Excel Care At Manalapan

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of medical records, other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 2 of 27 residents reviewed (Resident #10 and Resident #13). This deficient practice was evidenced by the following:1.On 8/6/25 at 11:54 AM, Resident #10 refused to speak with the surveyor. The resident refused to speak with the surveyor for the duration of the survey. On 8/12/25 at 10:59 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #1, who stated that Resident #10 had specific CNAs that they want and only allowed them to provide care and would shout, yell, curse, and refuse everything for others. The surveyor reviewed the Comprehensive admission MDS dated [DATE], which indicated that Resident #10 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident had an intact cognition, no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #401653, #401655Based on observation, interview and record review, it was determined that the facility failed to ensure medications were administered in accordance with professional standards of nursing practice. This deficient practice was identified for 3 of 7 residents reviewed for medication management, (Resident #9, #120 & #57), and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation performed on 8/7/25, the surveyor observed two (2) nurses administer medications to five (5) residents. There were 35 opportunities, and three (3) errors were observed which calculated to a medication administration error rate of 8.57 %. The deficient practice was identified for two (2) of five (5) residents, (Resident #30 and #55), that were administered medications by two (2) of two (2) nurses. The deficient practices were evidenced as follows: 1.On 8/7/25 at 8:24 AM, the surveyor observed the Registered Nurse (RN) #1 administer four (4) medications to Resident #30. The resident then stated that they wanted their cough medicine.On 8/7/25 at 8:29 AM, the surveyor observed RN #1 measure 10 milliliters (ML) of Gertussin DM (Guaifenesin Dextromethorphan) liquid. RN #1 stated Guaifenesin DM was an over-the-counter/house stock (OTC/HS) medication meaning that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY NJ401652Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to effectively accommodate the needs and preferences of residents during dining. This deficient practice was identified for 1 of 10 residents (Resident #43) reviewed for tray accuracy during dining and was evidenced by the following: On 8/6/25 at 10:34 AM, the surveyor observed Resident #43 lying in bed asleep, with the head of the bed elevated, on an air mattress. The resident did not respond when the surveyor knocked on the door or in response to verbal stimuli. The surveyor observed a sign that hung over the resident's bed which indicated, No Straws and Thickened liquids, do not leave thickener packets with the resident. The surveyor reviewed the medical record for Resident #43. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included but were not limited to: unspecified dementia, unspecified severity, without behavioral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NJ401661, NJ401667, NJ401652Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to follow appropriate infection control procedures during the provision of incontinence care for a resident who was previously identified to have been at risk for recurrent urinary tract infection.This deficient practice was identified for 1 of 1 resident (Resident #43) reviewed for bladder and bowel incontinence and was identified by the following: On 8/6/25 at 10:34 AM, the surveyor observed Resident #43 lying in bed asleep, with the head of the bed elevated, on an air mattress. The resident did not respond when the surveyor knocked on the door or in response to verbal stimuli.The surveyor reviewed the medical record for Resident #43. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included but were not limited to: urinary tract infection, site not specified, overactive bladder, other specified noninfective gastroenteritis and colitis (conditions that affect the gastrointestinal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #s NJ 152910, 152911, 159956 Based on observation, interview and document review, it was determined that the facility failed to ensure that all residents were treated with respect and dignity by ensuring the facility acted promptly to respond to ongoing residents grievances affecting quality of life by failing to consistently and uniformly address grievances regarding: a) ensuring residents had consistent access to their personal needs account funds (PNA), b) food complaints identified on 02/28/2022 when the resident council was alerted to the menu being changed to kosher style, and c) the menu not being posted, not having access to menus to select meal choices and the repetitiveness of the menu. This deficient practice was identified by 6 of 6 residents who attended a resident council meeting and affected all residents who resided on 2 of 2 units. The deficient practice was evidenced by the following: Refer to: 567F and 568F On 02/20/24 at 9:41 AM, during the initial tour of the kitchen with the Food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review it was determined that the facility failed to ensure that a system was in place for residents to receive their Personal Need Account (PNA) funds without restrictions, ensure that the residents had access to at least $50.00 which would be provided the same day it was requested, and ensure a system was in place which included receipts provided to residents to confirm disbursement. The deficient practice effected all residents who maintained PNA funds who resided in the facility. The deficient practice was evidenced by the following: Refer to 565F On [DATE] at 8:50 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with the requested list of current PNA balances and stated that the Human Resources Director (HRD) was responsible for the PNA accounts. The list included 94 accounts and listed 6 residents with a Current Balance more than $50.00 who were listed as Expired [deceased ] under Status. On [DATE] at 1:22 PM, the surveyor interviewed the HRD who…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to have a system in place to ensure all residents who had the facility manage Personal Needs Account (PNA) funds were provided with a quarterly statement. The deficient practice effected all resident who had PNA funds and was evidenced by the following: Refer to 565F and 567F. On [DATE] at 8:50 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with the requested list of current PNA balances and stated that the Human Resources Director (HRD) was responsible for the PNA accounts. The list included 94 accounts and listed 6 residents with a Current Balance more than $50.00 who were listed as Expired [deceased ] under Status. On [DATE] at 1:22 PM, the surveyor interviewed the HRD who confirmed that she handled the PNA money for the resident's accounts during the week. She clarified and stated, during the week, the residents will come find her and on the weekends the residents would obtain money from the activity staff. She stated that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review it was determined that the facility failed to have a process in place to ensure that within 30 days of a resident's death the facility conveyed, the resident's funds, and a final accounting of those funds to the individual or probate jurisdiction administering the resident's estate. This deficient practice occurred for 6 of 6 expired residents identified with a current Personal Needs Account balance (Resident #236, #237, #238 and 3 unsampled residents) and was evidenced by the following: On [DATE] at 8:50 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with the requested list of current PNA balances and stated that the Human Resources Director (HRD) was responsible for the PNA accounts. The list included 94 accounts and listed 6 residents with a Current Balance who were listed as Expired [deceased ] under Status. The Expired residents included: 1. Unsampled Resident (UR #1); Expired [DATE] with a Current Balance $100.15. 2. UR #2; Expired [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ 169440 Based on observation and interview it was determined that the facility failed to have a system in place to ensure all resident rooms and common areas were maintained in a clean, sanitary and homelike manner, and resident equipment was maintained in good condition. The deficient practice was observed throughout the 200 unit and was observed by the following: On 02/20/24 at 10:26 AM through 11:15 AM, surveyor #1 observed the following on the 200 Unit: -room [ROOM NUMBER], Resident in bed, a gray chair next to the bed was visibly stained on the seat cushion, the bed and bed frame appeared rusted, the bedside table had chips, and the privacy curtain was visibly soiled. -room [ROOM NUMBER] A, There was no handle on the middle drawer of the door side bedside table. Bed frame appeared rusty, and a male Certified Nurse Aide (CNA) entered room with a burgundy recliner chair that had a ripped arm rest and was for resident use. -room [ROOM NUMBER], The resident was in bed and the bedside curtain and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaints NJ #s: 159956, 161569, 165971, 169440 Based on observation, interview, record review, and review of pertinent documents, it was determined that the facility failed to ensure that Activities of Daily Living Care (ADLs) was consistently provided to residents by failing to a.) provide appropriate incontinent care to dependent residents (Resident #6, #18, #22, #23, #31, #32, #38 #50, #51 #53 #55); and b.) provide residents with scheduled showers (Resident #233 and #80). This deficient practice occurred for 12 of 12 residents, 1 of 1 closed record (Resident #80) reviewed for ADLs, and 1 of 6 residents who attended a resident council meeting. The deficient practice was evidenced by the following: On 02/23/24 at 11:14 AM, a resident council meeting was held with 6 residents which revealed that 1 of 6 stated they leave me wet for hours sometimes, and double diaper me, which I don't ask them to. On 02/20/24 at 9:16 AM, upon entrance to the facility, the survey team observed a strong odor of urine that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #s NJ 152905, 152910, 152911, 159956, 161569, 165971, 160660, 169440 Based on observation, interview and review of pertinent documents it was determined that the facility failed to ensure sufficient and competent staff were available to a) provide appropriate incontinence care to dependent residents (Resident #6, #18, #22, #23, #31, #32, #38, #50, # 51, #53 and #55), b) provide residents with scheduled showers (Resident #80 and #233), and c) ensure all residents were treated in a dignified manner. This deficient practice was identified for 12 of 12 residents, 1 of 1 closed record (Resident #80) reviewed for ADLs, expressed by 6 of 6 Residents who attended a Resident Council meeting, and affected all residents on 2 of 2 units. This deficient practice was evidenced by the following: Refer to 677F, 690H On 02/23/24 at 11:14 AM, the surveyor held a resident council meeting with six residents. The resident's expressed the following concerns: -3 of 6 Residents stated they waited anywhere from 30 minutes to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and review of pertinent documentation, it was determined that the facility failed to ensure the designated licensed Director of Nursing (DON) worked on a full-time basis as DON to oversee the care of all residents in the facility. This deficient practice was evidenced by the following: On 02/21/24 at 11:34 AM, the DON stated that the previous facility Infection Preventionist (IP) was a corporate nurse who was covering multiple facilities. He stated that the facility had been interviewing candidates for the IP position, but they did not have enough experience or wanted a lot of money so he had been also performing the job as IP. On 02/22/24 at 11:02 AM, the DON in the presence of the survey team, confirmed his job was to be the full-time DON, but he was also working as the facility IP. On 03/05/24 at 10:44 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team, stated that the DON assumed the responsibilities of the Infection Preventionist (IP) for the facility a few months ago in the fall. The LNHA stated he was responsible to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Complaint # NJ # 160660 Based on observation, interview and document review it was determined that the facility failed to serve hot and cold foods at an appetizing temperature for 4 of 4 hot food items, 2 of 2 cold food items and for 6 of 6 residents who attended a resident council meeting. The deficient practice was evidenced by the following: On 02/22/24 at 8:44 AM, the last meal tray was tested for temperature by two surveyors utilizing a calibrated thermometer and the Food Service Director (FSD). The resident meal was labeled a Chopped Diet. Hot food items: -Chopped French Toast; FSD- 90 degrees Farenheight (F), Surveyor-88 F. -Sausage; FSD- 89 F, Surveyor -90 F. -Hot Cereal; FSD-132 F, Surveyor-129 F. -Coffee; FSD- 124 F. The surveyor asked the FSD what the hot food temperature should be, and he stated 140 F or above. Cold food items: -4 ounces skim milk; both 51 F -4 ounces orange juice; FSD-54 F The surveyor asked the FSD what the cold food temperatures should be, and he stated cold should be 35 F or below. The surveyor asked if the food temperatures were in appropriate range…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review it was determined that the facility failed to ensure a) foods were stored properly and labeled with a use by date, b) equipment was maintained in a clean and sanitary manner, and c) hair restraints were appropriately worn to prevent the spread of potential infection or food borne illness. The deficient practice was evidenced by the following: On 02/20/24 from 9:41 AM through 10:15 AM, the surveyor conducted an initial tour with the Food Service Director (FSD) and observed the following: The walk-in refrigerator contained: -A package of undated meat was in a plastic -type wrap, stored in a metal pan, on a shelf and was covered with aluminum foil. The FSD stated, sometimes they throw on a use by date and stated it was pulled from the freezer on 02/17/24 and it's beef stew for tomorrow. -A large metal pan of chicken thighs was next to the container of meat, had a plastic covering on it with a handwritten label Chicken Pulled 2-17-24 and did not contain a use by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and document review it was determined that the facility administration failed to ensure policies, procedures and effective systems were implemented to maintain each resident's highest practicable physical, mental, and psychosocial well-being by failing to ensure a) a resident with documented food allergies were provided with appropriate food items, b) that appropriate and timely incontinence care was provided to dependent residents, c) residents were treated with dignity and respect, d) residents were consistently provided with physician ordered medications, e) interventions were implemented to prevent falls for a resident with frequent falls with history of fractures, residents received appropriate incontinent care to limit urinary tract infections, f ) resident council grievances were addressed, e) residents resided in a homelike environment, g ) resident's had unrestricted access to their Personal Needs Accounts, h) transportation was available to ensure outside trips were scheduled, i) the facility maintained a comprehensive emergency preparedness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, it was determined that the facility failed to ensure that medical record access was provided in a timely manner during an on-site survey conducted from 02/20/24 through 03/06/24. The deficient practice was evidenced the following: On 02/20/24 11:19 AM, the surveyor conducted an entrance conference with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the [NAME] President of Nursing (VPON) from a management company. The VPON stated the management company was the company that was purchasing the facility. The surveyor asked about the electronic medical record (EMR) system the facility utilized and the LNHA stated they have a new EMR since November 2023. The surveyor asked if the facility still had access to records prior to the November 2023 and he stated, the facility still has access and the information was imported into the new system. On 02/21/24 at 11:21 AM, the facility provided the survey team with a tablet and was informed that the EMR access for medical records prior to 11/2023 would need to be accessed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and document review, it was determined that the facility's Quality Assessment and Assurance Committee (QAPI) failed to ensure the facility self- identified areas for improvement including environmental concerns, resident care related concerns, the Antibiotic Stewardship Program and adverse events. This deficient practice had the potential to affect all residents that resided in the facility and was evidenced by the following: Refer to F550F, F565F, F567F, F584F, F677E, F689G, F690H, F742H, F806J, F890G 1.) During a tour of the 200 unit on 02/20/24 and 02/21/24, the surveyors observed several rooms with broken furniture, soiled privacy curtains, missing privacy curtains, dust in rooms and air conditioners cracked. On 02/21/24 at 11:25 AM, two surveyors (Surveyor #1 and #2) conducted a tour with the Licensed Nursing Home Administrator (LNHA) and observed the broken furniture, soiled privacy curtains, missing privacy curtains, cracked air conditioners. The LNHA stated that he made environmental rounds daily but did not document the rounds. On 02/21/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and the review of pertinent facility documentation, it was determined that the facility failed to have the a.) the Medical Director (MD) and the Infection Preventionist (IP) present for one (1) of four (4) quarterly Quality Assurance Performance Improvement (QAPI) meetings and b.) Infection Preventionist (IP) report on the Infection Prevention and Control Program (IPCP) for four (4) out of four (4) QAPI meetings reviewed. The deficient practice had the potential to affect all residents who resided in the facility and was evidenced by the following: a.) On 03/06/24 at 9:17 AM, the surveyor reviewed the last four (4) quarterly sign in sheets for the QAPI meetings. The sign in sheet dated 04/18/23 did not include the signature of the IP and the sign sheet dated 07/08/23 did not include a signature that the MD was in attendance. The 10/17/23 and the 01/17/24 sign in sheets were missing the IP's signature. On 03/06/24 at 10:24 AM, the Licensed Nursing Home Administrator (LNHA) acknowledged that the IP signature was missing on 04/18/23 and the MD's signature was missing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to follow infection control practices to prevent the spread of potential infection by a) storing dirty meal trays apart from clean, not yet served, resident meals trays on 1 of 2 units; b) adhering to accepted standards of infection control practices for the proper storage of respiratory tubing and mask after use for 1 of 1 residents reviewed (Resident #31); c.) ensuring the ice scoop and ice scoop container were clean for 1 of 2 units; and d.) ensuring staff performed appropriate hand hygiene (HH). The deficient practice was identified on 2 of 2 units and evidenced by the following: 1. On 02/22/24 at 8:35 AM, Surveyor #1 went to the 200 Unit to observe the breakfast meal. The surveyor observed a facility's staff exited a room with an uncovered dirty tray with the remaining of the food not eaten and placed the tray on the food cart with the other breakfast trays that had not yet been served. The surveyor remained in the hallway and observed a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint NJ #159556 Based on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to ensure a.) 1 of 1 resident (Resident # 51) was reviewed for reoccurring Urinary Tract Infections (UTI), and b.) a facility-wide implementation of the Antibiotic Stewardship program, which included a system for routine feedback reports and tracking measures of outcome surveillance related to antibiotic use was followed, as per facility policy and national standards. This deficient practice was evidenced by the following: 1.) On 02/21/24 at 11:01 AM, the surveyor observed Resident #51 awake and alert sitting in his /her wheelchair in dining room eating lunch. A review of the Electronic medical record (EMR) revealed the following physician's orders (PO) and corresponding progress notes: On 11/15/23, a PO for Keflex (an antibiotic used to treat bacterial infections) 500 mg (milligram) 1 capsule orally three times a day for Extended Spectrum. Beta-Lactamase (ESBL- enzymes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and document review, it was determined that the facility failed to ensure residents were treated with dignity and respect by failing to ensure a) resident requests for water were honored, b) meals were served in a dignified homelike manner without the use of disposable dishware, c) consistently communicated with residents by their preferred name and not label residents as feeders, d) staff did not speak in a foreign language in the presence of the residents, e) staff conducted personal phone calls during resident interactions, and f) all residents were provided with privacy curtains. The deficient practice was identified during a resident council meeting held with six residents, and evidenced during a survey conducted from 02/20/24 through 03/06/24, and affected all residents who resided on 2 of 2 resident units. The deficient practice was evidenced by the following: On 02/23/24 at 11:14 AM, the surveyor held a resident council meeting with six residents. The following concerns…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to develop and implement an individualized resident-centered comprehensive care plans with measurable goals: a) to integrate approaches for a resident with a history of aggression and exhibited behaviors, b) for a resident with a history of falls including falls with injury, c) and interventions for a resident who had a history of psychosis, and d) for a resident with allergies. This deficient practice was identified for 4 of 18 residents (Resident #1, #5, #76, and #32) reviewed for Care Plans (CP) and was evidenced by the following: a. On 02/20/24 at 12:34 PM, Surveyor #1 observed Resident #1 in bed with the lunch tray on the bedside table. The lunch tray was covered with a plastic wrap and the resident was eating off of disposable dinnerware and with disposable cutlery. The surveyor left the room and observed the Director of Nursing (DON) in the hallway. Surveyor #1 inquired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Complaint NJ 161569, NJ 169440 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure that the resident call bells were accessible. This deficient practice was identified for 3 of 18 residents (Residents #1, #78 and #288) reviewed for the call bells and was evidenced by the following: 1) During the tour of the facility on 02/20/24 at 10:04 AM, Surveyor #1 observed Resident #1 sitting in the bed. The resident responded to the surveyor's greetings then asked for a drink of water. The surveyor informed the resident that she was just a visitor and not staff and instructed the resident to activate the call light. The resident informed Surveyor #1 that [he/she] did not have a call light. The surveyor looked on the bed and on the floor and did not observe a call light. The surveyor left the room and observed a Certified Nursing Assistant (CNA) #1 in the hallway. The surveyor asked CNA #1 to activate the call light. The CNA was unable to locate the call light. The surveyor asked the CNA to send the nurse to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility failed to ensure the required Minimum Data Set (MDS) assessments were submitted timely as evidenced by 1 of 1 resident reviewed (Resident #66) for a system selected MDS Record over 120 days old. The deficient practice was evidenced by the following: On 02/22/24 at 11:33 AM, the surveyor reviewed the MDS for Resident #66 and interviewed the Licensed Practical Nurse MDS coordinator (MDSC) regarding submission of the MDS. The MDSC stated she was not at the facility at that time and an old medical record system was utilized. The MDSC then viewed an MDS report on the old system and stated the quarterly MDS and discharge MDS did not appear to be submitted and she would research further. On 02/23/24 at 10:00 AM, the Licensed Nursing Home Administrator (LNHA) provided a report for Resident #66's Discharge Assessment scheduled as due no later than 09/14/23 which was Accepted. The Quarterly Assessment stated was Submitted, not accepted per the document, and Transmission date no later than 09/26/23. On 03/05/24 at 1:35 PM, the surveyor informed the LNHA and Director of Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and document review, it was determined that the facility failed to ensure that an ongoing activity program was designed to meet the needs of all residents, specifically those who enjoyed outside of the facility trips. The deficient practice was identified for 1 of 2 residents reviewed for activities (Resident #18) and was evidenced by the following: On 02/29/24 at 9:00 AM, the surveyor reviewed the Electronic Medical Record for Resident #18, and reviewed the current Care Plan which did not include a care plan for activity preferences. The annual minimum data set (MDS) dated [DATE] revealed Resident #18 scored a 15 out of 15 on the Brief Interview for Mental Status, and was cognitively intact. The Interview for Activity Preferences revealed it was very important to go outside for fresh air when the weather was good. On 02/29/24 at 10:29 AM, the surveyor conducted an interview with Resident #18 who also served as the resident council president. The surveyor asked Resident #18 if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of medical records, and review of other pertinent documentation, it was determined that the facility failed to ensure residents received pain management consistent with professional standards of practice and physician's orders. This deficient practice was identified for 2 of 2 residents (Resident #75 and #286) reviewed for pain and was evidenced by the following: 1.) On 02/20/24 at 9:31 AM, the surveyor observed Resident #75 lying in bed awake and alert. Resident #75 stated that his/her back had been hurting. He/she stated that Tylenol (medication used to relieve mild to moderate pain) helps some. He/she further stated that he/she used to get a patch on their back but not for a while. A review of the admission Record revealed that Resident #75 had diagnoses which included but were not limited to; repeated falls, muscle wasting and atrophy multiple sites, and cardiac arrhythmia (irregular heartbeat). A review of the Order Summary Report included but was not limited to; a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Complaint #s NJ 154702, NJ 154763 Based on interviews, review of medical records and other facility documentation, it was determined that the facility failed to notify a resident representative and/or physician for 2 of 3 residents reviewed for change in condition. This deficient practice was identified for Resident #19 and Resident #45 reviewed for a change in condition and was evidenced by the following: 1) Review of Resident #19's Medication Administration Record (MAR) revealed that Resident #19 did not receive Clozapine 100 milligrams (mg) as ordered by the physician for three consecutive days 03/18/22, 03/19/22, and 03/20/22. The resident did not receive the same medication on an additional three consecutive days 03/29/22, 3/30/22 and 3/31/22. There was no documented evidence that the resident's physician was notified of the resident not being administered the medication as ordered. Review of Resident #19's Electronic Medical Record (EMR) revealed a Progress Note dated 03/22/2022 at 9:43 PM, by the Registered Nurse (RN) which revealed, Received resident by front of [his/her]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Complaint # NJ 159956 Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to obtain a physician's order from the attending physician as recommended by the consulting podiatrist for a resident with a diabetic foot ulcer for 1 of 1 resident (Resident #51) reviewed for foot care. A review of the Electronic medical Record (EMR) revealed that Resident #51 was admitted to the facility with diagnosis including but not limited to: Type 2 diabetes mellitus, dementia, overactive bladder, urinary tract infection (UTI), acquired absence of left great toe and coronary angioplasty implant and graft (a treatment used to widen and open narrowed or blocked arteries supplying your heart muscle). The Annual Minimum Data Set (MDS), as assessment tool, dated 11/30/23, revealed that Resident # 51 had severe cognitive impairment, an active diagnosis of Diabetes Mellitus, acquired absence of the left great toe, transfers with maximum assistance and is non- ambulatory. A review of the comprehensive care plan, initiated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and review of facility documentation, it was determined the facility failed to a.) maintain medications with appropriate labeling and b.) maintain a clean, orderly medication cart for 2 of the 3 carts observed on 2 of 2 nursing units. This deficient practice was evidenced by the following: On 11/18/21 from 11:19 to 11:54 AM, in the presence of the Registered Nurse (RN) #1, the surveyor observed the following in the medication cart labeled B on the 100 unit: 1. In the first row of the second drawer, there were two yellow oval tablets, one pink oval tablet, one large white oval tablet, one small white oval tablet, and one white round tablet which were unwrapped and unmarked. There was also paper debris. 2. In the third row of the second drawer, there was one large pink oval tablet, seven white oval tablets, six small white round tablets, one small pink oval tablet, two pink round tablets, one green round tablet, and two yellow oval tablets which were unwrapped and unmarked. There was also paper and foil debris. 3. In the fourth row of the second…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and other facility documentation, it was determined that the facility failed to ensure that kitchen staff were properly trained and capable of performing assigned duties to maintain proper kitchen sanitation and prevent food-borne illness. This deficient practice was evidenced by: During the initial tour of the kitchen on 11/17/21 from 09:47 AM until 10:34 AM, the surveyor observed the following in the presence of the Director of Dining Services (DDS): During an interview with the surveyor at 10:16 AM, the DDS stated that a high temperature dish machine was utilized, and the required wash temperature was 150 degrees or higher and the required final rinse temperature was 180 degrees. The surveyor reviewed the Dish Machine Temperature log for the month of November 2021 which revealed that the required rinse temperature of 180 degrees was not met during all recorded breakfast and lunch washes from 11/1/21 through 11/16/21 and only met the rinse requirement during dinner on 11/01/21, 11/03/21, and 11/08/21. Review of the October 2021 Dish Machine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.