Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Mary's Center For Rehabilitation & Healthcare during CMS and state inspections, most recent first.
A resident with ESRD and HTN had a care plan focused on hydration risk related to a fluid restriction, but after readmission the hospital discharge summary showed no fluid restrictions and the care plan was not revised. The UM and DON both acknowledged the care plan should have been updated when the order changed, and the facility policy required periodic review and adjustment based on provider orders/guidance.
Bilateral floor mats were not kept in place for two residents with fall risk. One resident with repeated falls and gait impairment was observed with a floor mat leaning against the wall instead of on both sides of the bed, and another resident with hemiplegia and a recent fall was observed with only one mat at bedside while the other side had none. The UM and DON stated that ordered bilateral mats should be on the floor on both sides of the bed while the resident is in bed.
A resident with heart failure and comfort care was observed receiving oxygen via nasal cannula at 3 L while the oxygen condenser was on, but the EMR did not contain a physician order for oxygen. The UM acknowledged the resident had been receiving oxygen for awhile without an order, and the DON confirmed that oxygen should be administered under a physician order. Facility policy on oxygen administration did not mention the need for a physician order.
Respiratory equipment was found stored open to air for three residents reviewed for respiratory care. Surveyors observed a nebulizer mask in a nightstand drawer, another nebulizer with the mask beside it on a bedside table, and a CPAP mask not stored in a bag when not in use. The IP and DON stated that cleaned and dried masks should be kept in a labeled plastic bag, but the facility’s Respiratory Equipment policy did not address storage when equipment was not in use.
Kitchen equipment was found in disrepair when the surveyor observed a stove with no knobs and a portable holding temperature box with gaskets falling off. The FSD stated the stove knobs had been broken for 1 month and acknowledged the stove top should have knobs, and also stated the box gaskets should be replaced. Facility policy required maintenance to address equipment not functioning as designed.
Two residents with complex medical needs did not receive prescribed medications and nutritional treatments as ordered, and providers were not notified in a timely manner. Documentation in the MAR showed missed and refused doses, but there was no evidence in progress notes that providers were informed, as required by facility policy. Staff interviews confirmed that provider notification and documentation were expected but not completed.
The facility failed to accommodate dietary preferences for several residents, as evidenced by missing or incorrect food items on meal trays. A resident on a specific diet did not receive their ordered items, and another resident reported not receiving requested beverages. The Dietary Department's policy was not followed, leading to unmet resident preferences and inadequate communication among staff.
The facility failed to handle potentially hazardous food and maintain sanitation, as observed by surveyors. Issues included expired hot dog rolls and cucumber salad, unlabeled pizza dough, and open containers of food thickener and flour. Additionally, an unlabeled plate of food and outdated blueberries were found in unit pantry refrigerators. These practices were not in compliance with the facility's food storage and dietary policies.
The facility's Arbitration Agreement failed to inform residents or their representatives of their right not to sign as a condition of admission or continued care. The agreement also lacked language allowing communication with officials, as confirmed by the LNHA and Admissions Director.
The facility did not properly test and maintain battery-operated smoke detectors in resident rooms, as required by NFPA 101. Documentation lacked details such as make, model, and battery type, and only included monthly checkmarks. The manufacturer's manual required weekly testing, which was not documented. This affected all 114 smoke detectors, potentially impacting all residents.
The facility failed to conduct fire drills with varying activation types and times as required by NFPA 101: 2012 Edition. The fire drill reports lacked specificity regarding the method of alarm transmission, and six out of twelve drills were conducted on a Saturday without varying times for the first shift. This deficiency had the potential to affect all residents.
The facility's emergency generator annunciator panel was found to be malfunctioning, as the test lamp button did not work and no alarm condition lights functioned, despite the generator running. This issue was identified during an observation and had the potential to affect all residents.
The facility failed to keep an exit stairway free of storage, as required by NFPA 101. During an observation, two chairs were found obstructing the path of egress in the physical therapy stairway, potentially affecting 50 residents. A U.S. FOIA representative confirmed that nothing should be stored in stairway exits.
The facility failed to ensure that an electrical outlet next to a water source in the Physical Therapy room was equipped with GFCI protection, as required by NFPA 70 and NFPA 99. This deficiency, observed during an inspection, had the potential to affect ten residents.
The facility failed to maintain a clean and safe environment, as observed by a surveyor. Linen was found unfolded and piled on a linen cart handle, and soiled utility rooms had overflowing linens and untied trash bags on the floor. The Infection Preventionist and LNHA acknowledged the issues, with the LNHA noting that soiled utility rooms are checked twice during the day shift, but additional checks were requested.
A resident with a history of falls and severe cognitive impairment experienced multiple falls without thorough investigation or documentation. Incident reports lacked witness statements, vital signs, and clarity on whether falls were witnessed. Staff interviews confirmed inconsistencies in following facility policy, and the Director of Nursing acknowledged the deficiencies.
A facility staff member failed to wear a gown during high-contact activities for a resident under Enhanced Barrier Precautions, despite the requirement outlined in the resident's care plan and facility policy. The CNA was observed providing incontinence care with only gloves and a mask, which was confirmed by the UM/LPN, Infection Preventionist, and DON. The facility's policy mandates gown and glove use during such activities to prevent the spread of MDROs.
The facility failed to maintain the required minimum CNA-to-resident ratios as mandated by New Jersey law. Multiple instances of insufficient staffing were identified across several weeks in 2023 and 2024, with the facility consistently falling short of the required number of CNAs during the day shift. Despite the facility's policy to provide sufficient staffing, the documented levels did not meet the state-mandated ratios, as confirmed by interviews with the Staffing Coordinator and the DON.
Care Plan Not Revised After Fluid Restriction Order Changed
Penalty
Summary
The facility failed to revise Resident #232’s care plan when the physician’s orders for fluid restriction changed. Resident #232 was admitted with diagnoses including end-stage renal disease and hypertension, and the electronic medical record showed the resident had been on a 1500 mL daily fluid restriction prior to hospitalization on 03/02/2026. After the resident was readmitted, the hospital discharge summary indicated there were no fluid restrictions, but the care plan still contained a focus for risk of alteration in hydration related to the fluid restriction initiated on 12/11/2025. The surveyor observed Resident #232 resting in bed during the initial tour. Review of the care plan showed no revision after readmission, despite the change in orders. During interviews, the Unit Manager stated care plans are reviewed every three months and as needed if changes occur, and agreed the care plan should have been updated. The DON stated care plans are updated quarterly or during audits and should be updated upon readmission as orders and care can change. The facility policy titled Resident Evaluation/Assessment required periodic review of progress and adjustment of treatments based on provider orders/guidance.
Bilateral floor mats not maintained at bedside for residents at fall risk
Penalty
Summary
The facility failed to ensure an environment free from accident hazards by not keeping ordered bilateral floor mats in place for two residents. Resident #147 was observed in bed with one floor mat on its side leaning against the wall on the far side of the room on 04/23/2026 and again on 04/24/2026. The resident had diagnoses including repeated falls and other abnormalities of gait and mobility, and the EMR showed a physician’s order for bilateral floor mats every shift with a start date of 01/23/2026. The care plan identified a fall risk related to medication side effects, unsteady gait, and history of falls, with an intervention for bilateral floor mats at bedside. Resident #43 was observed in bed with one floor mat on the side of the bed between the resident and the roommate, with no mat on the other side of the bed on 04/24/2026 and again on 04/28/2026. A family member stated that the resident’s floor mat had previously been found behind the bed while the resident was in bed. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and unspecified fall. The most recent MDS dated 04/02/2026 indicated a fall since the prior assessment, and the EMR showed a physician’s order for bilateral floor mats every shift with a start date of 01/23/2026. The care plan identified a fall risk due to history of falls and included an intervention for bilateral floor mats at bedside.
Oxygen Administered Without Physician Order
Penalty
Summary
The facility failed to provide specialized respiratory care in accordance with professional standards of practice by administering oxygen without a physician's order for one resident. During the initial tour, the surveyor observed the resident lying in bed with a nasal cannula in place, the oxygen condenser turned on, and oxygen being delivered at 3 liters. The resident's admission record showed diagnoses including heart failure and comfort care, and the EMR contained an order for comfort care but did not show a physician's order for oxygen. During interviews, the Unit Manager stated that oxygen must be administered under a physician's order and acknowledged that the resident had been receiving oxygen for awhile without such an order. The DON also stated that there should be a physician's order for oxygen if a resident is receiving it. The facility's policy titled Oxygen Administration - Resident did not mention the need for a physician's order, while the Medication and Treatment Orders policy stated that orders for medications and treatments would be consistent with principles of safe and effective order writing.
Respiratory Equipment Stored Open to Air
Penalty
Summary
The facility failed to ensure that respiratory equipment was stored in a manner that prevented contamination for 3 of 6 residents reviewed for respiratory care: Resident #5, Resident #79, and Resident #86. During the initial tour, surveyors observed Resident #86’s nebulizer mask lying in the nightstand drawer open to air, Resident #5’s nebulizer with the mask beside it on top of the bedside table open to air, and Resident #79’s CPAP machine with the mask not stored in a bag when not in use. Resident #86’s record showed admission with hypertension and palliative care, and a physician’s order for Ipratropium-Albuterol Solution every 8 hours for 5 days starting 04/20/2026. Resident #5’s record showed a diagnosis of heart failure, a physician’s order for Albuterol Sulfate Nebulization solution 0.083% every four hours as needed for shortness of breath and wheezing, and a care plan focused on comfort care due to terminal/end-stage disease. Resident #79’s record showed diagnoses including COPD and chronic respiratory failure, a physician’s order to apply CPAP at bedtime, and a care plan for altered respiratory status/difficulty breathing related to sleep apnea with CPAP use as an intervention. The Infection Preventionist and DON stated that nebulizer and CPAP masks should be cleaned, dried, and stored in a labeled plastic bag when not in use, but the facility-provided Respiratory Equipment policy did not mention how respiratory equipment should be stored when not in use.
Kitchen Equipment Not Maintained in Safe Working Condition
Penalty
Summary
Essential kitchen equipment was not maintained in a safe and operable condition. During an initial tour of the kitchen, the surveyor observed that the stove had no knobs, and the Food Service Director stated the knobs had been broken for 1 month and that more had been ordered. The Food Service Director also stated that a new stove was supposed to be arriving. In addition, the portable holding temperature box had gaskets that were falling off, and the Food Service Director stated the box was new but that this could happen because of the high heat. During a later interview, the Food Service Director acknowledged that the stove top should have knobs and that the gaskets on the portable temperature box should be replaced. The facility policy titled Facility Equipment stated that if equipment is not functioning as designed, the maintenance department will work with the department head to correct the concern and will orchestrate the overall maintenance of facility equipment.
Failure to Notify Providers of Unadministered and Refused Medications
Penalty
Summary
The facility failed to notify providers in a timely manner when prescribed treatments and medications were not administered as ordered for two residents. For one resident with severe cognitive impairment and multiple complex diagnoses, including epilepsy and cancer, there were several missed doses of phenobarbital documented in the Medication Administration Record (MAR) over multiple dates. The MAR indicated missed doses using a chart code, and progress notes showed that the medication was on order and not yet delivered. However, there was no documentation that the provider was notified of these missed doses until several weeks later, and for some missed doses, no provider notification was documented at all. For another resident with moderate cognitive impairment and multiple medical and psychiatric conditions, including anorexia nervosa, malnutrition, and gastrointestinal disorders, there were missed and refused doses of intravenous nutritional support (Clinimix and Clinolipid) documented in the MAR. The chart codes indicated both unadministered and refused doses, but there was no documentation in the progress notes that a provider was notified of these events. Interviews with staff, including a unit manager and the Director of Nursing (DON), confirmed that provider notification and documentation were expected but not completed or recorded in these cases. Facility policy required that the attending physician or nurse practitioner be notified of changes in condition or when medical intervention was warranted, and that such notifications be documented in the medical record. The DON and other staff acknowledged that the medical record should reflect all care provided, including provider notifications, and that the lack of documentation was not consistent with facility policy. Interviews with providers did not confirm that they had been notified of the missed or refused medications, further supporting the finding that timely provider notification and documentation did not occur.
Failure to Accommodate Resident Dietary Preferences
Penalty
Summary
The facility failed to accommodate resident preferences with specific food items as documented on meal tickets for four out of six sampled residents. Resident #2, who was cognitively intact and on a specific diet due to medical conditions, reported not receiving their food preferences. The Dietician confirmed that Resident #2's lunch tray did not contain the ordered items and communicated this issue to relevant staff. However, the Food Service Director acknowledged that the resident's request for sugar packets was not fully met, and there was no documentation of staff education to prevent recurrence. Resident #1 also reported not receiving requested items like coffee with creamer and sugar, and tea during meals, which was a common complaint in Resident Council Meetings. The Licensed Nursing Home Administrator was aware of a tray being delivered to the wrong room, indicating a lapse in communication and coordination among staff. Additionally, Resident #5 did not receive the ordered two juices and garlic spinach, as confirmed by the Unit Manager and the Certified Nursing Assistant, who admitted to being sidetracked and not fulfilling the resident's request. The Dietary Department's policy required that meal trays be provided as ordered, with routine checks by the Food Services Manager or supervisor. However, the facility's failure to adhere to these policies resulted in residents not receiving their dietary preferences, as evidenced by the surveyor's observations and interviews with staff and residents. The deficiency highlights a lack of effective communication and documentation within the dietary department, impacting the residents' rights to receive meals according to their preferences.
Deficient Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner, as observed by the surveyor. In the kitchen's walk-in refrigerator, 15 bags of hot dog rolls were found with a received by date of 11/11/24, and an opened plastic container of prepared cucumber salad with a received by date of 11/21/24. Both items were acknowledged by the Dietary Director (DD) and were discarded. Additionally, in the walk-in freezer, an opened clear plastic bag with pizza dough was found without a label or date, which the DD also discarded. In the prep area, large containers of food thickener and flour were left open and exposed to air, which the DD subsequently closed. Further observations included an unlabeled, covered plate with fish, pork, and fries in a unit pantry refrigerator, which was removed by a Nurse Manager. Another observation in a different pantry refrigerator revealed a plastic container of fresh blueberries dated 11/23/2024, with some appearing dry. The Nurse Manager was unaware of the expiration date for fresh fruit and removed the blueberries. The facility's policies on food storage, freezer management, and dietary practices were reviewed, indicating that the observed practices were not in compliance with the established guidelines.
Plan Of Correction
Plan of Correction F812 Level F Completion Date: 1/15/2025 Corrective Action: Items that were outdated (hotdog rolls and cucumber salad were discarded). Pizza dough was discarded. Open containers in work area were closed. Personal resident food in pantry (blueberries) were discarded. ID Other Residents: Residents who require nutrition from the Dietary Department or who have personal food brought into the facility. Systemic Change: In-service Labeling, Dating and Discarding Food to the Dietary Department by the Dietary Director completed by 1/15/2025. In-service Resident Food Brought into the Facility to Dietary and Nursing Department by the Dietary Director completed by 1/15/2025. Daily rounds will be completed by the dietary staff in the kitchen and pantry to monitor for outdated items and dispose of them per policy. Monitoring: Audit - Labeling and Dating of Items will be completed on the following schedule: (4) weekly xs 2 weeks then (4) monthly xs 2 months then (4) quarterly x 1 quarter by the Dietary Director. Audit Nursing Pantry Refrigerator will be completed on the following schedule: (4) weekly xs 2 weeks then (4) monthly xs 2 months then (4) quarterly x 1 quarter by Nursing Administration. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Deficiency in Arbitration Agreement Language
Penalty
Summary
The facility failed to include explicit language in their Arbitration Agreement to inform residents or their representatives of their right not to sign the agreement as a condition of admission or continued care. This deficiency was identified through a review of the facility's admission packet, which included an Arbitration Agreement titled 'Voluntary, Binding Arbitration.' The agreement did not contain any language explicitly stating that signing was not a requirement for admission or continued care. Additionally, the agreement lacked language allowing residents or others to communicate with federal, state, or local officials, including representatives of the Office of the State Long Term Care Ombudsman. During interviews, the Licensed Nursing Home Administrator (LNHA) and the Admissions Director confirmed the absence of such language in the arbitration agreement. The LNHA acknowledged that the agreement did not explicitly state that signing was not a condition for admission or continued care. Furthermore, the LNHA confirmed that the agreement did not allow for communication with federal, state, or local officials, although an Ombudsman notification form was included in the admission agreement. This oversight has the potential to affect all residents who signed the binding arbitration clause.
Plan Of Correction
1/15/25 Plan of Correction F847 Level F Completion Date: 1/15/2025 Corrective Action: Admissions Agreement changed to reflect appropriate language in regards to Voluntary Binding Arbitration. Admissions Agreement now will state THIS AGREEMENT IS OPTIONAL FOR RESIDENTS AND FACILITY. ADMISSION TO THE FACILITY IS NOT CONDITIONAL UPON A RESIDENT'S WILLINGNESS TO ENTER INTO THIS AGREEMENT. Appropriate officials and departments for the New Jersey Department of Health and Human Services Division of Aging and Long-Term Care Ombudsman contact information added to Admissions Agreement. Added information will be available to those individuals who have previously signed admissions agreements prior to the above changes being made. ID Other Residents: Any resident or Responsible Party who sign an Admission Agreement. Systemic Change: In-service Updated Admissions Agreement to the Admissions Department by the LNHA completed by 1/15/2025. Monitoring: Audit - Admissions Agreement will be completed on the following schedule: (4) weekly x 2 weeks then (4) monthly x 2 months then (4) quarterly x 1 quarter by the Admissions Coordinator. Results of the audits will be brought to QA/QAPI on a quarterly basis x 3 quarters.
Failure to Maintain Smoke Detectors
Penalty
Summary
The facility failed to ensure proper testing and maintenance of battery-operated smoke detectors in resident rooms, as required by the NFPA 101 Life Safety Code: 2012 Edition. This deficiency was identified during an interview and documentation review, which revealed that the facility's preventative maintenance logs lacked detailed information about the smoke detectors, such as make, model, installation date, and battery type. The logs only contained a checkmark for each room every month, without any further details. Additionally, the manufacturer's user manual indicated that the smoke detectors should be tested at least once a week, a requirement that was not reflected in the facility's documentation. This oversight affected all 114 documented battery-operated smoke detectors in the facility, potentially impacting all residents. The findings were communicated to the U.S. FOIA (b)(6) during the Life Safety Code exit conference.
Plan Of Correction
Plan of Correction K0347 Level F Completion Date: 1/15/2025 Corrective Action: 10 year maintenance free battery operated smoke detectors were tested in all resident rooms on 12/12/24 and operational as designed. ID Other Residents: Any resident within the facility Systemic Change: In-service Monitoring Smoke Detectors to the Maintenance Department by the Maintenance Director completed on 12/20/24. Smoke Detectors will be tested monthly and a log maintained by the Maintenance Department. Monitoring: Audit - Smoke Detectors will be completed on the following schedule: (10) quarterly x 3 quarter by the Maintenance Director/Designee. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Inadequate Fire Drill Procedures
Penalty
Summary
The facility failed to conduct fire drills with varying activation types as required by NFPA 101: 2012 Edition, Sections 19.7.1.4 through 19.7.1.7. This deficiency was identified during a document review and interview on December 3, 2024, in the presence of the U.S. FOIA (b)(6). The review revealed that the facility's fire drill reports did not specify the method used for the simulation of alarm transmission signals. Additionally, six out of twelve drills were conducted on a Saturday, and the times for the first shift drills were not varied, which is a requirement for ensuring staff preparedness under different conditions. The lack of specificity in the fire drill reports and the failure to vary drill times and activation types had the potential to affect all residents in the facility. The findings were verified by the [R] at the time of the record review, and the U.S. FOIA (b)(6) confirmed the inadequacies in the documentation and execution of the fire drills. These issues were discussed at the Life Safety Code exit conference on December 4, 2024.
Plan Of Correction
Plan of Correction K0712 Level F Completion Date: 1/15/2025 Corrective Action: - Additional 12/24 Fire Drill will be performed during the day shift and not on a weekend. - Additional 12/24 Fire Drill will reflect type of signal. ID Other Residents: - All residents within the facility have the potential to be affected. Systemic Change: - In-service Fire Drill Testing, Scheduling, Monitoring to the Maintenance Department by the Maintenance Director on 2/2/24. - Fire Drills will be performed during the evening and night shifts and not on the weekend to ensure fire drill training is completed on all shifts. - Supervision log will be utilized to ensure fire drills are completed timely, note signal type and vary for the appropriate shift and time. Monitoring: - Audit - Fire Drill will be completed on the following schedule: (3) quarterly x 3 quarters by the Maintenance Director/Designee. - Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Emergency Generator Annunciator Panel Malfunction
Penalty
Summary
The facility failed to ensure that the emergency generator annunciator was fully functional and operating in normal mode, as required by NFPA 99: 2012 Edition, Section 6.4.1.1.17 and 6.4.1.1.17.5. During an observation at 11:32 AM, it was noted that the generator annunciator panel's test lamp button did not work when activated. Although the generator produced a green light on the annunciator panel indicating it was running, no other alarm condition lights functioned at the time of observation. This deficiency was identified for the only generator annunciator panel in the facility and had the potential to affect all residents. The findings were communicated to the relevant personnel at the Life Safety Code exit conference.
Plan Of Correction
K0916 Level F Completion Date: 1/15/2025 Corrective Action: The generator was inspected and found to be functioning as designed and a new annunciator control board ordered for Generator Annunciator Panel. ID Other Residents: All residents within the facility have the potential to be affected. Systemic Change: In-service Annunciator Panel Monitoring and Resident Safety to the Maintenance Department by the Maintenance Director completed by 12/20/2024. Monitoring: Audit - Annunciator Panel will be completed on the following schedule: every quarter x 3 quarters by the Maintenance Director/Designee. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Obstruction in Exit Stairway
Penalty
Summary
The facility failed to maintain one of its six exit stairways free of storage, as required by NFPA 101: 2012 Edition, Sections 19.2.2.3, 19.2.2.4, and 7.2. During an observation conducted on December 4, 2024, in the presence of a U.S. FOIA representative, it was noted that two chairs were obstructing the path of egress in the physical therapy stairway. One chair was located on the middle landing, and another was on the lower level of the exit/egress stairs leading to the public way. This deficiency had the potential to affect 50 residents. In an interview at the time of the observation, the U.S. FOIA representative acknowledged that nothing should be stored in the stairway exits at any time. The findings were communicated during the Life Safety Code exit conference on the same day.
Plan Of Correction
1/15/25 Plan of Correction K0225 Level E Completion Date: 1/15/2025 Corrective Action: - 2 chairs removed from therapy stairwell. - Other stairwells were checked and no obstruction noted. ID Other Residents: - Any resident within the facility have the potential to be affected. Systemic Change: - In-service Stairwells Free of Obstruction to the Maintenance and Therapy Departments by the Maintenance Director completed on 12/20/24. Monitoring: - Audit - Obstruction in Stairwell will be completed on the following schedule: (4) quarterly x 3 quarter by the Maintenance Director. - Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Failure to Equip Electrical Outlet with GFCI Protection
Penalty
Summary
The facility failed to ensure that one of ten electrical outlets located next to a water source was equipped with Ground-Fault Circuit Interrupter (GFCI) protection, as required by NFPA 70 and NFPA 99. This deficiency was observed on December 4, 2024, during an inspection in the Physical Therapy room. At 11:50 AM, it was noted that a device was plugged into a standard duplex wall outlet instead of the required GFCI outlet for wet locations. This oversight had the potential to affect ten residents. The finding was confirmed by the U.S. FOIA (b)(6) at the time of observation and was communicated during the Life Safety Code exit conference on the same day.
Plan Of Correction
Plan of Correction K0912 Level F Completion Date: 1/15/2025 Corrective Action: Existing outlet was removed and replaced with GFCI outlet. Facility wide inspection has been completed for GFCI outlets. ID Other Residents: All residents within the facility have the potential to be affected. Systemic Change: In-service Testing and Inspection of GFCI Outlets to the Maintenance Department by the Maintenance Director on 12/20/2024. Facility wide inspection of installed GFCI. Monitoring: Audit - GFCI Outlet will be completed on the following schedule: (4) quarterly x 3 quarters by the Maintenance Director/Designee. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment, as evidenced by observations made by a surveyor. On December 3, 2024, in the St. [NAME] hallway, linen including towels and blankets were found unfolded and piled onto the outside handle of the linen cart. Additionally, in the St. [NAME] Soiled Utility room, linens were observed overflowing and not bagged from the receptacle, with two trash bags placed on top of the trash receptacle. In the St. Mary's soiled utility room, linens in untied trash bags were left on the floor. During an interview on December 4, 2024, the Infection Preventionist acknowledged that soiled utility rooms should not be piled up and confirmed that she ensures nothing is on the floor. On December 5, 2024, the Licensed Nursing Home Administrator (LNHA) stated that soiled utility rooms are checked twice during the day shift, but additional checks by housekeeping were requested. The LNHA confirmed that trash bags should be in receptacles and not on the floor.
Plan Of Correction
Plan of Correction F584 Level D Completion Date: 1/15/2025 Corrective Action: Linen found outside of the linen cart was placed in soiled laundry. Linens in the Soiled Utility Room were tied, taken off the floor and placed in the receptacle. Soiled linen was removed from Soiled Utility Room. ID Other Residents: Any resident within the facility Systemic Change: In-service Proper Storage of Linens will be given to the Nursing Department and Laundry by Nurse Educator completed by 1/15/2025. In-service Proper Disposal of Soiled Linens will be given to the Nursing Staff and Laundry by Nurse Educator completed by 1/15/2025. Soiled linens will be collected by laundry service 3 xs daily on the morning shift and 2 xs daily on the evening shift. Additional laundry disposal bins will be purchased to handle the amount of soiled linen that is created. Monitoring: Audit - Clean and Soiled Linen will be completed on the following schedule: (4) weekly xos 2 weeks then (4) monthly xos 2 months then (4) quarterly x 1 quarter by Infection Preventionist. Audit Soiled Utility Room Linen Disposal will be completed on the following schedule: (4) weekly xos 2 weeks then (4) monthly xs 2 months then (4) quarterly x 1 quarter by Infection Preventionist. Results of the audits will be brought to QA/QAPI on a quarterly basis xos 3 quarters.
Inadequate Fall Investigation and Documentation
Penalty
Summary
The facility failed to maintain proper documentation and conduct thorough investigations for a resident who experienced repeated falls. The surveyor reviewed incident reports for falls that occurred on three separate occasions. The reports lacked essential details such as statements from witnesses, vital signs, and whether the falls were witnessed or unwitnessed. The facility's policy required these elements to be included in the incident reports, but they were missing in the cases reviewed. The resident involved had a history of repeated falls and was admitted with diagnoses including cardiomegaly and hypomagnesemia. The resident's cognitive status was severely impaired, as indicated by a low score on the Brief Interview for Mental Status (BIMS). Despite these conditions, the incident reports did not include comprehensive assessments or documentation of the resident's condition following the falls, such as vital signs or any potential injuries. Interviews with facility staff, including CNAs, LPNs, and the Director of Nursing, revealed inconsistencies in the documentation process. Staff confirmed that statements from witnesses and detailed assessments were not consistently obtained or recorded. The Director of Nursing acknowledged the deficiencies in the incident reports and confirmed that the facility's policy was not followed, as the reports lacked signatures, titles, and complete information about the incidents.
Plan Of Correction
Plan of Correction F610 Level D Completion Date: 1/15/2025 Corrective Action: Resident #347 incident report dated 26 was reviewed and reinvestigated by Nursing Administration. Statements were obtained by nursing staff involved in care of resident during incident. Post incident follow up was rewritten. ID Other Residents: Any resident within the facility who has an incident that requires an investigation. Systemic Change: In-service How to Complete a Thorough Investigation to the Nursing Department by Nursing Administration by 1/15/2025. In-service What to Include in an Incident Report: to the Nursing Department by Nursing Administration by 1/15/2025. Statements will be obtained for all unwitnessed incidents by those individuals who interacted with resident within the timeframe of the incident. Monitoring: Audit - Incident Reports and Investigations will be completed on the following schedule: (4) weekly xos 2 weeks then (4) monthly xs 2 months then (4) quarterly x 1 quarter by Nursing Administration by 1/15/2025. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to adhere to appropriate infection control practices by not wearing a gown during high-contact activities in a resident's room who was under Enhanced Barrier Precautions. This deficiency was identified for a resident reviewed for respiratory care. The resident's electronic medical record indicated an order for Enhanced Barrier Precautions every shift for catheter/wound care, requiring staff to wear a gown and gloves during high-contact activities such as dressing, bathing, transfers, linen changes, providing hygiene, brief changes, toileting assistance, indwelling medical device care, and wound care. During an observation, a Certified Nurse Aide (CNA) was seen providing incontinence care to the resident without wearing a gown, despite wearing gloves and a mask. The Unit Manager/Licensed Practical Nurse (UM/LPN) confirmed the CNA's failure to wear a gown during the care. The Infection Preventionist and the Director of Nursing (DON) both confirmed that staff are expected to wear a gown and gloves when providing incontinence care to residents under Enhanced Barrier Precautions. The facility's policy on Enhanced Barrier Precautions, dated March 2024, also outlined the requirement for gown and glove use during high-contact resident care activities to reduce the transmission of multiple-drug resistant organisms.
Plan Of Correction
Plan of Correction F880 Level E Completion Date: 1/15/2025 Corrective Action: 1:1 in-service provided to CNA #1 regarding appropriate PPE when providing care to a resident on Enhanced Barrier Precautions. ID Other Residents: Any resident within the facility who requires care. Systemic Change: In-service Enhanced Barrier Precautions and Proper PPE will be given facility to the Nursing Department by Infection Preventionist will be completed by 1/15/2025. Personal Protective Equipment (PPE) will be made available in clean work rooms as well as in each resident room who is identified on Enhanced Barrier Precautions (EBP). Monitoring: Audit - PPE for Enhanced Barrier Precautions will be completed on the following schedule: (4) weekly xos 2 weeks then (4) monthly xs 2 months then (4) quarterly x 1 quarter by Infection Preventionist. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.
Deficiency in CNA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficiency was identified through a review of the facility's Nurse Staffing Report (AAS-11) and interviews with facility staff. The report highlighted multiple instances where the facility did not meet the staffing requirements for Certified Nurse Aides (CNAs) during the day shift across several weeks in 2023 and 2024. For example, during the week of October 29, 2023, to November 4, 2023, the facility was deficient in CNA staffing on four out of seven day shifts, with the number of CNAs ranging from 13 to 21, while at least 25 were required for the number of residents present. Further deficiencies were noted in subsequent periods, including April 28, 2024, to May 11, 2024, where the facility was deficient on 11 out of 14 day shifts. The number of CNAs ranged from 16 to 21, while at least 25 were required for the resident count. Similar patterns of insufficient staffing were observed in August and November 2024, with the facility consistently failing to meet the mandated staffing ratios. These deficiencies were confirmed through interviews with the Staffing Coordinator and the Director of Nursing, both of whom claimed that the facility met the staffing requirements despite evidence to the contrary. The facility's policy titled "Staffing," revised in March 2020, stated that the facility would provide sufficient numbers of staff with the necessary skills and competency to care for all residents. However, the documented staffing levels did not align with this policy, as the facility repeatedly failed to meet the minimum staffing requirements based on the residents' needs and the state-mandated ratios. This discrepancy between policy and practice contributed to the identified deficiency in staffing levels.
Plan Of Correction
Plan of Correction S560 Completion Date: 1/15/2025 Corrective Action: - No residents were identified - Staffing levels were reviewed for all deficient dates listed - Additional staff were recruited to meet the minimum staffing standards moving forward ID Other Residents: - Potential to affect all residents residing within the facility Systemic Change: - Bonuses are offered for double shifts, extra shifts, and weekends - Perfect attendance bonuses are offered on a weekly basis - In-service Lateness and Attendance Policy - Usage of Staffing Agencies to supplement staffing needs - Offering of Certified Nursing Assistant Courses within the facility - Referral Program promoted for staff - Sign on bonuses to assist with staff recruitment - Employee Appreciation parties - In-service State Mandated Staffing Levels: to the Nursing Department by Nursing Administration by 1/15/2025 - Additional shifts will be made available to meet staffing levels for Certified Nursing Assistants - Licensed staff will supplement Certified Nursing Assistant positions if the need arises that staffing levels go below the state required minimum Monitoring: - Nursing Administration will conduct weekly CNA staffing schedule audits - Nursing Administration will report findings to the Administrator - Results of the audits will be brought to QA/QAPI on a quarter basis for 3 quarters.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Careone At Evesham | 1.4 mi | ★★★★★ | 1 | 0 |
| Complete Care At Kresson View, Llc | 1.6 mi | ★★★★★ | 0 | 0 |
| Complete Care At Voorhees, Llc | 1.9 mi | ★★★★★ | 1 | 0 |
| Barclays Rehabilitation And Healthcare Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Echelon Care & Rehab | 2.5 mi | ★★★★★ | 0 | 0 |
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