Palace Rehabilitation And Care Center, The

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate medication dispensing and administration for 1 of 6 residents (Resident #50) observed during the medication pass. This deficient practice was evidenced by the following:On 2/18/26 at 8:22 AM, the surveyor observed Licensed Practical Nurse (LPN #1) dispense five medications for Resident #50. As the LPN pulled the medications from the medication cart, she handed them to the surveyor. The LPN handed the surveyor an over-the-counter (OTC) pill bottle of calcium citrate 200 milligrams (mg) and then the LPN dispensed one pill from the bottle into the medication cup. When the LPN finished dispensing the medications, she locked the medication cart and turned on the privacy screen on the monitor. Before the LPN entered the resident's room, the surveyor asked the LPN to review the resident's medications. The LPN verified the resident had the following physician's order:…

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 pertinent facility documentation, it was determined that the facility failed to ensure that a medication was secured in a locked compartment accessible only to authorized personnel with a key. This deficient practice was identified for 1of 1 resident (Resident #143).On 2/17/26 at 11:15 AM, the surveyor observed Resident #143 seated in his/her wheelchair in their bedroom, waiting to go to therapy. A nebulizer medication vial was noted on the bedside table. The resident stated that he/she administered their own breathing treatments after the nurses leave the medication for him/her. The surveyor reviewed the medical record for Resident #143. A review of the admission Record, indicated the resident was admitted to the facility with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) (long-term lung disease that makes it hard to breathe). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care management, dated 1/15/26, included a Brief Interview for Mental Status (BIMS) score of…

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, interview, and review of pertinent facility documentation it was determined that the facility failed to follow the planned written menu for 2 of 2 meals observed. This deficient practice was evidenced by the following:On 2/19/26 at 11:10 AM, the surveyor entered the kitchen during lunch preparation. The menu for lunch was crispy baked chicken, macaroni and cheese, and roasted zucchini. The surveyor observed a vegetable mix cooking on the stove top which had cauliflower, carrots, and zucchini. It was simmering in a stainless-steel pan with water on the stove top. At that time, the surveyor interviewed a [NAME] who stated the lunch was chicken and the alternate lunch was glazed ham. During the observation the [NAME] was cleaning chicken thighs. The surveyor asked about the menu process for resident choices and the [NAME] stated that the Food Service Director (FSD) hanged the menus on the units an hour before lunch was served and residents could choose the main meal, the alternate, or the always available options. On 2/19/26 at 12:33 PM, the surveyor went into…

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 and interviews it was determined that the facility failed to ensure the Licensed Nursing Home Administrator (LNHA) and the Medical Director's (MD) licenses were visibly displayed. This deficient practice was evidenced by the following:On 2/20/26 at 12:15 PM, two surveyors toured the facility and there was no evidence that the current MD (MD #1) or the LNHA's licenses were visibly displayed. During the tour, the two surveyors observed in the facility's copier room a copy of MD #2's license on the bulletin board. On 2/20/26 at 12:30 PM, the surveyor interviewed the Director of Nursing (DON) who stated that MD #2 was the previous Medical Director and MD #1 was the current Medical Director. At that time, the Regional DON, the Director of Social Services (DSS), and the DON, with the surveyor, looked in the main hallway and they stated that the license was previously visibly posted. They all confirmed it was not currently posted and would have to see where it went. The DSS stated that one of the bulletin boards fell and they put it somewhere. The DSS further stated,…

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 documentation, it was determined that the facility did not ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to a.) follow appropriate hand hygiene practices for 1 of 2 nurses who administered medications to 3 of 6 residents (Resident #42, Resident #50, and Resident #59) during the medication pass, and b.) properly store a nebulizer mask leaving the mask exposed to air on a bed table for 1 of 1 resident (Resident #143) reviewed for respiratory care. This deficient practice was evidenced by the following:1.) On 2/18/26 at 8:15 AM, the surveyor observed Licensed Practical Nurse (LPN) #1 exit a resident's room and return to the medication cart. The surveyor explained to the LPN that the surveyor would be observing the medication pass and the LPN informed the surveyor that she was going to prepare Resident #59's medications. At that time, without performing hand hygiene, the LPN dispensed five…

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 review of pertinent facility documents, it was determined that the facility failed to a.) store food in a manner to prevent food-borne illness, b.) maintain the kitchen equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness, and c.) label all food items in the refrigerator. This deficient practice was identified in the facility kitchen and in 1 of 1 nursing unit pantry and was evidenced by the following: On 10/22/24 at 9:39 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1.) In the refrigerator identified as the walk-in cooler, a cluster of bok choy and lemongrass was noted on the shelf. Both items were dated 10/9/24. At that time, the surveyor interviewed the FSD who stated that he was unsure of when the items needed to be discarded. 2.) In the food preparation area, a heavy duty commercial blender base was observed with hardened food stain and a moderate amount of discoloration. At that time, the surveyor…

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 #: NJ175570 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a safe and sanitary physical environment in the central supply room. This deficient practice has the potential to affect 3 of 3 nursing units and was evidenced by the following: On 10/23/24 at 12:25 PM, the surveyor conducted a tour of the facility's basement, in the presence of the facility's Regional Licensed Nursing Home Adminstrator (RLNHA) and the staff member in charge of Central Supply. At that time, the surveyor entered the Central Supply room and observed, adhered on the wall board ceiling to the right of the doorway near the pipes, a black substance approximately 24 inches in length. On 10/23/24 at 1:00 PM, the surveyor revisited the Central Supply room and observed the RLNHA and the Maintenance Assistant (MA) present in the room. The MA had a pitcher of white paint with a brush and was applying the white paint over the black substance on the ceiling. At that time, the surveyor interviewed the RLNHA who stated, it was dirt…

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 #: NJ172102 Based on observations, interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to report an alleged violation of misappropriation of resident property to the New Jersey Department of Health (NJDOH). This deficient practice was identified for 2 of 7 residents (Resident #58 and Resident #365) reviewed for unneccessary medications and was evidenced by the following: 1.) On 10/22/24 at 12:14 PM, the surveyor interviewed Resident #58 who reported that pain medications were always available when requested. The resident further stated that there was never a time when he/she did not receive pain medication when the resident asked for it. A review of the admission Record, an admission summary, revealed that the resident had diagnoses which included, but were not limited to: borderline personality disorder, dorsalgia (a sensation of unpleasant feeling indicating potential or actual damage to some body structure felt in the back), and osteoarthritis (a degenerative disease that worsens over time, often…

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 #: NJ172102 Based on observations, interviews, records review, and review of other pertinent facility documentation, it was determined that the facility failed to thoroughly investigate an allegation of misappropriation of property for 1 of 3 residents (Resident #58) reviewed for personal property. This deficient practice was evidenced by the following: On 10/22/24 at 12:14 PM, the surveyor interviewed Resident #58 who reported that pain medications were always available when requested by the resident. The resident further stated that there was never a time when he/she did not receive pain medication when the resident asked for it. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: borderline personality disorder, dorsalgia (a sensation of unpleasant feeling indicating potential or actual damage to some body structure felt in the back), and osteoarthritis (a degenerative disease that worsens over time, often resulting in chronic pain). A review of the quarterly Minimum Data Set (MDS), an…

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, record review, and review of pertinent facility documents, it was determined that the facility failed to revise a resident's care plan with related goals and interventions each time the resident violated the facility's smoking policy. This deficient practice was identified for 1 of 5 residents (Resident #72) reviewed for smoking and was evidenced by the following: Refer to F689 During the initial tour of the facility on 10/22/24 at 11:56 AM, the surveyor observed Resident #72 as he/she self-propelled in their wheelchair in the hallway. The resident's left upper extremity was flaccid (hung loosely) and the resident's left hand was edematous (swollen), without the use of a splint or sling to aid in supporting the affected extremity. A review of Resident #72's admission Record, an admission summary, revealed the resident had diagnoses that included, but were not limited to: tobacco use, nicotine dependence, unspecified, uncomplicated, hemiplegia (paralysis of one side of the body) and hemiparesis (another term for hemiplegia) following cerebral infarction (stroke)…

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 other pertinent documents, it was determined that the facility failed to provide adequate supervision during resident smoking sessions and consistently follow and implement the facility smoking policy to ensure the safety of all residents at the facility for 2 of 5 residents (Resident #72 and Resident #137) reviewed for smoking. This deficient practice was evidenced by the following: During the initial tour of the facility on 10/22/24 at 11:56 AM, the surveyor observed Resident #72 as he/she self-propelled in their wheelchair in the hallway. The resident's left upper extremity was flaccid (hanging loosely) and the resident's left hand was edematous (swollen), without the use of a splint or sling to aid in supporting the affected extremity. A review of Resident #72's admission Record, an admission summary, revealed that the resident had diagnoses that included, but were not limited to: tobacco use, nicotine dependence, unspecified, uncomplicated, hemiplegia (paralysis of one side of the body) and hemiparesis (another term…

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, review of medical records and other facility documentation, it was determined that the facility failed to complete the dialysis communication book for a resident on dialysis (a treatment that replicates the kidney's function and cleans the waste from blood for individuals with kidney disease or kidney failure). This deficient practice was identified for 1 of 2 residents (Resident # 61) reviewed for dialysis and was evidenced by the following: On 10/23/24 at 9:14AM, the surveyor reviewed the medical records for Resident #61. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: dependence on renal dialysis. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/23/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated that the resident's cognition was moderately impaired. A review of the resident's individual comprehensive care plan (ICCP)…

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, record review, and review of other facility documentation, it was determined that the facility failed to administer medication in accordance with the physician's orders. This deficient practice was identified for 1 of 7 residents (Resident #110) reviewed for unnecessary medications and was evidenced by the following: According to the admission Record, an admission summary, Resident #110 had diagnoses including, but not limited to: paroxysmal atrial fibrillation (an irregular, often heart rate that commonly causes poor blood flow.) A review of the Physician's Orders (PO) revealed a physician's order dated 5/27/24 for Cardizem oral tablet 120 milligram give one tablet by mouth three times a day for atrial fibrillation related to paroxysmal atrial fibrillation, hold for systolic blood pressure less than 130, to be crushed into pudding or applesauce. A review of the June 2024 and July of 2024 Medication Administration Record (MAR) revealed the referenced medication was administered by nursing staff when the resident's systolic blood pressure (SBP) [the first number…

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#: NJ172102 Based on observations, interviews, medical records review, and review of other pertinent facility documentation, it was determined that the failed to maintain an accurate and complete medical record in accordance with acceptable standards and practice. This deficient practice was identified for 2 of 7 residents (Resident #58 and Resident #365) reviewed for unneccessary medications and was evidenced by the following: 1.) On 10/22/24 at 12:14 PM, the surveyor interviewed Resident #58 who reported that pain medications were always available when requested by the resident. The resident further stated that there was never a time when he/she did not receive pain medication when the resident asked for it. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: borderline personality disorder, dorsalgia (a sensation of unpleasant feeling indicating potential or actual damage to some body structure felt in the back), and osteoarthritis (a degenerative disease that worsens over time, often…

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, record review, and review of facility documents, it was determined that the facility failed to maintain proper infection control practices for donning (putting on) appropriate Personal Protective Equipment (PPE) prior to providing care to a resident who was on Enhanced Barrier Precautions (EBP) for 1 of 1 resident (Resident #138) reviewed for pressure ulcers. This deficient practice was evidenced by the following: On 10/24/24 at 10:26 AM, the surveyor reviewed the electronic medical record for Resident #138. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: pressure-induced deep tissue damage of right ankle and pressure-induced ulcer of left heel unstageable. A review of the comprehensive Minimum Data Set (MDS), an assessment tool, dated 9/18/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS revealed the resident had multiple…

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 record review, it was determined that the facility failed to have a process in place to ensure that all recommendations, grievances and concerns presented by the residents during the monthly resident council meetings were consistently addressed. This deficient practice was identified for 6 of 6 residents who attended a resident council meeting and was evidenced by the following: A review of the Resident Council Meeting 02/22/23, included the following: Maintenance: Issues in some bathrooms have been fixed; asking again not to flush paper towels, Dietary: Residents are requesting banana cream pie. A review of the Resident Council Meeting minutes from 03/24/23, included the following: Repair has begun in the rooms and painting; Rooms too cluttered need to downsize; Social Worker is the only one that can go shopping, Social Services will assist resident buying container to help with decluttering. We ask all residents to stop giving their [type of card name redacted] money card to other…

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 review of other facility documentation it was determined that the facility failed to maintain the resident environment, equipment and living areas in a safe, sanitary, and homelike manner. This deficient practice was evidenced on 3 of 3 resident Wings (Wing A, B, & C) and was evidenced by the following: Observations conducted by Surveyor #1 revealed: On 05/23/23 at 12:35 PM, during a tour of the B- Wing hallway, while the lunch meal was being distributed, and in the presence of Surveyor #2. Both surveyors smelled a pervasive smell of urine permeating in the hallway outside of room [ROOM NUMBER]. Residents were observed eating meals in both room [ROOM NUMBER] and the adjacent room [ROOM NUMBER]. At that time, the Director of Nursing (DON) was in the hallway and Surveyor #1 asked the DON if she could smell anything in the hallway. The DON stated she could not, and walked away from the surveyors. On 05/23/23 at 12:36 PM, both surveyors interviewed the B-Wing Registered Nurse (RN)…

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 Registered Dietitian provided resident care per the Facility Assessment and completed nutritional assessments, implemented and updated nutrition care plans and implemented and revised interventions. The deficient practice affected residents who resided on 3 of 3 resident care units and was evidenced by the following: Refer to 692G, 693D, 800F On 05/22/23 at 12:03 PM, the surveyor received the Facility Assessment, dated October, 2022, from the Licenced Nursing Home Administrator (LNHA). The document revealed Part 1: Our Resident Profile, 1.3, The [Facility Name] typically accepts residents or continues to provide care for residents that may develop the following common diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management. Each resident is assessed and reviewed on an individual basis . ; Part 2: Services and Care We Offer…

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.

This is a repeat deficiency from the Standard Survey Date: 03/31/22. Based on observation, interview and document review it was determined the facility failed to maintain the kitchen environment, and all of the equipment, dishware and other items in a clean, intact and sanitary manner to limit the potential of food borne illness and potential injury. The deficient practice was evidenced by the following: On 05/22/23 from 9:49 AM through 10:47 AM, the surveyor completed an initial tour with the Food Service Director (FSD) and Regional Administrator (RA #1) and observed the following: 1. A large black floor fan was in the back area of the kitchen, facing the food preparation area. The fan was running and the grate was embedded with dust like debris throughout. The surveyor asked the FSD who was responsible for cleaning the fan and she stated, it was just brought out. 2. The walk-in refrigerator had what appeared as rust through on the shelving which contained food items that included a glass jar of sliced pickles with hand-written date on metal lid 10-13 and the lid appeared visibly…

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 and interview it was determined that the facility failed to ensure that garbage was maintianed in a manner to prevent potential contamination as evidenced by the following: On 05/22/23 at approximately 10:00 AM, the surveyor began a tour of the dietary department with the Food Service Director and observed the Dumpster area with 1/2 uncovered dumpsters. A Regional Administrator (RA #1) joined the tour. The area next to the dumpsters contained a large field of debris that included gloves, cups, papers and various other debris. There were two dumpsters observed and 1/2 dumpsters did not have a lid in place. When asked who was responsible for keeping the area clean the FSD stated she did not know and the RA #1 immediately interjected and failed to provide information pertinent to the surveyor inquiry. On 06/02/23 at 2:05 PM, the Regional Administrator (RA #2) and Director of Nursing (DON) were informed of concerns regarding the debris. No additional information regarding the debris was provided. NJAC 8:39-19.7(b)

Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure all residents received the care and services needed to enhance their quality of life related by failing to ensure: a) a safe, sanitary, and home-like resident environment on 3 of 3 Resident Wings (Wing A, B & C), b) a thorough investigation of an injury of unknown origin was completed for 1 of 31 residents (Resident #23) reviewed, c) mandatory reporting to the New Jersey Department of Health (NJDOH) for a reportable event of an injury of unknown origin (Resident #23) for 1 of 31 residents reviewed, d) the facility Dietitian was a credentialed Registered Dietitian (RD) per the Facility Assessment, e) there was a process in place to respond to issues and concerns presented by residents during the Resident Council Meeting (RCM), and f) the LNHA provided oversight for the Quality Assurance Performance Improvement (QAPI) to ensure the facility consistently self-identified concerns. The deficient…

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 review of facility documentation, it was determined that the facility Quality Assurance Performance Improvement (QAPI) failed to make good faith attempts to correct and maintain identified issues to address conditions that adversely affected the resident population and were identified during Resident Council Meeting and the condition of the facility environment. The deficient practice was evidenced as follows: Refer to F584 and F565 On 05/22/23, the survey team entered the facility. The Licensed Nursing Home Administrator (LNHA) was asked to provide the entrance documents which included the QAPI plan. During the survey ranging from 05/22/23 through 06/05/23, the survey team made multiple observations on 3 of 3 Wing (A, B, and C) which included but were not limited to, resident rooms with broken, missing, or damaged furniture; visibly soiled walls, floors, furniture, toilets, air conditioner units, curtains, privacy curtains, window blinds; dead insects; exposed wires hanging…

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 This is a repeat deficiency from the Standard Survey Date: 03/31/22. Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to a.) maintain proper isolation procedures for a resident identified as a Person Under Investigation (PUI) for Covid-19 for 1 of 1 resident (Resident #509) reviewed for Transmission Based Precautions (TBP), b.) perform hand hygiene during the passing out of the lunch meal trays on 1 of 3 units (Unit B), and c.) ensure the cleanliness of respiratory equipment for 1 of 3 residents (Resident #83) reviewed for respiratory care. This deficient practice occurred on 2 of 3 Wings (Wing B & C) was evidenced by the following: a.) During a tour of Wing C on 05/23/23 at 11:53 AM, Surveyor #4 observed a three- tier white plastic bin which contained Personal Protective Equipment (PPE), two red paper signage attached to the doorway, indicating how to don (put on) and doff (take off) PPE and a red trash can located in the hallway…

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 record review, it was determined that the facility failed to provide: a) a comfortable chair for each resident in his or her room for use by the resident or the resident's visitor for 66 of 157 residents, (b) a bed table with drawers for 3 of 157 residents, and c) individual closet space in the resident's bedroom with clothes racks and shelves accessible to the resident for 2 of 157 residents. This deficient practice was observed on 3 of 3 resident Wings (Wing A, B, C) and was evidenced by the following: 1.On 05/30/23 at 8:47 AM, Surveyor #3 conducted resident room rounds on Unit A and observed the following: room [ROOM NUMBER] housed 2 residents and one chair room [ROOM NUMBER] housed 2 residents and one chair room [ROOM NUMBER] housed 2 residents and one chair room [ROOM NUMBER] housed 2 residents and one chair room [ROOM NUMBER] housed 2 residents and no chairs room [ROOM NUMBER] housed 2 residents and no chairs room [ROOM NUMBER] housed 2 residents and no chairs room [ROOM…

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, observation, and record review it was determined the facility failed to develop person-centered comprehensive care plans to address the residents medical, physical, mental, and psychosocial needs. This deficient practice was identified for 4 of 31 residents reviewed (Resident #33, #49, #128, #138), for 1 of 2 closed records reviewed (Resident #157) for care plans and was evidenced by the following: 1.) On 05/22/23 at 11:00 AM, during the initial tour of the facility, the surveyor observed Resident #33 in bed and was wearing a nasal cannula (a device used to deliver supplemental oxygen). The surveyor observed that the nasal cannula was connected to an oxygen concentrator that was set to 3 liters per minute (LPM) of oxygen. The resident stated that he/she was on oxygen most of the time. On 05/23/23 at 12:19 PM, the surveyor observed Resident #33 lying in bed with their eyes closed. The surveyor observed that the resident was wearing the nasal cannula and that the oxygen concentrator was set 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to arrange for an audiology consult when a hearing impairment was identified. This deficient practice was identified for 1 of 31 residents (Resident #8) reviewed and was evidenced by the following: On 05/26/30 at 9:30 AM, the surveyor observed the Certified Nursing Assistant(CNA), while in in Resident #8's room repeat herself several times during a conversation she had with Resident #8, the resident responded huh? to several questions/comments from the CNA. Resident #8 stated when people talk to me, I can't hear them, I cannot hear on both ears. The CNA stated to the surveyor that Resident #8 had some hearing loss, but she had not observed him/her wearing hearing aides. The surveyor reviewed Resident #8's medical record. Resident #8 was admitted to the facility with diagnoses which included but were not limited to, unspecified dementia without behavioral disturbances, major depressive disorder, schizophrenia 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 Based on interview, observation and document review it was determined that the facility failed to ensure each resident was provided with meals that were palatable, met specific preferences related to their clinical condition and were offered alternate meal options, including options that the facility only provided to a subset of the resident population. The deficient practice occurred for 6 of 6 residents who attended a resident council meeting, for 1 of 3 residents reviewed for food (Resident #49) and was evidenced by the following: Refer to 692G On 05/23/23 at 2:23 PM, a copy of a three week menu cycle was provided by the Licensed Nursing Home Administrator LNHA and signed by [Name] Dietitian, and an unsigned two week [Asian] menu cycle. On 05/24/23 at 10:30 AM, the surveyor conducted a resident council meeting with six residents. The residents were asked about the meals and residents stated to the surveyor the food is inedible, everything is mushy and the vegetables were over done, you get whatever they offer…

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 documentation, it was determined that the facility failed to ensure a.) Resident Rights were not violated, and b.) promote the dignity of one resident by ensuring residents who were awake alert and ambulatory were provided with regular clothing to wear and ensure their belongings were being protected. This deficient practice was identified for 1 resident reviewed, Resident #8. The deficient practice was evidenced by the following: On 05/22/23 at 9:54 AM, the surveyor observed Resident #8 standing at the resident's room door in the hallway undressed. Resident #8 had no incontinent brief on. Resident #8 had a shirt covering his/her private area. The surveyor observed several staff ambulating back and forth in the hallway entering and exiting other resident's room. Resident #8 attempted to get the staff's attention but no staff stopped and asked Resident #8 if he/she needed assistance. The surveyor continued to ambulate further in the hallway on the right side and was intercepted by Resident #8. Resident #8 was…

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 review of other facility documentation, it was determined that the facility failed to follow the facility policy and report to the New Jersey Department of Health (NJDOH) a facility reportable event for a resident with a history of falls with injury which included an unwitnessed fall on 02/15/23 at 18:40 (6:40 PM), resulting in pain, required transfer to emergency room on [DATE], with a diagnosis of an acute comminuted (a broken bone that is broken in at least two places) mildly displaced (a gap between the broken bones) fracture of the left humeral head (left shoulder and socket). A subsequent unwitnessed fall occurred on 05/21/23 and required 911 transport to the emergency room, and resulted in a laceration to the forehead measuring 6 centimeters (cm) X 5 cm and a mild frontal scalp swelling per a computerized tomography (CT) scan, that sustained an injury of an unknown origin. This deficient practice was identified for 1 of 3 residents reviewed for falls with injury 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.

Based on observation, interview, record review, and document review, it was determined that the facility failed to conduct an investigation for an injury of unknown origin for Resident #23. This deficient practice was identified for 1 of 31 residents reviewed for incident investigations and was evidenced by the following: On 05/22/23 at 10:40 AM, the surveyor toured the B-Wing of the facility and observed Resident #23 in bed positioned on the right side, facing the wall. On 05/24/23 at 8:16 AM, the surveyor observed Resident #23 in bed and again was positioned in the same manner, facing the wall. On 05/24/23 at 1:05 PM, the surveyor returned to the room and observed Resident #23 in bed positioned on the back side. The surveyor observed a large black raised area on the right forehead. The Licensed Practical Nurse (LPN) who was at the bedside assisting Resident #23 with the lunch meal, revealed that the observed injury was from a fall. On 05/24/23 at 1:25 PM, the surveyor left the room and reviewed both the electronic and paper medical records which reflected that Resident #23 was…

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 complete a resident assessment that accurately reflected the resident's status of weight loss. This was identified during a review of the Comprehensive Minimum Data Set (MDS), an assessment tool to facilitate the management of care, for (Resident # 128) 1 of 31 residents reviewed for MDS. This deficient practice was evidenced by the following: On 05/24/23 at 10:30 AM, the surveyor observed Resident #128 during a Resident Council Meeting. At that time, Resident #128 stated that he/she had been losing weight because of lack of edible food. A review of admission Record, an admission summary revealed diagnoses which included but were not limited to Type 2 Diabetes, Folate (Vitamin B) deficiency, Anemia, hyperkalemia (elevated potassium in the blood), Alcohol use, and other psychoactive substance abuse. A review of the facility provided, Weights and Vitals Summary, undated, indicated…

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 documentation, it was determined that the facility failed to ensure a.) a resident dependent on staff for Activities of Daily Living (ADL) received nail care, and b.) a resident dependent on staff for ADLs received nail care and was shaved. This deficient practice was identified for 2 of 3 residents (Resident #35 and #28) reviewed for ADL care. The deficient practice was evidenced by the following: a.) On 05/24/23 at 8:31 AM, Surveyor #1 observed Resident #35 in their room sitting in a wheelchair. Resident #35 reached towards Surveyor #1 and slightly scratched the surveyors right arm. Surveyor #1 requested to see Resident #35's fingernails. The surveyor observed that all 10 nails on both hands were long, eight of the nails had jagged edges, and there was a visible black substance under the nails. On 05/25/23 at 8:53 AM, Surveyor #1 observed Resident #35 in the hallway in their wheelchair. The resident's fingernails were still in the same condition. At that time, Resident #35 stated that he/she needed help to cut…

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 facility documentation, it was determined that the facility failed to ensure: (a) that a resident received supplemental oxygen as prescribed by the physician, and (b) received the necessary respiratory care and services for residents who received oxygen (O2) treatment according to standards of practice for 2 of 3 residents reviewed (Resident #21 and Resident #33) for respiratory care. The deficient practice was evidenced by the following: 1.) On 05/22/23 at 11:00 AM, the surveyor observed Resident #33 in bed wearing a nasal cannula (a device used to deliver supplemental oxygen). The surveyor observed that the nasal cannula was connected to an oxygen concentrator that was set to 3 liters per minute (LPM) of oxygen. The resident stated that he/she was on oxygen most of the time. On 05/23/23 at 12:19 PM, the surveyor observed Resident #33 lying in bed with their eyes closed. The surveyor observed that the resident was wearing the nasal cannula and that the oxygen concentrator was set to 3 LPM. On 5/24/23 at 8:41 AM, 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 Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to: a.) have a system in place to ensure that all nursing and related services were consistently provided for residents to maintain the highest practicable physical, mental, and psychosocial wellbeing for each resident, as determined by resident assessments, individual plans of care and in accordance with the facility assessment. This deficient practice was observed on 1 of 3 nursing units and for 2 of 31 residents reviewed, (Resident #28, #35) for care. This deficient practice was evidenced by the following: Refer to F677 a) On 05/22/23 at 09:49 AM, Surveyor #2 toured the B-Wing of the facility and observed Resident #28 lying in bed. Resident #28 appearred disheveled and unkempt. The left hand was rested on the blanket with nails long and jagged with a black coated substance underneath the fingernails. Resident #28 was unshaven. At the surveyor's request, the resident was able to use 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.

Based on observation, interview and document review it was determined that the facility failed to serve foods at an acceptable temperature for 1 of 6 residents interviewed during a resident council meeting and for 1 of 1 resident reviewed for Hospice Care (Resident #86). The deficient practice was evidenced by the following: On 05/24/23 at 8:37 AM, Resident #86 was observed in bed, a puree meal tray was at the bedside. Resident #86 greeted the surveyor, and the surveyor observed that the meal appeared congealed and uneaten. When the surveyor asked the resident if he/she liked the food, the resident stated, food, not so good. On 05/24/23 at 11:11 AM, during the surveyor conducted resident council interview, 1 of 6 residents stated the food was inedible, vegetables are over done, and the food is mushy. On 05/24/23 at 11:15 AM, the surveyor observed that the posted menu for the lunch meal was barbeque chicken, steamed rice, oriental mixed vegetables, fruit cocktail, whole milk and coffee. On 05/24/23 at 12:09 PM, the surveyor requested regular meal which consisted of barbeque chicken,…

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 review of facility provided documentation, it was determined that the facility failed to ensure corridors were equipped with intact, firmly secured handrails. The deficient practice occurred on 3 of 3 units and was evidenced by the following: On 05/23/23 at 1:02 PM, on A-Wing, two surveyors were observing the facility environment. In the hallway outside of room [ROOM NUMBER] A, the surveyors observed a broken handrail with sharp edges. On 05/23/23 at 1:14 PM, during an interview with the two surveyors, the Licensed Nursing Home Administrator (LNHA) stated that she made rounds in the mornings. She stated that most of the whole floor (A Wing) does for themselves. She further stated, you do realize the whole building is behavioral. On 05/23/23 at 1:16 PM, the two surveyors escorted the LNHA to the broken handrail. The LNHA stated, I didn't see it. The surveyors and LNHA observed a loose handrail in the hallway outside of room [ROOM NUMBER]. A Certified Nursing Assistant (CNA)…

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.