Trenton Gardens Rehabilitation And Nursing Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that dishwashing equipment and manual warewashing processes were maintained and operated according to manufacturer specifications and facility policy, resulting in improper sanitation of dishware, cookware, and utensils. Surveyors found that the dish machine’s hot water booster had not been functioning since a snowstorm, and the machine had been converted by the vendor from a high‑temperature to a low‑temperature chemical sanitizing system. Despite this change, there was no evidence that staff were monitoring or documenting dish machine temperatures or chemical sanitizer concentrations. The last recorded entry on the dish machine temperature log was dated 12/31/25, and the acting Food Service Director (FSD) could not demonstrate how to check or interpret chemical concentrations, nor locate appropriate test strips. The dish machine vendor later informed the facility that the chemical sanitizer attached to the dish machine was expired and not properly sanitizing dishware. Surveyors also observed significant deficiencies in the use of the three‑compartment sink for manual warewashing. A dietary staff member was seen washing pots and pans in the first sink and then placing them directly into the third sink containing sanitizer, skipping the required rinse step in the second sink. The staff member stated, "I don't check for anything" and was unable to explain the correct setup or process for the three‑compartment sink. There was no log documenting sanitizer concentration checks for the three‑compartment sink, and the acting FSD could not initially locate test strips or provide policies beyond a poster above the sink. When the acting FSD attempted to test the sanitizer in the three‑compartment sink, she first used chlorine test strips incorrectly (wrong contact time and no color change), then later used the correct quaternary test paper and obtained a reading between 200–400 ppm, but still reported there was no documentation system in place. During meal service observations, surveyors noted that most residents were being served meals on disposable dishware and utensils, while some residents continued to receive meals on regular washable dishware and utensils. On two nursing units, breakfast trays included both disposable and regular dishware, and used meal trays in the hallway contained a mix of ceramic and disposable items. The acting FSD stated that disposable dishware was being used for most residents because the dish machine was not reaching the required sanitizing temperature, but that two residents who refused disposables continued to receive meals on regular dishware and washable utensils. Nursing staff on the units could not explain why disposables were being used and deferred questions to kitchen staff. The LNHA gave conflicting explanations, at one point stating the dish machine had been working and disposables were used due to an influx of evacuated residents, and at another point acknowledging that the machine had been converted to low‑temperature chemical sanitizing. The LNHA was not aware that sanitizer levels needed to be monitored with the low‑temperature setup, and neither he nor dietary staff could provide documentation that sanitizer concentrations were being checked or recorded. These combined failures in equipment maintenance, monitoring, staff competency, and adherence to written policies led to an Immediate Jeopardy determination related to food safety and sanitation for all residents. The facility’s written policies required specific wash and final rinse temperatures for high‑temperature dishwashers and specified sanitizer concentration requirements for low‑temperature dishwashers, but there was no policy guidance on converting from high‑temperature to low‑temperature chemical sanitization when the booster failed. The dish machine failure policy directed the use of disposables when the dishwasher was out of service, but did not address monitoring of chemical sanitizers or procedures for a low‑temperature system. The Safety Data Sheet for the low‑temperature sanitizer attached to the dish machine described it as a hazardous chemical capable of causing eye and skin burns, respiratory irritation, and harm if swallowed, underscoring the need for correct use and monitoring. Despite this, staff were unable to demonstrate proper testing of sanitizer concentrations, did not maintain logs, and in at least one instance did not follow the manufacturer’s required wash‑rinse‑sanitize sequence in the three‑compartment sink. These documented observations and interviews formed the basis of the cited deficiency for failure to procure, prepare, and serve food under sanitary conditions and in accordance with professional standards.

Removal Plan

• The LNHA contacted the dish machine vendor.
• The LNHA re-educated the Cook, dietary cooks, and dietary aides regarding kitchen sanitation to ensure proper handling of pots, pans, cutlery, and dishware.
• The LNHA re-educated dietary staff on proper use of the dish machine and the three-compartment sink to ensure washing, rinsing, and sanitizing are done correctly, in the correct order, with proper temperatures and sanitizing.
• The LNHA re-educated dietary staff on the importance of documenting sanitizer test results on flow sheets with each use.
• Return demonstrations/competencies were completed by the pot washers and observed by the LNHA and interim FSD.
• All dietary staff will be re-educated and required to complete competencies and return demonstrations prior to working.
• The LNHA re-educated the Cook and dietary staff regarding the use of disposables/paper goods in the event the dishwasher is out of service.
• All necessary dishware was immediately re-sanitized.
• Signs in English and Spanish with instructions for sanitizer use were posted by the dish machine and three-compartment sink.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure competent dietary staffing and proper sanitation practices in the food and nutrition service, particularly related to dishwashing and use of the three-compartment sink and dish machine. Surveyors observed that residents on multiple nursing units were being served meals on disposable dishware and utensils, while some residents still received meals on regular ceramic dishware and utensils. Used meal trays in the hallway contained a mix of disposable and reusable items. When the surveyor questioned staff, the acting Food Service Director (FSD) stated that the dish machine had not been functioning for one week and that disposable dishware was being used throughout the facility. The acting FSD also stated that insulated bowls and cups, which were non-disposable, had been washed in the non-functioning dish machine and that the LNHA was aware. During kitchen observations, a dietary staff member was seen using the three-compartment sink incorrectly by scraping and washing pots and pans in the first compartment, skipping the rinse compartment, and then submerging them directly into the sanitizer compartment. This staff member stated he did not have to check anything and was unable to check the sanitizer concentration due to lack of test strips. The acting FSD could not provide a log or test strips for the three-compartment sink. When the surveyor requested information about the dish machine, the acting FSD could not operate it, could not locate the dish machine log, and could not identify who had checked the chemical sanitizer that morning. The LNHA also could not operate the dish machine, stated that the temperature did not need to be checked because it was a low-temperature machine, and could not locate test strips. The dish machine log that was eventually found showed the last entry dated more than a month prior to the survey. Information from the dish machine vendor showed that the dish machine had been converted to a low-temperature, chemical-sanitizing process due to a non-functioning heat booster and roof exhaust issues, and that staff had been advised to check the chemical sanitizer regularly. The facility was unable to provide documentation that the sanitizer had been checked. On a subsequent observation, the surveyor found that the dish machine was not in use, disposable dishware was still being used, and non-disposable meal trays were submerged in the sanitizer compartment of the three-compartment sink. The sanitizer level in the sink did not meet the fill line, and when the acting FSD tested the solution with chlorine test strips, the strip did not change color and was used for an incorrect immersion time. The acting FSD stated the solution was “no good” and admitted unfamiliarity with the chemicals. A poster above the sink described a quaternary sanitizer process requiring different test strips and a specific concentration range, and when the correct quaternary test paper was used, the sanitizer registered between 200–400 ppm, but there was no thermometer to check water temperature and no log documenting concentrations. The facility’s policies addressed high- and low-temperature dishwashing and dish machine failure but did not address conversion to low-temperature chemical sanitization when the heat booster failed, and there was no documentation of staff competencies or consistent monitoring of sanitizer concentrations as required by the vendor’s instructions and the facility’s own policies. The surveyor also reviewed the Safety Data Sheet for the low-temperature sanitizer attached to the dish machine, which described it as a hazardous chemical capable of causing eye and skin burns, respiratory irritation, and harm if swallowed. Despite this, there was no evidence that staff were consistently monitoring or documenting the sanitizer concentration in the dish machine or the three-compartment sink. The Food Service Director job description indicated responsibility for ensuring infection control and the highest sanitation standards in the dietary department, but the observations showed that dietary staff, including the acting FSD, were not competent in operating the dish machine, using appropriate test strips, following posted procedures for the three-compartment sink, or maintaining required logs. These actions and inactions resulted in a failure to maintain the kitchen in a sanitary manner and to ensure appropriate measures were in place to prevent potential foodborne illness or exposure to hazardous chemicals for all residents served by the dietary department. The facility’s written policies on dishwasher temperature and dish machine failure specified required wash and rinse temperatures for high-temperature machines, required hypochlorite concentration for low-temperature machines, and the use of disposable products when the dishwasher was out of service. However, there was no policy guidance on converting to a low-temperature chemical sanitizing process when the heat booster failed, and no documentation that staff had been trained or deemed competent in this process. The LNHA acknowledged that staff had only been verbally instructed on how to use test strips and that there were no completed competencies. The combination of a non-functioning or improperly converted dish machine, lack of appropriate test strips and logs, incorrect use of the three-compartment sink, and staff unfamiliarity with chemical sanitizers and posted procedures led to the cited deficiency in providing sufficient, competent support personnel to safely and effectively carry out the functions of the food and nutrition service. Residents throughout the facility were affected in that their meals were being served on a mix of disposable and reusable dishware without assurance that reusable items were being properly washed, rinsed, and sanitized. The report notes that this deficient practice had the potential to affect all residents, as the dietary department serves the entire resident population. No specific resident medical histories or conditions are described in the report, but the observations and interviews collectively demonstrate that the facility did not ensure dietary staff competency in maintaining kitchen sanitation and managing hazardous sanitizing chemicals in accordance with regulatory requirements and facility policies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors determined that the facility failed to provide privacy curtains in certain resident rooms, resulting in residents not being afforded full visual privacy. On 2/5/26, between 9:00 AM and 10:45 AM, during a tour of the 5th floor with the LNHA, the surveyor observed that rooms 511A, 514A, 517A, and 519A, which housed a total of eight residents recently transferred from another facility, did not have privacy curtains installed. Later that day at 12:55 PM, when the surveyor asked the LNHA why those residents did not have privacy curtains, the LNHA stated that the maintenance staff had forgotten to install them. The deficiency was communicated to the Administrator at 3:28 PM during the Life Safety Code exit conference. The facility’s written Residents Rights policy, provided by the LNHA, states that employees should treat all residents with kindness and dignity and that federal and state laws guarantee residents’ rights to privacy and confidentiality, including visual privacy, as referenced in NJAC 8:39-31.2(e) and 31.8(c)5. No additional clinical details or specific medical histories of the eight affected residents were provided in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors determined that the facility failed to ensure residents had access to a functioning call system, as required by facility policy. During a tour on 2/5/26 at approximately 10:10 AM, a dependent resident with diagnoses including sciatica, depression, Parkinson’s disease, and peripheral vascular disease asked a surveyor to call the nurse. When the surveyor instructed the resident to activate the call bell, it was observed that there was no functioning call bell available. At 10:30 AM, this concern was shared with another surveyor, and at 10:45 AM both surveyors returned to the room and again observed that the residents in that room did not have a functioning call bell. At 10:50 AM, one resident reported that they had been transferred from another facility on 2/3/26 and had not had a call device since the transfer, explaining that their roommate had to go into the hallway to call staff for assistance. The roommate, who reported needing only minimal assistance with care, confirmed that the other resident could not get out of bed and that she had to get out of bed and shout for staff to assist the dependent resident. In a subsequent interview at 12:30 PM, the DON acknowledged awareness that the room’s call device was not functioning and stated she had previously requested that a manual call device be provided, but neither resident had been given one. Review of the facility’s “Call bell Use Responsibility” policy dated 12/25 showed that it required all residents to always have access to a functioning call bell system and stated that failure to ensure access or timely response may place residents at risk.

Penalty

Fine: $241,35076 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a cognitively impaired resident with a history of restlessness, impulsivity, and multiple prior falls sustained a non-displaced fracture of the left clavicle. The resident was known to be at high risk for falls, as indicated by repeated high scores on the Morse Fall Scale and documented incidents of previous falls resulting in injuries such as skin tears and hematomas. The resident's care plan included specific interventions, such as transferring the resident to a recliner chair at the nursing station for increased supervision during periods of restlessness at night. On the night in question, the resident exhibited restlessness from approximately 11:00 PM until 4:00 AM, as reported by the CNA assigned to the shift. However, the intervention to transfer the resident to the recliner chair at the nursing station was not implemented, despite the resident not refusing the transfer. There was also a lack of documentation regarding the resident's restlessness in the plan of care or progress notes, and the nurse on duty was not informed of the resident's behavior. The following morning, the resident was found to be guarding their left arm and grimacing in pain, which led to the discovery of the clavicle fracture after an x-ray was performed. Interviews with staff revealed inconsistencies in the reporting and documentation of the resident's behavior during the night. The CNA stated she was aware of the care plan intervention but did not carry it out or properly document the resident's restlessness. The nurse on duty confirmed that, had she been informed, she would have taken additional steps to address the resident's needs. The failure to implement the care plan intervention and provide adequate supervision during a period of increased restlessness directly contributed to the resident's injury.

Penalty

Fine: $241,35076 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unsanitary conditions, pest infestations, and delayed removal of soiled items. Surveyors observed heavily soiled ice machines with black and white substances, rust buildup, and water leaks on several floors. Food carts with leftover, uncovered food from previous meals were left unattended, and resident rooms contained food debris, soiled linens, and broken furniture. Bathrooms were found with debris, broken fixtures, and in one instance, a cockroach was observed crawling on the wall during incontinence care. Staff confirmed the presence of cockroaches and described the protocol for reporting pest sightings, which included documentation in a pest control log and notification of the Maintenance Director. Pest logs revealed ongoing documentation of cockroach sightings in resident rooms and common areas dating back several months. Residents and staff consistently reported and observed cockroach infestations throughout the facility, including in bedrooms, bathrooms, closets, and on personal belongings. Surveyors directly observed swarming live cockroaches and dead cockroaches on sticky traps in resident closets, with personal items such as blankets and clothing exposed to the pests. Multiple residents expressed distress about the presence of cockroaches, describing them crawling on their faces and beds, and reported taking measures such as blocking beds with towels to prevent contact. Staff also reported wrapping their personal belongings in plastic bags to protect them from cockroaches. Despite ongoing pest control efforts, the infestation persisted, with sightings documented on all resident floors and in various locations, including on a clean linen cart and near medication carts. In addition to pest issues, the facility failed to promptly clean up resident excrement and address strong odors. Surveyors noted a strong odor of feces in a hallway, and upon investigation, found that a resident's bedside commode had not been cleaned after an episode of incontinence and vomiting overnight. The roommate reported the odor to staff, but the issue was not resolved in a timely manner, and the responsible LPN acknowledged being aware of the situation but did not ensure it was addressed. Damaged and chipped furniture, cracked countertops, and exposed wallboard were also observed, contributing to an environment that was not clean or homelike. Residents and staff confirmed that these conditions had been ongoing and were not adequately addressed.

Penalty

Fine: $241,35076 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in multiple deficiencies across several units. Two residents were observed to have not received timely incontinence care, with one resident remaining unchanged and un-repositioned for over 10 hours, resulting in saturated bedding and visible skin redness. Another resident, who was nonverbal and totally dependent on staff, was found with two saturated incontinence briefs and a wound dressing soaked with urine and bloody drainage. Staff interviews confirmed that incontinence care was not provided as required, and that staff shortages contributed to the lack of care, with CNAs responsible for an excessive number of residents per shift. Medication administration practices were also deficient. One resident was found with a medication cup containing four tablets left unattended at the bedside for over three hours after the MAR had been initialed as administered. The resident was unable to reach the medication due to weakness, and staff interviews confirmed that medications should not be left unattended and that the nurse failed to ensure the resident swallowed the medications before documenting administration. The facility's policy prohibits leaving medications in resident rooms or unattended on the medication cart. Additionally, the facility failed to maintain cleanliness and respond to resident needs in a timely manner. A strong odor of feces and vomit was noted in a resident room, with one resident reporting that the smell persisted overnight and that staff had not cleaned the bedside commode or removed vomit from the garbage can. Staff confirmed awareness of the issue but cited workload and staffing shortages as reasons for not addressing it. Review of staffing records revealed that the facility did not consistently meet New Jersey's minimum CNA staffing requirements on multiple day shifts, with several days falling below the mandated ratios.

Penalty

Fine: $241,35076 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement an effective infection prevention and control program (IPCP), as evidenced by a widespread cockroach infestation affecting all resident units, improper handling and storage of clean linens, and the absence of a water management policy to prevent Legionella and other pathogens. Surveyors observed cockroaches in multiple locations, including resident rooms, closets, bathrooms, and on clean linen carts. Food debris and soiled linens were found on floors, and residents and staff reported frequent sightings of cockroaches on personal belongings, clothing, and even on residents themselves. Documentation in pest control logs confirmed ongoing cockroach activity for several months, with staff and residents consistently reporting the problem. Interviews with staff, including CNAs, the Infection Preventionist (IP), the Maintenance Director, and the Licensed Nursing Home Administrator (LNHA), revealed a lack of coordinated response to the infestation. The IP was not involved in pest control efforts and was unaware of the extent of the problem, deferring responsibility to the maintenance department. The pest management company identified the cockroaches as German cockroaches, known for being difficult to eradicate and capable of transmitting disease. Despite recommendations from pest control service reports for improved sanitation, there was little evidence of follow-up or comprehensive action to address the infestation or to protect residents' personal belongings and clean linens from contamination. Additionally, the facility did not have a water management program or policy in place to prevent the growth and spread of Legionella. When surveyors requested documentation of water testing or preventive measures, facility management was unable to provide any evidence of such activities. The Director of Nursing confirmed the absence of a water management program, and no logs or policies were available to demonstrate compliance with infection control standards related to water safety.

Penalty

Fine: $241,35076 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a deficiency related to the maintenance and sanitation of ice machines on the 2nd, 3rd, and 4th floor resident units. During initial tours, surveyors observed that all three ice machines had significant visible soiling, including white and black substances inside the ice chutes, rust-like buildup on drain covers, peeling molding, and spatter-type debris on the exteriors. The drain areas were also noted to be soiled and stained. These observations were confirmed in the presence of the Licensed Nursing Home Administrator (LNHA), who acknowledged the debris and unsanitary conditions. Interviews with the Maintenance Director (MD) revealed a lack of knowledge regarding the cleaning schedule and procedures for the ice machines. The MD was unable to confirm when the machines were last cleaned, whether there was documentation of cleaning, or the steps required for proper cleaning. The MD also stated that he had not cleaned the machines since his appointment and was unaware of the need to do so. The facility had discontinued service contracts for the ice machines after a change in management, and the MD indicated that the previous company had performed monthly cleanings, but this practice had not continued. A review of the manufacturer's manual provided by the facility outlined specific maintenance requirements, including weekly exterior cleaning and descaling/sanitizing procedures at least every six months. The manual also described additional procedures for heavily soiled machines and emphasized the use of appropriate cleaning agents. The surveyors found that these maintenance protocols were not being followed, as evidenced by the condition of the machines and the lack of staff knowledge or documentation regarding cleaning and maintenance activities.

Penalty

Fine: $241,35076 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified that staff failed to provide routine and appropriate incontinence care and maintain fingernail hygiene for residents dependent on staff for activities of daily living. One resident was repeatedly observed with long, jagged fingernails containing a black substance underneath, despite being alert, requesting nail care, and having a scheduled weekly shower. The resident's care records did not include a physician's order for fingernail care, and nail care was not completed during the scheduled shower. Another resident reported not receiving incontinence care or being repositioned since the previous night, resulting in the resident being found saturated with urine and lying in soiled bedding. The resident, who was cognitively intact and required assistance with personal hygiene, stated that staff did not respond to their call light. The CNA assigned to the resident was unaware of the lack of care due to not receiving a shift report, and the unit was short-staffed due to a call-out, with each CNA responsible for 23 residents. A third resident, who was nonverbal and totally dependent on staff, was found with contracted extremities, saturated with urine, and wearing two incontinence briefs, both soaked. The resident's dressing was also saturated with urine and bloody drainage. The CNA responsible for the resident confirmed placing two briefs on the resident and could not recall when the resident was last changed. Staff interviews confirmed that incontinence care was expected every two hours, but staffing shortages impacted care delivery. Facility policy required individualized ADL care, including regular incontinence care and maintaining resident dignity and hygiene.

Penalty

Fine: $241,35076 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that staff received behavioral health training as required, specifically in managing residents with maladaptive behaviors such as being disruptive, cursing, and spitting at staff. This deficiency was identified during the review of an incident involving a resident with diagnoses including bipolar disorder, post-traumatic stress disorder, and frontotemporal neurocognitive disorder. The resident, who had a history of making false statements and being easily frustrated with staff, was involved in an altercation where they took a piece of cake intended for another resident, ate it, and then spat it at a CNA after being confronted. The CNA involved in the incident attempted to retrieve the cake and placed her hand in front of the resident's mouth to prevent being spat on, which led to the resident alleging that the CNA hit them. The CNA later acknowledged that her response was inappropriate and that she should have walked away instead. The facility's documentation did not provide evidence that the CNA had received specific behavioral health or mental health training, nor was there documentation confirming completion of the required annual in-service training on these topics. The facility's assessment indicated that services were provided for residents with mental health and behavioral needs, and that training and competency checks were to be conducted upon hire, monthly, and annually, including dementia management and care of cognitively impaired residents. However, the lack of documented evidence of behavioral health training for the CNA contributed to the deficient practice, as staff were not adequately prepared to cope effectively with residents exhibiting challenging behaviors.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident, whose smoking privileges had been revoked due to repeated violations of the facility's smoking policy, was found smoking a cigarette inside another resident's room where oxygen was in use. The Nursing Supervisor observed the resident in a wheelchair, smoking in the room of two other residents, one of whom was receiving continuous oxygen therapy for chronic respiratory failure and had severely impaired cognition. Upon entering the room, the supervisor confiscated the cigarette, and a subsequent search of the resident's wheelchair revealed a pack of cigarettes and a bottle of vodka. The resident had a documented history of noncompliance with the smoking policy, including sharing cigarettes, smoking outside designated areas, and failing to leave tobacco products at the front desk, as required by facility policy. The facility's records indicated that the resident's smoking privileges had been revoked prior to this incident, and the care plan had been updated to reflect this, with interventions such as re-education on the smoking policy and the use of nicotine patches. Despite these measures, the resident continued to access and use tobacco products within the facility. Staff interviews revealed that previous incidents involving the resident's possession and use of smoking materials had been reported, but there was inconsistency in follow-up actions and documentation. Additionally, the facility's documentation did not include statements or assessments for the other residents present in the room at the time of the incident, one of whom was cognitively impaired and dependent on supplemental oxygen. The facility's smoking policy explicitly prohibited residents from keeping tobacco products or lighting materials on their person or in their rooms, especially in the presence of oxygen, due to the risk of fire or explosion. However, the resident was able to circumvent these safeguards, resulting in a situation where smoking occurred in a high-risk environment. The lack of consistent enforcement of the smoking policy and insufficient monitoring allowed the resident to possess and use prohibited items, directly leading to the identified deficiency.

Removal Plan

• The Nursing Supervisor (NS) removed the cigarette from Resident #2.
• Resident #2 was searched, and a pack of cigarettes and a pint of vodka was confiscated and destroyed.
• Resident #2 was placed on 1:1 assignment until their discharge from the facility.
• The NS educated Resident #2 and Resident #3 that smoking was prohibited in a resident room.
• Nurse leaders began educating all residents who smoked on the facility's smoking policy and the dangers of smoking near oxygen, and their rooms and equipment were searched by the Assistant Director of Nursing (ADON) for violation of the smoking policy.
• The nurse leaders and Consultant Registered Nurse (RN) re-educated all staff on the smoking policy and the dangers of smoking near oxygen.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that its facility-wide assessment (FA) adequately evaluated the resident population and identified the necessary resources to provide care and services for residents with a history or current use of tobacco, drugs, or alcohol. The FA, completed on 05/03/2025 and provided by the DON, did not include documentation addressing residents admitted with these specific needs. During an interview, the DON confirmed that the FA did not identify smokers as a category of the population served, despite the facility currently having 41 smokers. The deficiency was identified through interviews and review of facility documentation, and the DON acknowledged the omission after reviewing the FA in the presence of the surveyor.

Penalty

Fine: $177,030

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions by staff or details about the residents involved are not provided in the report. The deficiency centers on the lack of appropriate measures to identify and eliminate accident hazards, as well as insufficient supervision to safeguard residents from potential harm.

Penalty

Fine: $119,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure resident safety and well-being by not preventing unauthorized individuals from entering the facility and not preventing incidents involving residents. There was a lack of safety measures to prevent the use of prohibited substances by residents, and the facility did not conduct thorough investigations into incidents involving staff-to-resident and resident-to-resident interactions. Specifically, the administrative staff did not investigate an incident involving a resident who was found in distress and later transferred to the hospital, despite the resident's history of substance use and suspicious behavior observed by staff. The staff did not report or investigate the incident as required, and there was no notification to the Department of Health or law enforcement regarding the event. Additionally, the facility failed to conduct a thorough investigation into an allegation involving a staff member and a resident. When a resident reported observing an LPN in a resident's room under suspicious circumstances, the administrative staff did not interview all relevant residents or staff members, nor did they collect statements as per facility policy. The investigation was limited and did not follow the established procedures for handling such allegations, as acknowledged by the staff during interviews with surveyors. The facility's job descriptions for the Administrator and Director of Nursing outlined responsibilities for maintaining safety standards and conducting thorough investigations, but these were not followed in practice. The lack of proper investigation and failure to implement safety measures placed all residents at risk and resulted in a finding of Immediate Jeopardy by surveyors.

Plan Of Correction

F835 Administration ELEMENT ONE: CORRECTIVE ACTION: The abuse and illicit drug policies were reviewed and updated. The U.S. FOIA (b) (6) and U.S. FOIA (b) (6) received re-education by the corporate officer on job description and abuse and illicit drug policies, which includes reporting to the New Jersey Department of Health and police on 5/9/25. The Licensed Nursing Home Administrator and Director of Nursing re-educated staff on abuse and illicit drug policies, which includes reporting to the New Jersey Department of Health and police on 5/9/25. The Social Worker met with residents with a history of NJ Ex Order 26.4(b)(1) and/or NU EXOTORRADX to educate on the availability of NJ Ex Order 26.4(b)(1) programs, the medical risks of NJ Ex Order 26.4(b)(1) NJ Ex Order 20 involvement, possible discharge from the facility, and revoking of facility leave privileges on 5/9/25. Nursing staff was re-educated on signs of NU EXOrder 26.4DX and policies to follow in cases of suspected ExOrder 254(DX(1)) and the availability of NU Ex Order 26.4(b)(1) programs for residents on 5/9/25. The Director of Nursing / designee re-educated staff on signs of J Ex Order 25.4(D)(1) and policies to follow in cases of NJ Ex Order 26.4b1. The Director of Nursing re-investigated the incidents involving Residents #3, #6, #8, and #15. Care plans of residents cited in the 2567 were reviewed and/or updated by the interdisciplinary team. Incidents and accidents occurring from January through May were audited to ensure there were no identified, unresolved NJ Ex Order 26.4(b)(1) and/or NJ Ex Order 26.4(b)(1). ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS: All residents have the potential to be affected by this practice. ELEMENT THREE: SYSTEMIC CHANGES: Policy signage was posted at the entrance stating that [R] and [R] are not allowed in the home on 5/9/25. The Social Worker meets with new residents who have a history of [R] and/or [R] to discuss policy and options for treatment of [R]. [R] and violations of [R] policy are discussed at weekday clinical meetings and reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. ELEMENT FOUR: QUALITY ASSURANCE: Root cause analysis was conducted and a QAPI performance improvement project team formed to address clinical concerns. Abuse allegations and violations of illicit drug abuse policy are discussed at weekday clinical meetings, and all concerns are reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. The Director of Nursing will report on audits of the daily meeting and any actions taken at the monthly Quality Assurance and Process Improvement Committee meeting for 3 months. Based on the results of these audits, a decision will be made regarding review and further direction as appropriate. DATE OF COMPLIANCE: June 9, 2025

Removal Plan

• The Corporate Officer re-educated staff on their job descriptions and the facility's policies on conducting a thorough investigation and the facility's elimination efforts.
• Signage was posted in the front of the building that no alcohol or drugs were allowed in the facility.
• The designee educated all the facility staff on elimination of use in the facility and to report any use to the Department of Health.
• Incidents and accidents were audited to ensure there were no additional unresolved issues identified.
• An audit process was implemented during the clinical meeting to assess concerns and ensure these were addressed per the facility policy.

Penalty

Fine: $119,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the safety of its residents by not implementing effective interventions to prevent illicit drugs from entering the facility and to prevent drug-related incidents among residents. Despite being aware that a resident had a history of drug use and overdose, the facility did not take adequate measures to monitor or restrict access to substances, resulting in multiple incidents where the resident was found unresponsive or in distress and required hospitalization for drug-related diagnoses. The facility also did not conduct thorough investigations into these incidents, and staff were uncertain about the source of the drugs or whether the resident had used substances within the facility. On several occasions, the resident was found in a compromised state, such as being unresponsive in a wheelchair, and required emergency intervention and transfer to the hospital. Documentation and interviews revealed that staff observed symptoms consistent with drug overdose, administered emergency medications, and called for emergency services. However, there was a lack of consistent incident reporting, and some staff did not complete incident reports or investigations, believing the incidents may have been related to the resident's activities outside the facility. There was also confusion among staff regarding the requirements for reporting such incidents to regulatory agencies. The facility's policies acknowledged an increase in residents with a history of drug use and outlined the need for assessment and follow-up treatment if drug use was suspected. However, the facility did not follow its own protocols for incident reporting and failed to notify the appropriate state and local authorities about the drug-related incidents. Staff interviews indicated uncertainty about their ability to search residents or prevent drugs from entering the facility, and there was a lack of clear action to investigate or address the repeated incidents involving the resident.

Plan Of Correction

F 000 F 000 *Free of Accident Hazards/Supervision/Devices ELEMENT ONE: CORRECTIVE ACTION: - The U.S. FOIA (b) (6) [R] and [R] received re-education by the corporate officer on job description and facilities policies on conducting a thorough investigation for [R] and [R] and the requirements to report these incidents to the DOH [R] /LTCO or [R]. All nursing staff was re-educated on the illicit drug use policy which includes reporting overdoses to the New Jersey Department of Health and police on 5/9/25. The Director of Nursing re-investigated the incidents involving Resident #6 on [R]. An audit was conducted to identify all residents with a history of [R] and/or [R] on [R]. The Social Worker met with all residents with a history of [R] and/or [R] to educate residents on the medical risks of [R] use and [R] involvement. All residents were notified that upon return from out on pass they will be subjected to a search by nursing and/or security. Upon any suspicion of [R], a room search will be conducted by nursing/security. All residents suspicious of [R] will be required to open any incoming packages/deliveries in the presence of a staff member of nursing or security. If resident is found to be in possession of [R] and/or if an [R] occurs, the resident will be subject to a possible 30-day discharge notice from the facility, and/or revoking of facility out on pass privileges on 5/9/25. The Social Worker provided education to all residents with a history of [R] use and/or [R] on the availability of [R] programs on 5/9/25. The Social Worker met with Resident #6 to educate the resident on the availability of [R] programs, the medical risks of NJ Ex Order 26.4(b)(1) [R] involvement, possible 30-day discharge notice from the facility, and revoking of facility out on pass privileges on 5/9/25. All nursing staff were re-educated on signs of overdose and policies to follow in cases of suspected overdose and availability of drug cessation programs for residents on 5/9/25. ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS: All residents have the potential to be affected by this practice. ELEMENT THREE: SYSTEMIC CHANGES: Policy signage was posted at the entrance stating that drugs and alcohol are not allowed in the home on 5/9/25. All residents are educated about illicit drug use policy at Resident Council meetings. The Social Worker meets with new residents who have a history of illicit drug use / overdose to discuss policy and options for treatment of addiction. Violations of illicit drug abuse policy are discussed at weekday clinical meetings and reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. ELEMENT FOUR: QUALITY ASSURANCE: Root cause analysis was conducted, and a QAPI performance improvement project team formed to address clinical concerns. Violations of illicit drug abuse policy are discussed at weekday clinical meetings. Drug overdoses in the home are reported to the Licensed Nursing Home Administrator and Director of Nursing to ensure that the police were called and the New Jersey Department of Health was notified. The Director of Nursing will report on audits of the weekday clinical meetings and any actions taken at the monthly Quality Assurance and Process Improvement Committee meeting for three months. Based on the results of these audits, a decision will be made regarding review and further direction as appropriate. DATE OF COMPLIANCE: June 9, 2025

Removal Plan

• Provided education to all residents with a history of drug overdose on the medical risks with illegal drug use, police involvement, possible discharge from the facility, and revoking of facility leave privileges.
• Provided education to the residents on cessation programs and psychiatric consultations.
• Placed signage at the entrance of the facility stating that drugs and alcohol were not allowed in the facility.
• Educated facility staff that any drug overdose is to be reported to the appropriate regulatory agencies immediately.
• Educated facility staff on new interventions implemented to help prevent illegal drug use.
• Implemented new interventions including education to the residents on the risks of a drug overdose, room searches, police involvement, possible discharge from the facility, and revoking of facility leave privileges.
• Implemented an audit process during the morning daily clinical meeting to identify residents with a new history of use and any incidents that occur in the facility, ensuring police were called and appropriate regulatory agencies were notified.
• Re-educated administrative staff on their job descriptions and the facility's policies on conducting a thorough investigation and the facility's elimination efforts on illicit drug use at the facility.
• Posted signage in the front of the building that no alcohol or drugs were allowed in the facility.
• Educated all facility staff on elimination of illicit drug use in the facility and to report any illicit drug use to the DOH and the police.
• Audited all incidents and accidents to ensure there were no additional unresolved allegations of abuse, neglect, and illicit drug use identified.
• Implemented an audit process during the morning daily clinical meeting to assess potential abuse and any illicit drug activity and ensure these concerns were addressed per the facility policy.

Penalty

Fine: $119,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct thorough investigations into allegations of abuse, neglect, or mistreatment as required by federal regulations and its own policies. In one instance, a resident was observed to have experienced an incident involving another resident, but the facility did not conduct a comprehensive investigation beyond speaking with the two residents involved. There was no documented follow-up, no collection of witness statements, and no further inquiry outside of a grievance filed for the affected resident. The facility's policy, which mandates timely and thorough investigation including obtaining written statements from staff and interviewing witnesses, was not followed. In another case, a resident reported witnessing an incident involving an LPN and another resident. The LPN was suspended immediately after the report, but the investigation was limited to interviews with the reporting resident, the accused LPN, and two other staff members. The facility did not interview or assess other residents who were under the care of the LPN, nor did it obtain statements from other staff who worked on the unit during the time frame in question. The responsible staff member acknowledged that a more thorough investigation, including interviews with all potentially affected residents and staff, was not conducted due to uncertainty about the timing of the alleged incident. These failures to follow investigative protocols and facility policy resulted in the facility not ensuring the protection of residents during the investigation process. The lack of comprehensive investigation and documentation placed multiple residents at risk, as the facility did not take all necessary steps to determine the extent of potential abuse or mistreatment. The surveyor found that these deficiencies affected several residents, some of whom had cognitive impairments or other medical conditions, and that the facility did not implement its abuse prevention and investigation policy as required.

Plan Of Correction

F610 *Investigate/Prevent/Correct Alleged Violation ELEMENT ONE: CORRECTIVE ACTION: The U.S. FOIA (b) (6) received re-education by the corporate officer on job description and facilities policies on conducting a thorough investigation for NJ Exec Order 26.4b1 and the requirements to report these incidents to the DOH/police/LTCO on NJ Exec Order. The Licensed Nursing Home Administrator and Director of Nursing re-educated the U.S. FOIA (b) (6) and all nursing staff on the abuse policy to include reporting abuse and conducting a thorough investigation on NJ Exec Order 25 and NJ Exec Order 2. The resident-to-resident involving Resident #8 and Resident #15 on NJ Exec Order 26.401 was reinvestigated by the U.S. FOIA (b) (6) on NJ Exec Order. The NJ Exec Order 26.4(b)(1) involving LPN #1 and Resident #3 on 4/25/25 was reinvestigated by the U.S. FOIA (b) (6) to include interviews with residents on LPN #1's work assignment and witness statements from staff on 5/8/25. Incidents and accidents occurring from January 2025 through May 2025 were audited to ensure there were no identified, unresolved allegations of abuse and neglect. ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS: All residents have the potential to be affected by this practice. ELEMENT THREE: SYSTEMIC CHANGES: Allegations of abuse are discussed at weekday clinical meetings and all concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. All residents are educated about abuse policy at Resident Council meetings. ELEMENT FOUR: QUALITY ASSURANCE: Root cause analysis was conducted and a QAPI performance improvement project team formed to address clinical concerns. Allegations of abuse are discussed at weekday clinical meetings and all concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. The Director of Nursing will report on audits of the daily meeting and any actions taken at the monthly Quality Assurance and Process Improvement Committee meetings for 3 months. Based on findings, a decision will be made regarding review and further directives. DATE OF COMPLIANCE: June 9, 202

Removal Plan

• All facility staff were educated on the facility's abuse-prevention policy, recognition of and types of abuse, reporting urgency, and reporting to regulatory agencies.
• Audited all incidents and accidents to assure there were no additional unresolved incidents identified.
• Implemented an auditing process to assess potential incidents and ensure concerns are addressed through the policy.
• Auditing of all incidents/accidents will occur Monday through Friday, with weekend incidents/accidents included in the Monday audit.
• Residents that were on LPN #1's schedule were interviewed and assessed for any complaints of inappropriate behaviors requested or witnessed by LPN #1.
• Educated the social workers and administrative nursing staff on the facility's policy on reporting of abuse and conducting a thorough investigation.
• Conducted an investigation into incidents and accidents.
• Implemented an auditing process to assess potential incidents and ensure concerns are addressed through the policy.
• Auditing of all incidents/accidents will occur Monday through Friday, with weekend incidents/accidents included in the Monday audit.

Penalty

Fine: $119,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from abuse and did not follow its own policy titled "Abuse, Resident Behavior and Facility Practice." An incident occurred in which a resident was observed to have injuries of unknown origin after sharing a room with another resident who had a documented history of behavioral issues. The staff did not immediately separate the residents or implement the abuse policy as required. There was no documentation in the medical record or progress notes to indicate that the care plan for the resident with behavioral issues was followed at the time of the incident. Additionally, the facility did not conduct a thorough investigation into the incident. There was no record of a Facility Reportable Event (FRE) being filed with the New Jersey Department of Health, and no investigation was completed for the event. Staff interviews revealed that key steps were missed, such as interviewing the roommate and other potential witnesses, and there was a lack of follow-up outside of a grievance form. The supervisor and LPN involved did not speak with all relevant parties or document their actions in accordance with facility policy. The failure to follow established procedures and policies resulted in the residents not being protected from potential abuse. The lack of immediate action, incomplete documentation, and insufficient investigation placed the affected resident and others at risk. The facility's own staff acknowledged that the abuse policy was not followed and that necessary steps, such as interviewing all involved individuals, were omitted.

Plan Of Correction

F 000 F600 *Free from Abuse and Neglect ELEMENT ONE: CORRECTIVE ACTION: The U.S. FOIA (b)(6) received re-education by the corporate officer on job description and facilities policies on conducting a thorough investigation for NJ Exec Order 26.4b1 and the requirements to report these incidents to the DOH/police/LTCO on 5/9/25. Resident #15 was evaluated for signs of NJ Exec Order 26.4b1 and none were noted. The LPN involved in the incident involving Resident #8 and Resident #15 no longer works at the building. The caring for Residents #8 and #15 on NJ Ex Order 26.4(b)(1) was re-educated on the abuse policy on 5/9/25. The care plans of Residents #8 and #15 were reviewed and updated on 5/9/25. The U.S. FOIA (b) (6) met with Resident #15 to support and offer a room change on NJ Exec Order 26.4b1. Resident #8 and Resident #15's incident of der 26.4b1 was reinvestigated by the U.S. FOIA (b) (6) on 5/9/25. The Director of Nursing / designee re-educated all nursing staff about the abuse policy on 5/9/25. Incidents and accidents occurring from January 2025 through May 2025 were audited to ensure there were no identified, unresolved allegations of abuse and neglect on 5/12/25. ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS: All residents have the potential to be affected by this practice. ELEMENT THREE: SYSTEMIC CHANGES: Allegations of abuse are discussed at weekday clinical meetings and all concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. All residents were educated regarding the abuse policy at the resident council meeting held on 5/7/25. ELEMENT FOUR: QUALITY ASSURANCE: Root cause analysis was conducted and a QAPI performance improvement project team formed to address clinical concerns. Allegations of abuse are discussed at weekday clinical meetings and all concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. The Director of Nursing will report on audits of the daily meeting and any actions taken at the monthly Quality Assurance and Process Improvement Committee meetings for 3 months. Based on findings, a decision will be made regarding review and further directives. DATE OF COMPLIANCE: June 9, 2025 audits of the daily meeting and any actions taken at the monthly Quality Assurance and Process Improvement Committee meetings for 3 months. Based on findings, a decision will be made regarding review and further directives. DATE OF COMPLIANCE: June 9, 2025 F 600 F 600

Removal Plan

• The facility implemented a corrective action plan to remediate the deficient practice.
• All facility staff were educated on the facility's policy abuse prevention, recognition of and types of abuse, reporting urgency and reporting to the regulatory agencies.
• The facility audited all incidents and accidents to assure there were no additional unresolved of identified.
• The facility implemented an auditing process to assess potential and ensure concerns are addressed through the policy.
• Auditing of all accidents will occur Monday through Friday, with weekend incidents included in the Monday audit.
• The residents that were on LPN #1's schedule were interviewed and assessed for any complaints of NJ Ex Order 26.4(b)(1) requested or witnessed by LPN #1.
• The SMRT and the US FOIA (D) educated the social workers (SW) and administrative nursing staff on the facility's policy on reporting of Exous and conducting a thorough investigation.
• The U.S. FOIA (b)(6) conducted an investigation into incidents and accidents from NJ Ex Order 26.4(b)(1).
• An audit was implemented daily at morning clinical meeting on all accidents and incidents to determine if conducted investigations were completed correctly.

Penalty

Fine: $119,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to update the care plan with appropriate interventions for a resident who experienced multiple incidents while at the facility. Despite the resident being sent to the hospital on several occasions with significant changes in condition and new diagnoses, the care plan was not revised to address these events. Medical record reviews and staff interviews confirmed that the care plan did not reflect updated interventions after each incident, even though the resident returned from the hospital with new or ongoing medical issues. Staff interviews revealed that there was an expectation for care plans to be updated after incidents or significant changes in a resident's condition. However, the responsible staff either believed the existing interventions were sufficient or were unaware that updates had not been made. Documentation showed that the care plan remained unchanged after the resident's hospitalizations and subsequent returns, despite clear evidence of changes in the resident's health status. The facility's own policy required care plans to be reviewed and updated as changes in the resident occurred, including changes in diagnosis or condition. The failure to update the care plan as required by both facility policy and federal regulations resulted in a deficiency, as the care plan did not accurately reflect the resident's current needs or provide guidance for staff following significant health events.

Plan Of Correction

F 000 F657 Care Plan Timing and Revision ELEMENT ONE: CORRECTIVE ACTION: The care plan of Resident #6 was reviewed and updated to reflect history and potential risk of NJ Exec Order 26.4b1 [R]. The staff caring for Resident #6 were educated on the updates to the care plan. The Director of Nursing / designee re-educated the nursing administrative team and U.S. FOIA (b) (6) on the resident care plan policy. An audit of the care plans of residents with history and/or potential risk of NU EXOD or NJ Ex Order 26.4(b)(1) [R] was conducted and care plans updated as needed. ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS: All residents have the potential to be affected by this practice. ELEMENT THREE: SYSTEMIC CHANGES: Residents with incidents of illicit drug abuse and/or overdose will be discussed and care plans updated at weekday clinical meetings. ELEMENT FOUR: QUALITY ASSURANCE: Root cause analysis was conducted and a QAPI performance improvement project team formed to address clinical concerns. Illicit drug abuse and/or overdose are discussed at weekday clinical meetings and all concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. The Director of Nursing will report on audits of care plans at the weekday clinical meeting and any actions taken at the monthly Quality Assurance and Process Improvement Committee meeting for 3 months. Based on the results of these audits, a decision will be made regarding review and further direction as appropriate. DATE OF COMPLIANCE: June 9, 2025

Removal Plan

• Resident #6's care plan was updated.
• Administrative nursing staff and social workers were educated on updating and implementing care plans when incidents occur.
• A process was implemented to occur during daily morning clinical meetings to ensure that care plans are updated when incidents occur.

Penalty

Fine: $119,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report multiple alleged violations involving abuse, neglect, or mistreatment to the New Jersey Department of Health (NJDOH) and other required authorities within the regulatory timeframes. In one instance, a resident was observed with injuries of unknown origin, and the facility did not provide documentation that a Facility Reportable Event (FRE) was completed or submitted to the NJDOH. The resident was unable to recall how the injury occurred, and the staff member interviewed stated they did not consider the incident reportable due to the resident's lack of recollection, despite acknowledging that such events should be reported. In another case, a resident reported to an LPN that they intended to report the LPN for an incident involving another resident. The LPN was suspended pending investigation, but the FRE did not indicate whether the required notification to the NJDOH was made. The staff member interviewed admitted to not notifying the appropriate authorities because they felt the allegation was unsubstantiated, contrary to regulatory requirements. A third incident involved a resident reporting to staff and the Ombudsman that an LPN had spoken to them inappropriately. The event was eventually reported to the NJDOH, but not within the required timeframe. The staff member confirmed that the report was delayed and acknowledged that it should have been made sooner. The facility's own policy requires timely reporting of all allegations of abuse, neglect, or mistreatment to regulatory agencies, but this was not followed in these cases.

Plan Of Correction

F609 Reporting of Alleged Violations ELEMENT 1 The U.S. FOIA (b) (6) and [R] received re-education by the corporate officer on job description and facilities policies on conducting a thorough investigation for [R] and the requirements to report these incidents to the DOH/police/LTCO on 5/9/25. The Director of Nursing / designee re-educated all leadership staff about the abuse policy to include abuse prevention, recognition of and types of abuse, reporting urgency, and reporting to the regulatory agencies. Incidents and accidents occurring from January 2025 through May 2025 were audited to ensure there were no identified, unresolved allegations of abuse and neglect. The New Jersey Department of Health, police, and ombudsman were notified regarding the 10/12/24 incident between Residents #8 and #15. The police were notified regarding the 4/25/25 incident between LPN #1 and Resident #3. ELEMENT 2: All residents have the potential to be affected by this practice. ELEMENT 3: Allegations of abuse are discussed at weekday clinical meetings and all concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. ELEMENT 4: QUALITY ASSURANCE: Root cause analysis was conducted and a QAPI performance improvement project team formed to address clinical concerns. Allegations of abuse are discussed at weekday clinical meetings and all concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. The Director of Nursing will report on audits of the daily meeting and any actions taken at the monthly Quality Assurance and Process Improvement Committee meetings x 3 months. Based on findings, a decision will be made regarding review and further directives. Date of Completion: June 9, 2025

Penalty

Fine: $119,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a failure to maintain a clean and homelike environment on two of three units, specifically on the second and fourth floors. During tours, the surveyor observed multiple sanitation and housekeeping deficiencies in the central bath areas. These included a sink filled with discarded items such as an isolation gown, black pad, wash sponge, and basin; a shower bed with hair clippings, toilet paper, personal care products, and debris; visible water on the floor inside and outside the shower stall; and the presence of brown, green, and black substances in various corners and on the floors of the shower stalls. Additional findings included wet towels and socks left in the shower, a build-up of unknown debris and hair in the shower drain grate, and missing molding with a hard brown substance on the wall. Interviews with staff revealed a lack of clarity regarding responsibilities for cleaning and maintaining the shower areas. An LPN stated that CNAs were responsible for gathering residents' belongings after showers, and that housekeeping was responsible for cleaning the shower rooms. However, staff were unsure about the nature of the substances found in the showers and who was responsible for cleaning specific areas such as the shower grate. Staff confirmed that the observed conditions did not create a homelike environment for residents. A review of the facility's housekeeping and environmental services job descriptions indicated that housekeeping staff were expected to perform cleaning and sanitation of resident rooms and common areas, conduct regular inspections, and collaborate with other team members to maintain cleanliness. The director of environmental services was responsible for supervising housekeeping and laundry activities to keep the facility orderly, clean, and sanitary. Despite these outlined responsibilities, the observed deficiencies indicated that these standards were not met in the central bath areas on the affected units.

Plan Of Correction

F584 Safe/Clean/Comfortable/Homelike Environment ELEMENT ONE: CORRECTIVE ACTION: The second and fourth floor Central Baths were cleaned and sanitized by housekeeping on 5/9/25. Noted black, brown, green, and red substances were removed from the second and fourth floor Central Baths on 5/9/25. Personal hygiene and linen items were removed from the second-floor Central Bath sink on 5/9/25. Hygiene and toiletries were removed from the second-floor Central Bath shower bed. The molding in the 1st stall in the second-floor Central Bath was repaired on 6/7/25. The build-up of unknown debris and hair in the 1st stall second-floor Central Bath shower was removed on 5/9/25. Visible water on the floor inside and outside the second-floor Central Bath shower stall was removed on 5/9/25. The housekeeping staff were re-educated in daily responsibilities to clean showers and to report any cleaning concerns to their director. The nursing staff was re-educated to remove all personal items after showers on 6/9/25. The maintenance staff was alerted to evaluate drainage in the second-floor shower. ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS: All residents have the potential to be affected by this practice. ELEMENT THREE: SYSTEMIC CHANGES: Leadership makes weekly rounds to check on cleanliness of showers. The process for requesting maintenance work was reviewed and staff re-educated. Maintenance and housekeeping issues are discussed at daily operation meetings. The Licensed Nursing Home Administrator reviews and acts upon issues reported. ELEMENT FOUR: QUALITY ASSURANCE: Root cause analysis was conducted and a QAPI performance improvement project team formed to address maintenance and housekeeping concerns. The housekeeping director/nurse leadership designee will conduct weekly rounds to inspect the cleanliness, neatness, and functioning of showers. Maintenance will be notified to correct any repairs needed. Findings of rounds shall be reported to the Licensed Nursing Home Administrator weekly for 3 months. The findings and actions taken will be reported to the QAPI committee for review and further direction as appropriate. DATE OF COMPLIANCE: June 9, 2025

Penalty

Fine: $119,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident was discharged from the facility without receiving the required 30-day advance discharge notice. The resident, who had a documented history of certain diagnoses and a Brief Interview of Mental Status (BIMS) score, was involved in an incident with a roommate. Following this incident, the resident did not return to the facility, and staff communicated the discharge to the resident's responsible party via phone call. There was no evidence in the record that the required written notification was provided to the resident or their representative. Interviews with facility staff, including two social workers and another staff member, revealed that the decision to not readmit the resident was made by administration and admissions, not by the social workers. Staff described the discharge as 'safe' because the resident had nowhere else to go and because medications and the electronic Medication Administration Record (eMAR) were provided to the responsible party upon the resident's departure. However, there was no documentation of a formal discharge process or orientation to ensure a safe and orderly transition, as required by regulations. Record review confirmed the absence of documentation for a 30-day advance discharge notice or evidence of a comprehensive discharge plan. The facility failed to comply with federal and state requirements regarding transfer and discharge, including the need for proper documentation, communication, and preparation for discharge. The lack of adherence to these procedures resulted in the resident being discharged without the protections and planning mandated by regulation.

Plan Of Correction

F 627 F627 Inappropriate Discharge ELEMENT 1 The Director of Nursing reviewed the discharge documentation of Resident #16 and clarified the actions taken by Resident #16 regarding the disposition of the resident. A clarifying note was also placed in the chart of Resident #16 regarding the actions taken by NJ Ex Order 26.4(b)(1). Per the direction of NJ Ex Order 26.4(b)(1), all needed physician orders and medications were provided to NJ Ex Order 26.4(d)(1). Who Nex order 26.4(b)(1) Resident #16 into their custody and placed the resident in a safe location with medical staff available to provide care. The family and physician were notified of the NJ Ex Order 26.4(b)(1) actions. Social work and all nursing staff received re-education about 30-day notice of discharge and safe discharge. ELEMENT 2 All residents have the potential to be affected by this practice. ELEMENT 3 The policy for discharge when necessary was reviewed and updated as appropriate by the Licensed Nursing Home Administrator and Director of Nursing. The Director of Nursing re-educated leadership on documentation of discharge when necessary. Discharges occurring from January 2025 through May 2025 were audited to ensure that there were no other occurrences of discharge when necessary. The documentation of Resident #16 and clarified the actions taken by Resident #16 regarding the disposition of the resident. A clarifying note was also placed in the chart of Resident #16 regarding the actions taken by NJ Ex Order 26.4(b)(1). Per the direction of NJ Ex Order 26.4(b)(1), all needed physician orders and medications were provided to NJ Ex Order 26.4(d)(1). Who Nex order 26.4(b)(1) Resident #16 into their custody and placed the resident in a safe location with medical staff available to provide care. The family and physician were notified of the NJ Ex Order 26.4(b)(1) actions. Social work and all nursing staff received re-education about 30-day notice of discharge and safe discharge. ELEMENT 4 A root cause analysis was conducted and a QAPI performance improvement project team formed to address discharge concerns. The Social Worker reports on discharges monthly. Findings shall be reported to the Licensed Nursing Home Administrator weekly for three months. The findings and actions taken will be reported to the QAPI committee for review and further direction as appropriate. Date of Completion: June 9, 2025

Penalty

Fine: $119,920

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow a physician's order for a treatment for one resident, as well as its own policies regarding physician orders and medication administration. Specifically, the treatment and medication ordered by the physician were not administered on several specified dates, as evidenced by blank entries on the Treatment Administration Record (TAR). There was no documentation of the treatment being provided, nor was there any record of the resident refusing the treatment or the physician being notified of missed doses. Interviews with nursing staff confirmed that the expectation is for all treatments to be administered as ordered, with proper documentation on the TAR. Staff stated that a blank on the TAR indicates the treatment was not done, and that refusals or missed treatments should be documented, with the physician notified as appropriate. The facility's policies require that all treatments and medications be documented, and that any medication not given, including refusals, must be recorded with the reason and physician notification as needed. A review of the resident's medical record showed that the required treatment was not administered on multiple occasions, and there was no documentation in the progress notes or TAR to indicate that the physician was notified of these missed treatments. The deficiency was identified for one of eighteen residents reviewed, and the failure to follow physician orders and facility policy was confirmed through record review and staff interviews.

Plan Of Correction

F658 Services Provided Meet Professional Standards ELEMENT 1 The staff caring for Resident #5 on days 7/6, 7/7, 7/20, 7/25, and 7/31/24 were re-educated on physician order and medication administration policies on documentation. Staff was re-educated to follow up with notification to medical provider and document when treatments are not performed. ELEMENT 2 All residents have the potential to be affected by this practice. ELEMENT 3 Leadership staff are educated on use of the Point Click Care dashboard to track missing medication and treatment signatures. Staff are directed by nurse leadership to complete electronic treatment record documentation before the end of shift. ELEMENT 4 Root cause analysis was conducted and a QAPI performance improvement project team formed to address discharge concerns. The Director of Nursing / designee audits numbers of missed documentation monthly. Findings shall be reported to the Licensed Nursing Home Administrator x 3 months. The findings and actions taken will be reported to the QAPI committee for review and further direction as appropriate. Date of Completion: June 9, 2025

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet mandatory staffing ratios as required by New Jersey law for certified nurse aides (CNAs) and direct care staff. During a review of staffing records for a two-week period, it was found that the facility did not have the required number of CNAs on 12 out of 14 day shifts and was also deficient in total direct care staff on one evening shift. Specific examples include having only 17 CNAs for 176 residents on one day when at least 22 were required, and similar shortfalls on multiple other days. The facility also had one overnight shift where the total staff was below the required minimum. These deficiencies were identified through interviews and document reviews conducted during the complaint survey. The staffing requirements referenced are based on New Jersey statutes and regulations, which mandate specific CNA-to-resident ratios for each shift. The facility's failure to meet these ratios was documented for several consecutive days, with the number of CNAs consistently falling short of the minimum required for the number of residents present. The report does not mention any specific residents affected or detail any adverse outcomes, but it notes that the deficient practice had the potential to affect all residents in the facility.

Plan Of Correction

S560 Mandatory access to care ELEMENT 1 • The Staffing Coordinator was re-educated on New Jersey minimum staffing requirements for nursing homes. ELEMENT 2 • All residents have the potential to be affected by this practice. ELEMENT 3 The Staffing Coordinator will report staffing weekly to the Administrator / Director of Nursing / designee. Flyers are hung in staff areas advertising open staff positions. Indeed is used to advertise for open staff positions. Agencies are used to fill open staff positions. ELEMENT 4 Root cause analysis was conducted and a QAPI performance improvement project team formed to address staffing concerns. Staffing is discussed at weekday clinical meetings and concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. The Director of Nursing will report on staffing audits and any actions taken at the monthly Quality Assurance and Process Improvement Committee meetings for three months. Based on findings, a decision will be made regarding review and further directives. Date of Completion: June 9, 2025

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the mandatory nurse staffing requirements as outlined in N.J.A.C. 8:39-25.2(b)(1)&(2). Specifically, the review of Nurse Staffing Reports for the weeks of 04/20/2025 to 05/03/2025 revealed that on two out of fourteen days, the actual nursing staff hours provided were below the minimum required levels. On 04/27/25, the facility provided 416 actual staffing hours against a required 459.25 hours, resulting in a shortfall of 43.25 hours. On 05/03/25, the facility provided 440 actual staffing hours, which was 19.25 hours less than the required amount. These deficiencies were identified during the investigation of multiple complaints, as referenced by the complaint numbers listed in the report. The calculation of required staffing hours included both the base requirement per resident and additional hours for residents receiving specialized services such as wound care, tube feedings, oxygen therapy, tracheostomy care, intravenous therapy, respirator use, and advanced neuromuscular or orthopedic care. The report does not provide specific details about individual residents or their medical histories, but it documents the facility's failure to provide the mandated level of nursing care on the identified dates.

Plan Of Correction

S1680 Mandatory nurse staffing ELEMENT 1 The Staffing Coordinator was re-educated on New Jersey minimum staffing requirements for nursing homes. ELEMENT 2 All residents have the potential to be affected by this practice. ELEMENT 3 • The Staffing Coordinator will report staffing daily to the Administrator / Director of Nursing / designee. • Flyers are hung in staff areas advertising open staff positions. • Indeed is used to advertise for open staff positions. • Agencies are used to fill open staff positions. ELEMENT 4 • Root cause analysis was conducted and a QAPI performance improvement project team formed to address staffing concerns. • Staffing is discussed at weekday clinical meetings and concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. • The Director of Nursing will report on staffing audits and any actions taken at the monthly Quality Assurance and Process Improvement Committee meetings x 3 months. Based on findings, a decision will be made regarding review and further directives. Date of Completion: June 2025

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store, label, and date potentially hazardous foods properly, leading to several deficiencies observed during a survey. The handwashing sink in the kitchen lacked paper towels, and multiple food items in the walk-in refrigerator were improperly stored, labeled, or dated. For instance, a gallon of ranch dressing had spillage on the rim and lid, a jug of salsa had no opened date, and a gallon of hot sauce had spillage on the container. Additionally, a jar of dill pickle chips had a slit in the lid, exposing the contents to air, and a gallon of sweet relish had green fuzzy debris on the packaging and inside contents. Other items, such as French dressing, sour cream, and cream cheese, were either past their expiration dates or lacked proper labeling and dating. The ice cream freezer chest had significant ice accumulation, preventing proper air circulation and raising sanitation concerns. In the milk refrigerated box, an opened half-gallon container of milk was not dated, and in the Cook's refrigerator, several items, including cole slaw, provolone cheese, and sliced tomatoes, were either undated or past their discard dates. In the dry storage area, food items were improperly stored on the floor, and cans had black debris on the lids or were dented and unlabeled. The Dietary Director (DD) acknowledged these issues during the survey. The Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) confirmed the deficiencies during interviews with the survey team. The facility's Food Storage policy and Labeling and Dating Procedure were reviewed, revealing that the facility failed to adhere to its own guidelines for food storage, labeling, and dating. The policies emphasized the importance of maintaining sanitary conditions, proper labeling, and timely disposal of perishable items, which were not followed in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to perform proper hand hygiene during and after medication administration, as well as before and after serving residents meals. On multiple occasions, staff members were observed not washing their hands for the required duration or not using alcohol-based hand rub (ABHR) between glove changes. For instance, a Unit Manager/Licensed Practical Nurse (UM/LPN) did not perform hand hygiene correctly during tracheostomy care for a resident, breaking sterility multiple times. Similarly, another LPN was observed not washing hands for the required time after administering medications and handling oxygen tubing that had fallen on the floor. The Director of Nursing (DON) and Infection Preventionist/Registered Nurse (IP/RN) confirmed these lapses in hand hygiene practices during interviews with the surveyor. The facility also failed to maintain enhanced barrier precautions (EBP) for residents requiring such measures. A resident on EBP had a sign indicating the need for gloves and gowns during high-contact care activities, but staff members were observed not adhering to these precautions. For example, an LPN flushed a resident's gastrostomy tube without wearing a gown, and multiple staff members entered and exited rooms without performing hand hygiene. The IP/RN and DON confirmed that these actions were against the facility's policy and the importance of following EBP to prevent the spread of multi-drug resistant organisms (MDROs). Additionally, the facility did not ensure that oxygen tubing was changed and dated according to their policy. A resident's oxygen tubing, dated 4/15/24, was observed to be unchanged for several weeks. The DON and IP/RN confirmed that the tubing should be changed every two weeks and that this practice was not documented in the Electronic Medical Record (EMR). The facility had a Respiratory Therapist until February 2024, who managed the tubing changes, but the protocols were not put on paper until May 2024. The DON acknowledged that the tubing should have been changed and dated on 4/30/24, and that nurses should check the expiration dates during respiratory care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the smoking policy was followed to screen and assess a resident for the ability to safely smoke cigarettes. This deficiency was identified for one resident who was observed smoking despite the most recent smoking assessment indicating that the resident was not a smoker. The resident's electronic medical record and interdisciplinary care plan did not contain any focus area for smoking, and the smoking contract in the paper medical record was crossed out and marked as 'Do Not Smoke.' Despite this, the resident was listed on the smoking schedule and was observed smoking on multiple occasions. The surveyor's investigation revealed that the facility's staff, including the Unit Manager/Registered Nurse (UM/RN) and the Receptionist, were not aware of the resident's smoking status. The UM/RN confirmed that the smoking assessment was completed inaccurately and that the resident was not care planned for smoking. The facility's smoking policy required residents to be screened for tobacco use and their ability to smoke safely upon admission, with assessments to be repeated quarterly and annually. However, this policy was not followed for the resident in question. The Director of Nursing and the Licensed Nursing Home Administrator confirmed that there was no smoking contract in the resident's medical record and that smoking was not addressed in the resident's interdisciplinary care plan. The facility's failure to adhere to its smoking policy and procedures resulted in a lack of proper assessment and supervision for the resident, potentially compromising the safety of the resident and others in the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure safe and appetizing temperatures of food for residents on the Third Floor nursing unit. During a Resident Council meeting, one resident reported that lunch and dinner had been served cold and in takeout containers since February 2024. On 5/8/24, the surveyor observed the lunch meal preparation and noted that the facility used disposable Styrofoam containers due to a shortage of insulated bases and dome lids. The surveyor recorded the temperatures of various food items before and after delivery to the Third Floor nursing unit, finding that most hot foods were below the required 135 degrees Fahrenheit and cold foods were above the required 41 degrees Fahrenheit when served to residents. The Dietary Director (DD) acknowledged that only the barbecue chicken and scalloped potatoes were served at acceptable temperatures. The facility's Food Serving Policy and Procedure, revised in May 2024, mandates that hot food be served at a minimum of 135 degrees Fahrenheit and cold food at a maximum of 41 degrees Fahrenheit. The Licensed Nursing Home Administrator (LNHA) and the Director of Nursing acknowledged the deficiency in food and beverage temperatures when informed by the survey team.