Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Joseph's during CMS and state inspections, most recent first.
Kitchenette and pantry equipment was not maintained in a clean, safe, and sanitary manner. Microwaves in multiple kitchenette and pantry units had food debris on the interior ceilings and rotating trays, and refrigerators in two pantry units had copious standing water on the glass shelving. The FSD acknowledged the equipment was not cleaned per facility policy, and the LNHA acknowledged the concern.
A resident with a history of stroke, left-sided hemiplegia, and chronic embolism, and with intact cognition per BIMS, had an order for Eliquis 2.5 mg BID discontinued without any documented discussion of risks and benefits with the resident or his durable power of attorney for health care. The resident later reported that neither he nor his sister were informed of the change and only discovered it when an outside cardiologist noted the discontinuation and recommended restarting the anticoagulant. Review of the EHR showed no documentation of informed discussion by the physician or facility staff, and leadership confirmed the absence of such documentation, while the physician acknowledged discontinuing the medication and that there should have been a note.
A resident who spoke only Arabic and had no cognitive deficits did not receive assigned personal care for an entire day shift when the CNA avoided the resident after perceiving the family as rude and did not notify a supervisor. The resident’s care plan required use of a translator phone for communication when family was absent, and EMR review showed the CNA did not document any care for that shift, although nurses entered for medications and the resident received meals. Another CNA reported the lack of care and provided personal care late in the shift, and the resident’s family confirmed that the regular CNA did not come in to see the resident during that period.
A resident was observed in bed with a bed controller cord that had a broken sheath in several areas and exposed wires. The resident said the cord had been that way for many months and had been reported to the facility, but it was never fixed. An LPN and the DON both stated they had not noticed the damage.
Delayed Criminal Background Checks for Newly Hired Employees: The facility failed to ensure that newly hired staff underwent CBI screening before starting work. Record review of 82 employees found 9 staff members, including CNAs, nurses, a housekeeper, and a dietary aide, whose CBI requests were made after employment began. The report stated that none of the CBI results would have disqualified employment, and the surveyor discussed the concerns with the Administrator and DON.
A resident with dementia and severe cognitive impairment had a quarterly MDS that was not completed by the due date. The MDS Coordinator/RN stated the quarterly assessment was missed by mistake, and the DON acknowledged the late completion and submission of the MDS.
A facility failed to properly reconcile a controlled medication for a resident receiving Lacosamide when the declining inventory log and card count did not match and the RN had not signed the log after administration. The facility also failed to follow a physician order for another resident receiving furosemide with a BP parameter, as no BP was documented at the time of administration in the MAR, progress notes, or EMR. Staff acknowledged the missing documentation and the RN/UM confirmed the expected process for documenting BP and medication holds.
A resident was denied admission after the facility reviewed the referral and later documented the denial as due to C. auris. Surveyors found no supporting documentation that the resident needed a higher level of care or that the facility could not meet the resident’s needs, and the facility’s IP/RN stated that contact isolation and a private room would be used for a resident with C. auris. The DON said there was concern for the resident population and preferred room placement, but the facility’s census showed empty rooms on the unit at the time of the referral.
Uncapped Midline IV Connector: A resident with a midline IV was observed with the line clamped but the connector uncapped after receiving IV antibiotics for cellulitis. The LPN acknowledged the connector should have been capped, and the DON stated it should have been capped while the facility awaited the physician’s decision about continuing the IV and antibiotic.
The facility failed to maintain proper pharmaceutical services, with deficiencies in DEA Form-222 record-keeping, lack of policies for controlled substances, and improper medication storage. Missing and incomplete forms, unremoved medications of a discharged resident, and undated blood glucose test strips were observed, highlighting issues in tracking and accountability.
The facility did not ensure the Infection Preventionist attended the required quarterly QA meetings, as evidenced by sign-in sheets showing the IP's absence from four meetings. The Administrator could not explain the absence, despite policies requiring the IP's participation.
The facility failed to maintain infection control standards during wound care for two residents with pressure ulcers. An RN and an LPN did not adhere to proper hand hygiene and wound care procedures, leading to potential contamination. Additionally, personal care items were shared between residents, and a linen cart was improperly used, compromising the sanitary environment. CNA #2 also failed to perform proper hand hygiene.
The facility failed to offer updated pneumococcal vaccinations to residents according to CDC and ACIP guidelines. A resident with heart failure and COPD, another with colon cancer and COPD, and a third with severe cognitive impairment were not documented as having been offered the updated vaccine, despite having received previous vaccinations. The facility's policy to offer immunizations per CDC guidelines was not followed, as confirmed by the RN/IP and DON.
The facility failed to provide timely incontinence care to three residents on the 4th floor unit. A resident was found with two saturated briefs, another with a saturated brief due to lack of two-hourly care, and a third with a wet brief and bladder pad. All three residents had cognitive impairments and required assistance, yet lacked care plans for incontinence. The DON confirmed the need for two-hourly rounds and proper use of briefs and pads.
A resident with Alzheimer's and a stage 3 pressure ulcer was observed receiving oxygen therapy at 4 LPM, contrary to the physician's order of 2 LPM. The LPN and DON confirmed the discrepancy, acknowledging the failure to adhere to the physician's order.
The facility failed to meet the required CNA staffing ratios on several day shifts, as mandated by New Jersey state law. Additionally, a resident was found to have not received timely incontinence care, with a CNA confirming the lapse in care. The DON stated that incontinence care should be provided every two hours, highlighting a deficiency in the standard of care.
A facility failed to accurately relay medication orders for a newly admitted resident, resulting in the administration of six discontinued medications. The resident, with intact cognition, refused the medications, stating they were not ordered. Facility staff interviews revealed a lack of communication with the AP, who was unaware of the discontinued medications. The facility's policy required resolving medication discrepancies on the day of admission, which was not followed.
A facility failed to maintain an accurate and complete list of a resident's discharged medical records, missing crucial medication instructions. The resident had multiple diagnoses, and the hospital's After Visit Summary was incomplete, leading to unawareness of six discontinued medications. The facility's policy on maintaining accurate medication information was not effectively implemented.
Kitchenette and Pantry Equipment Not Kept Clean and Sanitary
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean, safe, and sanitary manner in 3 of 4 kitchenettes and 4 of 4 pantries on the nursing floors. During observation with the Food Service Director (FSD), the kitchenette microwaves in the 2nd, 3rd, and 4th units had multicolored food debris on the interior ceilings. The pantry microwaves in the 2nd, 3rd, and 4th units also had multicolored food debris on the interior ceilings and food particles on the rotating trays. The FSD acknowledged that the microwaves were not cleaned according to facility policy. The refrigerators in the 1st and 3rd unit pantries were observed to have copious amounts of standing water on the glass top shelving. The FSD acknowledged the condition and cleaned the water with paper towels, stating it had been an ongoing issue since he started at the facility and had been entered into the electronic maintenance system several times. The FSD stated kitchenettes are to be cleaned daily and that equipment cleaning should be done on a schedule to prevent food borne illness and maintain a safe and sanitary environment. The LNHA also acknowledged the concern and stated the equipment should be cleaned and maintained to prevent food borne illness, contamination, or injury.
Failure to Inform Resident and Health Care Proxy of Anticoagulant Discontinuation
Penalty
Summary
The deficiency involves the facility’s failure to include a cognitively intact resident in care planning by informing him and his health care proxy of the risks and benefits of discontinuing an anticoagulant medication. The resident, who had left-sided hemiplegia and hemiparesis following a stroke and a chronic embolism of the left upper extremity, had been receiving Eliquis 2.5 mg twice daily since June 2024. The order for Eliquis was discontinued on May 31, 2025. The resident’s most recent MDS showed a BIMS score of 14/15, indicating no cognitive impairment. During an interview, the resident stated that his Eliquis was stopped at the end of May, that the doctor never talked to him about it, and that there was no notice or discussion with him or his sister, who was his durable power of attorney for health care. He reported that he only learned of the discontinuation when his cardiologist identified it and restarted the medication in July. Review of the electronic health record showed that a physician progress note dated June 1, 2025 did not list Eliquis and contained no documentation of a discussion about the risks and benefits of continuing versus discontinuing anticoagulation therapy. There was no documentation anywhere in the record that the physician or facility staff discussed the discontinuation of Eliquis with the resident or his sister prior to the medication being stopped. A cardiology consultation from July 22, 2025 recommended restarting Eliquis 2.5 mg twice daily. In interviews, the DON and LNHA confirmed that the EHR lacked documentation of any such conversation. The primary physician acknowledged that he discontinued the medication around that time and stated he probably had a discussion with the resident but could not recall and agreed that there should have been a note. The resident’s sister, interviewed with the resident present, confirmed that no physician or facility representative discussed the discontinuation before or after it occurred and stated she was shocked when the cardiologist questioned why it had been stopped.
Failure to Provide Assigned Personal Care for an Entire Shift Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from neglect when assigned personal care was not provided for an entire 8-hour day shift. The resident, who spoke only Arabic and had no documented cognitive, mood, or behavioral issues, relied on staff using a translator phone or family members to communicate. The resident’s care plan included a communication focus with an intervention directing staff to use a translator phone when family was not present. On the identified day shift, the resident reported to the ADON that the assigned CNA did not provide morning care. Review of the EMR showed that the CNA’s documentation reflected that she did not provide care to the resident for that shift, while nurses were documented as entering the room multiple times to administer medications and the resident received meals. The ADON learned from another CNA that the assigned CNA had not cared for the resident during the shift, and that this second CNA provided personal care toward the end of the shift. When interviewed, the assigned CNA stated she had “distanced herself” from the resident because the resident’s family had been rude to her early in the shift and acknowledged she did not care for the resident. She did not report the family’s behavior or her decision to avoid the resident to her supervisor at the time. The resident’s daughter, with interpretation by the granddaughter, confirmed that the regular CNA did not come in to see the resident during that day shift, although nurses entered for medications and the resident received meals. The facility’s abuse, neglect, and exploitation policy defined neglect as the willful failure to provide services to the resident, and the incident was identified as a failure to follow the resident’s care plan and provide required personal care for the entire shift.
Broken Bed Controller Cord Sheath Observed in Resident Room
Penalty
Summary
The facility failed to maintain Resident #12’s living environment in a safe and homelike manner when the resident was observed in bed with a bed controller on the bedside that had a broken cord sheath in several areas and exposed wires. The resident stated that the cord had been like that for many months and that the facility had been told about it a while ago, but it was never fixed. When the surveyor showed the broken cord sheath to the LPN who cared for the resident, the LPN stated she had not noticed it even though she had been in the room earlier that day. The DON also stated she had not noticed the broken cord sheath and exposed wires.
Delayed Criminal Background Checks for Newly Hired Employees
Penalty
Summary
The facility failed to ensure that newly hired employees underwent criminal background checks before they began employment. During review of Human Resources records for 82 employees hired since the previous Department of Health recertification inspection, the surveyor identified 9 employee records in which the Criminal Background Investigation was requested after the employee had already started work at the facility. The affected employees included CNAs, nurses, a housekeeper, and a dietary aide. The record review showed that Employee #12 began employment on 10/20/25 and the CBI was requested on 10/27/25; Employee #13 began employment on 10/20/25 and the CBI was requested on 2/10/26; Employee #14 began employment on 12/15/25 and the CBI was requested on 2/9/26; Employee #17 began employment on 5/5/25 and the CBI was requested on 10/3/25; Employee #34 began employment on 6/2/25 and the CBI was requested on 10/10/25; Employee #38 began employment on 3/2/26 and the CBI was requested on 3/18/26; Employee #54 began employment on 12/22/25 and the CBI was requested on 1/6/26; Employee #55 began employment on 8/11/25 and the CBI was requested on 2/11/26; and Employee #67 began employment on 10/6/25 and the CBI was requested on 2/11/26. The report stated that none of the CBI results would have disqualified employment. On 4/14/26 at 1:00 PM, the surveyor discussed the concerns with the Administrator and DON, and no further information or documentation was provided.
Late Quarterly MDS Completion
Penalty
Summary
The facility failed to complete a quarterly MDS for Resident #104 within the required timeframe. The resident was admitted with diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The most recent quarterly MDS had an ARD of 12/5/25 and documented a BIMS score of 3 out of 15, indicating severe cognitive impairment. The next quarterly assessment was due on 3/5/26, but it was not completed until 4/14/26, 40 days late and after the surveyor’s inquiry. During interview, the MDS Coordinator/RN stated that he missed the quarterly assessment due date and said it was a mistake on their part. The DON acknowledged the concern with the late completion and submission of the MDS.
Medication Reconciliation and Parameter Documentation Failures
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards when a controlled medication was not properly reconciled for one resident. During observation of the medication cart, the surveyor found that the declining inventory log for Lacosamide 200 mg showed 15 tablets remaining while the medication card showed 14 tablets remaining. Review of the resident’s record showed an order for Lacosamide 200 mg twice daily for seizure disorder, and the eMAR documented the dose as given at 9:00 AM. The RN acknowledged that she had administered the medication but had not signed the declining inventory log, and the LPN/UM stated that the nurse should sign the reconciliation sheet as soon as the medication is removed from the card and then sign the eMAR after the resident swallows the pills. The DON stated this had happened previously with the same nurse. The facility also failed to follow a physician order for another resident receiving furosemide with a blood pressure parameter. The resident had diagnoses including dementia, CHF, hypertension, and a cardiac pacemaker, and the MDS showed moderate cognitive impairment. The physician ordered furosemide 40 mg twice daily for CHF with instructions to hold for systolic BP less than 100. Review of the March and April MARs and progress notes showed no documentation of blood pressure at the time the medication was administered, and no BP results were found in the EMR at the time of administration. When interviewed, the LPN stated the MAR should prompt the nurse to enter BP results at the time of administration and that the physician’s order indicated when the medication should be held. The RN/UM confirmed that BP should be assessed and documented in the MAR at the time of administration and acknowledged that no BP results were documented. The DON later provided a physician progress note stating the resident’s BP had been stable and did not require BP monitoring with every medication administration, but there was no documentation that the order had been clarified with the physician before surveyor inquiry.
Denied Admission Based on C. auris Diagnosis
Penalty
Summary
The facility failed to provide services in compliance with applicable Federal, State, and local laws, regulations, codes, and accepted professional standards when it denied admission to a referred resident because of a Candida auris diagnosis. The deficiency involved one of three referral records reviewed, and the resident had previously been admitted to the facility in 2024. The report states that CDC guidance and New Jersey Department of Health guidance indicate that most healthcare facilities can provide adequate care for C. auris-positive individuals and should not deny admission based solely on that diagnosis. Surveyors reviewed the facility’s referral rejection records and found an entry for the resident with a declined reason of “facility cannot provide for patient's need.” When asked for the reason for denial, the facility later provided a letter stating the denial was due to Candida auris. An additional facility letter later stated the resident was denied because of limited availability of private rooms, increased vulnerability to the existing population, and the need for strict infection prevention measures, and it also stated that admission of residents with confirmed or suspected Candida auris may be declined when appropriate isolation, staffing, and infection control resources are not available. The Infection Preventionist/RN stated that prior to admission the diagnosis should be known so the facility could prepare, and explained that a private room and contact isolation precautions would be used for a resident with C. auris. The census records reviewed by surveyors showed empty rooms on the sub-acute unit on the dates tied to the referral. The DON stated there was concern for the resident population and that a room on one end of a wing was preferred for a resident with C. auris, but no additional documentation was provided showing the resident required a higher level of care or that the facility could not care for the resident. The facility’s own policies stated residents should be admitted when needs can be safely and appropriately met and that residents on transmission-based precautions should be placed in a private room if available or cohorted according to national standards.
Uncapped Midline IV Connector
Penalty
Summary
Failure to follow appropriate infection control measures was identified when a resident with a midline IV had an uncapped connector observed during surveyor observation. The resident was in bed with a midline IV in the left arm, and the dressing over the IV site was dated 4/6/26. The IV line was clamped, but the connector was uncapped. The resident stated that nurses had given medicine through the IV the day before. The resident had been admitted with diagnoses including sepsis and cellulitis of the right lower limb, and the Quarterly MDS dated 2/3/26 showed a BIMS score of 15/15, indicating cognitive intactness. Record review showed a physician order dated 3/16/26 to insert a midline and an eMAR order for Ertapenem Sodium 1 gram IV daily for right leg cellulitis until 04/07/2026. When the surveyor asked the LPN about the IV site, the LPN confirmed that the line was clamped but stated the connector should have been capped and acknowledged that it was not. The LPN said she had been in the room earlier that morning and had not noticed the uncapped connector. The DON also stated that the connector should have been capped and that the resident was on hospice care while the facility was waiting for the physician to determine whether the antibiotic and IV line would continue.
Deficiencies in Pharmaceutical Services and Record-Keeping
Penalty
Summary
The facility failed to maintain proper pharmaceutical services, as evidenced by several deficiencies related to the handling and documentation of controlled substances. The surveyor found inconsistencies in the record-keeping of DEA Form-222, which is crucial for the accurate reconciliation of narcotic medications. Specifically, several forms were missing, had incorrect addresses, or were not properly completed, with missing information such as the number of packages received and the date received. These discrepancies were identified during a review of the facility's records and were acknowledged by the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). Additionally, the facility lacked a comprehensive policy and procedure for handling controlled substances, including the DEA Form-222. The DON admitted that there were no existing policies to address the discrepancies found, nor were there procedures for the accurate ordering, receiving, and administration of narcotic medications. This lack of policy contributed to the facility's inability to ensure proper tracking and accountability of narcotic medications. The surveyor also observed issues with medication storage and labeling. In one instance, medications belonging to a discharged resident were not removed from active inventory, posing a risk for medication administration errors. Furthermore, an opened bottle of blood glucose test strips was found undated, contrary to the manufacturer's instructions, which require dating upon opening to ensure proper usage within the specified timeframe. These observations were confirmed by the nursing staff and acknowledged by the DON.
Infection Preventionist Absence from QA Meetings
Penalty
Summary
The facility failed to ensure that the required staff attended the quarterly Quality Assurance (QA) meetings, specifically the Infection Preventionist (IP), who was absent from all four reviewed meetings. The surveyor, upon entrance, requested the QA meeting sign-in sheets and found that the IP did not attend the meetings held on 10/17/24, 7/18/24, 4/18/24, and 1/18/24. During an interview, the Administrator could not provide a reason for the IP's absence, stating that the IP would attend if present in the building. The facility's policies, reviewed by the surveyor, indicated that the IP is required to participate in the QA committee, highlighting a failure to adhere to these policies.
Infection Control Deficiencies in Wound Care and Hygiene Practices
Penalty
Summary
The facility failed to maintain proper infection control standards during wound care treatments for two residents with pressure ulcers. For Resident #181, the RN did not adhere to the correct hand hygiene protocol, washing hands for only 10 seconds instead of the required 20 seconds, and turning off the faucet with bare hands. During the wound care procedure, the RN contaminated the wound by wiping from the wound bed back into the peri-wound area and used soiled gloves to handle clean supplies, including placing a contaminated gauze pad into the wound bed. For Resident #6, the LPN also failed to follow proper wound care procedures. The LPN used the same gloves to handle both clean and contaminated supplies, and improperly cleansed the wound by wiping from the peri-wound area back into the wound bed. Additionally, the LPN did not apply Periguard to the peri-wound before covering it with a bordered dressing and returned contaminated supplies to the treatment cart instead of discarding them. The facility also failed to provide a safe and sanitary environment by allowing the sharing of personal care items between residents and bringing a linen cart into a resident's room, which was then returned to the hallway. CNA #1 acknowledged the error in sharing personal care items and bringing the entire linen cart into the room. Furthermore, CNA #2 did not perform proper hand hygiene by failing to lather hands for 20 seconds outside the stream of water, as required by the facility's policy.
Failure to Offer Updated Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that pneumococcal vaccinations were offered to residents according to the current CDC and ACIP recommendations. This deficiency was identified during a survey where three out of five residents reviewed for immunization status were not offered the pneumococcal vaccine as per the updated guidelines. The Registered Nurse/Infection Preventionist acknowledged awareness of the new guidelines but confirmed that the facility had not offered the newest pneumococcal vaccine to residents who had previously received the vaccine. Resident #23, who was diagnosed with type 2 diabetes, heart failure, and chronic obstructive pulmonary disease, was observed to have an intact cognitive status with a BIMS score of 15 out of 15. Despite having received the Pneumovax vaccine in 2022, there was no documentation in the resident's medical records indicating that the updated pneumococcal vaccine was offered or declined, nor was there evidence of education provided in 2023. Similarly, Resident #36, with diagnoses including colon cancer and chronic obstructive pulmonary disease, also had a BIMS score of 15 out of 15. This resident received the Pneumovax vaccine in 2021, but again, there was no documentation of the updated vaccine being offered or declined, or any educational efforts in 2023. Resident #83, who had severe cognitive impairment with a BIMS score of 6 out of 15, was also not documented as having been offered the updated vaccine, despite having received the Pneumovax vaccine in 2022. The facility's policy stated that immunizations should be offered in accordance with CDC guidelines, but this was not adhered to, as confirmed by the Director of Nursing and the Licensed Nursing Home Administrator.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to three residents on the 4th floor unit, as observed by the surveyor. Resident #22 was found with two saturated incontinence briefs, which CNA #1 attributed to the night CNA's practice of double-diapering, a practice acknowledged as incorrect by CNA #1. Resident #22 had severe cognitive impairment and required extensive assistance for personal hygiene, yet there were no care plans addressing bowel and bladder incontinence. Similarly, Resident #109, who also had severe cognitive impairment and required maximum assistance, was found with a saturated brief, and CNA #1 admitted to not providing the necessary two-hourly incontinence care due to being too busy. Resident #87, with moderate cognitive impairment, was found with a wet incontinence brief and an inserted bladder pad, which CNA #2 stated was placed by the night CNA. Resident #87 expressed a desire to be changed and washed, indicating a lack of care throughout the morning. The Director of Nursing confirmed that incontinence rounds should occur every two hours and that residents should not have two briefs or bladder pads unless requested. None of the three residents had care plans addressing their incontinence needs, despite their conditions requiring such care.
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order for a resident. The resident, who was admitted with diagnoses including Alzheimer's disease, a stage 3 pressure ulcer, and gastrostomy status, was observed receiving oxygen therapy at a rate of 4 liters per minute (LPM) via nasal cannula, contrary to the physician's order of 2 LPM. This discrepancy was noted during observations on two separate occasions, where the resident was found in bed with the oxygen concentrator set at 4 LPM. The Licensed Practical Nurse (LPN) confirmed the incorrect oxygen setting and acknowledged that the physician's order should have been followed. The Director of Nursing (DON) also confirmed that the physician's order for oxygen administration was not adhered to. The facility's policy on oxygen therapy specifies that oxygen should be administered only as ordered by a physician, with the rate of oxygen flow specified in the order.
Deficient Staffing Ratios and Resident Care Lapses
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. Specifically, the facility was deficient in Certified Nurse Aide (CNA) staffing for residents on four out of fourteen day shifts during the two-week period from October 13, 2024, to October 26, 2024. On these days, the number of CNAs on duty was insufficient to meet the state-mandated ratio of one CNA to every eight residents for the day shift. This staffing shortfall was documented in the New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Reports (AAS-11 and AAS-12). Additionally, the surveyor observed a specific incident involving a resident who had not received necessary care. On November 4, 2024, a resident reported not being changed or bathed all morning. The CNA responsible for the resident confirmed that she had not yet provided care to the resident, who was found with a wet incontinence brief and a bladder pad inserted by the night CNA. The Director of Nursing stated that incontinence care should be provided every two hours, indicating a lapse in the standard of care expected. The surveyor informed the facility administration of these staffing ratio concerns, but no further information was provided by the facility.
Failure to Accurately Relay Medication Orders for New Admission
Penalty
Summary
The facility failed to ensure that medication orders for a newly admitted resident from the hospital were completely and accurately relayed to the Attending Physician (AP). Upon admission, there were six medications that had been discontinued by the hospital, but this information was not clarified with the AP for continuance. This oversight was identified during a review of admission orders for one of three newly admitted residents. The resident in question had a range of diagnoses, including Type 2 Diabetes Mellitus, Anemia, Hypothyroidism, Bipolar Disorder, Depression, and Acute Pancreatitis without Necrosis or Infection. The resident's After Visit Summary (AVS) from the hospital indicated changes in medication, including the discontinuation of six specific drugs. However, these changes were not reflected in the facility's Order Recap Report (ORR) or the Medication Administration Record (MAR), which showed that the discontinued medications were still being administered. The resident, who had an intact cognitive status as per the Minimum Data Set (MDS), refused the medications, stating they were not ordered. Despite this, the facility's records showed that the medications were administered on multiple occasions. Interviews with facility staff revealed a lack of communication and verification of the medication list with the AP. The Licensed Nursing Home Administrator (LNHA) and a House Supervisor Registered Nurse (RN) acknowledged that the facility's procedure was to follow the hospital's medication list and confirm it with the AP. However, the AP was not aware of the discontinued medications and typically did not see the patient until two days post-admission. The facility's policy required discrepancies in medication orders to be resolved by consulting the resident's physician on the day of admission, which was not adhered to in this case.
Incomplete Medical Records for New Admission
Penalty
Summary
The facility failed to maintain an accurate and complete list of a resident's discharged medical records from the hospital, which included crucial medication discharge instructions. This deficiency was identified in one of the three residents reviewed for admission orders. The resident in question had multiple diagnoses, including Type 2 Diabetes Mellitus, Anemia, Hypothyroidism, Bipolar Disorder, Depression, and Acute Pancreatitis. The Minimum Data Set (MDS) assessment indicated that the resident's cognition was intact. However, the After Visit Summary (AVS) from the hospital, which should have contained detailed discharge instructions, was incomplete, missing pages 4 through 7. This incomplete documentation led to a lack of awareness regarding the discontinuation of six medications for the resident. During an interview, the House Supervisor RN stated that the facility follows the medication list from the hospital for newly admitted residents and that the nurse responsible for the admission would review the medication list with the physician. However, the RN was unaware of the six medications that were discontinued at the hospital and could not provide an explanation for the missing pages in the AVS. The facility's policy on new admissions emphasizes maintaining and communicating accurate resident medication information, but in this case, the policy was not effectively implemented, resulting in the deficiency.
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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) |
|---|---|---|---|---|
| Alaris Health At Hamilton Park | 0.6 mi | ★★★★★ | 0 | 0 |
| Optima Care Harborview | 0.9 mi | ★★★★★ | 20 | 0 |
| Hoboken University Medical Center Tcu | 1.4 mi | ★★★★★ | 0 | 0 |
| Acclaim Rehabilitation And Nursing Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Optima Care Castle Hill | 2.8 mi | ★★★★★ | 2 | 1 |
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