for Two CNAs: The facility failed to ensure that mandatory annual QAPI education was completed for two CNAs. Review of CNA training records showed that two CNAs did not have QAPI training listed in their transcript hours, and the Director of Staff Development confirmed they were not included on the 2025 QAPI education list and did not receive it. The facility policy required CNA training to include the elements and goals of the QAPI program.
Nursing staff did not consistently document medication administration on the MAR for two residents, leaving blank spaces for scheduled medications without corresponding notes. Interviews with an LPN and the DON confirmed that facility policy requires all medication administrations, refusals, or holds to be documented, and that blank spaces are not acceptable. Review of the facility's policy also supported the need for complete MAR documentation.
A cognitively alert resident expressed discomfort due to excessive facial hair, which was not addressed by the nursing staff during scheduled ADL care. Despite the facility's policy to provide grooming services, observations confirmed the facial hair remained, compromising the resident's dignity.
A facility failed to accurately code the MDS for a resident prescribed Rivaroxaban for atrial fibrillation. The MDS did not reflect the use of this anticoagulant, contrary to the RAI manual's instructions. Interviews with staff, including the MDS Coordinator and DON, confirmed the oversight, acknowledging that the medication should have been coded. This inaccuracy could lead to care areas not being addressed in the resident's care plan.
Two residents experienced significant weight loss due to the facility's failure to monitor and address their nutritional needs. One resident lost 29.6% of body weight over several months without receiving necessary interventions, while another lost 10% in 18 days with inconsistent weight monitoring. The facility's policies were not effectively implemented, leading to inadequate communication and documentation of the residents' nutritional status.
The facility failed to follow infection control protocols, as an LPN did not clean a blood pressure cuff between uses for two residents and did not perform hand hygiene after administering medications to a resident. This was against the facility's policies and CDC guidelines, potentially promoting the spread of multi-drug resistant organisms.
Facility Assessment Missing Staffing Contingency Planning
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included the resources needed to establish policies and procedures for staffing contingency plans. During the entrance conference, the LNHA provided the facility assessment and stated the census was 107 residents. Review of the facility assessment for the resident population profile dated 8/11/24 to 8/10/25 showed that it did not include information about the facility's contingency plan for staffing or a staffing grid to follow. Review of the Nurse Staffing Reports showed CNA staffing deficiencies on 1 of 14 day shifts for the week of 8/31/25 to 9/13/25, on 2 of 14 day shifts for the week of 12/14/25 to 12/27/25, and on 2 of 14 day shifts for the two weeks of staffing prior to survey from 2/15/26 to 2/28/26. During interview, the LNHA stated the facility reviewed the assessment annually and as needed, but was unaware of the updated guidance and acknowledged that the 8/10/25 assessment should have included the NJ mandated staffing law and contingency plan. The LNHA also stated the facility followed a CNA staffing pattern by shift and acknowledged the facility was not able to meet the required minimum staffing requirement 100% of the time due to challenges with a snow storm.
Unsafe and Unclean Resident Areas
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment in multiple resident areas, including the 2nd and 3rd floors, resident rooms, family rooms, dining rooms, bathing areas, hallways, and a soiled utility room. During observations, surveyors found peeling wood on CNA charting station drawers where residents used the phone, stained rugs in family rooms, a broken floor tile at a bathroom entry, and stained ceiling tiles in a dining room. Facility staff, including an LPN, CNA, maintenance staff, and the RN/unit manager, acknowledged the peeling wood, broken tile, stained rugs, and stained ceiling tiles and stated they should be cleaned or repaired, while also indicating they did not know how long some of the conditions had been present. In the 2nd floor bathing area, surveyors observed ceiling vents, wall vents, and a window sill with accumulations of blackish, grayish, and dusty substances in multiple cubicles, along with dimmed ceiling lights in the hallway and soiled utility room. The LPN/unit manager confirmed the dust accumulation and the dimmed lights, and stated the areas should have been cleaned or that maintenance should be notified. Housekeeping staff stated they did not usually clean the ceiling lights and vents, indicating uncertainty about responsibility for cleaning those areas. On the 3rd floor, surveyors observed a resident room with blackish stains on the baseboard molding, scattered blackish and grayish substances on the floor, dust on the window sill and toilet room vent, and similar staining and dust accumulation around both sides of the room. In the hallway near the computer desk, four ceiling lights were dimmed and had scattered blackish substances. The RN/unit manager confirmed the dust and staining and stated the areas needed cleaning or buffing, while housekeeping staff were unable to remove the substances and said they did not usually clean the lights. The LNHA and DON were notified of the environmental findings, and the LNHA stated that housekeeping was responsible for cleaning rugs and that soiled rugs should be cleaned right away.
Failure to Complete Pre-Employment Screening Before Hire
Penalty
Summary
The facility failed to verify criminal background screening reports and reference checks for newly hired employees before their dates of hire, as required by its abuse prevention policy. Review of 79 newly hired employee files identified that 9 staff members had criminal background screening reports completed after their dates of hire, including a recreation aide, certified nursing aides, a registered nurse, a licensed practical nurse, and a human resources employee. In addition, two files reviewed for an environmental service staff member and a social worker contained no references in the file. The facility’s New Hire Background Investigations Policy stated that job reference checks, licensure verifications, and criminal conviction record checks are conducted on all personnel applying for employment. Surveyors reviewed multiple employee files and found that Staff #24, #33, #42, #43, #56, #64, and #78 had criminal background screening reports dated after their dates of hire, with one report completed more than 10 months after hire. Staff #69 and Staff #71 had no reference checks found in their files. The interim HR staff stated that all new employees were expected to have criminal background checks and reference checks completed, and the LNHA and DON were notified of the concerns during the survey.
Respiratory equipment not stored properly and care plans missing for oxygen and nebulizer use
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for residents receiving oxygen and nebulizer treatments. For one resident with COPD, staff observed the oxygen concentrator set at 6 lpm even though the physician order was for 4 lpm continuously via nasal cannula, and the nasal cannula was not properly positioned in the resident’s nares. The oxygen tubing and humidifier were also not dated when first observed. The RN/IP confirmed these findings and corrected the equipment during the observation. The resident’s record showed an active order for oxygen at 4 lpm continuously and an order to change oxygen tubing weekly, and the care plan included oxygen at 4 lpm for COPD. A second resident with asthma and COPD was observed in a wheelchair without oxygen in use, while the oxygen concentrator remained in the room with the nasal cannula attached and the tubing laid over the call bell cord. The resident stated they had not used the oxygen since the prior Saturday. On a later observation, the nasal cannula was still attached to the concentrator and not stored in a bag. The RN stated that when not in use the cannula should be stored in a bag, and the LPN/UM stated it should be placed in a plastic bag or blue pouch when not in use. The cannula was dated, but it was not stored appropriately on two separate days. A third resident receiving oxygen and nebulizer treatment was observed with a nebulizer machine in an open dresser drawer, and the resident’s nebulizer mask was laid on top of a plastic bag in the drawer rather than stored in a bag. The RN and LPN/UM both stated the nebulizer mask should be stored in a bag. A fourth resident’s record showed prior orders for oxygen and nebulizer treatments, but there was no order for when to change oxygen cannula or nebulizer tubing, and the care plan did not address oxygen, nebulizer use, or respiratory equipment care. The facility’s policies stated that pre-filled humidifiers must be dated and initialed, oxygen tubing changed every seven days, and nebulizer tubing changed every 72 hours or per facility policy.
Missing Written Bed-Hold Notifications After Hospital Transfers
Penalty
Summary
The facility failed to provide written information to residents or their resident representatives explaining the bed-hold and reserve bed payment policy when residents were transferred to the hospital. The deficiency was identified during review of discharge processes for three residents, including one resident with severe cognitive impairment, one with moderately impaired cognitive skills for daily decision making, and one with severely impaired cognitive skills for daily decision making. Resident #132 had an acute transfer to the hospital for hypernatremia and sepsis. The resident’s record showed diagnoses including cerebral infarction, Parkinson’s disease with dyskinesia, and unspecified dementia, and the MDS reflected a BIMS score of 6 out of 15. The record included a physician order to transfer the resident to the hospital and a progress note documenting that critical labs were reported to the MD and the resident left the unit by stretcher, but there was no documented bed-hold notification sent to the resident or RR. Resident #11 was transferred to the hospital for G-tube dislodgement, and Resident #129 was transferred to the hospital for shortness of breath. Both residents had records showing significant cognitive impairment, and their charts included transfer notification letters to the RR, but no written notification of the bed-hold policy or reserve bed payment was found. Staff interviews indicated that the admission staff were expected to notify the RR of bed hold, but the AD stated the facility did not have an official bed-hold letter and relied on the admission agreement paragraph discussing bed holds.
Pressure ulcer care, assessment, documentation, and wound treatment failures
Penalty
Summary
The facility failed to ensure consistent pressure ulcer/pressure injury care for multiple residents by not promptly monitoring, evaluating, reporting, and documenting new or changing skin conditions, not developing relevant care plans with measurable goals and interventions, not using clean technique during wound dressing care, and not using a formal method to evaluate pressure ulcers/injuries in accordance with facility policy. Surveyors identified these issues for four residents whose records showed pressure-related skin problems, wound treatments, and gaps in assessment and documentation. One resident with severe cognitive impairment, mobility limitations, and incontinence had an open area to the sacrum noted in the record, but the chart did not contain a nursing progress note describing the wound, a formal skin assessment tool, or an incident report. Staff stated that if a CNA found a skin impairment, the nurse would measure it, document it, start treatment, and notify the wound team, resident representative, DON, and physician, but the record did not reflect that process. The resident’s transfer paperwork and other forms also conflicted about whether a wound was present, and the RN/IP confirmed that the wound should have been assessed and that the transfer form was completed incorrectly. Another resident with dementia, cancer history, and CHF had a facility-acquired left buttock pressure ulcer that was treated with Santyl, Silvadene, and later zinc oxide, but there was no care plan for the actual wound, no documented nursing note when the wound was first identified, and no formal skin risk assessment tool found in the record. The wound consult documented a stage 3 ulcer with slough and granulation tissue, and later improvement, but the nursing documentation did not show the initial discovery, measurements, or an investigation. During observed wound care, the nurse used the same gloves to clean the wound and apply zinc oxide, did not disinfect items before returning them to the cart, did not sanitize the bedside table, and left the room without hand hygiene or alcohol-based hand sanitizer despite the resident being on enhanced barrier precautions. A third resident with diabetes and gout had a stage 3 sacral pressure injury treated with Silvadene, but the record lacked a Braden Scale assessment on admission, lacked a nursing progress note describing when the wound was discovered and its measurements, and lacked an incident report or investigation. The care plan only addressed potential skin impairment and did not include the actual pressure injury. Nursing documentation after treatment began still stated that no skin issues were identified, even though wound consultant notes showed the resident had already been seen for the pressure injury. A fourth resident transferred from the hospital with a coccyx pressure ulcer and moisture-associated skin damage had conflicting documentation between transfer paperwork, nursing notes, and the MDS, including a coded stage 3 pressure ulcer on admission, but no formal assessment tool was found and no care plan was initiated for the coccyx ulcer or MASD.
Call Bells Not Kept Within Reach
Penalty
Summary
The facility failed to ensure that the call bells for 3 of 22 residents were within reach and usable to accommodate their needs. During an initial tour, the surveyor observed one resident seated in a chair with the call bell wrapped around a siderail and hanging down between the bed and wall, another resident in bed with the call bell hanging off the bed near the floor, and a third resident in bed with the call bell hanging off the back of the bed just above the floor. When the surveyor asked one resident how help was requested, the resident stated they used the button and someone comes. While in that room, a CNA from an outside provider entered and placed the call bell on the resident’s bed so it was within reach. The surveyor later re-observed two of the residents with the call bells still positioned in the same inaccessible manner. When the surveyor and RN/UM observed the call bells, the RN/UM adjusted them so they were on the bed or next to the resident. The RN/UM stated that one resident may not be alert enough to use the call bell and said staff would be informed to look closer at the call bells and be sure residents could reach them. The record review showed one resident had osteomyelitis and epilepsy with severe cognitive impairment, another had HTN and difficulty walking with a BIMS score of 0, and the third had HTN and CKD stage 4 with moderate cognitive impairment. The facility policy stated staff will ensure the call light is within reach of the resident and secured, as needed.
Failure to Complete Required SCSA for Change in Condition
Penalty
Summary
The facility failed to ensure that a Significant Change in Status Assessment (SCSA) was completed for two residents when their conditions changed in ways that met the criteria described in the CMS RAI Manual. The report states that an SCSA must be completed within 14 days of determining a significant change from baseline, and that documentation of the criteria met is essential in the resident’s medical record. The facility’s own policy also stated that a significant change assessment would be completed within 14 days after the facility determines or should have determined there has been a significant change in the resident’s physical or mental condition. For one resident, the record showed diagnoses including type 2 diabetes mellitus, seizures, dementia, and difficulty walking. The resident’s records showed a stage 3 sacral wound on a wound visit note, significant weight loss over time, and an annual MDS that coded severe cognitive impairment, weight loss, and a facility-acquired stage 3 pressure injury. The prior quarterly MDS did not show the wound and did not show the same decline, and there was no documented evidence that an SCSA was completed to reflect the two areas of decline identified in the record. For the second resident, the record showed diagnoses including moderate protein calorie malnutrition, major depressive disorder, and Alzheimer’s disease, and a physician order indicated hospice admission. The care plan also reflected hospice care, but the SCSA completed with an ARD of 11/18/25 did not check hospice in Section O. During interview, the RN/MDSC stated that hospice residents usually had the assessment done between 11 and 13 days and that hospice should have been checked off on the MDS. She later stated that the MDS was modified after the surveyor’s inquiry. The survey team notified the LNHA and DON of the findings, and they stated that they had hired an MDS Lead to ensure MDS were done accordingly.
Late Transmission of MDS Assessments
Penalty
Summary
The facility failed to transmit MDS assessments within the required timeframe for 2 of 25 residents reviewed. Resident #1 had an Entry MDS with an ARD of 12/26/25 that was completed on 1/2/26 and transmitted on 1/10/26, which was two days late. Resident #131 had a DRNA MDS with an ARD of 1/5/26 that was completed on 1/19/26 and transmitted on 2/6/26, which was nine days late. During an interview on 3/6/26, the RN/MDS Coordinator stated she followed the RAI Manual for completing and transmitting MDS assessments and said that if a resident was under Medicare, she tried to hold off transmission for five days, especially if the resident would be coming back to the facility. She also stated that discharge MDSs were transmitted within 14 days. At that time, she confirmed that the two residents’ MDSs were late and acknowledged that the MDSs were in red, indicating lateness. The survey team also reviewed the facility’s Assessment Frequency/Timeliness Policy, which addressed completing standardized assessments in a timely manner according to the current RAI Manual but did not include information on when assessments should be transmitted.
Inaccurate MDS Coding for Skin, Catheter, Insulin, and Oxygen Services
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for multiple residents after surveyors compared MDS entries with medical records, transfer forms, progress notes, treatment orders, and eTAR/eMAR documentation. The deficiencies involved inaccurate coding of skin conditions, urinary catheter status, and oxygen services, all of which were documented in the residents’ records but not reflected correctly in the MDS assessments reviewed by surveyors. For one resident, the annual, discharge return anticipated, and quarterly MDS assessments contained inconsistent and inaccurate coding related to a stage 3 pressure ulcer and insulin use. The resident’s record showed a sacral wound with stage 3 measurements and later treatment orders for Silvadene, while the January medication records showed Humalog insulin administered before meals and at bedtime. Surveyors found that insulin injections were not coded in Section N of the MDS, and the stage 3 pressure ulcer was coded inaccurately across the reviewed assessments. The RN/MDSC stated the facility followed the RAI manual and later acknowledged the coding concerns raised by surveyors. For another resident transferred from the hospital, the transfer form documented a stage 2 coccyx pressure ulcer and moisture-associated skin damage to the groin, while nursing notes described MASD and wound care orders included Silvadene and zinc oxide. However, the discharge return not anticipated MDS coded a stage 3 pressure ulcer and MASD as present on admission. The RN/MDSC stated she relied on the notes, acknowledged the documentation was confusing, and said she did not review the transfer form and hospital records when completing the assessment. Surveyors also found that two other residents had Foley catheters documented in progress notes, consults, and treatment records during the lookback period, but their MDS assessments did not code a urinary catheter. In addition, one resident’s quarterly MDS did not code oxygen services even though the resident was observed receiving oxygen at 3 L/min via nasal cannula and the eTAR showed the oxygen order was carried out each shift.
Expired Resident-Use Supplies Found in Med Rooms
Penalty
Summary
The nursing facility failed to ensure expired resident-use supplies were removed from medication storage areas and that medication storage areas were maintained in accordance with professional standards of nursing practice. During a med storage and label review, the surveyor inspected the 2nd floor med room and observed three urinary leg drainage bags with a use-before date that had expired. The Licensed Practical Nurse/Unit Manager confirmed that the items were for resident use, and the surveyor identified them as expired durable medical equipment (DME) supplies. During the same review, the surveyor inspected the 1st floor med room and observed seven tubes of toothpaste with an expiration date that had passed. The Unit Manager confirmed that the items were for resident use. The survey team then met with the DON and LNHA and notified them of the findings and concerns. The report cites NJAC 8:39-11.2(a)(b); 19.4(a); 27.1(a) and references the New Jersey Nurse Practice Act for RN and LPN practice standards.
Unlabeled Enteral Feedings and Unclear Tube Feeding Order
Penalty
Summary
The facility failed to ensure residents receiving enteral feedings were cared for in accordance with standard practice by not properly labeling feeding equipment and by not documenting total volume infused or clarifying the feeding order. This deficient practice was identified for 2 of 3 residents reviewed for enteral feeding, including a resident with a gastrostomy tube, cerebral infarction, and type 2 diabetes mellitus, whose cognitive skills for daily decision making were moderately impaired, and another resident with a feeding tube and nutritional support needs. For one resident, the surveyor observed enteral feeding formula being administered by pump, and the feeding bag had no resident name or date labeled on it. The RN/IP confirmed the bag was unlabeled. The resident’s physician orders included flushing the tube, checking placement, and maintaining head-of-bed elevation during and after feeding. The facility policy required enteral feeding bags and administration sets to be labeled with the date, time, and staff initials when initiated or replaced. For the second resident, the surveyor observed tube feeding in progress and the container was not labeled with the formula or the date and time it was started. The resident’s March 2026 eMAR showed an enteral feeding order for Jevity 1.5 cal at 50 ml/hr for 20 hours or until 1000 ml was infused, but there was no documentation of how much total volume was infused each shift and no documentation showing whether the feeding was stopped at 20 hours or at 1000 ml. Staff interviews confirmed confusion about the order, with statements that the feeding would continue until 1000 ml was reached even though the order also referenced stopping after 20 hours, and the order was not clarified.
Physician Did Not Review Medication Orders or Complete Required Visit Documentation
Penalty
Summary
The facility failed to ensure that the physician reviewed the resident’s total program of care, including medications and treatments, and wrote, signed, and dated the required history and physical and succeeding visit notes for one resident. Resident #131 was admitted with diagnoses including type 2 diabetes mellitus without complications, COPD, and chronic ischemic heart disease, and had a BIMS score of 12 out of 15, indicating moderately impaired cognition. Review of the hospital discharge medication list showed furosemide 40 mg tablets, 20 mg daily, was to be continued, but the January 2026 orders and eMAR did not reflect an order for furosemide, and there was no documentation explaining why it was not ordered. The record also lacked documented evidence that the physician reviewed the hospital records and orders reflected in the eMAR and eTAR, and there was no documented evidence that the H&P and succeeding visit notes were completed by the physician and APN. The LPN/UM stated that nurses were responsible for reviewing hospital records and relaying medications to the physician, and confirmed that the furosemide had been missed and should have been relayed. The LPN/UM also stated that it was expected for the physician to complete the H&P, sign orders, and provide follow-up notes, but after reviewing the electronic record she did not find that the H&P was done or that the physician signed the orders.
Unnecessary Medication and Missing Lab Monitoring
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs when Resident #4 was receiving risperidone for Bipolar despite the record not supporting that diagnosis. The admission record listed unspecified dementia and dysphagia, and the cMDS showed severe cognitive impairment with a BIMS score of 3. The physician orders included risperidone 0.25 mg daily and 0.5 mg at bedtime for Bipolar, and the care plan identified psychotropic medication use related to Bipolar. However, a psychiatry consult documented dementia and did not reflect Bipolar or a past medical history of Bipolar, and the resident’s diagnosis list also did not include Bipolar. The facility also failed to monitor requested laboratory results for Resident #7. The resident’s record showed diagnoses including chronic atrial fibrillation and unspecified dementia, and a psychiatry consult requested that a Depakote level be added with the next lab draw. The paper record did not show a current lab order or result for a Depakote level. When the survey team reviewed the resident’s records, the RN/UM identified two blood draws after the consult, but no Depakote level was ordered or completed. The DON later provided a Depakote level result dated before the psychiatry consult that requested the level.
Unsecured Medication Carts Observed Unattended
Penalty
Summary
The facility failed to properly store and secure medications in accordance with accepted professional principles. During a tour of the 1st floor, a med cart identified as the District 1 med cart was observed unattended with the lock not engaged, and the surveyor was able to open the cart and access its contents. When the Unit Manager was notified, the Unit Manager stated the cart should not have been left open and unattended. During med pass on the 3rd floor, the Licensed Practical Nurse assigned to the District 2 med cart left that cart open and unattended on two occasions. When asked, the LPN stated the cart should have been locked when entering a resident's room. The Consultant Pharmacist stated by telephone that med carts should always be locked when unattended, and the DON also stated that med carts should be secured when unattended. The facility's Medication Storage Policy stated that all medications will be stored in a locked cabinet, cart, or medication room accessible only to authorized personnel.
Infection Control Lapses in Soiled Utility Rooms
Penalty
Summary
The facility failed to follow appropriate hand hygiene and infection control practices in two soiled utility rooms that contained eyewash stations. In room R347, the surveyor and the RN/UM observed no soap in the dispenser and uncovered eyewash nozzles in the sink. The RN/UM stated that the plastic cover intended to protect the eyewash nozzles was broken, and the other cover had a brownish substance inside it and should have been cleaned. A posted eyewash flushing log in that room showed October, November, and December 2025 blank with no signatures, and there was no log for 2026. In room R247, the surveyor and the LPN/UM observed a posted eyewash flushing sign for 2025 with October, November, and December blank and no signatures, and there was no log for 2026. The LPN/UM acknowledged the log had no signatures and nothing for 2026. The Director of Maintenance later stated that the unit logs observed by the surveyor were old and were no longer being used. A facility-provided weekly sink flush/eyewash/bather sink and shower log also showed missing signatures for multiple weeks in late 2025, including 10/22/25, 10/29/25, 11/5/25, and 11/26/25 through 12/3/25. The facility’s Infection Preventionist stated that soap was expected to be refilled during environmental rounds and that eyewash nozzles should be covered when not in use to prevent dust from entering the eyewash. The facility’s eyewash policy stated that eyewash stations must be properly maintained, accessible, sanitary, and fully operational, that environmental services and maintenance were responsible for keeping them clean and maintained, and that protective dust covers must remain clean and intact. The facility’s hand hygiene policy stated that hands visibly dirty or contaminated with blood or body fluids must be washed with soap and water.
Missing Mandatory QAPI Training for Two CNAs
Penalty
Summary
The facility failed to ensure that mandatory annual education on the elements and goals of the facility’s QAPI program was provided to all staff, as required for certified nursing assistants. During review of five randomly selected CNA files, the surveyor found that CNA #1, with a date of hire of 8/1/22, had transcript hours that did not include QAPI training, and CNA #2, with a date of hire of 10/3/2018, also had transcript hours that did not include QAPI training. The surveyor reviewed the facility’s mandatory annual education records and identified that these two CNAs were not listed on the QAPI education for 2025. The DON stated that the Director of Staff Educator was responsible for CNA education, and the Director of Staff Development stated she was responsible for mandatory education and that staff were trained through the electronic system software. She confirmed that CNA #1 and CNA #2 were not listed on the QAPI education for 2025 and therefore did not receive it. The facility policy for required CNA training stated that minimum training includes the elements and goals of the facility’s QAPI program, in accordance with NJAC 8:39-33.4.
Failure to Document Medication Administration on MAR
Penalty
Summary
Facility nursing staff failed to consistently document medication administration on the Medication Administration Record (MAR) for two residents. For one resident with diagnoses including major depressive disorder, anxiety disorder, and asthma, there was a blank entry on the MAR for a scheduled dose of Tylenol Extra Strength, and no corresponding documentation in the progress notes to indicate whether the medication was administered. For another resident with anemia, diabetes, and hypertension, blank spaces were found on the MAR for scheduled applications of Clobetasol Propionate cream, with no documentation in the progress notes to confirm administration. Interviews with the LPN and the Director of Nursing confirmed that facility policy requires nurses to sign the MAR after administering medications and to document refusals or held medications with appropriate codes, ensuring no blank spaces are left. Both staff members acknowledged that the MARs for the two residents contained blank spaces, which was not in accordance with facility policy or professional standards. Review of the facility's medication administration policy further supported the requirement for timely and complete documentation on the MAR.
Failure to Address Resident's Grooming Needs
Penalty
Summary
The facility failed to ensure the dignity of a female resident, identified as R165, by not addressing her grooming needs, specifically the removal of excessive facial hair on her chin. R165, who was cognitively alert with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, expressed discomfort and a desire for the facial hair to be removed. Despite being scheduled for Activities of Daily Living (ADL) care on Tuesdays and Fridays, the nursing staff did not address this grooming need, which was confirmed by both the resident and a Certified Nurse Aide (CNA). Observations made on two separate occasions revealed that the facial hair remained unaddressed, and interviews with the resident and a Registered Nurse (RN) confirmed that the expectation was for CNAs to manage such grooming tasks during ADL care. The facility's policy on ADLs indicated that care and services should be provided based on the resident's comprehensive assessment and needs, which includes grooming. However, the failure to remove the facial hair compromised the resident's dignity and comfort, as noted in the report.
Inaccurate MDS Coding for Anticoagulant Medication
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident who was prescribed anticoagulant medication. The deficiency was identified during a review of the Resident Assessment Instrument (RAI) manual and the resident's records. The manual specifies that high-risk drug classes, such as anticoagulants, should be coded according to their pharmacological classification. However, the MDS for a resident with a diagnosis of unspecified atrial fibrillation did not reflect the use of Rivaroxaban, an anticoagulant prescribed to the resident. Interviews with facility staff revealed that the responsibility for completing the medication section of the MDS lay with the nursing unit manager on each floor. The MDS Coordinator confirmed that anticoagulants should be coded on the MDS if prescribed. Both a registered nurse and the Director of Nursing acknowledged the oversight, confirming that the resident was indeed prescribed an anticoagulant and that it should have been coded on the MDS. This inaccuracy in the MDS could potentially lead to care areas not being addressed appropriately in the resident's care plan.
Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for two residents, leading to significant weight loss without proper monitoring or intervention. Resident 49 experienced a drastic weight loss of 29.6% from July to September, dropping from 164 pounds in June to 120.6 pounds by September. Despite being classified as malnourished, there were no orders for nutritional supplements or medications to encourage appetite, and the resident's care plan did not address the weight loss. Interviews with the Registered Dietitian (RD) and other staff revealed a lack of close monitoring and failure to implement necessary interventions. Resident 52 also faced issues with weight monitoring and nutritional care. The resident, who had a history of significant weight loss and was at risk of malnutrition, lost 10% of body weight in 18 days. The RD was aware of the weight discrepancy but did not take timely action to verify the weight change or adjust the resident's dietary plan. The resident's weight was inconsistently measured using different methods, and the physician was not informed of the significant weight loss in a timely manner. The facility's policies and procedures for addressing weight changes and nutritional risks were not effectively implemented. The RD and other staff members failed to communicate and document the residents' nutritional status and weight changes adequately. The Director of Nursing (DON) acknowledged the lack of proper handling of weight loss cases and the absence of a policy for weight accuracy and consistency, contributing to the deficiencies observed in the care of these residents.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the cleaning and disinfection of patient equipment and hand hygiene practices. During observations, it was noted that an LPN did not clean a blood pressure cuff between uses for two residents, despite the facility's policy requiring disinfection with bleach wipes after each use. The LPN admitted to cleaning the cuff after two or three uses, contrary to the facility's guidelines and the Director of Nursing's statement that equipment should be cleaned before and after each use. Additionally, the facility did not follow proper hand hygiene practices during medication administration. An LPN was observed not performing hand hygiene after administering medications to a resident and before moving on to the next resident. This was against the facility's policy and CDC guidelines, which require hand hygiene before and after patient contact. The LPN acknowledged usually cleaning hands after every resident, but this was not done in the observed instance. The facility's policies on infection prevention and control, including the cleaning of non-critical equipment and hand hygiene, were not followed as per the guidelines. The failure to clean equipment and perform hand hygiene as required could promote the spread of multi-drug resistant organisms throughout the facility, as noted in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Jersey City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Acclaim Rehabilitation And Nursing Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Peace Care St Joseph's | 3.1 mi | ★★★★★ | 14 | 0 |
| Alaris Health At Hamilton Park | 3.3 mi | ★★★★★ | 0 | 0 |
| Staten Island Care Center | 3.9 mi | ★★★★★ | 0 | 0 |
| Optima Care Harborview | 4 mi | ★★★★★ | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.